The median effective concentration of ropivacaine for ultrasound-guided caudal block in children: a dose-finding study.

PURPOSE: To determine the 50% minimum effective concentration (MEC50) and the 95% effective concentration (MEC95) of ropivacaine for ultrasound-guided caudal block during hypospadias repair surgery of pediatric patients. METHODS: Children were enrolled with the American Society of Anesthesiologists (ASA) physical status I-II undergoing elective hypospadias repair surgery. Children were grouped into two age groups: toddlerhood (1-3 years old) and preschool (3-6 years old). We measured The MEC50 using Dixon's up-and-down method. The first children received the caudal block with 1.0 mL/kg of 0.15% ropivacaine. We determined each subsequent patient's concentration based on the previous patient's response and adjusted the concentration in intervals of 0.015%. Meanwhile, the probit regression analysis obtains 95% effective concentration (MEC95). In addition, we recorded the general condition, adverse events, and postoperative pain of each child. RESULTS: 46 children undergoing elective hypospadias repair surgery were included in this study, 22 in the toddlerhood group and 24 in the preschool group. Of the total number of patients, the caudal block was successful in 25 (54%) and failed in 21 (46%). The MEC50 of 1 ml/kg ropivacaine was 0.102% (95% CI 0.099%, 0.138%) in the toddlerhood group and 0.129% (95% CI 0.124%, 0.138%) in the preschool group. The MEC95 of 1 ml/kg ropivacaine was 0.148% (95% CI 0.131%, 0.149%) in the toddlerhood group and 0.162% (95% CI 0.134%, 0.164%) in the preschool group. Our results showed that ropivacaine concentration was statistically different between preschool children and toddlers (P < 0.001). None of the adverse events occurred. CONCLUSIONS: This study showed that children in the preschool group required higher concentrations of ropivacaine than children in the toddler group during ultrasound-guided sacral block combined with non-intubated general anesthesia. At the same time, this method of anesthesia is safe and effective for children undergoing surgery for hypospadias.

Awake caudal anesthesia in ex-premature infants undergoing lower abdominal surgery: A narrative review.

BACKGROUND AND OBJECTIVES: The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic-based techniques in premature and ex-premature infants undergoing lower abdominal surgery. METHODS: All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, abstracted data, and appraised quality. RESULTS: Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of "awake" caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation. The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7-18.4), intermediate for awake caudal (6.6%, 5.26-9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48-7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%-24%), intermediate for awake caudal (7.62%, 0%-60%), and lowest for CSEA (5.53%, 0%-14.3%). High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals). Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high-quality randomized controlled trials, and the eight single-center retrospective data reviews lacked sufficient data to perform meta-analysis. CONCLUSIONS: There is insufficient evidence to validate or refute the benefits of the use of "awake" caudal anesthesia in premature and ex-premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block.

Sex differences in pediatric caudal epidural anesthesia under sedation without primary airway instrumentation.

STUDY OBJECTIVE: To identify sex differences associated with caudal epidurals, the most commonly used technique of pediatric regional anesthesia, based on individually validated data of ultrasound-guided blocks performed between 04/2014 and 12/2020. METHODS: Prospectively collected and individually validated data of a cohort of children aged between 0-15 years was analyzed in a retrospective observational study. We included pediatric surgeries involving a primary plan of caudal epidural anesthesia under sedation (without airway instrumentation) and a contingency plan of general anesthesia. Sex-specific rates were analyzed for overall failure of the primary anesthesia plan, for residual pain, for block-related technical complications and for critical respiratory events. We used Fisher´s exact tests and multivariable logistic regressions were used to evaluate sex-specific associations. RESULTS: Data from 487 girls and 2060 boys ≤15 years old (ASA status 1 to 4) were analyzed. The primary-anesthesia-plan failure rate was 5.5% (95%CI 3.8%-7.8%) (N = 27/487) among girls and 4.7% (95%CI 3.9%-5.7%) (N = 97/2060) among boys (p = 0.41). Residual pain was the main cause of failure, with rates of 4.5% (95%CI 2.9-6.6%) (N = 22/487) among girls and 3.0% (95%CI 2.3-3.8%) (N = 61/2060) among boys (p = 0.089). Block-related technical complications were seen at rates of 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls vs 2.5% (95%CI 0.5-2.7%) (N = 51/2060) among boys and, hence, significantly more often among male patients (p = 0.023). Male sex was significantly associated with higher odds (adjusted OR: 3.18; 95% CI: 1.12-9; p = 0.029) for such technical complications regardless of age, ASA status, gestational week at birth or puncture attempts. Critical respiratory events occurred at a 1.7% (95%CI 1.2%-2.3%) rate (N = 35/2060) twice as high among boys as 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls (p = 0.21). CONCLUSIONS: While the the primary-anesthesia-plan failure rate was equal for girls and boys, technical complications and respiratory events are more likely to occur in boys.

