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Review

Revolutionizing Pediatric Surgery: The Transformative Role of Regional Anesthesia—A Narrative Review

by
Tomasz Reysner
1,
Katarzyna Wieczorowska-Tobis
1,
Aleksander Mularski
2,
Grzegorz Kowalski
1,
Przemyslaw Daroszewski
3 and
Malgorzata Reysner
1,*
1
Department of Palliative Medicine, Poznan University of Medical Sciences, 61-701 Poznań, Poland
2
Department of Forensic Medicine, Institute of Medical Sciences Collegium Medicum, University of Zielona Góra, 65-417 Zielona Góra, Poland
3
Department of Organization and Management in Health Care, Poznan University of Medical Sciences, 61-701 Poznań, Poland
*
Author to whom correspondence should be addressed.
Surgeries 2025, 6(1), 9; https://doi.org/10.3390/surgeries6010009
Submission received: 14 December 2024 / Revised: 8 January 2025 / Accepted: 19 January 2025 / Published: 31 January 2025
Versions Notes

Abstract

:
Regional anesthesia has gained increasing attention in pediatric surgery as a valuable tool for managing perioperative pain and improving surgical outcomes. This narrative review highlights the numerous advantages of regional anesthesia in pediatric populations, including superior pain control, reduced reliance on systemic opioids, fewer anesthetic-related complications, and enhanced recovery profiles. Using ultrasound-guided techniques has further expanded the safety and precision of regional blocks in children. Regional anesthesia also addresses critical concerns about the potential neurotoxicity of general anesthetics in developing brains, offering a safer alternative or complement for specific procedures. Reducing systemic anesthetic and opioid exposure minimizes the risk of adverse effects such as respiratory depression, nausea, and sedation, which are particularly significant in medically fragile or younger patients. Furthermore, regional techniques contribute to faster recovery times, better preservation of neurophysiological monitoring signals during surgery, and attenuation of the stress response. The integration of adjuvants like clonidine, dexmedetomidine, and dexamethasone further enhances the efficacy and duration of regional blocks while improving safety profiles. Despite these benefits, implementing regional anesthesia in pediatric populations requires specialized expertise and an understanding of children’s unique anatomical and physiological differences. This review underscores the growing role of regional anesthesia in modern pediatric perioperative care. It highlights its potential to optimize outcomes, reduce complications, and address emerging concerns about the safety of general anesthesia in children undergoing surgery.

1. Introduction

Effective pain management is a cornerstone of successful pediatric surgical care. Pediatric patients experience unique challenges in perioperative management due to their developing physiology, heightened sensitivity to pain, and limited ability to communicate discomfort [1]. While general anesthesia (GA) remains a cornerstone in pediatric surgery, concerns about its potential long-term effects on neurodevelopment, particularly in neonates and infants, have prompted increased interest in regional anesthesia as a safer alternative or complement [2]. Regional techniques, such as peripheral nerve blocks, neuraxial blocks, and truncal blocks, provide targeted analgesia with minimal systemic side effects, making them a valuable option in pediatric anesthetic practice [3].
Regional anesthesia offers several benefits beyond pain control [4,5]. By reducing the need for systemic anesthetics and opioids, regional blocks help minimize the risk of adverse effects such as respiratory depression, nausea, and sedation [6,7]. These benefits are particularly critical in medically fragile children and those with comorbid conditions where minimizing systemic drug exposure is essential [8]. Moreover, by attenuating the neuroendocrine and inflammatory stress responses to surgery, regional anesthesia contributes to more stable intraoperative and postoperative courses, improving overall outcomes [9].
In contrast, general anesthesia, while often necessary for complex procedures, carries certain risks, particularly in pediatric patients. Studies have raised concerns about the potential neurotoxic effects of GA on the developing brain, with animal models and clinical data suggesting links to cognitive and behavioral impairments [10]. Prolonged or repeated exposure to general anesthetic agents during critical periods of brain development may increase the risk of learning disabilities, attention deficits, and memory impairment [11]. These concerns have heightened the focus on alternative techniques, such as regional anesthesia, which can reduce overall exposure to general anesthetics [12].
Advances in ultrasound-guided techniques have further revolutionized the application of regional anesthesia in pediatric populations [13]. Real-time imaging enables precise localization of target nerves, reducing the risks of complications such as nerve injury or intravascular injection [14]. This technological innovation has significantly expanded the safety and efficacy of regional anesthesia, making it a preferred choice for various surgical procedures [15].
Despite these advantages, implementing regional anesthesia in children requires specialized expertise and careful consideration of anatomical and physiological differences compared to adults [16]. Children differ significantly from adults due to anatomical, physiological, and pharmacokinetic variations that impact the safety and efficacy of the regional anesthesia technique [3]. Pediatric nerve fibers are smaller and less myelinated, which allows for faster onset of nerve blockade but also increases sensitivity to local anesthetics, heightening the risk of toxicity [17]. The epidural space is smaller and more vascularized, and the thinner dura mater in children leads to faster diffusion of local anesthetics, requiring precise dosing and careful needle placement [18]. Additionally, children have a higher cardiac output and increased tissue vascularity, resulting in faster systemic absorption and distribution of local anesthetics [19]. This may reduce block duration while increasing the risk of systemic toxicity [17]. Immature liver enzymes and reduced plasma protein binding in neonates and infants prolong the metabolism and elimination of local anesthetics, further increasing the risk of drug accumulation [20]. The immature renal function also delays excretion, particularly for agents like bupivacaine and ropivacaine [21]. Effective dosing in children must be strictly weight-based, and ultrasound is highly beneficial for precise nerve localization and safe drug delivery [17]. Despite these challenges, regional anesthesia offers effective pain control in pediatric patients when applied with an understanding of these differences, ensuring both safety and efficacy [22]. Additionally, patient cooperation can be challenging, often requiring sedation or GA for block placement [23]. Nonetheless, with proper training and adherence to safety protocols, regional anesthesia can provide unparalleled benefits in pediatric surgical care [3].
This narrative review explores the advantages, techniques, medications, and potential risks of regional anesthesia in pediatric surgery. By providing an in-depth analysis of current evidence, we highlight regional anesthesia’s role in enhancing perioperative outcomes, reducing opioid dependence, and improving safety profiles. Furthermore, this review identifies areas for future research and advancements in pediatric regional anesthesia to optimize patient care. By highlighting recent advancements and clinical applications, this review underscores the potential of regional anesthesia as a cornerstone of modern pediatric anesthetic practice.

