Ultrasound‑Guided Brachial Plexus Block for Pediatric Elbow Reconstruction

Block Selection and Technique

The American Society of Anesthesiologists (ASA) recommends performing an ultrasound‑guided costoclavicular or infraclavicular brachial plexus block for healthy adolescents undergoing elbow reconstruction, using ropivacaine 0.5–1.5 mg·kg⁻¹ (maximum 2.5 mg·kg⁻¹) and optionally adding dexmedetomidine 1–2 µg·kg⁻¹ to prolong postoperative analgesia. 1
Ultrasound guidance is considered the gold standard for pediatric regional anesthesia because it provides direct visualization of nerves and surrounding structures, thereby minimizing the risk of vascular or pleural injury despite the overall low baseline complication rate (0–0.4 per 10 000 procedures). 1

The ASA and European Society of Regional Anaesthesia jointly state that ropivacaine 0.5–1.5 mg·kg⁻¹ is the preferred concentration for peripheral nerve blocks in children, supported by evidence level B2. 1
The maximum safe single‑dose limit for ropivacaine in pediatric patients is 2.5 mg·kg⁻¹ to reduce the risk of systemic toxicity. 1
Ropivacaine is preferred over bupivacaine because it produces less systemic toxicity and a lower degree of motor blockade, which facilitates early postoperative mobilization. 8
Pharmacokinetic data indicate that adolescents older than 10 years have a ropivacaine clearance of approximately 0.55 L·h⁻¹·kg⁻¹ and a terminal half‑life of about 3.3 h, comparable to adult values; therefore, dose reduction is not required in this age group. 2

The ASA guideline (evidence level A2) recommends adding dexmedetomidine 1–2 µg·kg⁻¹ to the local anesthetic solution to extend block duration without increasing the risk of respiratory depression. 1

Complete circumferential spread of local anesthetic around the brachial plexus cords is not required for an effective block when precise peri‑epineural injection is performed under ultrasound guidance. 2

When planning a peripheral nerve block, clinicians must optimize both the concentration (e.g., 0.5 % ropivacaine) and the injected volume independently; low volume should not be compensated by increasing concentration, nor vice‑versa, to ensure adequate sensory blockade while avoiding toxicity. 6

LAST occurs in approximately 8 per 100 000 pediatric regional anesthetic procedures and may present with loss of consciousness, seizures, bradycardia, or asystole. 9
Immediate availability of 20 % intralipid emulsion is required; the recommended initial treatment is a 1.5 mL·kg⁻¹ IV bolus followed by an infusion of 0.25 mL·kg⁻¹·min⁻¹ if LAST is suspected. 9

Bupivacaine should not be used in place of ropivacaine for brachial plexus blocks in adolescent athletes because ropivacaine’s superior safety profile reduces the likelihood of systemic toxicity and excessive motor block, which could impair postoperative rehabilitation. 8

Even in larger adolescents, the total ropivacaine dose must not exceed 2.5 mg·kg⁻¹, as the highly vascular nature of the brachial plexus region increases systemic absorption risk. 1