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LETTER TO EDITOR
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 149-151

New technique for caudal epidural block in pediatric patients


Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt

Date of Submission29-Jul-2014
Date of Acceptance27-Oct-2014
Date of Web Publication17-Mar-2016

Correspondence Address:
Abdelaziz A Abdelaziz
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.178898

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  Abstract 

Caudal block is one of the most popular and effective techniques of regional anesthesia in pediatric surgery. Good anatomic knowledge and accurate adherence to guidelines pertaining to the technique and to drug administration is necessary to perform this block safely. The usual approach is well-known and has been extensively described, but failure is seen in some cases. Another approach is the 'no turn' technique, which is a new method developed in the Ain-Shams University, Pediatric Surgical Unit by the author. It has a high success rate and can be easily learned and implemented even by junior staff.

Keywords: caudal block, new technique, pediatric


How to cite this article:
Abdelaziz AA. New technique for caudal epidural block in pediatric patients . Ain-Shams J Anaesthesiol 2016;9:149-51

How to cite this URL:
Abdelaziz AA. New technique for caudal epidural block in pediatric patients . Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2019 Sep 18];9:149-51. Available from: http://www.asja.eg.net/text.asp?2016/9/1/149/178898


  Introduction Top


Caudal epidural block is the most common technique for regional anesthesia among pediatric patients. It is commonly used to augment general anesthesia and to manage postoperative pain. Effective postoperative pain relief from caudal analgesia has numerous benefits, including earlier ambulation, reduced time spent in a catabolic state, lowered circulating stress hormone levels, and decreased need for postoperative analgesics including narcotics. Therefore, it is widely used for the management of pediatric day-case surgeries [1],[2],[3] .

To perform the block safely good knowledge of anatomy and accurate adherence to the steps of the technique and to drug administration is necessary.

The common technique of caudal block is well-known and often described but in some cases is not without risks. The new technique is a very easy approach, with fewer complications and lower failure rate and can be taught even to junior staff [4] .


  Anatomical considerations Top


Significant anatomic differences between adults and children should be considered when performing the caudal block. The sacrum of children is more narrow and flat compared with that of adults. At birth, the sacrum, which is formed of five sacral vertebrae, is not completely ossified and continues to fuse until 8 years of age. The incomplete fusion of the posterior arches of the fifth and sometimes the fourth sacral vertebrae forms the sacral hiatus, which is covered by a ligamentous membrane called the sacrococcygeal membrane [Figure 1]. The caudal epidural space can be accessed easily in infants and children through the sacral hiatus. The termination of the dural sac ascends from S3/S4 at birth to S2 by 3 years; therefore, caution is warranted when placing caudal blocks in infants because of the risk of accidental dural puncture. Sacral anomalies are found in 3-5% of individuals and can result in reduced distance from the sacral hiatus to the sacral sac. To identify the sacral hiatus, we can palpate the sacral cornua and the indentation that is a bit caudal and midline to the cornua, or locate the two posterior superior iliac spines and draw a line between them assuming this to be the base of an equilateral triangle. The apex of the triangle can be considered an approximation of the sacral hiatus+ [Figure 2] [5],[6],[7] .
Figure 1: Anatomy of the sacrum

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Figure 2: Anatomical landmark of the sacral hiatus

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Technique

There are two well-known techniques for performing a caudal epidural block: the common technique and the no turn technique.

In the common technique, the needle is inserted at a 90° angle to the cutaneous plane and, after passing the sacrococcygeal membrane, is lowered 30° and then advanced several millimeters into the sacral canal.

In the no turn technique [8] the needle is inserted at a 60° angle to the sacral plane instead of 90°, in the midline at the apex of the sacral hiatus, after crossing the sacrococcygeal ligament. The needle does not have to be advanced because the bevel (facing anteriorly) is at the beginning of the sacral canal and already within the epidural space.

In our new and easy technique, the sacral hiatus is first identified and the left index finger is placed over it (if the doctor is right handed) [Figure 3]. The needle is then inserted caudally 1-1.5 cm from the hiatus [Figure 4], introduced into the subcutaneous tissue, and advanced subcutaneously until the needle tip is felt by the left index finger.
Figure 3: Identification of the sacral hiatus by the left index finger

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Figure 4: Needle insertion 0.5– 1 cm from the sacral hiatus

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The needle is then raised 15°-30° and advanced slowly until loss of resistance is felt. Thereafter, the needle is advanced not more than 0.5 cm. An aspiration test is performed to avoid inadvertent intrathecal or intravascular injection of local anesthetics. The local anesthetic is injected slowly and the sacral area is inspected for inadvertent subcutaneous injection [Figure 5].
Figure 5: Local anesthetic injection

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Continuous caudal block can be achieved by placing the connection line (arterial line) to the cannula for intraoperative analgesia; a poster dose can be given before removing the cannula postoperatively [Figure 6].
Figure 6: Continuous caudal block

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This technique guarantees that no subcutaneous injection will be required, because the left index finger is placed over the hiatus, and for subcutaneous injection the needle should pass completely under the index finger, which will be easily felt because the skin and subcutaneous tissues in pediatric patients are very thin.

We can use traditional 22 G needles, spinal needles, Tuohy needles, 22 G intravenous cannulae, or 22 G arterial cannulae.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success rate and adverse effects in 750 consecutive patients. Anesth Analg 1989; 68:83-89.  Back to cited text no. 1
    
2.
Gunther J. Caudal anesthesia in children. A survey. Anesthesiology 1991; 75:A936.  Back to cited text no. 2
    
3.
Broadman L, Ivani G. Caudal block. Tech Reg Anesth Pain Manage 1999; 3:150-156.  Back to cited text no. 3
    
4.
Ivani G. Paediatric regional anaesthesia. A practical approach. Florence, Italy: SEE Editrice; 2001.   Back to cited text no. 4
    
5.
Adewale L, Dearlove O, Wilson B, Hindle K, Robinson DN. The caudal canal in children: a study using magnetic resonance. Paediatr Anaesth 2000; 10:137-141.  Back to cited text no. 5
    
6.
Bosenberg AT, Wiersma R, Hadley GP. Oesophageal atresia: caudothoracic epidural anesthesia reduces the need for postoperative ventilatory support. Pediatr Surg Int 1992; 7:289-291.  Back to cited text no. 6
    
7.
Gunter JB, Eng C. Thoracic epidural anesthesia via the caudal approach in children. Anesthesiology 1992; 76:935-938.  Back to cited text no. 7
    
8.
Ivani G, De Negri P. Techniques in Regional Anesthesia and Pain Management, 2002;6:136-140.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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