2. Methods

To enhance the reproducibility and transparency of this narrative review, we employed a structured approach in our literature search strategy. Although this is not a systematic review, we adhered to key elements of the PRISMA guidelines to ensure methodological rigor. The databases searched included PubMed, Scopus, and Web of Science, covering January 2015 to December 2024. The search terms used were “pediatric regional anesthesia”, “ultrasound-guided nerve blocks in children”, “local anesthetic toxicity in pediatrics”, “opioid-sparing techniques in pediatric surgery”, and “stress response in pediatric anesthesia”.
The inclusion criteria for studies were as follows:
  • Studies involving pediatric patients (0–18 years) undergoing surgery with regional anesthesia.
  • Articles in English report original research, reviews, or meta-analyses.
  • Publications focused on clinical outcomes, safety, and innovations in pediatric regional anesthesia.
The exclusion criteria were as follows:
  • Non-English publications.
  • Animal studies and experimental models unrelated to pediatric clinical practice.
  • Conference abstracts without complete data.

3. Results

A total of 142 articles were reviewed, of which 94 were included in the final analysis. These were selected based on relevance to the objectives of this review, as determined by title, abstract, and full-text evaluation. Any discrepancies in study selection were resolved through discussion among the authors. The findings were categorized into key thematic areas, including benefits of regional anesthesia, adjuvant use, specific block techniques, and risk management in pediatric populations.

