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Kiddie-Caudals Caudal Epidural Analgesia in Everyday Pediatric Practice

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.

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Kiddie-Caudals Caudal Epidural Analgesia in Everyday Pediatric Practice

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  1. Kiddie-CaudalsCaudal 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

  2. 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

  3. Disclosures • I have no relevant financial relationships with manufacturers of any commercial products or providers of commercial services discussed in these slides.

  4. Caudal Epidural Analgesia thoracic Advantages: Easy to perform High success rate Usually no hemodynamic changes lumbar caudal

  5. Caudal Epidural - Indications • Surgeries: • Urologic • Orthopedic • general • Locations: • lower abdomen • lower extremities • Regional Alternatives to consider: • Peripheral nerve block • Truncal block • Extremity blocks

  6. AnesthAnalg 2012;115:1353-64 Demographics for 13,725 patients in the Pediatric Regional Anesthesia Network (PRAN) database.

  7. Single Injection Caudal Placement by Age by age. Polaner D M et al. AnesthAnalg 2012;115:1353-1364

  8. 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

  9. 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

  10. Caudal BlockIdentification of Landmarks Post sup iliac spines Sacral cornu

  11. Caudal BlockPlacement of Cannula

  12. Caudal Block in Children No Touch Technique Distance to Caudal Space

  13. Location, location…is your needle where it should be? Clinical Assessment Technical Aides Ultrasound Experience, assistant • 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 Tiffterer l et al. Br JAnaesth 2012;108;670-4

  14. 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

  15. 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

  16. 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

  17. Choice of LA Bupivacaine: Ropivacaine: Duration similar Less motor block at lower concentrations Less toxicity Single dose 1 mL/kg 0.2% ropivacaine • 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

  18. Choice of LA Lidocaine: Chloroprocaine: Short onset, short duration Advantageous toxicity profile Single dose up to 14 mg/kg - or more • Short onset, medium duration • CNS toxicity>cardiac toxicity • Single dose • up to 5-7 mg/kg

  19. Epidural Additives – improved and prolonged analgesia The Common 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 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

  20. 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 matterBrenner L et al. Br J Anaeth 2011; 107:229-35; Tiffterer l et al. Br JAnaesth 2012;108;670-4 Thomas L< et al. PaediatrAnaesth 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

  21. 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. AnesthAnalg 2002;95:1219-23

  22. Complications Common: Rare, but serious Systemic toxicity Inadvertent IV injection Overdose Inadvertent IT injection Infection/Hematoma/Neuropathy • Pruritis • Nausea & emesis • Sedation • Urinary retention

  23. Risk of Systemic LA Toxicity • 10,098 epidurals • 8493 caudals • 7 with transient ECG changes – no treatment Pediatric Anesthesia 2010;20:1061-1069

  24. ASRA Recommendations – Prevention of LASTNeal JM et al. RegAnesth 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

  25. ASRA - recommended LAST -Management Neal JM et al. RegAnesth 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 • 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. • 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

  26. 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

  27. Adverse Events and Complications TD: positive test dose DP: dural puncture VP: vascular puncture AB: abandoned block FB: failed block C: cardiovascular R: respiratory N: neurological NO significant complications in caudal group! 93% of caudal blocks placed without technical aids or imaging 3% with ultrasound guidance

  28. 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

  29. Thank You Questions?

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