#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Current opinion on caudal epidural blockade and its complications in children


Authors: J. Šípek;  V. Mixa
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny 2. LF UK a FN v Motole, Praha
Published in: Anest. intenziv. Med., 27, 2016, č. 2, s. 78-86
Category:

Editor rubriky: Vladimír Mixa

Overview

Caudal block is a type of neuroaxial block (single shot or continuous), in which the local anesthetic is injected through the sacrococcygeal membrane into the caudal epidural area of the spinal canal. It provides analgesia which is important not just in the perioperative but mainly in the postoperative period. The single shot technique is more commonly used in paediatric anesthesia especially due to its very simple performance and low occurrence of complications. The complications include failure, infection or adverse effects of the local anaesthetics or their additives.

The continuous caudal block has higher occurrence of complications caused by the misplacement of the catheter, incorrect dosage or poor postoperative care of the catheter on the ward. Recently there have been increasing voices recommending the abandoning of the continuous caudal, especially the caudo-lumbar and caudo-thoracic blocks, and their replacement by peripheral nerve blocks.

Keywords:
single-shot caudal blocks – continuous caudal blocks – complications of epidural analgesia – paediatric anesthesia – epidural catheter


Sources

1. Jöhr, M., Berger, T. M. Regional anaesthetic techniques for neonatal surgery: indications and selection of technice. Best Pract. Res. Clin. Anaesthesiol., 2004, 18, p. 357–375.

2. Bozza, P., Morini, F., Conforti, A. Stress and ano-colorectal surgery in newborn/infant: role of anesthesia. Pediatr. Surg. Int., 2012, 28, p. 821–824.

3. Bösenberg, A. T., Jöhr, M., Wolf, A. R. Pro con debate: the use of regional vs systemic analgesia for neonatal surgery. Paediatr. Anaesth., 2011, 21, p. 1247–1258.

4. Lees, D., Frawley, G., Taghavi, K. et al. A review of the surface and internal anatomy of the caudal canal in children. Pediat. Anesth., 2014, p. 799–805.

5. Shin, S. K., Hong, J. Y., Kim, W. O. et al. Ultrasound evaluation of the sacral area and comparison of sacral interspinous and hiatal approach for caudal block in children. Anesthesiology, 2009, 111, p. 1135–1140.

6. Barson, A. J. The vertebral level of terminativ of the spinal cord during normal and abnormal development. J. Anat., 1970, 106, Pt 3, p. 489–493.

7. Porzionato, A., Macchi, V., Parenti, A. et al. Surgical anatomy of the sacral hiatus for caudal access to the spinal canal. Acta Neurochir. Suppl., 2011, 108, p. 1–3.

8. Senoglu, N., Senoglu, M., Oksuz, H. et al. Landmarks of the sacral hiatus for caudal epidural block: an anatomical study. Br. J. Anaesth., 2005, 5, p. 692–695.

9. Edler, A., Wellis, V. Caudal Epidural Anaesthesia for Paediatric Patients. World Federation of Societies of Anaesthesiologists, 2003. Dostupné na www: http://update.anaesthesiologists.org/

10. Adewale, L., Dearlove, O., Wilson, B. et al. The caudal canal in children: A study using magnetic resonance imaging. Paediatr. Anaesth., 2000, 10, p. 137–141.

11. Aggarwal, A., Sahni, D., Kaur, H. et al. The caudal space in in fetuses: an anatomical study. J. Anesth., 2012, 26, p. 206–212.

12. Triffterer, L., Machata, A. M., Latzke, D. et al. Ultrasound assessment of cranial spread during caudal blockade in children: effect of the speed of injection of local anaesthetics. Br. J. Anaesth. [Randomized Controlled Trial], 2012, 108, p. 670–674.

13. Lundblad, M., Forestier, J., Marhofer, D. et al. Reduction of cerebral mean blood flow velocity and oxygenation after high-volume (1.5 ml kg(-)(1)) caudal blocks in infants. Br. J. Anaesth., 2014, 113, p. 688–694.

14. Schuepfer, G., Konrad, C., Chmeck, J. et al. Generating a learning curve for pediatric caudal epidural blocks; An empirical evaluation of technical skills in novice and experienced anesthetists. Reg. Anesth. and P. Med., 2000, 25, 4, p. 385–388.