4. Discussion

4.1. Comparing Regional Anesthesia with General Anesthesia

Various factors, including the type and duration of the surgical procedure, patient characteristics, and anesthesiologist expertise, influence the choice between regional and general anesthesia [12]. While both techniques have their roles in pediatric surgery, regional anesthesia offers several distinct advantages over general anesthesia:
  • Reduced Neurodevelopmental Risk: General anesthesia has been associated with potential neurotoxicity in pediatric patients, especially in neonates and infants [24]. Prolonged exposure to GA agents such as sevoflurane and isoflurane during critical periods of brain development has been linked to cognitive and behavioral impairments [2]. In contrast, regional anesthesia minimizes or eliminates the need for GA, reducing the risk of long-term neurodevelopmental consequences [25].
  • Superior Pain Management: Regional anesthesia provides targeted and prolonged pain relief, often surpassing the analgesic efficacy of systemic medications used with GA [13]. Techniques such as caudal epidural blocks and peripheral nerve blocks ensure adequate postoperative analgesia, reducing the reliance on opioids [23].
  • Faster Recovery: Patients receiving regional anesthesia often experience quicker recovery times than those under GA [26]. Regional anesthesia promotes earlier mobilization, feeding, and discharge [27,28] by avoiding deep sedation and minimizing systemic drug effects.
  • Improved Neurophysiological Monitoring: In surgeries requiring neurophysiological monitoring, such as scoliosis correction, regional anesthesia allows for lighter planes of sedation, preserving somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) [29,30]. General anesthesia, particularly with inhalational agents, can suppress these signals, complicating intraoperative monitoring [31].
  • Reduced Surgery Stress Response: General and regional anesthesia differ significantly in their impact on the surgical stress response [28]. General anesthesia primarily suppresses consciousness but does not entirely block nociceptive signaling, often leading to a systemic stress response characterized by elevated levels of cortisol and catecholamines [32]. In contrast, regional anesthesia directly interrupts nociceptive pathways at the surgery site, significantly reducing the release of stress hormones and inflammatory mediators [9]. This stress response attenuation results in more stable intraoperative hemodynamics and a lower risk of stress-related complications such as metabolic imbalances or immune suppression [33]. These effects are particularly advantageous in vulnerable populations, such as pediatric or critically ill patients, who benefit from a reduced physiological burden during surgery.
  • Reduced Systemic Side Effects: General anesthesia is associated with side effects such as nausea, vomiting, respiratory depression, and hemodynamic instability. Regional anesthesia reduces the risk of these complications, leading to smoother perioperative courses [34,35].
In summary, while general anesthesia remains indispensable for specific complex and lengthy procedures, regional anesthesia offers significant advantages in pain control, recovery, and neurodevelopmental safety. Combining regional and general anesthesia in a multimodal approach can optimize perioperative care, leveraging the strengths of both techniques.

4.2. Advantages of Regional Anesthesia

4.2.1. Superior Pain Control

Regional anesthesia relieves localized pain by interrupting nerve conduction at the surgery site. This targeted approach ensures adequate analgesia, often outperforming systemic analgesics in intensity and duration. Techniques such as caudal epidural blocks [36], transversus abdominis plane (TAP) blocks [37], Erector Spinae Plane Blocks (ESPB) [28,38], and peripheral nerve blocks [39] can provide hours of pain relief, reducing the need for rescue analgesics postoperatively.
In pediatric surgery, adequate pain control is essential for preventing the long-term consequences of poorly managed acute pain, such as the development of chronic pain syndromes and heightened pain sensitivity. Regional anesthesia’s ability to provide consistent and predictable analgesia helps mitigate these risks.

4.2.2. Reduction in Systemic Opioid Use

One of the significant advantages of regional anesthesia is its opioid-sparing effect [40]. By providing effective pain relief at the site of surgery, regional blocks reduce the reliance on systemic opioids, minimizing the risk of opioid-related side effects such as nausea, vomiting, respiratory depression, and ileus [41]. This is particularly beneficial in pediatric patients, where the adverse effects of opioids can be more pronounced and challenging to manage [42].
Reducing opioid use also addresses the global concern regarding opioid misuse and dependency, even in pediatric populations [43]. By incorporating regional techniques, the reliance on opioids for postoperative pain management is significantly reduced, promoting safer and more sustainable analgesic practices.

4.2.3. Decreased Anesthetic Requirements

Regional anesthesia can significantly reduce the doses of general anesthetics required during surgery [44]. When used as part of a balanced anesthetic approach, regional techniques allow for lighter planes of GA, preserving hemodynamic stability and minimizing the risk of intraoperative hypotension or bradycardia [45]. Regional anesthesia alone can sometimes suffice, avoiding the need for GA altogether [46].
This reduction in anesthetic requirements is significant in neonates and infants, where high doses of general anesthetics are associated with concerns about potential neurotoxicity and delayed neurodevelopmental outcomes. These risks can be mitigated by complementing or replacing GA with regional techniques.

4.2.4. Improved Recovery Profiles

Children receiving regional anesthesia often demonstrate faster recovery and shorter hospital stays [23]. The effective control of pain promotes earlier mobilization and reduces the incidence of postoperative complications such as agitation, delayed feeding, and prolonged sedation [47]. Enhanced recovery translates to higher patient and parental satisfaction [48].
Moreover, regional anesthesia facilitates day-case surgeries, allowing pediatric patients to return home sooner while maintaining effective pain control [49]. This contributes to cost savings for healthcare systems and minimizes the psychological stress of hospitalization for children and their families [50].

