Some open questions in pediatric regional anesthesia.

The aim of the paper is to review the literature concerning 4 unanswered or debatable questions concerning the practice of regional anesthesia in pediatric patients. The published material concerning the 4 selected topics is reviewed, namely importance of ropivacaine, preoperative coagulation screening tests, hemodynamic stability following neuraxial blocks and prevention/treatment of post-dural puncture headache. Of the 4 questions considered in this article, 3 can be reasonably answered in a consensual way. Ropivacaine has limitations for single shot procedures in infants but its advantages for continuous infusions are significant in comparison with those of bupivacaine. Preoperative coagulation screening tests are not necessary, even not useful in children when clinical history is not suggestive of coagulation disorders, with the notable exception of neonates and prematurely born infants less than 45 weeks of post-conceptual age. The long established hemodynamic stability following neuraxial blocks results from well equilibrated compensatory mechanisms which may not be functional in children with preoperative hemodynamic instability or anomalies of the regional blood flow distribution. Finally, even though the post-dural puncture headache is not frequent in children, its management still remains difficult and no definitive recommendation can be currently made in case of inadvertent dural puncture during an attempted epidural anesthesia in children.