Risk of rectal puncture due to needle entry into the presacral space: Importance of measuring the distance between the rectum and sacrococcyx, and the thickness of the sacrococcyx.

During ganglion impar block, the needle may approach the presacral space and the sacrum may be penetrated during caudal anesthesia. Because the rectum is in front of the sacrococcyx and is thus at risk for puncture, it is important to determine the distance between the sacrococcyx and rectum, as well as the thickness of the sacrococcyx.Computed tomography was used to measure the distance between the rectum and sacrococcyx, as well as the thickness of the sacrococcyx. The distances between the coccyx and rectum, sacrococcygeal joint and rectum, sacral level 5 ('sacrum 5') and rectum, and 'sacrum 4 to 5 junction' and rectum were measured. The results were compared based on the presence or absence of stools in the rectum. The thickness of the sacrococcyx was measured at the sacrum 4 to 5 junction and sacrococcygeal joint.In total, 1264 patients were included in this study. All distances were less than 1 mm in both males and females, with the exception of the distance between the coccyx and rectum in males. In both males and females, there was no significant difference in distance between the sacrococcyx and rectum according to the presence or absence of feces in the rectum, but there was a difference in the distance between sacrum 5 and the rectum in males (P = .048). Several male and female patients showed thicknesses of less than 5 mm at the sacrococcygeal joint.Some patients have a distance of less than 1 mm between the sacrum and rectum. Practitioners should exercise caution when applying a needle to the presacral space. If the sacrum is accidentally penetrated during caudal block, rectum puncture cannot be ruled out. Excretion of feces does not influence the distance between the sacrococcyx and rectum in females.

Fluoroscopic evaluation of the influence of needle gauge on epidural spread in caudal block.

Caudal block has limited injectate distribution to the desired lumbar level due to the relatively long distance from the injection site and reduction in the volume of injectate due to leakage into the sacral foramen. The objective of this study was to investigate the influence of needle gauge on fluoroscopic epidural spread and to assess the correlation between the spread level and analgesic efficacy in patients undergoing caudal block. We retrospectively analyzed data from 80 patients who received caudal block for lower back and radicular pain. We categorized patients based on the epidural needle gauge used into group A (23 gauge), group B (20 gauge), and group C (17 gauge). Fluoroscopic image of the final level of contrast injected through the caudal needle and pain scores before the block and 30 minutes after the block recorded using a numerical rating scale, were evaluated. Of the 80 patients assessed for eligibility, 7 were excluded. Thus, a total of 73 patients were finally analyzed. Age, sex, body mass index, diagnosis, lesion level, lesion severity, and duration of pain did not differ among the 3 groups. All patients showed cephalic spread of contrast. Contrast spread beyond L5 was seen in 26.9% of patients in group A, 41.7% in group B, 39.1% in group C, and 35.6% overall; there was no significant difference among the groups (P = .517). Analgesic efficacy was not significantly different among the groups (P = .336). The needle gauge did not influence the level of epidural spread or analgesic efficacy in caudal block.

Combined spinal/caudal catheter anesthesia: extending the boundaries of regional anesthesia for complex pediatric urological surgery.

BACKGROUND: Spinal anesthesia (SA) is an established anesthetic technique for short outpatient pediatric urological cases. To avoid general anesthesia (GA) and expand regional anesthetics to longer and more complex pediatric surgeries, the authors began a program using a combined spinal/caudal catheter (SCC) technique. STUDY DESIGN: The authors retrospectively reviewed the charts of all patients scheduled for surgery under SCC between December 2016 and April 2018 and recorded age, gender, diagnosis, procedure, conversion to GA/airway intervention, operative time, neuraxial and intravenous medications administered, complications, and outcomes. The SCC technique typically involved an initial intrathecal injection of 0.5% isobaric bupivacaine followed by placement of a caudal epidural catheter. At the discretion of the anesthesiologist, patients received 0.5 mg per kilogram of oral midazolam approximately 30 min prior to entering the operating room. One hour after the intrathecal injection, 3% chloroprocaine was administered via the caudal catheter to prolong the duration of surgical block. Intra-operative management included either continuous infusion or bolus dosing of dexmedetomidine, as needed, for patient comfort and to optimize surgical conditions. Prior to removal of caudal catheter in the post-anesthesia care unit, a supplemental bolus dose of local anesthesia was given through the catheter to provide prolonged post-operative analgesia. RESULTS: Overall, 23 children underwent attempted SCC. SA was unsuccessful in three patients, and surgery was performed under GA. The remaining 20 children all had successful SCC placement. There were 11 girls and nine boys, with a mean age of 16.5 months (3.3-43.8). Surgeries performed under SCC included seven ureteral reimplantations, two ureterocele excisions/reimplantations, two megaureter repairs, four first-stage hypospadias repairs, one distal hypospadias repair, one second-stage hypospadias repair, two feminizing genitoplasties, and one open pyeloplasty. Average length of surgery was 109 min (range 63-172 min). Pre-operative midazolam was given in 13/20 (65%). All SCC patients were spontaneously breathing room air during the operation, and there were no airway interventions. Only one SCC patient received opioids intra-operatively. There were no intra-operative or perioperative complications. DISCUSSION: This pilot study shows that the technique of SCC allows one to do more complex urologic surgery under regional anesthesia than what would be possible under pure SA alone. The main limitations of the study include the relatively small number of patients and the small median length of the operative procedures. As a proof of concept, however, this does show that complex genital surgery bladder level procedures such as ureteral reimplantation can be performed under regional anesthesia. CONCLUSION: SCC allows for more complex surgeries to be performed exclusively under regional anesthesia, thus obviating the need for airway intervention, minimizing or eliminating the use of opioids, and thus avoiding known and potential risks associated with GA. The latter is of particular importance given current concerns regarding hypothetical neurocognitive effects of GA on children aged below 3 years.

