Caudal epidural Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics – Ph D physiology. Mahatma gandhi medical college and research institute, puducherry, India

Introduction easiest and safest approach to the epidural space sole anaesthetic for some procedures, or it may be combined with general anaesthesia. peri and post operative analgesia in adults and children 

History Cathelin 1901 Hingson 1943 (labour pain ) Brazilian anaesthetists 1962 popularized for paediatrics Failures?? 5 % failure if selection of cases is commonsense based

INDICATIONS Anaesthesia and analgesia below the umbilicus Obstetric analgesia for the 2nd stage or instrumental deliveries Chronic pain problems such as leg pain after prolapsed intervertebral disc, or post shingles pain below the umbilicus. Common in paediatrics – circumcision, hernia, orchiopexy, hypospadias

Newer adult indications vasospastic or vasocclusive disease, including frostbite and ergotamine toxicity Cancer pain management

Newer adult indications percutaneous epidural neuroplasty the use of caudal analgesia following lumbar spinal surgery caudal analgesia after emergency orthopedic lower extremity surgery;

And extra Better post op period Preemptive analgesia Only technique for premature infants

Contraindications Infection near the site of the needle insertion. Coagulopathy or anti coagulation. Pilonidal cyst Congenital abnormalities of the lower spine or meninges, Hydrocephalus and intracranial tumors decrease intracranial compliance

Anatomy

Triangle

The sacral hiatus is a defect in the lower part of the posterior wall of the sacrum formed by the failure of the laminae of S5 and/or S4 to meet and fuse in the midline The sacral canal is a continuation of the lumbar spinal canal which terminates at the sacral hiatus.

The sacral canal contains The terminal part of the dural sac, ending between S1 and S3. The five sacral nerves and coccygeal nerves making up the cauda equina The filum terminale Epidural fat, the character of which changes from a loose texture in children to a more fibrous close-meshed texture in adults.

So the problem is puberty

Technique There are three main approaches: prone, semi-prone, lateral

Practical problems in anatomy Size, position of sacral hiatus : Semi closed, closed or asymmetrical AP diameter 2 mm to 1.5 cm Lateral width

Practical problems in anatomy Volume of sacral canal : 12 ml to 65 ml Sacral foramina Posterior sacral foramina – sacro spinalis muscles. Anterior sacral foramina unobstructed Curvature : Less – more straight needle – females

Practical problems in anatomy Lordosis and lumbosacral angle Cephalad flow less in lordotics Epidural fat Loose wide meshed to tight fibrous in adults Predictable in children to unpredictable spread in adults

Equipment A Crawford needle similar to Touhy needle Crawford needle's bevel is in alignment with the shaft of the needle so that a catheter exits the needle in a straight line. The Crawford needle is ideal for either single-shot local anesthetic injection or for placement of a caudal epidural catheter. Routine needles of 21 to 25 G

Adults –prone ok -internal rotation of ankle -not sedated

Semiprone & lateral Sedation is ok Children - lateral is fine Easy to find landmarks Don’t overflex knees as in lumbar epidural

Palpate up from down coccyx feel hiatus depression- distance

Technique Local anaesth. Less than 0.5 ml 45 * from the sacrum Pierce sacro coc. Mem Angle to 30 - 15 degrees Two methods

Aspirate Midline lump?? Whoosch test

Gauge needle 22 or 23 or 21 21 = feel good Easy 23 or 24 good in infants

Flouroscopy

USG guided Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound.

Dose ?? Segment Age Weight Local anaesthetics

Dose 0.25 mg / kg / segment of 0.25 % bupivacaine T 10 level , 10 kg 13 * 10 * 0.25 = 32.5 mg of bupivacaine = 6.5 ml of 0.5 % bupi or 13 ml of 0.25 %

Armitage schedule Armitage recommends bupivacaine 0.5ml/kg for a lumbosacral block, 1 ml/kg for a thoraco-lumbar block, 1.25 ml/kg for a mid thoracic block one part of 0.9% NaCl to three parts local anaesthetic to produce a 0.19%

Verghese Sacral : 0.5 ml/kg Lumbar : 1 ml/kg Thoracolumbar : 1.25 ml/kg

Schrock Sacral : 0.7 ml/kg Lumbar : 1 ml/kg Thoracolumbar : 1.3 ml/kg

Dose with age 0.1 mL/ segment/year of age 1% lidocaine or 0.25% bupivacaine. Dose : adults = 3 ml /segment

Other drugs 1 mL/kg of 0.2% ropivacaine, 1 ml/kg of 1% lignocaine Levobupi 0.25 % 1 mg /kg

Tingling is OK Tingling or a feeling of fullness that extends from the sacrum to the soles of the feet is common during injection. The injection should never be more than 10 ml/30 seconds.

Additives Epinephrine : 1 in 2 lakh Ketamine : 0.5 mg/kg Clonidine at 1 to 2 mcg/kg Tramadol 1 mg/kg Neostigmine 2 mcg/kg Morphine 30 mic/kg --others??

The large capacity of the sacral canal significant volumes may be lost through the wide anterior sacral foramina. the caudal dose requirements of local anaesthetics are significantly larger to effect the same segmental spread. Roughly twice Drugs injected in the caudal space take longer to spread

Caudal catheters Intraop and postop analgesia and stress reduction in major cases 0.1 % bupi - 0.4 mL/kg per hr Add opioids – if necessary - fentanyl sos

Complications Intravascular or intraosseous injection. This may lead to grand mal seizures and/or cardio-respiratory arrest. Test dose & aspiration Perforation of the rectum – beware of infection than needle prick

Complications- continued Sepsis – very rare Urinary retention. Subcutaneous injection Inadequate block Haematoma Unpredictability Hypotension ??

Some examples 2 kg infant for herniotomy 0.25 mg / kg / segment 13 * 2 * 0.25 = 6.5 mg = 2.6 ml of 0.25% bupi

Some examples what to follow ?? 15 kg 4 years child - club foot 0.25 mg / kg / segment 0.25 * 15 * 10 = 37.5 mg 15 ml of 0.25 % BUPI OR 0.1 mL/ segment/year of age 0.1 * 10 * 4 = 4 ml

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