Is tissue coring a real problem after caudal injection in children

Caudal epidural blockade in adolescents

BACKGROUND

Various options are available for the provision of analgesia following major surgical procedures including systemic opioids and regional anesthetic techniques. Regional anesthetic techniques offer the advantage of providing analgesia while avoiding the deleterious adverse effects associated with opioids including nausea, vomiting, sedation and respiratory depression. Although used commonly in infants and children, there is a paucity of experience with the use of caudal epidural blockade in adolescents.

METHODS

We retrospectively reviewed the perioperative care of adolescents undergoing major urologic or orthopedic surgical procedures for whom a caudal epidural block was placed for postoperative analgesia.

RESULTS

The cohort for the study included 5 adolescents, ranging in age from 13 to 18 years and in weight from 42 to 71 kilograms. Caudal epidural analgesia was accomplished after the induction of anesthesia and prior to the start of the surgical procedure using 20-25 mL of either 0.25% bupivacaine or 0.2% ropivacaine with clonidine (1 μg/kg). The patients denied pain the recovery room. The time to first request for analgesia varied from 12 to 18 hours with the patients requiring 1-3 doses of analgesic agents during the initial 24 postoperative hours.

CONCLUSIONS

Our preliminary experience demonstrates the efficacy of caudal epidural block in providing analgesia following major urologic and orthopedic surgical procedures. The applications of this technique as a means of providing postoperative analgesia are discussed.

[Pediatric caudal anesthesia : importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. These are discussed in detail in this review. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

Recent developments in paediatric neuraxial blocks

Paediatric anaesthesia and paediatric regional anaesthesia are intertwined. Almost all surgeries unless contradicted could be and should be supplemented with a regional block. The main objective of this review is to elaborate on the recent advances of the central neuraxial blocks, such as application of ultrasound guidance and electrical stimulation in the pursuit of safety and an objective end point. This review also takes account of the traditional technique and understand the benefits as well the risk of each as compared with the recent technique. The recent trends in choosing the most appropriate peripheral block for a given surgery thereby sparing the central neuroaxis is considered. A penile block for circumcision or a sciatic block for unilateral foot surgery, rather than caudal epidural would have a better risk benefit equation. Readers will find a special mention on the recent thoughts on continuous epidural analgesia in paediatrics, especially its rise and fall, yet its unique importance. Lastly, the issue of block placements under sedation or general anaesthesia with its implication in this special population is dealt with. We conducted searches in MEDLINE (PubMed) and assessed the relevance of the abstracts of citations identified from literature searches. The search was carried out in English, for last 10 years, with the following key words: Recent advances in paediatric regional anaesthesia; ultrasound guidance for central neuraxial blocks in children; role of electrical stimulation in neuraxial blocks in children; complications in neuraxial block. Full-text articles of potentially relevant abstracts were retrieved for further review.

[Pediatric caudal anesthesia: importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

Caudal blocks

Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).

Caudal epidural block in children and infants: retrospective analysis of 2088 cases

BACKGROUND AND OBJECTIVES

Regional anesthesia is usually preferred as caudal block via the epidural space. However, the number of large-scale studies including pediatric caudal blocks is small. The objective of this study was to evaluate complications and side effects of local anesthetics and adjuvant drugs.

DESIGN AND SETTING

Retrospective, descriptive study of cases occurring during the period December 2007 to October 2009.

METHODS

Of 4815 medical records were screened, 2088 pediatric cases were identified and included in this study.

RESULTS

As a local anesthetic, we preferred mostly levobupivacaine in 1669 (79.9%) patients and bupivacaine in 419 (20.1%) patients. As adjuvant drug, we preferred mostly morphine (41 patients), fentanyl (7 patients) and adrenaline (6 patients) in 54 (2.5%) patients. For general anesthesia induction, we preferred mostly propofol (1996 patients, 94.2%); for maintenance, sevoflurane (1773 patients, 84.9%). For airway control, we preferred mostly the ProSeal laryngeal mask (PLMA), in 1008 (48.2%) patients. One thousand six hundred five (76.9%) patients were from outpatient clinics and 483 (23.1%) patients were from inpatient clinics. No permanent complication was encountered after caudal blocks.

CONCLUSION

We conclude that caudal epidural blocks are a safe and effective method for subumbilical day-case pediatric surgeries when performed by anesthetists.

Body art and pregnancy

Body art has gained tremendously in popularity over the past 20 years, and a substantial number of pregnant women may have tattoos or piercings. In most cases, pregnancy will be uneventful. However, on rare occasions, body art may become an issue or cause complications. Navel and abdominal surface piercing and microdermal implants may cause unsightly stretch marks from gravid distension. Nipple piercing could impair breastfeeding. In emergency situations, oral piercing may interfere with airway management and nasal jewelry can be inhaled or swallowed during orotracheal intubation. Tattoos may become distorted if placed on a distended area or they may cover surgical incision lines. The risk of introducing tattoo pigments during epidural analgesia, with the potential for tumor growth, is currently under debate, although the arguments are highly speculative and without solid basis.