4.2.5. Reduced Stress Response

Surgical procedures elicit a systemic stress response characterized by the release of catecholamines, cortisol, and inflammatory mediators [51]. Regional anesthesia blunts this response by blocking afferent nociceptive pathways, reducing the neuroendocrine and inflammatory cascades [9]. This mainly benefits neonates and infants, where exaggerated stress responses can have significant physiological consequences [32].
Regional anesthesia also contributes to a more stable intraoperative and postoperative course by attenuating the stress response, reducing hemodynamic fluctuations and metabolic disturbance risks [52]. This is especially crucial in medically fragile or critically ill pediatric patients.

4.2.6. Safety and Precision with Ultrasound Guidance

The advent of ultrasound-guided regional anesthesia has revolutionized its application in pediatric populations [53]. Real-time imaging improves the accuracy of needle placement, reducing the risk of complications such as intravascular injection, nerve injury, or local anesthetic systemic toxicity (LAST). Ultrasound also allows for lower volumes of local anesthetic, which is critical in minimizing toxicity risks in minor patients [54].
The ability to visualize anatomical structures in real-time enhances clinician confidence and patient safety, making ultrasound-guided techniques a gold standard in pediatric regional anesthesia [15]. Training programs emphasizing ultrasound skills have further expanded the availability and adoption of these techniques.

4.3. Risks of Local Anesthetic Systemic Toxicity (LAST) and Prevention Strategies

LAST is a rare but potentially life-threatening complication of regional anesthesia, particularly in pediatric patients who are more vulnerable due to their smaller size and lower physiological reserves [55]. LAST results from excessive plasma levels of local anesthetics, which can lead to central nervous system and cardiovascular toxicity, manifesting as seizures, arrhythmias, or even cardiac arrest [56].
Careful attention must be paid to dosing calculations based on weight and age to minimize the risk of LAST [57]. Using ultrasound guidance improves the precision of local anesthetic delivery, reducing the likelihood of intravascular injection [58]. Additionally, adherence to recommended maximum doses and using lipid emulsions as an antidote in case of LAST are essential safety measures. Continuous monitoring during and after block placement is critical to detect early signs of toxicity and intervene promptly [59].

4.4. Adjuvants to Local Anesthetics in Pediatrics

Adjuvants are commonly added to local anesthetics to enhance the efficacy and duration of regional blocks while minimizing the total dose of local anesthetic required [60]. In pediatric anesthesia, agents such as clonidine, dexmedetomidine, and dexamethasone are frequently used as adjuvants.
  • Clonidine: An alpha-2 adrenergic agonist, clonidine prolongs the duration of analgesia by enhancing the nerve-blocking effects of local anesthetics [61]. Additionally, it has sedative properties, which may benefit pediatric patients requiring prolonged postoperative comfort [62]. However, clonidine can cause side effects such as hypotension, bradycardia, and sedation, which need careful monitoring, especially in younger children or those with hemodynamic instability [63].
  • Dexmedetomidine: Another alpha-2 adrenergic agonist, dexmedetomidine provides sedative and analgesic properties without significant respiratory depression [64]. It is particularly beneficial in caudal and peripheral blocks, extending the duration of analgesia [65]. Side effects of dexmedetomidine include bradycardia and transient hypotension [64]. Still, these are generally well-tolerated and manageable.
  • Dexamethasone: A corticosteroid, dexamethasone is widely used to prolong the duration of nerve blocks by reducing local inflammation and sensitization of nociceptors [66]. Its use is associated with significantly longer analgesia duration and improved postoperative comfort [67]. While systemic side effects such as hyperglycemia and immunosuppression are potential concerns with higher doses or prolonged use, they are rarely significant at the doses used for regional anesthesia [68].
In addition to these commonly used adjuvants, other agents have been explored but are less frequently employed due to limited efficacy or a higher risk of adverse effects:
  • Epinephrine: While epinephrine has historically been used to prolong block duration by causing vasoconstriction and reducing systemic absorption of local anesthetics, its utility in pediatric anesthesia is limited due to potential cardiovascular effects such as tachycardia, hypertension, and arrhythmias [69]. The risk-to-benefit ratio makes it less favorable than newer agents like dexmedetomidine or dexamethasone. Moreover, epinephrine only slightly prolongs the duration of action of local anesthetics [70].
  • Midazolam: Midazolam has been investigated as an adjuvant for its anxiolytic and sedative effects [69]. However, its impact on the duration of analgesia is inconsistent, and its potential for respiratory depression limits its use in pediatric regional anesthesia [71].
  • Magnesium Sulfate: Magnesium sulfate has shown promise in prolonging nerve block duration and reducing postoperative pain in adult populations [72]. However, its use in children remains limited due to insufficient data on safety and efficacy, as well as concerns about potential neurotoxicity [73].
  • Ketamine: Ketamine, an NMDA receptor antagonist, has been used as an adjuvant in regional anesthesia for its analgesic and anti-inflammatory effects [74]. While it can enhance block efficacy, concerns about neurotoxicity in younger children and the potential for psychomimetic side effects restrict its routine use [75].
By using adjuvants like clonidine, dexmedetomidine, and dexamethasone, clinicians can improve block performance and reduce the total required dose of local anesthetic, enhancing safety profiles, particularly in pediatric patients with limited physiological tolerance [76]. However, the choice of adjuvant must be tailored to the individual patient, considering the specific surgical procedure, the child’s health status, and the risk of side effects. Future research must explore new adjuvants with improved efficacy and safety profiles tailored to the pediatric population.