A comparison of operative and anesthetic techniques for inguinal hernia repair in infants.

BACKGROUND: Pediatric inguinal hernia repair (IHR) is increasingly performed using minimally invasive surgery (MIS) but has only recently been described using caudal block without endotracheal intubation. We evaluated the surgical outcomes and resource utilization of infants undergoing hernia repair, comparing both the operative approach (open/MIS) and anesthetic technique (general anesthesia [GA]/caudal). METHODS: All infants <1 year-of-age undergoing elective IHR without concomitant procedures from July 2016 to July 2021 at a single tertiary care teaching center were retrospectively reviewed. Eight surgeons and 25 anesthesiologists contributed patients, with approach dictated by practitioner preference. Data collected included patient demographics, surgical and anesthetic details, and operating room (OR) utilization metrics. Post-operative complications were evaluated and aggregated, including recurrent hernia, metachronous hernia, hematoma, hydrocele, testicular atrophy, and acquired cryptorchidism. Descriptive statistics were performed with R Studios (p < 0.05). RESULTS: Of the 338 patients included for analysis, most underwent an open procedure (n = 275) while anesthetic technique was evenly split between GA (n = 185) and caudal (n = 153). Most patients were male (87.6%) and born premature: mean gestational age of 31.4 ± 4.1 weeks. MIS-to-Open conversion was noted once (3.3%) in the GA MIS group, but none in caudal. Median follow up was 2.5 (1.4-3.8) years. No differences were noted in aggregate surgical complication rates (p = 0.4). The Caudal Open group had the shortest total OR time (p < 0.01); caudal anesthesia shortened post-procedure times (p < 0.01). CONCLUSION: MIS IHR performed under caudal block and sedation yields comparable complication rates compared to the open approach or GA. Open IHR with caudal blockade was the most efficient operative room utilization. TYPE OF STUDY: Original Article, Clinical Research. LEVELS OF EVIDENCE: Level III.

Levobupivacaine plasma concentrations following repeat caudal anesthetics.

AIM: A single caudal anesthetic at the start of lower abdominal surgery is unlikely to provide prolonged analgesia. A second caudal at the end of the procedure extends the analgesia duration but total plasma concentrations may be associated with toxicity. Our aim was to measure total plasma levobupivacaine concentrations after repeat caudal anesthesia in infants and to generate a pharmacokinetic model for prediction of plasma concentrations after repeat caudal anesthesia in neonates, infants and children. METHODS: Infants undergoing definitive repair of anorectal malformations or Hirschsprung's disease received a second caudal anesthesia at the end of the procedure. Total levobupivacaine concentrations were assayed 3-4 times in the first 6 h after the initial caudal. These data were pooled with data from four studies describing plasma concentrations after levobupivacaine caudal or spinal anesthesia. Population pharmacokinetic parameters were estimated using nonlinear mixed-effects models. Covariates included postmenstrual age and body weight. Parameter estimates were used to simulate concentrations after a repeat levobupivacaine 2.5 mg kg-1 caudal at 3 or 4 h following an initial levobupivacaine 2.5 mg kg-1 caudal. RESULTS: Twenty-one infants (postnatal age 11-32 weeks, gestation 37-39 weeks, weight 5.2-8.6 kg) were included. The measured peak plasma concentration after repeat caudal levobupivacaine 2.5 mg kg-1 4 h after initial caudal was 1.38 mg L-1 (95% prediction interval 0.60-2.6 mg L-1 ) and 3 h after initial caudal was 1.46 mg L-1 (0.60-2.80) mg L-1 . Simulation of total plasma concentrations in neonates (7 kg, 57 weeks postmenstrual age) given caudal levobupivacaine 4 h after the initial caudal were 1.76 mg L-1 (0.68-3.50) mg L-1 if 2.5 mg kg-1 levobupivacaine was used and 0.88 mg L-1 (0.34-1.73) mg L-1 if 1.25 mg kg-1 of 0.125% levobupivacaine was used. In simulated older children (20 kg, 6 years), the mean maximum concentration was 1.43 mg L-1 (0.60-2.70) mg L-1 if 2.5 mg kg-1 levobupivacaine was repeated at 3 h. CONCLUSION: Repeat caudal levobupivacaine 2.5 mg kg-1 at 3 h after an initial 2.5 mg kg-1 dose does not exceed the concentration associated with systemic local anesthetic toxicity. In 2.5% of simulated neonates (weight 3.8 kg, PMA 40 weeks), repeat caudal anesthesia demonstrates broaching of the lower concentration limit associated with toxicity at both 3 and 4 h after initial caudal.

