Local Anesthetic Dosing
With special thanks to Robin Leopold for his incalculable assistance.
To date, there are no definitive evidence-based recommendations regarding dosage or concentrations of local anesthetics to be used in pediatric regional anesthesia. Recognizing this dearth of clinical information, a recent Joint Committee Practice Advisory with ESRA and ASRA was published. While the authors of this advisory recognize that there is no high-level evidence to guide LA dosing, in an effort to reduce variability in LA dosing and reduce the likelihood of LA toxicity in setting of physiologic differences between adults and pediatrics, they have made recommendations based on the type of local anesthetic, as well as treatment modality and location. It is very comprehensive and well worth the read, though as a practice advisory it is not without some disagreement about the dosing parameters recommended. A recent Letter to the Editor touches upon this and advocates for slightly higher dosing parameters, especially in the setting of bilateral procedures, volume-dependent fascial blocks, and multiple catheters. A recent study by PRAN found that the single greatest driver of local anesthetic dose is the institution where the block was performed, indicating that local anesthetic dosing is based more on local culture than on evidence.
For now, one must consider all the available evidence and viewpoints and do what one thinks is both effective and safe.
Suresh, S., Ecoffey, C., Bosenberg, A., Lonnqvist, P.A., de Oliveira Jr, G.S., de Leon Casasola, O., De Andrés, J. and Ivani, G., 2018. The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine Recommendations on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia. Regional anesthesia and pain medicine, 43(2), pp.211-216.
Tsui, B.C., Boretsky, K. and Berde, C., 2018. Maximum Recommended Dosage of Ropivacaine and Bupivacaine for Pediatric Regional Anesthesia. Regional anesthesia and pain medicine, 43(8), pp.895-896.
Taenzer, A.H., Herrick, M., Hoyt, M., Ramamurthi, R.J., Walker, B., Flack, S.H., Bosenberg, A., Franklin, A. and Polaner, D.M., 2020. Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the pediatric regional anesthesia network (PRAN). Regional Anesthesia & Pain Medicine, 45(12), pp.964-969.