4.5. Dosages of Medications in Pediatric Regional Anesthesia

Providing accurate and weight-based dosages is crucial in pediatric regional anesthesia to ensure efficacy while minimizing the risk of toxicity. Medications commonly used in regional anesthesia include local anesthetics (bupivacaine, ropivacaine), alpha-2 adrenergic agonists (dexmedetomidine, clonidine), and corticosteroids (dexamethasone) as adjuvants to prolong analgesia duration and enhance block effectiveness. Dosages must account for the child’s age, weight, and specific surgical requirements. Local anesthetics are typically administered as a function of body weight to prevent systemic toxicity, while adjuvants are dosed to optimize block duration without significant side effects. Below is a table summarizing the most commonly used medications, their typical dosage ranges, and regions of application in pediatric regional anesthesia (Table 1).
This section and table aim to provide clinicians with a quick reference guide for dosing medications safely and effectively in pediatric regional anesthesia. Further research into optimal dosing strategies and potential new adjuvants is needed to refine these recommendations further.

4.6. Complications Related to Improper Aspiration During Injection

One of the most critical steps during regional or local anesthetic administration is proper aspiration before injecting the anesthetic agent. Failure to aspirate can lead to serious complications if the anesthetic is inadvertently administered into a blood vessel [77]. In the case of intra-arterial injection, mainly when the anesthetic solution contains adrenaline, the resultant vasoconstriction can lead to localized ischemia and tissue necrosis [78]. This occurs due to adrenaline’s potent vasoconstrictive properties, which reduce blood flow and oxygen supply to the affected tissues [3].
Additionally, intravenous injection of local anesthetics poses significant systemic risks, including arrhythmia and other severe cardiac complications. This is particularly dangerous in pediatric patients, as their more minor cardiovascular system makes them more vulnerable to even small doses of anesthetic agents entering the systemic circulation [79]. Proper technique, including slow injection with frequent aspiration, is essential to prevent these potentially life-threatening complications. Awareness and adherence to these procedural safeguards are critical in pediatric anesthesia to ensure safety and efficacy.

4.7. Methemoglobinemia Due to Prilocaine in Newborns

Methemoglobinemia is a rare but serious complication associated with prilocaine use in newborns. This condition occurs when hemoglobin is oxidized to methemoglobin, which cannot effectively carry oxygen. Newborns are particularly at risk due to immature enzyme systems that are less efficient at reducing methemoglobin back to hemoglobin [80].
The primary clinical sign is cyanosis unresponsive to oxygen therapy, often accompanied by tachypnea, irritability, and decreased oxygen saturation despite adequate ventilation. Diagnosis is confirmed by measuring methemoglobin levels, with levels above 10% causing visible cyanosis and levels over 20% leading to significant symptoms [81].
The standard treatment is intravenous methylene blue at a dose of 1–2 mg/kg, which rapidly converts methemoglobin back to functional hemoglobin. In cases where methylene blue is contraindicated, supportive care and alternative therapies may be used [82].
To prevent methemoglobinemia, prilocaine should be avoided in newborns, especially preterm infants. Safer alternatives such as lidocaine or bupivacaine are recommended, with strict adherence to weight-based dosing and careful monitoring during administration [83].

4.8. Common Regional Anesthesia Techniques in Pediatric Surgery

Regional anesthesia in pediatric patients extends beyond the commonly performed caudal epidural block. Advanced ultrasound technology has enabled the safe and precise application of various regional techniques, broadening the scope of pediatric regional anesthesia and enhancing perioperative care [15]. These techniques now encompass a wide range of blocks that address the diverse needs of pediatric surgical procedures.