Ultrasound determination of the dural sac to sacrococcygeal membrane distance in premature neonates.

BACKGROUND: Caudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements. METHODS: Sacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded. RESULTS: 20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860-2350) g and average age (SD; range) of 35.0 (1.35; 32.2-39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6-26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion. CONCLUSION: Ultrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

Anestesia peridural caudal en neonatos: una alternativa segura para el anestesiólogo / Caudal peridural anesthesia in neonates: a safe alternative for the anesthesiologist

Introducción: Las técnicas de anestesia y analgesia regional en la población pediátrica garantizan la estabilidad hemodinámica y respiratoria. El uso de la anestesia caudal ha aumentado enormemente sobre todo para cirugías de abdomen inferior lo que ofrece ventajas sobre la anestesia general. Objetivo: Argumentar sobre la base de la mejor evidencia científica, la opinión de los autores en relación a la efectividad del uso de la anestesia caudal en los pacientes neonatos. Método: El marco inicial de búsqueda bibliográfica se constituyó por los artículos publicados acerca de la utilización de la anestesia caudal en neonatos. Las fuentes de información que se utilizaron fueron: Registro Cochrane central de ensayos clínicos controlados, Pubmed, LILACS, SciELO, Ebsco, Science, Google académico. Resultados: El bloqueo caudal es la aplicación de un anestésico local en el espacio peridural, pero a nivel sacro, lo que ocasiona un bloqueo de conducción en las raíces nerviosas que cubre la analgesia, no solo el período intraoperatorio sino también el posoperatorio, lo cual permite una adecuada estabilidad hemodinámica, reduce el sangrado, evita el uso de opioides, anestésicos generales y relajantes musculares. La necesidad de asistencia respiratoria se ve reducida. Conclusiones: Es una técnica segura y económica en ocasiones subvalorada en el recién nacido. Esto, junto a una más rápida recuperación, lleva a considerar la anestesia regional como una alternativa a la anestesia general(AU)

Introduction: Regional anesthesia and analgesia techniques in the pediatric population guarantee hemodynamic and respiratory stability. The use of caudal anesthesia has increased enormously, especially for lower abdominal surgeries, which offers advantages over general anesthesia. Objective: To argue, based upon the best scientific evidence, the opinion of the authors regarding the effectiveness of the use of caudal anesthesia in neonatal patients. Method: The initial framework for the bibliographic search consisted of the articles published about the use of caudal anesthesia in neonates. The sources of information were the Cochrane Central Register of Controlled Trials, Pubmed, LILACS, SciELO, Ebsco, Science, Google Scholar. Results: Caudal block is the application of a local anesthetic into the epidural space, but at the sacral level, which causes a conduction block in the nerve roots that covers analgesia, not only in the intraoperative period but also in the postoperative one, which allows adequate hemodynamic stability, reduces bleeding, avoids the use of opioids, general anesthetics and muscle relaxants. The need for respiratory support is reduced. Conclusions: It is a safe and economical technique, sometimes undervalued in the newborn. This, together with a faster recovery, leads to considering regional anesthesia as an alternative over general anesthesia(AU)

