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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. - PowerPoint PPT Presentation
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Kiddie-CaudalsCaudal Epidural Analgesia in Everyday Pediatric
Practice
Sabine Kost-Byerly, MD, FAAPAssociate 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
caudal
lumbar
thoracic Advantages:
Easy to performHigh success rateUsually 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
Demographics for 13,725 patients in the Pediatric Regional Anesthesia Network (PRAN) database.
Anesth Analg 2012;115:1353-64
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 BlockIdentification of Landmarks
Post sup iliac
spines
Sacral cornu
Caudal BlockPlacement of Cannula
Caudal Block in ChildrenNo Touch Technique Distance to Caudal Space
Location, location…is your needle where it should be?
Clinical Assessment
• The “pop” – the sacrococcygeal membrane
– No visible/palpable subcutaneous injection
• The whoosh (air) test– Risk: patchy block, venous air
embolus
• The swoosh (NS) test– Risk: dilution of LA
Technical Aides
• Ultrasound– Experience, assistant
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 blood30 HR increases >10 bpm25 T-wave amplitude increases29 ECG changes in T-wave or rhythm
Amide Local Anesthetics• Lidocaine
• Bupivacaine
• Ropivacaine
• Sodium channel blockers
• Protein binding– 65% (lido.)– 95% (bupiv., ropiv.)
– Α1 acid glycoproteine (AAA), albumin• Neonate low AAA: ↑ free fraction of LA
• Metabolism:– cytochrome P450 system
• 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 LABupivacaine:• Slower onset, longer
duration• Cardiac toxicity>CNS
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
Ropivacaine:• Duration similar• Less motor block at
lower concentrations• Less toxicity
• Single dose– 1 mL/kg 0.2% ropivacaine
Choice of LALidocaine:
• Short onset, medium duration
• CNS toxicity>cardiac toxicity
• Single dose– up to 5-7 mg/kg
Chloroprocaine:
• Short onset, short duration• Advantageous toxicity
profile
• Single dose– up to 14 mg/kg - or more
Epidural Additives – improved and prolonged analgesia
The Common
Opioids• Inpatients only
– Fentanyl 2 mc/kg– Morphine 12-50 mcg/kg
• Pruritis, emesis, respiratory depression
Clonidine• Alpha -2-agonist• Single dose 1-2 mcg/kg
– Risk: bradycardia, apnea in young infants
– Increasing sedation with higher doses
The Rare
• Continued concerns of safety for neuroaxial use:– preservative, ph, neurotoxicity
• Ketamine 0.25 – 1 mg/kg• Neostigmine 2 mcg/kg
– Emesis common
• Midazolam 50 mcg/kg• Dexmedetomidine 1-
2mcg/kg– Analgesia similar to clonidine
• Tramadol 2 mg/kg
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
ComplicationsCommon:
• Pruritis• Nausea & emesis• Sedation• Urinary retention
Rare, but serious
• Systemic toxicity– Inadvertent IV injection
• Overdose– Inadvertent IT injection
• Infection/Hematoma/Neuropathy
Risk of Systemic LA Toxicity
• 10,098 epidurals– 8493 caudals– 7 with transient ECG changes – no treatment
Pediatric Anesthesia 2010;20:1061-1069
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
• 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 – ACLS , but
• epinephrine - small initial doses (10mcg to 100 mcg boluses in the adult) preferred• Vasopressin not recommended • Calcium channel blockers and A-adrenergic receptor blockers – avoid• Amiodorone for ventricular arrhythmias, treatment with local anesthetics (lidocaine or procainamide) not
recommended
– Lipid emulsion therapy -Consider administering at the first signs of LAST, after airway management• 1.5 mL/kg 20% lipid emulsion bolus• 0.25 mL/kg per minute of infusion, continued for at least 10 mins after circulatory stability is attained• 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
– 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.
Neal JM et al. Reg Anesth Pain Med 2010;35: 152-61
Lipid emulsion therapyConsider administering at the first signs of LAST, after airway management
1.5 mL/kg 20% lipid emulsion bolus0.25 mL/kg per minute of infusion, continued for at least 10 mins after circulatory stability is attained
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
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
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
Sub-arachnoid
/ / 0 2 2 1 0 0 1 6 83 7.2
Total 18 7 38
76 28 2 0 0 15 184 6210 3.0TD: positive test doseDP: dural punctureVP: vascular punctureAB: abandoned blockFB: failed blockC: cardiovascular R: respiratoryN: neurological
NO significant complications in caudal group!
93% of caudal blocks placed without technical aids or imaging
3% with ultrasound guidance
Adverse Events and
Complications
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 Question
s?
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