Kiddie-Caudals
Caudal Epidural Analgesia in Everyday Pediatric Practice
Sabine Kost-Byerly, MD, FAAP
Associate Professor and Director, Pediatric Pain Management
Department of Anesthesiology/Critical Care Medicine
Johns Hopkins University, Baltimore, Maryland
Objectives
Upon completion of this lecture, the attendee will be
able to:
• Appreciate the technical aspects of caudal analgesia
• Select appropriate local anesthetic solutions for caudal
analgesia
• Recognize and manage complications of caudal epidural
analgesia
Disclosures
• I have no relevant financial relationships
with manufacturers of any commercial
products or providers of commercial
services discussed in these slides.
Caudal Epidural Analgesia
thoracic
Advantages:
lumbar
caudal
Easy to perform
High success rate
Usually no hemodynamic
changes
Caudal Epidural - Indications
• Surgeries:
– Urologic
– Orthopedic
– general
• Locations:
– lower abdomen
– lower extremities
• Regional Alternatives to
consider:
– Peripheral nerve block
– Truncal block
– Extremity blocks
Anesth Analg
2012;115:1353-64
Demographics for 13,725 patients in the Pediatric
Regional Anesthesia Network (PRAN) database.
Single Injection Caudal Placement by Age by age.
Polaner D M et al. Anesth Analg 2012;115:1353-1364
Caudal Block in Children: Technique
• Position: lateral
decubitus, knees flexed
• Landmarks: sacral
cornuea at sacral hiatus
• Needle position: 45°-60°
angle to coronal plane
• “pop” : piercing the
sacro-coccygeal
membrane
• Reduce angle to 10°-20°
and advance a few mm
Kiddie- Caudal - Single Injection
• Needle:
– 22-g needle
– 22 – g angiocath
• (risk: epidermal-cell graft
tumor – but: no reports)
– 22-g short-beveled,
styletted needle
Caudal Block
Identification of Landmarks
Post sup iliac
spines
Sacral cornu
Caudal Block
Placement of Cannula
Caudal Block in Children
No Touch Technique
Distance to Caudal Space
Location, location…is your needle where it
should be?
Clinical Assessment
Technical Aides
•
• Ultrasound
The “pop” – the sacrococcygeal
membrane
– No visible/palpable subcutaneous
– Experience, assistant
injection
•
The whoosh (air) test
– Risk: patchy block, venous air
embolus
•
The swoosh (NS) test
– Risk: dilution of LA
Tiffterer l et al. Br JAnaesth 2012;108;670-4
Testdose – sometimes the caudal IV is the easiest…
• Aspiration
• Avoid patient simulation
• Dose
– Epinephrine 0.5 mcg/kg
in 0.1 mL/kg of LA
• Continuous ECG monitoring
– T-wave changes >25% increase
– HR increases
– BP increases
• Inject rest of LA dose slowly in
increments
Results:
742 pediatric epidural blocks
644 caudal
284 single caudal injections
42 (5.6%) Intravascular injection
3.8% with single caudal injections
Detection:
6 immediate aspiration of blood
30 HR increases >10 bpm
25 T-wave amplitude increases
29 ECG changes in T-wave or rhythm
Amide Local Anesthetics
• Lidocaine
• Sodium channel blockers
• Protein binding
– 65% (lido.)
– 95% (bupiv., ropiv.)
• Bupivacaine
– Α1 acid glycoproteine (AAA), albumin
• Neonate low AAA: ↑ free fraction of LA
• Metabolism:
– cytochrome P450 system
• Ropivacaine
• CYP3A4 for bupivacaine and lidocaine
– Bupiv. at 1 mo 1/3 of adult, at 6 mo 2/3
• CYP1A2 for ropivacaine
– Max for ropiv not reached till age 5
Choice of LA
Bupivacaine:
Ropivacaine:
• Slower onset, longer duration
• Cardiac toxicity>CNS toxicity
• Duration similar
• Less motor block at lower
concentrations
• Less toxicity
• Single dose
– 1 mL/kg of 0.25% bupivacaine
– max <2.5 mg/kg
• “Ideal”: concentration
– 0.125 - 0.175% comparable
duration of analgesia, less
motor block
• Single dose
– 1 mL/kg 0.2% ropivacaine
Choice of LA
Lidocaine:
Chloroprocaine:
• Short onset, medium duration
• CNS toxicity>cardiac toxicity
• Short onset, short duration
• Advantageous toxicity profile
• Single dose
• Single dose
– up to 5-7 mg/kg
– up to 14 mg/kg - or more
Epidural Additives – improved and prolonged analgesia
The Common
The Rare
Opioids
• Continued concerns of safety
• Inpatients only
– Fentanyl
2 mc/kg
– Morphine 12-50 mcg/kg
• Pruritis, emesis, respiratory depression
Clonidine
for neuroaxial use:
– preservative, ph, neurotoxicity
• Ketamine 0.25 – 1 mg/kg
• Neostigmine 2 mcg/kg
– Emesis common
• Alpha -2-agonist
• Midazolam 50 mcg/kg
• Single dose
• Dexmedetomidine
1-2 mcg/kg
– Risk: bradycardia, apnea in young
infants
– Increasing sedation with higher doses
2mcg/kg
– Analgesia similar to
clonidine
• Tramadol 2 mg/kg
1-
Caudal single Injection – Volume
• Correlation between cranial level and volume
• Exact prediction of level not possible
• Volumes < 1 ml/kg not likely to reach higher than L2
• Speed of injection does not matter
Brenner L et al. Br J Anaeth 2011; 107:229-35;
Tiffterer l et al. Br JAnaesth 2012;108;670-4
Thomas L< et al. Paediatr Anaesth 2010;11:1017-21
• Volume for injection:
– 0.5 ml/kg for perineal surgery
– 1.0 ml/kg for lower abdominal surgery
– 1.25 ml/kg for upper abdominal surgery
Volume versus Concentration
• RCT
• Bupivacaine with epi O.8 mL/kg 0.25% B vs 1 ml/kg 0.2 % B
• Lower GA requirement with higher volume
• Maybe better postop analgesia with higher volume
Vergehese ST et al. Anesth Analg 2002;95:1219-23
Complications
Common:
Rare, but serious
• Pruritis
• Systemic toxicity
• Nausea & emesis
• Sedation
• Urinary retention
– Inadvertent IV injection
• Overdose
– Inadvertent IT injection
• Infection/Hematoma/Neuro
pathy
Risk of Systemic LA Toxicity
Pediatric Anesthesia 2010;20:1061-1069
• 10,098 epidurals
– 8493 caudals
– 7 with transient ECG changes – no treatment
ASRA Recommendations – Prevention of LAST
Neal JM et al. Reg Anesth Pain Med 2010;35:152-61
• Lowest effective dose of local anesthetic
• Incremental injection of local anesthetics
• Aspirate the needle or catheter before each injection
• Use of an intravascular marker (epinephrine) is recommended.
