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Caudal Block (caudal + block)
Selected AbstractsSpread of ropivacaine by a weight-based formula in a pediatric caudal block: a fluoroscopic examinationACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010B.-N. KOO Background: Caudal block is the most common regional technique to provide post-operative analgesia in pediatric infra-umbilical surgery. This study was designed to define how many spinal segments would be covered by the weight-based dosage of caudally administered 0.2% ropivacaine in children using the fluoroscopic method. Methods: After an approval from the institutional human research review board, in 83 ASA I boys undergoing day-case urological surgery, the distribution of ropivacaine mixed with a radioactive dye in relation to the volume injected caudally was studied. Three groups were studied: for perineal surgery 0.5 ml/kg (group C0.5), for inguinal hernia repair 1 ml/kg (group C1.0), and for orchiopexy 1.25 ml/kg (group C1.25). The dose of 0.2% ropivacaine containing radiopaque dye at a ratio of 1 : 4 was injected at a rate of 1 ml 3 s,1. Fluoroscopic examination was performed immediately to define the level of the drug spread within the extradural space. Results: The highest spinal levels [median with ranges] of spread were L2 [L4-T12] in group C0.5, T12 [L1-T8] in group C1.0, and T10 [L2-T7] in group C1.25. Analysis by age distribution (infants: <12 months; toddlers: 12,36 months; and children: >36 months) revealed a larger spread in younger patients. Conclusions: Based on the fluoroscopic findings, the weight-based doses for caudally administered 0.2% bupivacaine suggested by Armitage are also useful for ropivacaine to block the spinal level required for the different types of surgeries studied. [source] Caudal block and ventricular shunt devices: beware of the consequences of increasing epidural pressure!PEDIATRIC ANESTHESIA, Issue 7 2007Francis Veyckemans No abstract is available for this article. [source] DOSE,RESPONSE OF ROPIVACAINE ADMINISTERED CAUDALLY TO CHILDREN UNDERGOING SURGICAL PROCEDURES UNDER SEDATION WITH MIDAZOLAMCLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 7 2004F Tonatiu Aguirre-Garay SUMMARY 1.,In a double-blind randomized controlled design, 50 children were allocated to receive bupivacaine 0.25% or ropivacaine 0.25%, 0.32%, 0.40% or 0.50% by caudal block. 2.,Caudal block was performed after induction of anaesthesia with 2,5% sevoflurane, atropine 10 µg/kg and midazolam 100,300 µg/kg. During the surgical procedure, patients were maintained under spontaneous ventilation and no intravenous or inhalatory anaesthetic agent was administered. For transoperative sedation, midazolam 100,300 µg/kg was administered every 0.5,1.0 h. Transoperative cardiovascular response, postoperative analgesia and local and systemic complications were evaluated. 3.,Groups were similar (P > 0.05) in sex, age, weight and in the time elapsed from caudal block to the beginning of the surgical procedure. The surgical time was significantly lower in the ropivacaine 0.25% group. The duration of analgesia was 24 h with ropivacaine 0.25% and approximately 10 h in the other four groups (P < 0.001). Linear regression analysis revealed a significant relationship between the postoperative analgesic period produced by ropivacaine and the surgical time (r = , 0.48, two-sided P = 0.002). Systolic and diastolic blood pressures remained in the physiologically normal range for the duration of the transoperative period. Vomiting was present in only one patient receiving ropivacaine 0.50%. 4.,In children, the duration of analgesia produced by caudal block with ropivacaine may be affected by surgical time. At surgical times of 0.5,1 h, ropivacaine 0.25% produced at least 24 h postoperative analgesia. At similar surgical times, ropivacaine 0.32%, 0.40% and 0.50% produced similar analgesic times to bupivacaine 0.25%. [source] Caudal analgesia for prostate biopsyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010M. CESUR Background: Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)-guided prostate biopsy, the best method has not yet been defined. The present prospective, double-blind, randomized study aims to investigate the clinical efficacy of ,walking' caudal block compared with an intrarectal lidocaine gel for this procedure. Methods: One hundred patients were randomly assigned to two groups. In the lidocaine gel group, 10 ml of gel containing 