Bloqueo caudal más anestesia general balanceada en un paciente con pentalogía de Cantrell, presentación de un caso clínico / Caudal block plus inhaled general anesthesia in a patient with pentalogy of Cantrell, presentation of a clinical case

The pentalogy of Cantrell is a disorder characterized by congenital abnormalities in the abdominal wall, lower sternum, anterior diaphragm, diaphragmatic pericardium, and cardiac anomalies. It is a rare disease with 250 cases registered around the world. The anesthetic implications will require a specialized management given the ventilatory mechanics and cardiac function which are compromised by the disease in the newborn. We present the case of a female patient with pentalogy of Cantrell without prenatal diagnosis, who had an operative procedure to correct patent ductus arteriosus and abdominal mesh placement under balanced general anesthesia with sevoflurane and fentanyl plus caudal block. This case is reported to provide our experience in the anesthetic management of this type of patients.

La pentalogía de Cantrell es una enfermedad caracterizada por anormalidades congénitas de la pared abdominal supraumbilical, esternón inferior, diafragma, pericardio diafragmático y anomalías cardiacas. Se trata de una enfermedad rara con 250 casos registrados alrededor del mundo. Las implicaciones anestésicas requieren de un manejo especializado debido a la mecánica ventilatoria y función cardíaca que se encuentran comprometidas en el recién nacido. Se presenta el caso de una recién nacida portadora de pentalogía de Cantrell, no diagnosticada prenatalmente, quien fue sometida a corrección de ductus arterioso persistente y colocación de malla abdominal bajo anestesia general balanceada con sevofluorano y fentanilo más bloqueo caudal. Se reporta el presente caso para brindar nuestra experiencia en el manejo anestésico de este tipo de pacientes.

Cerebral blood flow alterations associated with high volume caudal block in infants.

BACKGROUND: High-volume (1.5 ml kg-1) caudal block in infants results in major reductions of cerebral blood flow velocity (CBFV) and cerebral oxygenation, caused by rostral CSF movement which increases intracranial pressure. The primary aim of this study was to determine the relationship between injected volume and CBFV changes. We hypothesised that this volume-blood flow relationship would have a similar albeit inverted shape to the well-known intracranial pressure volume-pressure curve. METHODS: Fifteen subjects, age 0-6 months, mean (range) weight 4.9 (2.1-6.4) kg, were studied. A 1.5 ml kg-1 caudal injection of 0.2% ropivacaine was administered in three phases separated by two pauses. Subjects were randomised into five groups, in whom the pauses were implemented at different pre-set proportions of the total injected volume. Middle cerebral artery Doppler ultrasonography was used for CBFV measurements (Vmax, peak CBF velocity; Vmin, lowest CBF velocity; velocity time index). Mean flow velocity, pulsatility index, and resistivity index were calculated, and haemodynamic parameters were recorded. RESULTS: CBFV parameters decreased in all patients. The most affected parameter, Vmin, was reduced by ∼50% (range 15-68%) compared with baseline. There was a nonlinear relationship between the volume of the first phase injection and the CBFV measurement during the first pause. Across all time points, there was a linear relationship between volume administered and CBFV. Systemic haemodynamic parameters remained stable throughout the study. CONCLUSIONS: Injection pauses appear to attenuate adverse CBFV increases during administration of a high-volume caudal block.

Effects of awake caudal anesthesia on mean arterial blood pressure in very low birthweight infants.