4.8.1. Infiltration Anesthesia

Infiltration anesthesia is a commonly used technique in pediatric anesthesia for providing localized analgesia during minor surgical procedures or as an adjunct to regional blocks [84]. This method involves injecting a local anesthetic into the subcutaneous tissue to desensitize the skin and surrounding structures [85]. The goal of infiltration anesthesia is to block the peripheral nerve endings at the intervention site, resulting in adequate pain control with minimal systemic absorption of the anesthetic agent.
The procedure begins with identifying the area where local anesthesia is required. A fine-gauge needle (commonly 25–27 G) minimizes patient discomfort during needle insertion. The needle is inserted at an angle of approximately 30–45 degrees to the skin, and small aliquots of the anesthetic solution are injected as the needle is advanced through the tissue. The injection should be performed slowly, with frequent aspiration to ensure that the needle tip is not within a blood vessel, thereby reducing the risk of intravascular administration and systemic toxicity [86].
The anesthetic is injected incrementally in a fan-like pattern, ensuring even distribution throughout the targeted area. Care is taken to avoid excessive pressure during injection, which may cause tissue distortion and increase discomfort. Multiple injections may be necessary when a large area requires desensitization, with overlapping infiltration fields, to ensure complete coverage [87].
In pediatric anesthesia, the choice of anesthetic agent and its concentration depends on the patient’s age, weight, and the duration of the procedure [88]. The following local anesthetic agents are frequently used for infiltration anesthesia [23,57,89]:
  • Lidocaine
    • Concentration: 0.5–1%.
    • Dose: 3–5 mg/kg (maximum dose without epinephrine: 5 mg/kg).
    • Onset: Rapid (1–2 min).
    • Duration: Short (30–60 min).
  • Bupivacaine
    • Concentration: 0.125–0.25%.
    • Dose: 1–2 mg/kg (maximum dose without epinephrine: 2.5 mg/kg).
    • Onset: Slower than lidocaine (5–10 min).
    • Duration: Longer (2–4 h).
  • Ropivacaine
    • Concentration: 0.2%.
    • Dose: 2–3 mg/kg (maximum dose: 3 mg/kg).
    • Onset: Intermediate (5–10 min).
    • Duration: Long (2–6 h).
Infiltration anesthesia is widely used for a variety of pediatric procedures, including skin laceration repairs, venous cannulation, minor soft tissue surgeries, and as an adjunct for postoperative pain control after more invasive interventions [46]. Its simplicity, rapid onset, and minimal systemic side effects make it an essential tool in pediatric anesthetic practice. However, given the potential for systemic toxicity in children due to lower body weight and reduced metabolic clearance, strict adherence to weight-based dosing and proper injection technique is crucial.

4.8.2. Caudal Epidural Block

Caudal epidural blocks remain one of the most widely used regional anesthesia techniques in pediatric patients, particularly for lower abdominal, pelvic, and lower limb surgeries [90]. This block provides reliable analgesia with minimal systemic effects. When combined with additives like clonidine or dexmedetomidine, the duration of analgesia can be significantly prolonged [91,92]. Caudal blocks are particularly advantageous for procedures such as inguinal hernia repair, circumcision, and hypospadias surgery, where they provide excellent postoperative pain relief and reduce the need for additional analgesics [93]. Despite its popularity, the caudal block is just the starting point for modern pediatric regional anesthesia.

4.8.3. Peripheral Nerve Blocks

Peripheral nerve blocks have transformed pediatric anesthesia by providing highly targeted analgesia tailored to specific surgical sites [79]. The femoral, brachial plexus, and sciatic nerve blocks are invaluable for extremity surgeries. For upper limb procedures, brachial plexus blocks can eliminate the need for general anesthesia in select cases, reducing systemic drug exposure and promoting faster recovery. Similarly, femoral and sciatic blocks in lower limb surgeries [39]. The Pericapsular Nerve Group (PENG) Block for hip procedures, iPACK block, and Adductor Canal Block [27] for knee surgeries offer effective pain control, improve postoperative comfort, and facilitate early mobilization [35,94]. The precision afforded by ultrasound guidance has been instrumental in making these blocks safer and more effective, even in neonates and infants [95].

