Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair.

INTRODUCTION: The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. OBJECTIVE: Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. STUDY DESIGN: We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. RESULTS: Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. DISCUSSION: Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. CONCLUSIONS: After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

Fatal Clostridium perfringens Meningitis Following Caudal Anesthesia in an Infant: A Case Report.

Caudal anesthesia is referred to as a simple and safe method to obtain analgesia in infants during various surgical procedures. Here, we present a fatal course of a premature infant that received caudal anesthesia for inguinal hernia repair. While anesthesia and surgery were uneventful, the child developed an acute bacterial meningoencephalitis within a few hours. Microbiology revealed the presence of Clostridium perfringens in the cerebrospinal fluid (CSF). The infant died 17 days after surgery. Preoperative screening for C. perfringens and particular caution in infants with intracerebral hemorrhages are discussed as potential factors to be considered when anesthesia is planned.

[Caudal regional anesthesia: a safe anesthetic procedure for abdominal and inguinal surgery in newborns and toddlers]. / Anestesia caudal en neonatos y lactantes como procedimiento anestésico en cirugía abdominal y del canal inguinal: nuestra experiencia.

OBJECTIVES: Caudal anesthesia is a safe and effective technique in children. Some surgical procedures, such as abdominal or inguinal surgeries, could be performed avoiding general anesthesia in newborns and babies, reducing the risk of respiratory depression and neurotoxicity. Our objective is to analyze the experience in a tertial referral center. MATERIAL AND METHODS: We carried a retrospective study in patients under 1 year of age who underwent abdominal or inguinal procedures under caudal regional anesthesia, between 2016 and 2018. Demographics, diagnosis, comorbidity, surgical procedure, operation time, oral intake, perioperative complications and hospital stay were recorded. RESULTS: We included 87 patients under 1 year of age. In 56 patients (23 males, 33 females) surgery was performed under caudal anesthesia (37 scheduled, 19 urgent). Mean age was 2 months (0-11). Comorbidity: 25 associated prematurity, 3 severe tracheomalacia, 1 apnea and 8 bronchopulmonary dysplasia. Surgical procedures: 34 inguinal hernia repair, 9 incarcerated inguinal hernias, 5 neonatal testicular torsions, 8 pyloromyotomies. Mean operation time was 35 min (15-80) and mean anesthetic time 30 min (20-60). Oral intake started 2 h after surgery in 55 patients. Discharge was given in 24 h (12-36). Complications were not noticed. Any patient needed conversion to general anesthesia. CONCLUSIONS: Caudal anesthesia should be the anesthetic technique of choice in newborns and babies who undergo abdominal or inguinal surgeries, especially in those with comorbidity. This procedure could be performed safely, avoiding respiratory or neurological complications, with a fast recovery of patients and short hospital stay.

OBJETIVOS: La anestesia caudal es una técnica que permite la realización de diversos procedimientos quirúrgicos en neonatos y lactantes evitando complicaciones respiratorias y neurotoxicidad asociada a la anestesia general, permitiendo un inicio precoz de la ingesta y una menor estancia hospitalaria. Presentamos la experiencia en un centro terciario. MATERIAL Y METODOS: Estudio retrospectivo en neonatos y lactantes intervenidos de cirugía abdominal o inguinal (2016-2018) mediante anestesia caudal asociada a sedación. Se recogieron datos epidemiológicos, comorbilidad, procedimientos quirúrgicos, tiempo quirúrgico y anestésico, inicio de ingesta, estancia hospitalaria y complicaciones asociadas a la técnica. RESULTADOS: Se intervinieron 87 pacientes menores de 1 año en nuestro centro, en 56 (23 varones, 33 mujeres) se realizó cirugía bajo anestesia caudal (37 programadas,19 urgentes), edad media 2 meses (0-11). En 25 se asociaba prematuridad, 3 traqueomalacia severa, un paciente monitorización de apneas y 8 displasia broncopulmonar. Procedimientos: hernia inguinal no complicada (34), hernia inguinal incarcerada (9), torsión testicular (5), piloromiotomía (8). Tiempo medio de cirugía 35 minutos (15-80), tiempo anestésico de 30 min (20-60) y tiempo quirúrgico total 60 min (40-120). La ingesta se inicio a las 2 horas salvo un paciente que precisó antieméticos. El alta hospitalaria se produjo a las 24 horas (12-36). No se registraron complicaciones durante la realización de la anestesia caudal ni necesidad de conversión a anestesia general. CONCLUSIONES: Consideramos la anestesia caudal de elección en neonatos y lactantes en determinadas cirugías, con escasa morbilidad asociada. Permite un rápido inicio de la ingesta acortando la estancia hospitalaria y minimiza las complicaciones respiratorias y neurotoxicidad a largo plazo, incluso en pacientes prematuros con comorbilidad grave.