15. Santhanam, S., Long, J., Birmingham, P. K. et al. Are Caudal Blocks for Pain Control Safe in Children? An Analysis of 18,650 Caudal Blocks from the Pediatric Regional Anesthesia Network (PRAN) Database. Analg. Anesth. Jan., 2015, 120, 1, p. 151–156. Dostupné na www: www.anesthesia-analgesia.org.

16. Birmin Park, J, Koo, B. N., Kim, J. et al. Determination of the optimal angle for the needle insertion during caudal block in children using ultrasound imaging. Anaesthesia, 2006, 61, p. 946–949.

17. Koo, B. N., Hong, J. Y., Kim, J. E. et al. The effect of flexion on the level of termination of the dural sac in paediatric patients. Anesthesia, 2009, 64, p. 1072–1076.

18. Shin, K., Park, J., Kil, H. et al. Caudal epidural in children: comparison of needle insertion parallel with caudal canal versus conventional two-step technique. Anaesth. Intensive Care, 2010, 38, p. 525–529.

19. Jöhr, M. Regional anaesthesia in neonates, infants and children. Eur. J. Anaesthesiol., 2015, 32, p. 289–297.

20. Broadman, L. M. Where should advocacy for pediatric patients end and concerns for patient safety begin. Reg. Anesth., 1997, 22, p. 205–208.

21. Batnitzky, S., Keucher, T. R., Mealey, J. et al. Iatrogenic intraspinal epidermoid tumors. JAMA, 1977, 237, p. 148–150.

22. Guldogus, F., Baris, Y. S., Baris, S. et al. Comparing tissue coring, 25, p. 498–501.

23. Moriarty, A. Pediatric epidural analgesia (PEA). Pediatr. Anesth., 2012, 22, p. 51–55.

24. Giaufre´, E., Dalens, B., Gombert, A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth. Analg., 1996, 83, p. 904–912.

25. Guinard, J. P., Borboen, M. Probable venous air embolism during caudal anesthesia in a child. Anesth. Analg., 1993, 76, p. 1134–1135.

26. Sethna, N. F., Berde, C. B. Venous air embolism during identification of the epidural space in children [editorial]. Anesth. Analg., 1993, 76, p. 925–927.

27. Schwartz, N., Eisenkraft, J. B. Probable venous air embolism during epidural placement in an infant. Anesth. Analg., 1993, 76, p. 1136–1138.

28. Tsui, B. C., Seal, R., Koller, J. Thoracic epidural placement via the caudal approach in infants by using electrocardiographic guidance. Anesth. Analg., 2002, 95, p. 326–330.

29. Rapp, H. J., Folger, A., Grau, T. Ultrasoundguided epidural catheter insertion in children. Anesth. Analg., 2005, 101, p. 333–339.

30. Polaner, D. M., Andreas, H. T., Benjamin, J. W. et al. Pediatric Regional Anesthesia Network (PRAN): A Multi-Institutional Study of the Use and Incidence of Complications of Pediatric Regional Anesthesia. Analg. Anesth., 2012, 115, 6, p. 1353–1364.

31. Kasai, T., Yaegashi, K., Hirose, M. et al. Spinal cord injury in a child caused by an accidental dural puncture with a single-shot thoracic epidural needle. Anesthesia and Analgesia, 2003, 96, 1, p. 65–e67.

32. Allison, C. E., Aronson, D. C., Geukers, V. G. et al. Paraplegia after thoracotomy under combined general and epidural anesthesia in a child. Paediatric Anaesthesia, 2008, 18, 6, p. 539–542.

33. Bösenberg, A. T., Bland, B. A., Schulte-Steinberg, O. et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology, 1988, 69, 2, p. 265–e269.

34. Bösenberg, A. T., Wiersma, R., Hadley, G. P. Oesophageal atresia: caudo-thoracic epidural anesthesia reduces theneed for post-operative ventilatory support. Pediatric Surgery International, 1992, 7, p. 289–291.

35. Lönnqvist, P. A. Regional anaesthesia and analgesia in the neonate. Best Pract & Research Clin. Anaesth., 2010, 24, p. 309–321.

36. Breschan, C., Krumpholz, R., Jost, R. et al. Intraspinalhaematoma following lumbar epidural anaesthesia in a neonate. Paediatric Anaesthesia, 2001, 11, p. 105–108.