A survey of pediatric caudal extradural anesthesia practice

BACKGROUND

Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice.

OBJECTIVES

To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia.

METHODS

An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008.

RESULTS

There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection.

CONCLUSIONS

This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.

Comparing tissue coring potentials of hollow needles without stylet and caudal needles with stylet: an experimental study

BACKGROUND AND OBJECTIVES

Although the association of tissue coring and development of epidermoid tumour has been proposed, the extent and frequency of such coring is still controversial and the viability of carried cells has not been substantiated. In the present study, we used an experimental model without needle removal to investigate the incidence of tissue coring using two different needle types.

METHODS

We inserted 22-G caudal (n = 34) or 22-G hollow (n = 25) needles to the tumour-free areas of fresh modified mastectomy specimens. The specimen was stretched and needles were inserted perpendicular to the skin and forced to penetrate the full thickness of the specimen. Without removing the needle, the needle cavity was then washed with 2 mL of RPMI 1640 with L-Glutamine and the washings were collected in a 15-mL falcon tube. The tubes were sealed and labelled and processed to obtain cytologic preparations. The slides were evaluated under a light microscope.

RESULTS

A high rate of epithelial cell transportation was noted. All the carried cells were stratum corneum cells with no nucleus. No nucleated cells were seen. The incidence of carried cells was 64.7% and 72.0% in the caudal and hollow needle groups, respectively (P > 0.05).

CONCLUSION

Only cells from the outermost layer, stratum corneum, which is made of dead flat skin cells, were transported with needle puncture. The risk of epidermoid tumour development after regional anaesthesia must therefore be low. The incidence of transporting non-nucleated stratum corneum cells was similar between hollow and caudal needles.

Periduralanästhesie

In epidural anaesthesia, the anaesthetist injects one or more drugs into the epidural space bordering on the spinal dura mater to achieve a "central" and/or "neuraxial" block. It is one of the earliest techniques in anaesthesia, originally performed exclusively with local anaesthetic agents. Adding other drugs and combining epidural with general anaesthesia or adapting the technique to the needs of children has extended the list of indications. Continuous epidural analgesia is an important tool in postoperative pain management. More and more often, the increasing proportion of patients who have comorbidities or are permanently taking medication that modulates the clotting system demands that the anaesthesiologist balance the individual risks and benefits before inducing epidural anaesthesia.

Caudal analgesia and anesthesia techniques in children

PURPOSE OF REVIEW

Caudal epidural blockade remains the cornerstone of pediatric regional anesthesia. In this article we provide a comprehensive review of the recent developments in caudal anesthesia in infants and children.

RECENT FINDINGS

Research has focused on prolonging the duration of single-shot caudal blocks and accurately positioning continuous caudal catheters. New local anesthetics with similar potencies but less toxicity have been introduced. Opioids prolong the duration of analgesia of local anesthetic, but have also been associated with unacceptable side effects, particularly in pediatric outpatients. Various non-opioid adjuncts with more favorable side-effect profiles may increase the duration of analgesia. New ultrasound and nerve-stimulation techniques have been developed to accurately guide epidural catheters to a specific spinal level.

SUMMARY

The addition of ketamine or clonidine to a caudal local anesthetic prolong the duration of the block. However, a preservative-free preparation of ketamine that is suitable for neuraxial use is not widely available. Ultrasound imaging and electrical stimulation are promising options to accurately position a caudal needle. However, because ultrasound imaging is more difficult in older children, nerve stimulation is a more-suitable technique to accurately guide caudal catheters in this patient population. Although complications associated with caudal block are rare, the risks and benefits must be carefully considered on an individual basis.

Pain management for pediatric thoracic surgery

PURPOSE OF REVIEW

Pain management after thoracic surgery in children presents the challenge of providing adequate analgesia without excessive sedation, and maintaining adequate respiratory function in the face of compromise resulting from existing pathology, surgical trauma, single-lung ventilation and postoperative ventilation-perfusion abnormalities. In the pediatric population, pain assessment and reporting present additional challenges. The number and complexity of surgical procedures, including video-assisted thoracoscopic procedures, is increasing in the pediatric population. There is a need to explore pain management for these types of patients.

RECENT FINDINGS

There are effective and safe strategies whereby analgesia can be provided to this pediatric population. This review will outline the progress that has been made in this field, including the use of regional techniques. The routine use of caudal catheters in neonates and infants for thoracic surgical procedures and the use of electrical guidance of epidural catheters, the 'Tsui' technique, are reviewed.

SUMMARY

These techniques, applied within a comprehensive pain management strategy, can be extremely beneficial in the care of the pediatric thoracic patient.