4.8.4. Truncal Blocks

Truncal blocks, including the transversus abdominis plane (TAP) block and the erector spinae plane (ESP) block, significantly expand regional anesthesia options in pediatric patients [96]. These blocks are particularly beneficial for abdominal and thoracic surgeries, providing adequate analgesia with minimal motor blockade [97]. The ability to spare motor function is critical in pediatric patients, as it allows early mobilization and minimizes the impact on functional recovery [98]. TAP blocks are frequently employed in laparoscopic surgeries, significantly reducing postoperative pain and facilitating early discharge [99]. Similarly, ESP blocks are gaining recognition for their ability to provide broad, reliable analgesia for thoracic and abdominal procedures with minimal risk of complications [31]. These blocks are also versatile, often used for managing pain in complex reconstructive surgeries or extensive trauma cases.

4.8.5. Neuraxial Anesthesia

Spinal anesthesia is experiencing a resurgence in neonatal and infant surgeries, particularly for lower body procedures. It offers a reliable alternative to general anesthesia, avoiding risks such as apnea in high-risk neonates [100]. Spinal anesthesia has been successfully used in preterm and ex-premature infants undergoing procedures such as inguinal hernia repair, providing excellent analgesia and eliminating the respiratory complications often associated with general anesthesia in this vulnerable population [101]. Advances in needle technology and a better understanding of pediatric anatomy have further enhanced the safety and reliability of this technique [23].

4.9. Expanding Possibilities with Ultrasound Guidance

The introduction of ultrasound guidance has been transformative in pediatric regional anesthesia, enabling the safe and practical application of novel blocks previously limited to adult practice [102]. Techniques such as quadratus lumborum blocks, pectoral nerve (PECS) blocks, and serratus anterior blocks are now being explored in children for thoracic, abdominal, and breast surgeries [15]. These techniques offer excellent analgesia with minimal systemic effects, supporting faster recovery and minimizing opioid use [103]. The ability of these blocks to spare motor function is particularly valuable, as it allows pediatric patients to maintain mobility and independence postoperatively, reducing hospital stays and enhancing rehabilitation outcomes [3]. Quadratus lumborum blocks, for instance, provide profound abdominal analgesia for major abdominal surgeries [104]. In contrast, PECS [105] and serratus anterior blocks are increasingly used for thoracic and upper abdominal surgeries, including thoracotomies [15].

4.10. Beyond Pain Management

The growing application of regional anesthesia in pediatric practice is not limited to pain control. These techniques also contribute to better intraoperative stability by reducing stress responses and minimizing the need for volatile anesthetics [9]. This can improve neurophysiological monitoring during surgeries, such as scoliosis correction, and enhance surgical outcomes [31]. Moreover, by reducing the reliance on opioids and systemic anesthetics, regional anesthesia plays a critical role in addressing broader concerns about opioid dependency and long-term neurodevelopmental risks in children [42].
The modern approach to pediatric regional anesthesia, fueled by advancements in ultrasound technology and a deeper understanding of pediatric anatomy and pharmacology, has expanded the scope of what is possible [15]. Far beyond the caudal epidural block, these techniques provide tailored, adequate analgesia for various procedures, ensuring better outcomes and higher satisfaction for patients and their families [102]. The growing emphasis on motor-sparing blocks ensures that children recover faster, maintain functional mobility, and experience fewer complications, setting a new standard for perioperative care in pediatric surgery [106].

4.11. Limitations and Future Directions

4.11.1. Limitations

As a narrative review, this study provides a comprehensive summary of the available evidence on the role of regional anesthesia in pediatric surgery. However, several inherent limitations must be acknowledged. Unlike systematic reviews, narrative reviews do not follow a rigid protocol for study selection and data extraction, which may introduce bias in selecting and interpreting studies. The lack of predefined inclusion and exclusion criteria can lead to overrepresentation or underrepresentation of specific findings based on the authors’ discretion. Additionally, the absence of a formal quality assessment of included studies means that the methodological variability of the cited literature may influence the findings presented in this review. Another limitation is the potential publication bias, where positive outcomes are more likely to be reported and published than negative or inconclusive results. This bias may skew the perception of the effectiveness and safety of regional anesthesia in pediatric populations. Moreover, the variability in reporting dosages, techniques, and outcomes across different studies complicates synthesizing standardized recommendations.