37. Flandin-Ble´ty, C., Barrier, G. Accidents following extradural analgesia in children. The results of a retrospective study. Paediatric Anaesthesia, 1995, 5, p. 41–46.

38. Gunter, J. B. Benefit and Risks of Local Anesthetics in Infants and Children. Pediatr. Drugs, 2002, 4, 10, p. 649–672.

39. Finster, M. Toxicity of local anesthetics in the fetus and newborn. Bull NY Acad. Med., 1976, 52, p. 222–225.

40. Arthur, D. S., McNicol, L. R. Local anaesthetic techniques in paediatric surgery. Br. J. Anaesth., 1986, 58, p. 760–778.

41. Chalkiadis, G. A., Anderson, B. J., Tay, M. A. et al. Pharmacokinetics of levobupivacaine after caudal epidural administration in infants less than 3 months of age. Brt. J. Anaesth., 2005, 95, 4, p. 524–529.

42. Anderson, B. J., Hansen, T. G. Getting the best from pediatric pharmacokinetic data. Paediatr. Anaesth., 2004, 14, p. 713–715.

43. Lerman, J., Strong, H. A., LeDez, K. M. et al. Effects of age on the serum concentration of α1-acid glycoprotein and the binding of lidocaine in pediatric patients. Clin. Pharmacol. Ther., 1989, 46, p. 219–225.

44. Reiz, S., Nath, S. Cardiotoxicity of local anaesthetic agents. British Journal of Anaesthesia, 1986, 58, p. 736–746.

45. Knudsen, K., Suurkula, M. B., Blomberg, S. et al. Central nervous and cardiovascular effects of i.v. infusion of ropivacaine, bupivacaine and placebo in volunteers. Br. J. Anaesth., 1997, 78, p. 507–514.

46. Leone, S., Di Cianni, S., Casati, A. et al. Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed., 2008, 79, p. 92–105.

47. Badgwell, J. M., Heavner, J. E., Kytta, J. Bupivacaine toxicity in young pigs is age dependent and is affected by volatile anesthetics. Anesthesiology, 1990, 73, p. 297–303.

48. Ved, S. A., Pinosky, M., Nicodemus, H. Ventricular tachycardia and brief cardiovascular collapse in two infants after caudal anesthesia using a bupivacaine epinephrine solution. Anesthesiology, 1993, 79, p. 1121–1123.

49. Clarkson, C. W., Hondeghem, L. M. Mechanism for bupivacaine depression of cardiac conduction: fast block of sodium channels during the action potential with slow recovery from block during diastole. Anesthesiology, 1985, 62, p. 396–405.

50. Arlock, P. Actions of three local anesthetics: lidocaine, bupivacaine and ropivacaine on guinea pig papillary muscle sodium channels (Vmax). Pharmacol. Toxicol., 1988, 63, p. 96– 104.

51. Gristwood, R. W. Cardiac and CNS toxicity of levobupivacaine: strengths of evidence for advantage over bupivacaine. Drug Saf, 2002, 25, p. 153–163.

52. Avery, P., Redon, D., Schaenzer, G. et al. The influence of serum potassium on cerebral and cardiac toxicity of bupivacaine and lidocaine. Anesthesiology, 1984, 61, p. 134–138.

53. Moller, R., Covino, B. G. Cardiac electrophysiologic properties of bupivacaine and lidocaine compared with those of ropivacaine, a new amide local anesthetic. Anesthesiology, 1990, 72, 2, p. 322–329.

54. Albright, G. A. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology, 1979, 51, p. 285–287.

55. Marx, G. F. Cardiotoxicity of local anesthetics – The plot thickens. Anesthesiology, 1984, 60, p. 3–5.

56. Lee, E. J. D., Williams, K. M. Chirality. Clinical phar­macokinetic and pharmacodynamic considera­tions. Clin. Pharmacokinet., 1990, 18, p. 339–345.

57. Thomas, J. M., Schug, S. A. Recent advances in the pharmacokinetics of local anaesthetics. Long-acting amide enantiomers and continuous infusi­ons. Clin. Pharmacokinet., 199, 36, 1, p. 67–83.