BACKGROUND: Intraoperative blood pressure is a relevant variable for postoperative outcome in infants undergoing surgical procedures. It is therefore important to know whether the type of anesthesia has an impact on intraoperative blood pressure management in very low birth weight infants. Here, we retrospectively analyzed intraoperative blood pressure in very low birthweight infants receiving either awake caudal anesthesia without sedation, or caudal block in combination with general anesthesia, both for open inguinal hernia repair. METHODS: Ethical approval was provided by the University of Tuebingen Ethical Committee on 05/29/2018 with the project number 403/2018BO2. Patient records of infants admitted by the neonatologist (median age at birth 31.1 ± 3.5 weeks, median weight at birth 1240 ± 521 g) which were scheduled for inguinal hernia repair were retrospectively evaluated for the course of mean arterial blood pressure and perioperative interventions to stabilize blood pressure. A total of 42 patients were included, 16 patients (11 boys, 5 girls) received awake caudal anesthesia, 26 patients (22 boys, 4 girls) a combination of general anesthesia and caudal block. RESULTS: Approximately 3% of the measured mean arterial blood pressure values in the caudal anesthesia group were below a critical margin of 35 mmHg, in contrast to 47% in the combined anesthesia group (p < 0.001). Patients in the latter group showed a significantly larger drop of mean arterial blood pressure below 35 mmHg (4.7 ± 2.7 mmHg vs. 1.9 ± 1.6 mmHg; p < 0.005) and a significantly longer time of mean arterial blood pressure below 35 mmHg (25.6 ± 26.0 min vs. 0.9 ± 2.3 min; p < 0.001), although they received more volume and vasopressor boluses for stabilization (27 ± 14.8 ml vs. 10 ± 4.1 ml; p < 0.01 and 0.15 ± 0.06 ml vs. 0 ml of cafedrine/theoadrenaline; p < 0.001). CONCLUSIONS: The study indicates that the use of caudal block as stand alone procedure for inguinal hernia repair in very low birthweight infants might be advantageous in preventing critical blood pressure drops compared to a combination of caudal block with general anesthesia.

Caudal block with steroid in the treatment of acute voiding dysfunction and pain caused by sacral herpes zoster: A case report.

RATIONALE: Herpes zoster (HZ) involving sacral dermatome is very rare, which can sometimes cause voiding dysfunction. PATIENT CONCERNS: A 52-year-old man presented with acute pain and voiding dysfunction, following HZ in his right sacral dermatomes. DIAGNOSES: Twenty two days before presentation HZ occurred and 9 days after the onset of the HZ, he had trouble with starting urination and weak urine stream which was managed with tamsulosin 0.4 mg orally once a day and intermittent urinary catheterization. He was treated with 150 mg of pregabalin 2 times a day, tramadol 50 mg 2 times, and acetaminophen 600 mg 2 times a day. However, his pain intensity was 5 on the numerical analogue scale (NRS) from 0 (no pain) to 10 (worst pain imaginable). INTERVENTIONS: Fluoroscopy guided caudal block was performed with a mixture of 0.5% lidocaine 10 mL and triamcinolone 40 mg. OUTCOMES: One day after the procedure, the pain decreased to 1 on the NRS score. In addition, voiding difficulty greatly improved. Three days after the intervention, the patient reported complete resolution of pain and voiding dysfunction. He currently remains symptom free at a 3-month follow-up. LESSONS: A caudal block with steroid can be an effective option for treatment of acute voiding dysfunction and pain following sacral HZ.

Anatomical Evaluation of the Sacral Hiatus Using Ultrasound Imaging: Factors That Inhibit Needle Insertion During Caudal Epidural Block Procedures.

OBJECTIVE: Caudal epidural blocks often fail due to the difficulty of appropriate needle insertion. This study aimed to evaluate the anatomy of the sacral hiatus using ultrasound imaging. METHODS: This was a retrospective study involving 76 patients with spinal disorders. The following factors were analyzed to see if they affected the palpability of the sacral hiatus: sex, body mass index (BMI), and the morphology of the sacral hiatus on ultrasound imaging. The difficulty of needle insertion and the factors that influenced it were investigated in 28 of the 76 patients, who underwent landmark-based caudal epidural block procedures performed by the same doctor. RESULTS: Among the 76 patients, the mean length of the sacral hiatus was 21.3 ± 5.6 mm, the mean distance from the skin to the sacral cornua was 5.2 ± 3.4 mm, and the mean angle of the sacral hiatus was 16.4 ± 5.5 degrees. Sacral base protrusion was present and absent in 35 and 41 cases, respectively. The sacral hiatus exhibited good and poor palpability in 53 and 23 cases, respectively. The mean distance from the skin to the sacral cornua and BMI were found to significantly influence the palpability of the sacral hiatus. Only sacral base protrusion significantly influenced the difficulty of needle insertion. CONCLUSION: The mean distance from the skin to the sacral cornua and BMI were found to be associated with the palpability of the sacral hiatus, and sacral base protrusion was demonstrated to be associated with the difficulty of needle insertion into the sacral hiatus.