Effect of anesthesia for hypospadias repair on perioperative complications.

BACKGROUND: Recent publications from the United States, India, and Korea report that children undergoing hypospadias repair with caudal regional anesthesia/analgesia could have increased postoperative surgical complications. AIMS: The purpose of this retrospective cohort study was to assess the impact between caudal regional anesthesia, other regional anesthesia, and no regional anesthesia on complications after hypospadias repair at a tertiary care children's hospital in Ottawa, Canada, with an expectation to changing practices if a link was found. METHOD: We reviewed the health records of 827 children with hypospadias undergoing penile surgery from January 1991-June 2017. The final sample size for the analysis consisted of 764 patients and 825 procedures. RESULTS: The overall complications were almost identical when considering anesthesia effects, and this similarity persisted when we assessed specifically for only surgical complications. We had 716, 94, and 15 subjects who had a caudal block, penile block, and general anesthesia only, respectively, and their complication rates were 28, 31, and 27%, respectively, and their fistula formation rates were 10, 6, and 0%, respectively, and their stricture formation rates were 8, 7, and 20%,, respectively. Hypospadias type and surgical repair technique were marked predictors of complications in the postoperative period. CONCLUSION: Anesthesia technique appears to have minor impact on complications after hypospadias repair, while surgical technique and type of hypospadias impact complications after hypospadias surgery in children. Based upon these results, we will not change our current practice of using a variety of regional anesthesia techniques for children undergoing hypospadias repair.

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.

Randomised controlled trial of dexmedetomidine sedation vs general anaesthesia for inguinal hernia surgery on perioperative outcomes in infants.

BACKGROUND: Neonates and infants undergoing general anaesthesia for hernia surgery are at risk of perioperative cardiorespiratory adverse events. The use of regional anaesthesia with dexmedetomidine preserves airway tone and may potentially avoid these complications. This study compares the perioperative conditions and adverse events between dexmedetomidine sedation with caudal block and general anaesthesia with caudal block for inguinal hernia surgery in infants. METHODS: A randomised controlled trial was conducted in a tertiary hospital in Singapore involving 104 infants younger than 3 months, who were randomised to receive either dexmedetomidine sedation (DEX) with caudal block or general sevoflurane anaesthesia with tracheal intubation and caudal block (GA) for inguinal hernia surgery. Perioperative conditions, haemodynamics and adverse events were compared between groups. RESULTS: Fifty-one infants received DEX and 48 infants received GA. In the DEX group, 46 infants (90.2%) had their operations completed solely under this technique, two (3.9%) were converted to general anaesthesia with intubation, and three (5.9%) required brief administration of nitrous oxide or low-dose sevoflurane. Overall, 96.1% of infants in the DEX group did not require intubation. Perioperative conditions were similar in both groups. The DEX group had significantly lower heart rates and higher mean arterial pressures intraoperatively. Two infants in the DEX group (3.9%) required postoperative intensive care admission compared with six infants (12.5%) in the GA group. CONCLUSIONS: Dexmedetomidine sedation with caudal block provides a feasible alternative to general anaesthesia in infants undergoing hernia surgery. This technique avoids the need for tracheal intubation, which may be beneficial in neonates. CLINICAL TRIAL REGISTRATION: NCT02559102.

Iatrogenic adrenal suppression following caudal epidural and facet joint injection.

Caudal epidural injections and facet joint injections using steroids and local anaesthetic are widely used methods of pain control in patients suffering from radicular leg pain. In the vast majority of cases this is low risk. We present an interesting case of a patient who suffered from symptomatic adrenal suppression following a caudal epidural injection, and thus wish to draw this rare but significant complication to the attention of orthopaedic practitioners.

Ultrasound-Guided versus Conventional Caudal Block in Children: A Prospective Randomized Study.