58. Koch, T., Fichtner, A., Schwemmer, U. et al. Levobupivacaine for epidural anaesthesia and postoperative analgesia in hip surgery. Anaesthesist, 2008, 57, p. 475–482.

59. Aberg, G. Toxicological and local anesthetic effects of optically active isomers of two local anesthetic compounds. Acta Pharmacol. Toxicol. Scand., 1972, 31, p. 273–286.

60. Vanhoutte, F., Vereecke, J., Verbeke, N., Carmeliet, E. Stereoselective effects of the enantiomers of bupivacaine on the electrophysiological proper­ties of the guinea-pig papillary muscle. Br. J. Phar­macol., 1991, 103, p. 1275–1281.

61. Royse Colin, F., Royse Alistair, G. The Myocardial and Vascular Effects of Bupivacaine, Levobupivacaine, and Ropivacaine Using Pressure Volume Loops. Anesth. Analg., 2005, 101, p. 679–687.

62. Llewellyn, N., Moriarty, A. The National Pediatric Epidural Audit. Pediatric. Anesthesia, 2007, 17, p. 520–533.

63. Ecoffey, C., Lacroix, F., Giaufré, E. et al. Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). Pediatr. Anesth., 2010, 20, p. 1061–1069.

64. Lonnqvist, P. A. Adjuncts should be always used in pediatric regional anesthesia. Pediatric Anesthesia, 2015, 25, p. 100–106.

65. de Beer, D. A. H., Thomas, M. L. Caudal additives in children – solutions or problems? Br. J. of Anaesth., 2003, 90, 4, p. 487–498.

66. Luz, G., Innerhofer, P., Haussler, B. et al. Comparison of ropivacaine 0.1% and 0.2% with bupivacaine 0.2% for single-shot caudal anaesthesia in children. Paediatr. Anaesth., 2000, 10, p. 499–504.

67. Ivani, G., De Negri, P., Conio, A. et al. Ropivacaine-clonidine combination for caudal blockade in children. Acta Anaesthesiol. Scand., 2000, 44, p. 446–449.

68. Sanders, J. C. Paediatric regional anaesthesia. A survey of practice in the United Kingdom. Br. J. Anaesth., 2002, 89, p. 707–710.

69. Eich, C., Strauss, J. Prompt and powerful effect of a practice guideline on caudal additives. Pediatr. Anesth., 2009, 19, p. 271–272.

70. Abdulatif, M., El-Sanabary, M. Caudal neostigmine, bupivacaine, and their combination for postoperative pain management after hypospadias surgery in children. Anesth. Analg., 2002, 95, p. 1215–1218.

71. Almenrader, N., Passariello, M., D’Amica, G. et al. Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine. Pediatr. Anesth., 2005, 15, p. 143–147.

72. Khan, F. A., Memon, G. A., Kamal, R. S. Effect of route of buprenorphine on recovery and postoperative analgesic requirerement in paeditric patiens. Pediatr. Anaesth., 2002, 12, p. 786–790.

73. Erol, A., Tavlan, A., Tuncer, S. et al. Caudal anesthesia for minor subumbilical pediatric surgery: A comparison of levobupivacaine alone and levobupivacaine plus sufentanil. Journal of Clinical Anesthesia, 2008, 20, p. 442–446.

74. De Mey, J. C., Strobbet, J., Poelaert, J. et al. The influence of sufentanil and/or clonidine on the duration of analgesia after a caudal block for hypospadias repair surgery in children. Eur. J. Anaesthesiol., 2000, 17, p. 379–382.

75. Lönnqvist, P. A. Adjuncts to caudal block in children-Quo vadis? Br. J. Anaesthesiol., 2005, 95, 4, p. 431–433.

76. Fares, K. M., Othman, A. H., Alieldin, N. H. Efficacy and Safety of Dexmedetomidine Added to Caudal Bupivacaine in Pediatric Major Abdominal Cancer Surgery. Pain Physician, 2014, 17, p. 393–400.

77. Tong, Y., Ren, H., Ding, X. et al. Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: a meta-analysis. Pediatric Anesthesia, 2014, 24, p. 1224–1230.

78. Lonnqvist, P. A., Ivani, G., Moriarty, T. Use of caudal epidural opioids in children: still state of the art or the beginning of the end? Paediatr. Anaesth., 2002, 12, p. 747–749.