Real-Time Ultrasound Improves Accuracy of Caudal Block in Children.

BACKGROUND: Caudal block, the most common regional anesthetic in children, is predominantly performed using palpation to determine placement. The efficacy of the palpation technique is unknown with respect to block success. While ultrasound has been suggested for use during caudal block, its use is infrequent. METHODS: A single-blinded prospective observational trial was performed evaluating provider success rate of caudal blocks placed by palpation alone. After needle insertion and partial local anesthetic injection, an ultrasound was performed to confirm correct location. RESULTS: A total of 109 caudal blocks were performed during the prospective observational study. Success rate for caudal blocks done by palpation alone was 78.9% as confirmed by ultrasound. In 21.1% of caudal blocks, the provider incorrectly judged the needle to be in the caudal space as confirmed with ultrasound. CONCLUSIONS: Real-time ultrasound visualization of local anesthetic injection provides reliable and immediate confirmation during caudal block in children.

Comparison of ultrasound-guided transversus abdominis plane block, quadratus lumborum block, and caudal epidural block for perioperative analgesia in pediatric lower abdominal surgery

Background/aim: Despite different regional anesthesia techniques used to provide intraoperative and postoperative analgesia in pediatric patients, the analgesic effectiveness of peripheral nerve blockades with minimal side effect profiles have not yet been fully determined. We aimed to compare the efficacy of ultrasound-guided transversus abdominis plane (TAP) block, quadratus lumborum (QL) block, and caudal epidural block on perioperative analgesia in pediatric patients aged between 6 months and 14 years who underwent elective unilateral lower abdominal wall surgery. Materials and methods: Ninety-four patients classified under the American Society of Anesthesiologists physical status classification system as ASA I or ASA II were randomly divided into 3 equal groups to perform TAP, QL or Caudal epidural block using 0.25% of bupivacaine solution (0.5 ml kg−1). Results: Postoperative analgesic consumption was highest in the TAP block group (P < 0.05). In the QL block group, Pediatric Objective Pain Scale (POAS) scores were statistically significantly lower after 2 and 4 h (P < 0.05). The length of hospital stay was significantly longer in the caudal block group than the QL block group (P < 0.05). Conclusion: We suggest that analgesia with ultrasound-guided QL block should be considered as an option for perioperative analgesia in pediatric patients undergoing lower abdominal surgery if the expertise and equipment are available.

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

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 métodos. 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

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

Severe lumbar radiculopathy with epidural venous plexus engorgement in a morbidly obese pediatric patient: A case report.

INTRODUCTION: Engorgement of the epidural venous plexus (EVP) is a rare cause of nerve root impingement. Dilated epidural veins cause compression of the thecal sac and spinal nerve roots, leading to lumbar radiculopathy. PATIENT CONCERNS: Here we describe a case of severe lumbar radiculopathy in a 15-year-old morbidly obese boy. DIAGNOSIS: Enhanced lumbar magnetic resonance imaging revealed left sided L1-L2 disc protrusion and engorgement of the lumbar EVP, resulting in narrowing of the thecal sac in the entire lumbar spine. There was no evidence of an intra-abdominal mass, thrombosis of the inferior vena cava, or vascular malformation. INTERVENTIONS: A caudal epidural block was administered under fluoroscopic guidance. The patient reported a 30% reduction in pain intensity for just 1 day. OUTCOMES: The patient has been followed up for 2 years. He continues to take medication, including morphine sulfate 15 mg, gabapentin 300 mg, and oxycodone 20 mg per day. He is on a diet with exercise for weight reduction. CONCLUSION: An engorged EVP should be considered in the differential diagnosis of radiculopathy in morbidly obese patients.

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.