Regional anaesthesia for awake children: a reply

Abstract

We thank Dr Mao and Dr Fu for their interest in our article [1] and for their thoughtful and constructive comments [2]. We are pleased to respond to the points they raised.

Although the hypothesis regarding sex-based differences in psychological maturity is reasonable, we did not observe any difference in success rates between boys and girls in our cohort. In the youngest 6-year-old subgroup, 10/15 boys and 2/3 girls underwent awake surgery with regional anaesthesia successfully, corresponding to identical success rates of 67%. However, our study was not powered nor designed to assess sex as an influencing factor specifically. Further research is needed to explore such factors and should also consider that boys are affected more frequently by upper limb trauma at school age [3].

We would also like to clarify that our sample size was calculated based on an anticipated 80% success rate in the 6–12 y age group, not to enable subgroup comparisons. Given the non-comparative design of the study, our sample size was determined to allow sufficiently narrow confidence intervals for interpreting the overall feasibility with acceptable statistical precision. This approach aligns with standard practice for cohort prospective observational studies.

We confirm that the anaesthetic skin patches were placed at the intended sites for venous access and regional anaesthesia by the anaesthetist performing the procedure during the pre-operative consultation. This allowed precise anticipation of the puncture sites based on anatomical landmarks and planned technique (e.g. axillary, forearm or supraclavicular block). The only scenario where patch placement might have been more challenging is in the case of digital blocks. However, in our study, the only digital block was performed under general anaesthesia in the one patient who received general anaesthesia and was thus not subject to this limitation.

We agree that long-term neurocognitive and behavioural outcomes after anaesthesia exposure remain an area of active research. However, the primary aim of our 2-week follow-up using the post-hospitalisation behaviour questionnaire (PHBQ) was not to assess neurodevelopmental changes but to identify signs of emotional or behavioural distress that might reflect a negative peri-operative experience. The PHBQ is a validated tool in paediatric anaesthesia and has been used widely to screen for short-term behavioural disturbances in children [4-6]. We felt that this timeframe was relevant to assess whether our awake regional anaesthesia protocol had been well tolerated from the child's perspective.

We appreciate the opportunity to clarify these points and thank the authors for their engagement with our work.