Regional anaesthesia for awake children

We read with great interest the study by Maupain et al. [1], which investigated the feasibility of awake regional anaesthesia for urgent upper limb surgery in children aged 6–12 y. The conclusions concur with our experience at a regional tertiary centre specialising in paediatric care where we perform many such urgent procedures, almost invariably under general anaesthesia. The potential impact of general anaesthesia on the developing nervous system [2] and on children's psychological wellbeing and cognitive or behavioural trajectories remains a matter of concern. We appreciate the authors proposing alternative techniques for these operations and would like clarification on several points.

The authors report that there were no significant differences between those patients who received regional anaesthesia alone in terms of female sex (35 vs. 5, p = 0.228). However, it is well recognised that, in childhood, girls typically achieve certain psychological and developmental milestones 1–2 years earlier than boys. In the youngest age stratum, specifically 6-year-olds, the success rate of awake regional anaesthesia was only 12/18 (≈ 67%), substantially below the 80% assumed for sample-size calculation. It follows that 6-year-old boys might have an even lower success rate, yet no sex- or age-specific data are provided. Without these subgroup data, it is difficult to accept the general conclusion that awake regional anaesthesia is uniformly feasible across both sexes and the full 6–12 y age range.

The Methods state that anaesthetic skin patches were applied to the intended venous access and peripheral regional anaesthesia sites at least 2 h before surgery. Yet, in practice, the block types included axillary, forearm/wrist, supraclavicular and digital approaches, each with a distinct puncture site, and the chosen vein for cannulation may vary with individual anatomy and clinician preference. How did the authors ensure that the patches were positioned reliably over the correct sites for both venous access and nerve block?

The potential neurocognitive and psychological effects of surgery and anaesthesia in children may emerge only after months or years [2]. In this study, behavioural changes were assessed using the post-hospitalisation behaviour questionnaire at 2 weeks only, which may be insufficient to capture medium- or long-term alterations in cognition or behaviour.