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Paediatric caudal anaesthesia: Difference between revisions
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[[File:Wfsahq-logo.png|200px|thumb|right]] | [[File:Wfsahq-logo.png|200px|thumb|right]] | ||
''Originally from Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia'' | ''Originally from Update in Anaesthesia | www.wfsahq.org/resources/update-in-anaesthesia'' | ||
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=== Puncture (Figures 3, 4 and 5) === | === Puncture (Figures 3, 4 and 5) === | ||
[[File:Bony landmarks.jpg|thumb|'''Figure 3.''' Bony landmarks]] | [[File:Bony landmarks.jpg|thumb|'''Figure 3.''' Bony landmarks|alt=|left]] | ||
After defining the bony landmarks of the sacral triangle, the two sacral cornuae are identified by moving your fingertips from side to side. The gluteal cleft is not a reliable mark of the midline. The puncture is performed between the two sacral cornuae. The needle is oriented 60° in relation to back plane, 90° to skin surface. The needle bevel is oriented ventrally, or parallel to the fibers of the sacro-coccygeal ligament. | After defining the bony landmarks of the sacral triangle, the two sacral cornuae are identified by moving your fingertips from side to side. The gluteal cleft is not a reliable mark of the midline. The puncture is performed between the two sacral cornuae. The needle is oriented 60° in relation to back plane, 90° to skin surface. The needle bevel is oriented ventrally, or parallel to the fibers of the sacro-coccygeal ligament. | ||
[[File:Puncture - orientation of the needle and reorientation after.jpg|thumb|'''Figure 4.''' Puncture - orientation of the needle and reorientation after crossing the sacro-coccygeal ligament]] | [[File:Puncture - orientation of the needle and reorientation after.jpg|thumb|'''Figure 4.''' Puncture - orientation of the needle and reorientation after crossing the sacro-coccygeal ligament]] | ||
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The distance between the skin and sacro-coccygeal ligament is between 5 and 15mm, depending on the child’s size. The sacrococcygeal ligament gives a perceptible ‘pop’ when crossed, analogous to the ligamentum flavum during lumbar epidural anaesthesia. After crossing the sacro-coccygeal ligament, the needle is redirected 30° to the skin surface, and then advanced a few millimeters into sacral canal. If in contact with the bony ventral wall of sacral canal, the needle must be moved back slightly. | The distance between the skin and sacro-coccygeal ligament is between 5 and 15mm, depending on the child’s size. The sacrococcygeal ligament gives a perceptible ‘pop’ when crossed, analogous to the ligamentum flavum during lumbar epidural anaesthesia. After crossing the sacro-coccygeal ligament, the needle is redirected 30° to the skin surface, and then advanced a few millimeters into sacral canal. If in contact with the bony ventral wall of sacral canal, the needle must be moved back slightly. | ||
[[File:Orientation of the needle during puncture.jpg|thumb|'''Figure 5'''. Orientation of the needle during puncture]] | [[File:Orientation of the needle during puncture.jpg|thumb|'''Figure 5'''. Orientation of the needle during puncture|alt=|left]] | ||
[[File:Needle misplacement.jpg|thumb|'''Figure 6A and B.''' Needle misplacement ('''A''' marrow (resistance +++. Equivalent to IV injection), '''B''' posterior sacral ligament (subcutaneous bulge), '''C''' subperiostal, '''D''' “decoy” hiatus, '''E''' intrapelvic (risk of damaging intrapelvic structures: rectum), '''F''' 4th sacral foramen (unilateral block)).]] | [[File:Needle misplacement.jpg|thumb|'''Figure 6A and B.''' Needle misplacement ('''A''' marrow (resistance +++. Equivalent to IV injection), '''B''' posterior sacral ligament (subcutaneous bulge), '''C''' subperiostal, '''D''' “decoy” hiatus, '''E''' intrapelvic (risk of damaging intrapelvic structures: rectum), '''F''' 4th sacral foramen (unilateral block)).]] | ||
After verifying absence of spontaneous reflux of blood or cerebrospinal fluid (more sensitive than an aspiration test), injection of LA should be possible be without resistance. Inject slowly (over about one minute). Where available this may be preceded with an epinephrine test dose under ECG and blood pressure monitoring, in order to detect intravascular placement. Subcutaneous bulging at the injection site suggests needle misplacement. Blood reflux necessitates repeating the puncture, however in case of cerebrospinal fluid reflux caudal anaesthesia should be abandoned, in order to avoid the risk of extensive spinal anaesthesia. Aspiration tests should be repeated several times during injection.[[File:US of sacro-coccygeal space.jpg|thumb|'''Figure 7.''' Ultrasound of sacro-coccygeal space]] | |||