79. Lönnqvist, P. A., Walker, S. M. Ketamine as an adjunct to caudal block in neonates and infants: is it time to re-evaluate? Br. J., 109, p. 138–140.

80. Green, S. M., Coté, C. J. Ketamine and neurotoxicity: clinical perspectives and implications for emergency medicine. Ann. Emerg. Med., 2009, 54, 2, p. 181–190.

81. Kopacz, D. J., Helman, J. D., Nussbaum, C. E. et al. A comparison of epidural levobupivacaine 0.5% with or without epinephrine for lumbar spine surgery. Anesth. Analg., 2001, 93, p. 755–760.

82. Hlavin, M. L., Kaminski, H. J., Ross, J. S. et al. Spinal epidural abscess: a ten year perspective. Neurosurgery, 1990, 27, p. 177–184.

83. Baker, A. S., Ojemann, R. G., Swartz, M. N. et al. Spinal epidural abscess. N. Engl. J. Med., 1975, 293, p. 463–468.

84. Philips, J. M. G., Stedeford, J. C., Hartsilver, E. et al. Epidural abscess complicating insertion of epidural catheters. Br. J. Anaesth., 2002, 89, p. 778–782.

85. Sethna, N. F., Clendenin, D., Athiraman, U. et al. Incidence of Epidural Catheter-associated Infections after Continuous Epidural Analgesia in Children. Anesthesiology, 2010, 113, p. 224 –232.

86. Kost-Byerly, S., Tobin, J. R., Greenberg, R. S. et al. Bacterial colonization and infection rate of continuous epidural catheters in children. Anesth. Analg., 1998, 86, p. 712–716.

87. McNeely, J. K., Trentadue, N. C., Rusy, L. M. et al. Culture of bacteria from lumbar and caudal epidural catheters used for postoperative analgesia in children. Reg. Anesth., 1997, 22, p. 428 –431.

88. Christie, I. W., McCabe, S. Major complications of epidural analgesia after surgery. Results of a six-year survey. Anaesthesia, 2007, 62, p. 335–341.

89. Seth, N., Macqueen, S., Howard, R. F. Clinical signs of infection during continuous postoperative epidural analgesia in children.The value of catheter tip culture. Paediatr. Anaesth., 2004, 14, p. 996 –1000.

90. Baker, A. S., Ojemann, R. G., Swartz, M. N. et al. Spinal epidural abscess. N. Engl. J. Med., 1975, 293, p. 463–468.

91. Darchy, B., Forceville, X., Bavoux, E. et al. Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit. Anesthesiology, 1996, 85, p. 988–998.

92. Hebl, J. R. The Importance and Implications of Aseptic Techniques During Regional Anesthesia. Reg. Anesth. and Pain Med., 2006, 31, 4, p. 311–323.

93. Fan, S. T., Teoh-Chan, C. H., Lau, K. F. et al. Predictive value of surveillance skin and hub cultures in central venous catheters sepsis. J. Hosp. Infect., 1988, 12, p. 191–198.

94. Bjornson, H. S., Colley, R., Bower, R. H. et al. Association between microorganism growth at the catheter site and colonization of the catheter in patients receiving total parenteral nutrition. Surgery, 1982, 92, p. 720–727.

95. Kinirons, B., Mimoz, O., Lafendi, L. et al. Chlorhexidine versus povidone iodine in preventiv colonization of continuous epidural catheters in children: A randomized, controlled trial. Anesth., 2001, 94, p. 239 –244.

96. Rosen, K. R., Rosen, D. A. Caudal epidural morphine for control of pain following open heart surgery in children. Anesthesiology, 1989, 70, p. 418–426.

97. Lerman, J., Nolan, J.,Eyres, R. et al. Efficacy, Safety and Pharmacokinetics of Levobupivacaine with and without Fentanyl after Continuous Epidural Infusion in Children A Multicenter Trial. Anesth., 2003, 99, p. 1166–1174.

98. De Negri, P., Ivani, G., Visconti, C. et al. The dose-response relationship for clonidine added to a postoperative continuous epidural infusion of ropivacaine in children. Anesth. Analg., 2001, 93, p. 71–76.

Labels
Anaesthesiology, Resuscitation and Inten Intensive Care Medicine
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#