BACKGROUND: Injection to the accurate area without any complications is the main factor for the efficiencies of caudal block. The aim of this study was to compare success and the complications of conventional and ultrasound method for caudal block in children. MATERIALS AND METHODS: Two-hundred sixty-six American Society of Anesthesiologists (ASA) category 1 children aged between 6 months and 6 years undergoing hypospadias, circumcision, or both surgeries were randomly allocated two groups (Group C or Group H, n = 133). About 0.25% bupivacaine with 1/200000 adrenaline (total volume: 0.5 mL/kg) was injected after the needle was inserted into the sacral canal in Group C, or right after the needle pierced the sacrococcygeal ligament under longitudinal ultrasound view in Group H. Success rate of block, block performing time, number of needle puncture, success at first puncture, complication rate, age and weight of the patients encountering these complications were recorded. RESULTS: The success rate of block was similar between two groups (94.7% in Group C vs 96.2% in Group U, p > 0.05). Success at first puncture was higher in Group U than in Group C (90.2 vs 66.2%, respectively; p < 0.001). Number of needle puncture, blood aspiration, subcutaneous bulging, and bone contact was higher in Group C but none in Group U (p < 0.001) and these complications were occurred in children weighing < 16 kg and less younger than 6 years old. CONCLUSION: We observed that the complications were not encountered, number of needle puncture was lesser, and the success rate of first puncture was higher under ultrasound with longitudinal view.

An open label pilot study of a dexmedetomidine-remifentanil-caudal anesthetic for infant lower abdominal/lower extremity surgery: The T REX pilot study.

BACKGROUND: Concern over potential neurotoxicity of anesthetics has led to growing interest in prospective clinical trials using potentially less toxic anesthetic regimens, especially for prolonged anesthesia in infants. Preclinical studies suggest that dexmedetomidine may have a reduced neurotoxic profile compared to other conventional anesthetic regimens; however, coadministration with either anesthetic drugs (eg, remifentanil) and/or regional blockade is required to achieve adequate anesthesia for surgery. The feasibility of this pharmacological approach is unknown. The aim of this study was to determine the feasibility of a remifentanil/dexmedetomidine/neuraxial block technique in infants scheduled for surgery lasting longer than 2 hours. METHODS: Sixty infants (age 1-12 months) were enrolled at seven centers over 18 months. A caudal local anesthetic block was placed after induction of anesthesia with sevoflurane. Next, an infusion of dexmedetomidine and remifentanil commenced, and the sevoflurane was discontinued. Three different protocols with escalating doses of dexmedetomidine and remifentanil were used. RESULTS: One infant was excluded due to a protocol violation and consent was withdrawn prior to anesthesia in another. The caudal block was unsuccessful in two infants. Of the 56 infants who completed the protocol, 45 (80%) had at least one episode of hypertension (mean arterial pressure >80 mm Hg) and/or movement that required adjusting the anesthesia regimen. In the majority of these cases, the remifentanil and/or dexmedetomidine doses were increased although six infants required rescue 0.3% sevoflurane and one required a propofol bolus. Ten infants had at least one episode of mild hypotension (mean arterial pressure 40-50 mm Hg) and four had at least one episode of moderate hypotension (mean arterial pressure <40 mm Hg). CONCLUSION: A dexmedetomidine/remifentanil neuraxial anesthetic regimen was effective in 87.5% of infants. These findings can be used as a foundation for designing larger trials that assess alternative anesthetic regimens for anesthetic neurotoxicity in infants.

Ultrasound-guided versus conventional injection for caudal block in children: A prospective randomized clinical study.

STUDY OBJECTIVE: The aim of this study was to compare the efficacies of ultrasound guided sacral hiatus injection and conventional sacral canal injection performed for caudal block in children. DESIGN: Randomized controlled clinical trial. SETTING: Operating rooms of university hospital of Erzurum, Turkey. PATIENTS: One hundred-thirty four children, American Society of Anesthesiologists I-II, between the ages of 5 and 12, scheduled for elective phimosis and circumcision surgery. INTERVENTIONS: Patients assigned to two groups for ultrasound guided caudal block (Group U, n=68) or conventional caudal block (Group C, n=66). Caudal solution was prepared as 0.125% levobupivacaine plus 10mcg/kg morphine (total volume: 0.5ml/kg), and was administered to both groups. MEASUREMENTS: The block performing time, the block success rate, the number of needle puncture, the success at first puncture and the complications were recorded. MAIN RESULTS: The block performing time and the success rate of block were similar between Group U and Group C (109.96±49.73s vs 103.17±45.12s, and 97% vs 93%, respectively p>0.05). The first puncture success rate was higher in Group U than in Group C (80% vs 63%, respectively p=0.026). No significant difference was observed between the groups with regard to the number of needle punctures (p=0.060). The rates of vascular puncture and subcutaneus bulging were higher in Group C than in Group U (8/66 vs 1/68, and 8/66 vs 0/68, respectively p<0.05). CONCLUSIONS: Despite the limitations in central neuroaxial anesthesia we recommend the use of ultrasound since it reduces the complications and increases the success rate of first puncture in pediatric caudal injection.

Awake caudal anaesthesia in neonates/young infants for improved patient safety.

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.

