Scalp nerve blocks for external ventricular drainage placement in children

External ventricular drainage (EVD) placement is usually performed in the operating room under general anesthesia with endotracheal intubation in pediatric patients with elevated intracranial pressure. Scalp nerve blocks (SNB) with sedation can avoid the safety concerns and complications associated with general anesthesia, such as airway and hemodynamic imbalance. Moreover, SNB can offer a reduced analgesic need when compared with incision-site infiltration. This prospective observational study aimed to compare perioperative outcomes between SNB with sedation and general anesthesia with incision-site infiltration for EVD placement in pediatric patients. Data from 63 EVD placement procedures performed in children under 8 years of age either under sedation with SNB ( n = 29) or under general anesthesia with incision-site infiltration ( n = 34) were analyzed. Outcomes included need for postoperative analgesics, total analgesic consumption in the first 24 h postoperatively, heart rate response to surgical incision, and the requirement for conversion to general anesthesia. Compared with incision-site infiltration, the incidence of heart rate response to surgical stimulus was significantly lower in patients with SNB (3.4% vs. 73.5%, p < 0.001). Postoperative analgesic requirement and total analgesic consumption within the first 24 h were also lower in the SNB group (both p < 0.001), with an absolute risk reduction of 47.4%. Compared with patients receiving SNB, those receiving incision-site infiltration had higher odds of postoperative analgesic requirement (OR 8.6, 95% CI 3.2–25.0, p < 0.001); however, this association was attenuated after adjustment for intraoperative fentanyl (OR 2.4, 95% CI 0.2–33.3, p = 0.49). No procedures required conversion to general anesthesia. SNB combined with sedation may represent a feasible alternative to general anesthesia for pediatric EVD placement. Lower rates of nociceptive responses and postoperative analgesic requirements, as well as lower intraoperative opioid use, were observed in patients receiving SNB, while spontaneous ventilation was preserved throughout the procedure.