After verifying absence of spontaneous reflux of blood or cerebrospinal fluid (more sensitive than an aspiration test), injection of LA should be possible be without resistance. Inject slowly (over about one minute). Where available this may be preceded with an epinephrine test dose under ECG and blood pressure monitoring, in order to detect intravascular placement. Subcutaneous bulging at the injection site suggests needle misplacement. Blood reflux necessitates repeating the puncture, however in case of cerebrospinal fluid reflux caudal anaesthesia should be abandoned, in order to avoid the risk of extensive spinal anaesthesia. Aspiration tests should be repeated several times during injection. | |||
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=== Catheter insertion === | === Catheter insertion === | ||
Although CA was initially described as a single shot technique, some authors have described use of a caudal catheter to prolong analgesic administration in postoperative period. In addition advancement of the catheter in the epidural space up to lumbar or even thoracic levels can achieve analgesia of high abdominal or thoracic areas.<ref>Tsui BC, Berde CB. Caudal analgesia and anesthesia techniques in children. Curr Op Anesthesiol 2005; 18: 283-8.</ref> However, two pitfalls restrict extension of this technique; a high risk of catheter bacterial colonization, particularly in infants and a high risk of catheter misplacement.<ref>Kost-Byerly S, Tobin JR, Greenberg RS, Billett C, Zahurak M, Yaster M. Bacterial colonisation and infectious rate of continuous epidural catheters in children. Anesth Analg 1998; 86: 712-6</ref>,<ref>Valairucha S, Seefelder D, Houck CS. Thoracic epidural catheters placed by the caudal route in infants: the importance of radiographic confirmation. Paediatr Anaesth 2002; 12: 424-8.</ref> Subcutaneous tunnelling at a distance from the anal orifice, or occlusive dressings decrease bacterial colonization.<ref>Bubeck J, Boss K, Krause H, Thies KC. Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters. Anesth Analg 2004; 99: 689-93.</ref> Electrical nerve stimulation or ECG recording on the catheter, or its echographic visualization have been suggested to guide its advancement in epidural space.<ref>Tsui BC, Wagner A, Cave D, Kearny R. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients. Anesthesiology 2004; 100: 683-9.</ref>,<ref>Chawathe MS, Jones RM, Gildersleve CD, Harrison SK, Morris SJ, Eickmann C. Detection of epidural catheters with ultrasound in children. Paediatr Anaesth 2003; 13: 681-4</ref> However, most anaesthetists presently prefer a direct epidural approach at the desired level that is appropriate to the surgical intervention.<ref>Bösenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth 1998; 8: 479-83.</ref>,<ref>Giaufré E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-language society of pediatric anesthesiologists. Anesth Analg 1996; 83: 904-12</ref> | [[File:US use in caudal block.jpg|thumb|'''Figures 8a and 8b.''' Ultrasound use in caudal block|alt=|left]]Although CA was initially described as a single shot technique, some authors have described use of a caudal catheter to prolong analgesic administration in postoperative period. In addition advancement of the catheter in the epidural space up to lumbar or even thoracic levels can achieve analgesia of high abdominal or thoracic areas.<ref>Tsui BC, Berde CB. Caudal analgesia and anesthesia techniques in children. Curr Op Anesthesiol 2005; 18: 283-8.</ref> However, two pitfalls restrict extension of this technique; a high risk of catheter bacterial colonization, particularly in infants and a high risk of catheter misplacement.<ref>Kost-Byerly S, Tobin JR, Greenberg RS, Billett C, Zahurak M, Yaster M. Bacterial colonisation and infectious rate of continuous epidural catheters in children. Anesth Analg 1998; 86: 712-6</ref>,<ref>Valairucha S, Seefelder D, Houck CS. Thoracic epidural catheters placed by the caudal route in infants: the importance of radiographic confirmation. Paediatr Anaesth 2002; 12: 424-8.</ref> Subcutaneous tunnelling at a distance from the anal orifice, or occlusive dressings decrease bacterial colonization.<ref>Bubeck J, Boss K, Krause H, Thies KC. Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters. Anesth Analg 2004; 99: 689-93.</ref> Electrical nerve stimulation or ECG recording on the catheter, or its echographic visualization have been suggested to guide its advancement in epidural space.<ref>Tsui BC, Wagner A, Cave D, Kearny R. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients. Anesthesiology 2004; 100: 683-9.</ref>,<ref>Chawathe MS, Jones RM, Gildersleve CD, Harrison SK, Morris SJ, Eickmann C. Detection of epidural catheters with ultrasound in children. Paediatr Anaesth 2003; 13: 681-4</ref> However, most anaesthetists presently prefer a direct epidural approach at the desired level that is appropriate to the surgical intervention.<ref>Bösenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth 1998; 8: 479-83.</ref>,<ref>Giaufré E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-language society of pediatric anesthesiologists. Anesth Analg 1996; 83: 904-12</ref> | ||
== LOCAL ANAESTHETIC AGENTS == | == LOCAL ANAESTHETIC AGENTS == | ||