INTRODUCTION: Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. METHODS: All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. RESULTS: We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications. CONCLUSIONS: In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

Measuring the depth of the caudal epidural space to prevent dural sac puncture during caudal block in children.

BACKGROUND: Caudal blocks are performed through the sacral hiatus in order to provide pain control in children undergoing lower abdominal surgery. During the block, it is important to avoid advancing the needle beyond the sacrococcygeal ligament too much to prevent unintended dural puncture. This study used demographic data to establish simple guidelines for predicting a safe needle depth in the caudal epidural space in children. METHODS: A total of 141 children under 12 years old who had undergone lumbar-sacral magnetic resonance imaging were included. The T2 sagittal image that provided the best view of the sacrococcygeal membrane and the dural sac was chosen. We used Picture Achieving and Communication System (Centricity® PACS, GE Healthcare Co.) to measure the distance between the sacrococcygeal ligament and the dural sac, the length of the sacrococcygeal ligament, and the maximum depth of the caudal space. RESULTS: There were strong correlations between age, weight, height, and BSA, and the distance between the sacrococcygeal ligament and dural sac, as well as the length of the sacrococcygeal ligament. Based on these findings, a simple formula to calculate the distance between the sacrococcygeal ligament and dural sac was developed: 25 × BSA (mm). CONCLUSION: This simple formula can accurately calculate the safe depth of the caudal epidural space to prevent unintended dural puncture during caudal block in children. However, further clinical studies based on this formula are needed to substantiate its utility.

Influence of caudal block on postoperative oliguria in infants undergoing bilateral ureteroneocystostomy: a retrospective analysis.

BACKGROUND: Caudal block has been widely used in children undergoing genitourinary surgery. However, the influence of caudal block on postoperative oliguria is unclear. AIM: The aim of this study was to assess the effect of caudal block on urinary flow through the reimplanted ureter after ureteroneocystostomy and the incidence of postoperative oliguria in infants. METHODS: This retrospective study analyzed the medical records of 121 infants aged less than 12 months who underwent bilateral ureteroneocystostomy for vesicoureteral reflux at a tertiary medical center. In all study infants, a ureteral catheter was placed in one of the two ureters in order to relieve the clinical consequences of transient ureteral obstruction and a urethral catheter was placed at the end of the ureteroneocystostomy procedure. Urinary output was assessed separately for each catheter. Logistic regression analysis was performed to identify the risk factors for oliguria from the urethral catheter. RESULTS: Among the 121 patients, 63 (52%) received caudal block (caudal block group) and 58 (48%) did not (no caudal block group). Patient characteristics, preoperative vesicoureteral reflux grade and renal function, and intraoperative profiles were comparable between the groups. The incidence of oliguria from the urethral catheter for 8 h after the surgery was significantly higher in the caudal block group than in the no caudal block group. However, the incidence of oliguria from the ureteral catheter was comparable between the groups. In multivariate analysis, oliguria from the urethral catheter was associated with caudal block, anesthesia duration, and intraoperative dexamethasone administration. The odds for oliguria was 3.069-fold greater in patients who received caudal block than in those who did not (95%CI, 1.303-7.228, P = 0.010). On the other hand, intraoperative dexamethasone reduced the risk of oliguria. CONCLUSION: Caudal block may be associated with postoperative oliguria in infants undergoing ureteroneocystostomy.

Caudal analgesia for herniotomy: Comparative evaluation of two dose schemes of bupivacaine.

OBJECTIVE: There is currently a wide range of volume schemes for bupivacaine caudal anesthesia. This study evaluated the quality of caudal analgesia achieved with a dosing scheme of 0.75 ml/kg compared with 0.5 ml/kg of 0.25% plain bupivacaine for herniotomy. METHODS: After the institutional approval, American Society of Anesthesiologists I-II patients aged between 1 and 6 years scheduled for unilateral inguinal herniotomy with consenting parents/guardian were recruited. The subjects were randomized to receive 0.5 ml/kg (Group 1) or 0.75 ml/kg of 0.25% bupivacaine. Anesthesia was maintained solely with halothane 0.5-1% in 100% oxygen. Postoperatively, pain was assessed using the objective pain scale (OPS). A favorable pain score was defined as <4 (8 point scale) or <5 (10 point scale). The primary outcome was the proportion of subjects with favorable pain scores. RESULTS: Fifty-six patients were enrolled and there was no difference in sociodemographic parameters, preoperative hemodynamic variables, or duration of surgery. Proportions of subjects with favorable OPS scores showed marked differences from 45 min and peaking at 180 min (11 [39%] favorable scores in Group 1 compared to all [100%] favorable scores in Group 2, P< 0.0001). Mean time to first analgesic requirement was 126 ± 34.2 min in Group 1 compared to 249 ± 23.7 min in Group 2 (P < 0.0001). There was no difference in the incidence of adverse events between groups. CONCLUSION: This study shows that 0.75 ml/kg of 0.25% plain bupivacaine is superior to the use of 0.5 ml/kg of the same concentration for postherniotomy caudal analgesia with low side effect profile.