4.11.2. Future Directions

Future research should focus on conducting high-quality, multicenter randomized controlled trials (RCTs) to evaluate the long-term outcomes of regional anesthesia in pediatric patients. Key research priorities include the following:
  • Comparative Efficacy Studies: Trials comparing different regional anesthesia techniques with general anesthesia or combined approaches in terms of perioperative pain control, recovery time, and safety.
  • Long-Term Neurodevelopmental Outcomes: Studies evaluating the impact of regional anesthesia on neurodevelopment, particularly in neonates and infants, given concerns about the potential neurotoxicity of general anesthesia.
  • Optimal Dosing of Local Anesthetics and Adjuvants: Further research on the optimal dosages of commonly used local anesthetics and adjuvants, particularly in younger children, to minimize toxicity while ensuring effective analgesia.
  • Cost-Effectiveness Analyses: Economic evaluations comparing regional anesthesia versus general anesthesia in pediatric surgery to determine its broader impact on healthcare costs and resource utilization.
  • Innovations in Technology: Studies exploring the role of emerging technologies, such as artificial intelligence-guided ultrasound or novel nerve block techniques, in enhancing the precision and safety of regional anesthesia.
By addressing these research gaps, future studies can provide stronger evidence to guide clinical practice, improve patient outcomes, and further refine the role of regional anesthesia in pediatric surgery.

5. Conclusions

Regional anesthesia offers numerous advantages in pediatric surgery, ranging from superior pain control and opioid-sparing effects to enhanced recovery profiles and reduced systemic stress responses. The integration of ultrasound-guided techniques has further expanded its safety and efficacy, making regional blocks a cornerstone of modern pediatric perioperative care. With ongoing research and technological advancements, regional anesthesia will continue to play a pivotal role in optimizing outcomes for pediatric surgical patients.

Author Contributions

Conceptualization, M.R., K.W.-T. and T.R.; methodology, M.R. and T.R.; software, P.D. and A.M.; validation, M.R., K.W.-T. and A.M.; formal analysis, T.R., G.K. and P.D.; investigation, M.R., G.K. and T.R.; resources, G.K.; data curation T.R. and K.W.-T.; writing—original draft preparation, T.R.; writing—review and editing, M.R., K.W.-T. and T.R.; visualization, K.W.-T.; supervision, K.W.-T.; project administration, M.R., K.W.-T. and G.K.; funding acquisition, T.R. and M.R. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The author reports no conflicts of interest in this work.

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Table 1. Summary of medications, recommended dosages, and regions of application.
Table 1. Summary of medications, recommended dosages, and regions of application.
MedicationDosage Range *Region of ApplicationNotes on Use
Bupivacaine1.5–2.5 mg/kgPeripheral nerve blocks, caudal blocksProlonged duration of action, risk of cardiotoxicity at higher doses
Ropivacaine2.0–3.0 mg/kgPeripheral nerve blocks, epidural blocksPreferred for reduced cardiotoxicity compared to bupivacaine
Dexmedetomidine0.5–1.0 µg/kg as an adjuvantCaudal, peripheral, neuraxial blocksEnhances duration of analgesia, can cause transient bradycardia or hypotension
Clonidine1–2 µg/kg as an adjuvantCaudal, epidural, peripheral nerve blocksProlongs block duration, provides sedation, risk of hypotension and bradycardia
Dexamethasone0.1–0.2 mg/kg (up to 10 mg) as an adjuvantPeripheral nerve blocksAnti-inflammatory, prolongs duration of analgesia, minimal systemic side effects at low doses
* Dosages are expressed per kg of body weight. Constantly adjust based on clinical judgment and patient-specific factors.
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MDPI and ACS Style

Reysner, T.; Wieczorowska-Tobis, K.; Mularski, A.; Kowalski, G.; Daroszewski, P.; Reysner, M. Revolutionizing Pediatric Surgery: The Transformative Role of Regional Anesthesia—A Narrative Review. Surgeries 2025, 6, 9. https://doi.org/10.3390/surgeries6010009

AMA Style

Reysner T, Wieczorowska-Tobis K, Mularski A, Kowalski G, Daroszewski P, Reysner M. Revolutionizing Pediatric Surgery: The Transformative Role of Regional Anesthesia—A Narrative Review. Surgeries. 2025; 6(1):9. https://doi.org/10.3390/surgeries6010009

Chicago/Turabian Style

Reysner, Tomasz, Katarzyna Wieczorowska-Tobis, Aleksander Mularski, Grzegorz Kowalski, Przemyslaw Daroszewski, and Malgorzata Reysner. 2025. "Revolutionizing Pediatric Surgery: The Transformative Role of Regional Anesthesia—A Narrative Review" Surgeries 6, no. 1: 9. https://doi.org/10.3390/surgeries6010009

APA Style

Reysner, T., Wieczorowska-Tobis, K., Mularski, A., Kowalski, G., Daroszewski, P., & Reysner, M. (2025). Revolutionizing Pediatric Surgery: The Transformative Role of Regional Anesthesia—A Narrative Review. Surgeries, 6(1), 9. https://doi.org/10.3390/surgeries6010009

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