Caudal epidural blocks in paediatric patients: a review and practical considerations.

Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.

Does ultrasound guidance add accuracy to continuous caudal-epidural catheter placements in neonates and infants?

BACKGROUND: Caudo-lumbar and caudo-thoracic epidural anesthesia is an established technique that carries a low risk of dural puncture or spinal cord trauma in infants. Traditionally catheter advancement is based on external measurements. However, malpositioning of catheters are known to occur. We hypothesized that caudal-epidural catheters inserted under real-time ultrasound guidance may be more accurate than the accuracy of the measurements traditionally used for their placement. METHODS: We studied 25 patients, aged 2 days to 5 months, posted for abdominal or thoracic surgery, receiving general anesthesia followed by caudo-epidural continuous block. External measurement defined as the distance from the caudal space and the surgically congruent vertebral level was measured in centimeters with the back gently flexed. Subsequently, a caudo-epidural block was performed in the same position. The epidural catheter insertion was followed under real-time ultrasound guidance till the predetermined vertebral level was reached. The actual length placed under real-time ultrasound scan was defined as the actual length. The high-frequency probe was placed longitudinal and paramedian to the spine. The vertebral level was determined by identifying the lumbosacral junction in longitudinal saggital view and counting the vertebrae up from L5. The catheter length at the skin was compared with the length recorded by external measurement. RESULTS: The actual length placed under real-time ultrasound scan were consistently longer than the external distance between the caudal space and selected vertebral level. The mean values of ultrasound were higher than the mean values of external measurement with a difference of 4.28 cm. Accuracy was not affected by age or affected by the selected vertebral level in the age group we studied. CONCLUSION: We conclude that catheters placed under ultrasound guidance are more accurate than the traditional method developed before the advent of ultrasound in young infants.

Epidural insertion height for ureteric reimplant surgery; does location matter?

BACKGROUND: Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain. AIM: To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques. METHODS: Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'-single-shot caudal; (iii) 'epidural'-epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 µg·ml(-1) ; (iv) 'caudal catheter'-caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain. RESULTS: Over the study period, the caudal catheter technique (mean interventions/patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload. CONCLUSIONS: Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required.

Successful use of ultrasound-guided caudal catheter in a child with a very low termination of dural sac and Opitz-GBBB syndrome: a case report.

We report a 2-year-old patient with Opitz-GBBB syndrome scheduled for a posterior sagittal anorectoplasty (PSARP). The ultrasound scan revealed the inferior end of dural sac just below sacrococcygeal membrane, although the patient had previously two successful caudal epidural blocks. Consequently, the epidural catheter was inserted under a real-time ultrasound guidance without dural puncture. Our patient had excellent pain relief without any side effects.

Epidural catheter design: history, innovations, and clinical implications.

Epidural catheters have evolved during the past several decades, as clinicians and manufacturers have sought to influence the quality of analgesia and anesthesia and reduce the incidence of catheter-related complications. This evolution has allowed a transformation from single-shot to continuous-infusion techniques and resulted in easier passage into the epidural space, more extensive medication distribution, and ultimately, improved patient satisfaction. Particular catheter features, including the materials used, tip design, and orifice number and arrangement, have been associated with specific outcomes and provide direction for future development.

Incidence of self-limiting back pain in children following caudal blockade: an exploratory study.

BACKGROUND: Currently, in pediatric anesthesia, there is no evidence-based information available to pediatric patients and their parents regarding the incidence of back pain after neuraxial injections performed for postoperative analgesia. Back pain postepidural blockade has been reported in numerous studies with adult patients; however, it has not been investigated in children. The main objective of this study is to examine the incidence of back pain symptoms after caudal blockade (early and late onset) in children. METHODS: Patients under the age of 18 years, who received caudal blockade at the Montreal Children's Hospital between July 2006 and December 2008 were recruited in this prospective observational study. Back pain was measured prospectively by patient self-report and parental observation during the 15-day postoperative period. Patients, or their parents, were contacted by phone on postoperative day 2 (POD2) and postoperative day 15 (POD15) to answer a seven-item symptom questionnaire. RESULTS: In a sample of 135 children, the incidence of back pain symptoms was 4.7% and 1.1% on POD2 and POD15, respectively. CONCLUSIONS: The results of this study provide support that transient self-limiting back pain after caudal blockade does occur in pediatric patients. Clinically, this is useful information for physicians to provide to their patients. An exploration of factors that may be associated with back pain following caudal blockade in children is an interesting area of future research.