• Ultrasound guidance may reduce frequency of intravascular
injection
– Effectiveness remains to be determined
ASRA - recommended LAST -Management
Neal JM et al. Reg Anesth Pain Med 2010;35: 152-61
•
ABC’s
•
Seizures:
•
–
Benzodiazepines, small dose propofol – avoid large dose propofol for risk of CV compromise
–
Succhinylcholine or other NDMB , small doses to minimize acidosis and hypoxemia
Cardiac arrest
Lipid emulsion therapy
– ACLS , but
Consider administering at the first signs of LAST, after airway management
•
epinephrine - small initial doses (10mcg to 100 mcg boluses in the adult) preferred
•
Vasopressin not recommended
1.5• mL/kg
20% lipid emulsion bolus
Calcium channel blockers and A-adrenergic receptor blockers – avoid
0.25
per
minutearrhythmias,
of infusion,
continued
for at(lidocaine
least or
10procainamide)
mins after
• mL/kg
Amiodorone
for ventricular
treatment
with local anesthetics
not
recommended
circulatory
stability is attained
–
Lipid emulsion therapy -Consider administering at the first signs of LAST, after airway management
• 1.5 mL/kg
20% lipid emulsion
bolus
Consider
rebolus
if circulatory
stability is not attained and increase infusion to
0.25 mL/kg
perminute
minute of infusion,
continued
for at least
10 mins
after circulatory
stability30
is attained
0.5• mL/kg
per
(up to
10 mL/kg
lipid
emulsion
within
mins)
•
Consider rebolus if circulatory stability is not attained and increase infusion to 0.5 mL/kg per minute (up to 10 mL/kg
lipid emulsion within 30 mins)
Propofol
is not a substitute for lipid emulsion
–
–
Propofol is not a substitute for lipid emulsion
Cardiopulmonary bypass
•
failure to respond to lipid emulsion and vasopressor therapy
•
notify the closest facility capable of providing it when CV compromise is first identified during an episode of LAST.
Intralipid for LA-induced Cardiotoxicity in infants
•
2-day-old 3.2 kg term infant
– Caudal, 1 mL/kg 0.25% bupivacaine, with US guidance and confirmation
– VT, cardiovascular collapse
– 20% Intralipid 1 ml/kg – recovery
Lin EP et al. Pediatric Anesthesia 2010;
20:955-7
•
40-day-old, 4.96 kg infant
– Caudal, 0.9 mL/kg 0.25% bupivacaine
– Tachycardia, T-wave inversion hypotension
– Epinephrine 2 mcg/kg x2, 20mL 55 albumin – no change
– 20% Intralipid 2 ml/kg – recovery
Shah S et al. J Anesth 2009; 23:430-41
Adverse Events
and Complications
TD
DP
VP
AB
FB
C
R
N
Other
Total
Events
Total
Procedures
%
Caudal
18
5
38
71
26
1
0
0
13
172
6011
(97%)
2.9
Lumbar
0
2
0
2
0
0
0
0
1
5
103
4.9
Thoracic
0
1
0
1
0
0
0
0
0
2
13
15.4
Subarachnoid
/
/
0
2
2
1
0
0
1
6
83
7.2
Total
18
7
38
76
28
2
0
0
15
184
6210
3.0
TD:
DP:
VP:
AB:
FB:
C:
R:
N:
positive test dose
dural puncture
vascular puncture
abandoned block
failed block
cardiovascular
respiratory
neurological
NO significant complications in caudal group!
93% of caudal blocks placed without technical
aids or imaging
3% with ultrasound guidance
Summary
Caudal anesthesia and analgesia is:
• An easy technique to supplement general anesthesia
• Requires few resources
• Easy to learn
• Provides several hours of postoperative analgesia
• Is overall a very safe analgesic technique
Thank You
Questions?