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Background: The knowledge regarding appropriate dosage of local anaesthetics for peripheral nerve blocks in children is very scarce. The main objective of the current investigation was to evaluate dosing patterns of local anaesthetics in children receiving peripheral nerve blocks across multiple paediatric hospitals in the USA. We also sought to estimate the incidence of local anaesthetic systemic toxicity.Methods: This is an observational study using the Pediatric Regional Anesthesia Network (PRAN) database. Data on every peripheral nerve block in patients aged <18 years placed from April 1, 2007 to May 31, 2015 were examined as a subset of the PRAN protocol. Data were examined for the type and dose of local anaesthetic and for the presence of local anaesthetic systemic toxicity.Results: In total, 40 121 peripheral nerve blocks in children were analysed. Individual analyses of block type demonstrated large local anaesthetic dose variability with a five- to 10-fold spread depending on the block type. Two patients developed local anaesthetic systemic toxicity, resulting in an estimated incidence (95% CI) per blocks performed of 0.005% (0.001-0.015%). None of the patients had any short- or long-term complications or sequelae.Conclusions: We detected a large variability in the local anaesthetic dosing practices for peripheral nerve blocks in children across multiple hospitals in the USA. Nonetheless, the risk of local anaesthetic systemic toxicity was very low. Due to the lack of dose findings studies, our results suggest the need to develop practice guidelines to minimize variability of regional anaesthesia practices in children. [ABSTRACT FROM AUTHOR]

Study Objectives: To develop evidence-based recommendations for prevention and management of infections, bleeding, and local anesthetic toxicity in children undergoing regional anesthesia.Design: A joint committee of the European Society of Regional Anesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) studied electronic literature databases of pediatric regional anesthesia to construct evidence-based recommendations.Main Results: For epidural anesthesia lumbar or thoracic placement is preferred. Skin preparation prior to block placement with chlorhexidine is preferred to povidone iodine. A tunneled catheter technique is suggested when using the caudal route or if the epidural catheter placement is kept in situ for more than 3 days. Inspection of the epidural catheter insertion site should be performed at least once a day as part of the postoperative management. When medical and physical examination is normal, coagulation tests are usually unnecessary but if coagulation tests are abnormal, neuraxial and deep peripheral nerve blocks are contraindicated. For patients receiving Low Molecular Weight Heparin thromboprophylaxis, a safety interval of two half-lives plus the time required for heparin to reach maximal levels is considered an adequate compromise between bleeding risk and thrombosis risk when removing epidural catheters. Ultrasound-guided peripheral nerve blocks reduce the risk of vascular puncture and thus the risk of local anesthetic toxicity is reduced.Conclusions: In children undergoing regional anesthesia the incidence of infection, hematoma, and local anesthetic toxicity is low. The ASRA/ESRA joint committee proposes a practice advisory to prevent and treat these complications. [ABSTRACT FROM AUTHOR]