Risk factors related to accidental intravascular injection during caudal anesthesia.

Recently, ultrasound-guided caudal anesthesia has been performed for postoperative pain management after lumbar spine surgery. Although it is well known that intravascular injection often occurs in the caudal part of the spine, and that this cannot be detected at the time of injection under ultrasound screening, the risk factors for intravascular injection have not been evaluated. To assess the risk index for prediction of accidental intravascular injection during caudal anesthesia, we retrospectively examined the hospital records of patients suffering from chronic low back pain who underwent sacral epidurography. Multivariate logistic regression analysis demonstrated that radicular symptoms of the lumbar spine (OR, 2.511, 95% CI, 1.097-5.748) and duration of symptoms (OR, 1.006, 95% CI, 1.002-1.010) were significant and independent risk factors for accidental intravascular injection during sacral epidurography. This study suggests that the incidence of accidental intravascular drug injection during caudal anesthesia would be higher in patients with chronic radicular symptoms of the lumbar spine.

[Regional anaesthesia in children--caudal anaesthesia and trunk blocks]. / Kinderanästhesie--Regionalanästhesie bei Kindern: Kaudalanästhesie und Bauchwandblockaden.

In children, elective surgery is often performed in the trunk region. Regional anaesthetic techniques allow good analgesia with reduced opioid consumption, and enhance rapid discharge of the small patients. This review focuses on indication, anatomic structures, puncture techniques and potential complications of caudal anaesthesia, transversus abdominis plane block, ilioinguinal/iliohypogastric nerve block and rectus sheath block.

Effects of caudal sufentanil supplemented with levobupivacaine on blocking spermatic cord traction response in pediatric orchidopexy.

PURPOSES: Caudal block is one of the most commonly used anesthetic techniques in subumbilical and genitourinary procedures. However, traditional administration of caudal levobupivacaine was inadequate on blocking peritoneal response during spermatic cord traction. The aim of this study was to evaluate whether the addition of caudal sufentanil to levobupivacaine provided better analgesia for children undergoing orchidopexy. METHODS: Sixty-two patients, scheduled for right orchidopexy, received caudal block after induction. Group LS (n = 31) received levobupivacaine 0.25% 1 ml/kg plus sufentanil 0.5 µg/kg, and group L (n = 31) received levobupivacaine 0.25% 1 ml/kg only. HR or MAP fluctuation >20% or entropy increase >15% during spermatic cord traction was defined as inadequate anesthesia and was treated with increasing sevoflurane concentration. The number of children who needed sevoflurane rescue was counted, and postoperative side effects and quality of sleep were also recorded. RESULTS: There were no statistically significant differences between the two groups in age, weight, and duration of surgery. Two (6.45%) children in group LS required inspired sevoflurane rescue to block hemodynamic fluctuation during spermatic cord traction, as compared with 12 (38.71%) patients in group L (P < 0.001). At the time of exerting spermatic cord traction, the median HR was, respectively, 134 and 145 (P < 0.001); the corresponding response entropy (RE) and state entropy (SE) was 65 and 54, respectively, in group LS versus 76 and 65 in group L (P < 0.001). CONCLUSION: In pediatric orchidopexy, the addition of sufentanil to levobupivacaine for caudal blockade offers clinical benefit over levobupivacaine alone in blocking the spermatic cord traction response.

Cauda equina syndrome after cesarean section.

This report describes a case of cauda equina syndrome possibly caused by arachnoiditis due to levobupivacaine after spinal-epidural anesthesia. A 39-yr-old woman delivered by cesarean section under a combined spinal-epidural anesthesia. After an uneventful procedure and surgery, she complained of weakness in her lower extremities, which increased in a few hours. Neurologic examination revealed severe weakness in both her lower extremities, perianal anesthesia, and absence of muscle stretch reflexes. She was unable to urinate. Magnetic resonance imaging performed immediately revealed entirely normal results; however, gadolinium-enhanced magnetic resonance imaging 10 days later revealed contrast enhancement in the cauda equina fibers concordant with arachnoiditis. The patient was included in an intense rehabilitation program with a diagnosis of cauda equina syndrome and recovered completely in 8 wks. Practitioners should be aware of neurologic complications of spinal-epidural anesthesia. Early detection and treatment of the complication are important to minimize the risk of adverse outcome.