[Sacral anesthesia, perspectives today].

The paper summarizes the experience of Russian and foreign specialists in dealing with the theoretical and practical aspects of sacral anesthesia. It presents anatomic data and information on the pathophysiological aspects and potentialities of clinical use of sacral anesthesia in modern anesthesiological practice that estimate its perspectives at this stage.

Determining the accuracy of caudal needle placement in children: a comparison of the swoosh test and ultrasonography.

BACKGROUND: The aim of the present study was to compare two confirmatory tests - the 'swoosh' test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block. METHODS/MATERIALS: This was a retrospective observational study of caudal injections administered to 83 pediatric patients (0-11 years) presenting for elective surgery over a 4 month time period. While injecting small aliquots of local anesthetic, a standard stethoscope was placed over the lower lumbar spine to auscultate for the 'swoosh' test. An ultrasound machine (Sonosite Titan, Sonosite Inc., Bothell, WA, USA) was then utilized for real-time visualization of caudal injectate. Each test performed during the caudal injection (swoosh, turbulence on 2D imaging, or color flow on Doppler imaging) was recorded as positive, negative or equivocal. RESULTS: Eighty out of 83 patients (96.4%) had a successful caudal block based on minimal or no perioperative narcotic use, minimal or no response to surgical stimulation, the presence of motor blockade and patient comfort in the PACU. Ultrasound was significantly superior to 'swoosh' for sensitivity (96.3% vs 57.5%), negative predictive (40% vs 5.6 value) % and likelihood ratio (2.89 vs 1.73). Specificity and positive predictive value were not different between 'swoosh' and ultrasound. Of the ultrasound tests, turbulence was more sensitive than color flow Doppler (95.0% vs 78.8%). CONCLUSION: Ultrasonography is superior to the 'swoosh' test as an objective confirmatory technique during caudal block placement in children. We found the presence or absence of turbulence during injection within the caudal space to be the best single indicator of caudal success. We think ultrasonography should be used, if available, when teaching this technique.

[Spinal regional anesthetic approaches in children: caudal block and spinal anesthesia]. / Rückenmarknahe Regionalanästhesieverfahren bei Kindern--Kaudalblock und Spinalanästhesie.

Caudal anesthesia is a safe, simple and very effective method to provide excellent perioperative analgesia. It is used routineously in pediatric anesthesia and can be applied to nearly all children with surgery below the umbilicus. In contrast, spinal anesthesia is a very special technique for former preterm infants below the 50th postconceptive week who are prone to develop postoperative apnea. It has been suggested that some of the problems associated with general anesthesia in these patients may be avoided by the use of spinal anesthesia.

Caudal injectate can be reliably imaged using portable ultrasound--a preliminary study.

BACKGROUND: Correct caudal cannula placement is essential for block success and the avoidance of complications. The aim of this study was to assess the use of a saline injection test bolus with ultrasound (US) imaging to identify correct cannula placement for caudal anesthesia. METHODS: A prospective observational study of 60 children undergoing caudal anesthesia. A Sonosite 180 Plus (Sonosite Inc., Bothwell, WA) was used to image the spine and look for caudal space expansion secondary to saline injection. RESULTS: Saline test bolus correctly identified position in 96.5% of all subjects, and was 100% successful in children under 2 years of age. CONCLUSIONS: These preliminary results suggest saline test bolus under US imaging is a reliable indicator of correct cannula position for caudal block. We found it safe, quick to perform, and provided additional useful information.

Is tissue coring a real problem after caudal injection in children.

BACKGROUND: The aim of this study was to determine whether tissue coring occurs with 22-G hollow needle and 22-G caudal block needle during caudal injection in children, as well as evaluating the nature of the coring material if it did occur. METHODS: Seventy children were randomly allocated to two groups and caudal block was performed with either 22-G hollow (group I) or 22-G caudal block (group II) needle under general anesthesia. The needles and guides were washed with 0.5 ml of 70% ethanol in a sterile tube and were evaluated by a pathologist blinded to the type of needle used, for the type and number of cells. RESULTS: Nucleated cells, which have no mitotic activity, were present in 8.5% in each study group and bloody material was present in 8.5 and 2.8%, in group I and II, respectively. Non-nucleated epidermal cells were detected in 94.2 and 97.1% of the patients in group I and II, respectively. However, cells with mitotic activity from the stratum basale were not detected in any slides. CONCLUSIONS: The incidence of transporting nucleated epidermal cells with no mitotic activity from stratum spinosum during puncture for caudal block is low and no differences exist between different types of needle used. However, it may also suggest that transporting nucleated cells with mitotic activity from the stratum basale may be possible during caudal puncture.