2% lidocaine was given intrarectally. In the caudal group, 20 ml 0.1% bupivacaine with 75 ,g fentanyl was injected. Pain scores, anal sphincter tone and patient satisfaction were evaluated. Results: The pain scores were significantly lower in the caudal group at all stages. Verbal rating scores (scale 1,4) during probe insertion, probe maneuver and biopsies were 1 (0,2), 1 (0,2) and 1 (0,2) vs. 3 (0,5), 2 (1,3) and 4 (2,6), respectively (P value <0.0001 at all stages). The anal sphincter was more relaxed in the caudal group than in the gel group (P value <0.0001 in all categories). Highly satisfied patients were more frequently encountered in the caudal group, 34 (68%) vs. 8 (16%), P<0.0001, and unsatisfied patients were more frequently found in the gel group 1 (2%) vs. 12 (24%); P<0.001. All patients were able to walk without any assistance immediately after the procedures. Conclusion: ,Walking' caudal analgesia is an efficacious method for relieving the pain during TRUS-guided prostate biopsies in ambulatory practice. [source] Spread of ropivacaine by a weight-based formula in a pediatric caudal block: a fluoroscopic examinationACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 5 2010B.-N. KOO Background: Caudal block is the most common regional technique to provide post-operative analgesia in pediatric infra-umbilical surgery. This study was designed to define how many spinal segments would be covered by the weight-based dosage of caudally administered 0.2% ropivacaine in children using the fluoroscopic method. Methods: After an approval from the institutional human research review board, in 83 ASA I boys undergoing day-case urological surgery, the distribution of ropivacaine mixed with a radioactive dye in relation to the volume injected caudally was studied. Three groups were studied: for perineal surgery 0.5 ml/kg (group C0.5), for inguinal hernia repair 1 ml/kg (group C1.0), and for orchiopexy 1.25 ml/kg (group C1.25). The dose of 0.2% ropivacaine containing radiopaque dye at a ratio of 1 : 4 was injected at a rate of 1 ml 3 s,1. Fluoroscopic examination was performed immediately to define the level of the drug spread within the extradural space. Results: The highest spinal levels [median with ranges] of spread were L2 [L4-T12] in group C0.5, T12 [L1-T8] in group C1.0, and T10 [L2-T7] in group C1.25. Analysis by age distribution (infants: <12 months; toddlers: 12,36 months; and children: >36 months) revealed a larger spread in younger patients. Conclusions: Based on the fluoroscopic findings, the weight-based doses for caudally administered 0.2% bupivacaine suggested by Armitage are also useful for ropivacaine to block the spinal level required for the different types of surgeries studied. [source] Effect of dexmedetomidine on the characteristics of bupivacaine in a caudal block in pediatricsACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 2 2009I. SAADAWY Background: Dexmedetomidine (DEX) is a highly selective ,2 -adrenoceptor agonist that has been used increasingly in children. However, the effect of caudal DEX has not been evaluated before in children. This prospective randomized double-blinded study was designed to evaluate the analgesic efficacy of caudal DEX with bupivacaine in providing pain relief over a 24-h period. Methods: Sixty children (ASA status I) aged 1,6 years undergoing unilateral inguinal hernia repair/orchidopexy were allocated randomly to two groups (n=30 each). Group B received a caudal injection of bupivacaine 2.5 mg/ml, 1 ml/kg; Group BD received the same dose of bupivacaine mixed with DEX 1 ,g/kg during sevoflurane anesthesia. Processed electroencephalogram (bispectral index score), heart rate, blood pressure, pulse oximetry and end-tidal sevoflurane were recorded every 5 min. The characteristics of emergence, objective pain score, sedation score and quality of sleep were recorded post-operatively. Duration of analgesia and requirement for additional analgesics were noted. Results: The end-tidal sevoflurane concentration and the incidence of agitation were significantly lower in the BD group (P<0.05). The duration of analgesia was significantly longer (P<0.001) and the total consumption of rescue analgesic was significantly lower in Group BD compared with Group B (P<0.01). There was no statistically significant difference in hemodynamics between both groups. However, group BD had better quality of sleep and a prolonged duration of sedation (P<0.05). Conclusion: Caudal DEX seems to be a promising adjunct to provide excellent analgesia without side effects over a 24-h period. It has the advantage of keeping the patients calm for a prolonged time. Implications statement: Caudally administered DEX (1 ,g/kg), combined with bupivacaine, was associated with an extended duration of post-operative pain relief. [source] Efficacy of bupivacaine-neostigmine and bupivacaine-tramadol in caudal block in pediatric inguinal herniorrhaphyPEDIATRIC ANESTHESIA, Issue 9 2010REZA TAHERI MD Summary Background:, Limited duration of analgesia is among the limitations of single caudal injection with local anesthetics. Therefore, the purpose of this study was to evaluate the effectiveness and safety of bupivacaine in combination with either neostigmine or tramadol for caudal block in children undergoing inguinal herniorrhaphy. Methods:, In a double-blinded randomized trial, sixty children undergoing inguinal herniorrhaphy were enrolled to receive a caudal block with either 0.25% bupivacaine (1 ml·kg,1) with neostigmine (2 ,g·kg,1) (group BN) or tramadol (1 mg·kg,1) (group BT). Hemodynamic variables, pain and sedation scores, additional analgesic requirements, and side effects were compared between two groups. Results:, Duration of analgesia was longer in group BT (17.30 ± 8.24 h) compared with group BN (13.98 ± 10.03 h) (P = 0.03). Total consumption of rescue analgesic was significantly lower in group BT compared with group BN (P = 0.04). There were no significant differences in heart rate, mean arterial pressure, and oxygen saturation between groups. Adverse effects excluding the vomiting were not observed in any patients. Conclusion:, In conclusion, tramadol (1 mg·kg,1) compared with neostigmine (2 ,g·kg,1) might provide both prolonged duration of analgesia and extended time to first analgesic in caudal block. [source] Presurgical fentanyl vs caudal block and the incidence of adverse respiratory events in children after orchidopexyPEDIATRIC ANESTHESIA, Issue 12 2009SAMIA N. KHALIL MD Summary Background:, There is controversy about the etiology of early postoperative hypoxemia. Age, weight, intubation, surgical procedure, use of muscle relaxants, and/or administration of opioids may affect the incidence of early postoperative hypoxemia. In this prospective, randomized, and single-blinded study, we evaluated whether the administration of caudal analgesia vs i.v. fentanyl affected the number of children who develop postextubation adverse upper airway respiratory events, (upper airway obstruction, laryngospasm) and/or early postoperative hypoxemia. Methods/materials:, Institutional approval and written parental informed consents were obtained. Thirty-eight healthy outpatient boys, aged 1,6 years, scheduled for elective orchidopexy were randomized to receive pain relief either with a presurgical caudal block or by i.v. fentanyl. The primary outcome of the study was the number of children who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia. Results:, The number of boys who developed postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia in the caudal group was less compared with those in the fentanyl group (P = 0.04). Conclusions:, Compared to fentanyl, placement of a presurgical caudal block in boys scheduled for orchidopexy was associated with a lower incidence of postextubation adverse upper airway respiratory events and/or early postoperative hypoxemia. [source] Unilateral groin surgery in children: will the addition of an ultrasound-guided ilioinguinal nerve block enhance the duration of analgesia of a single-shot caudal block?PEDIATRIC ANESTHESIA, Issue 9 2009NARASIMHAN JAGANNATHAN MD Summary Background:, Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single-shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double-blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. Methods:, Fifty children ages 1,6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US-guided ilioinguinal nerve block with 0.1 ml·kg,1 of preservative-free normal saline and Group B that received an US-guided nerve block with 0.1 ml·kg,1 of 0.25% bupivacaine with 1 : 200 000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml·kg,1 of 0.125% bupivacaine with 1 : 200 000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. Results:, Forty-eight patients, consisting of 46 males and two females, with a mean age of 3.98 (sd ± 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (sd ± 1.59) and 1.18 (sd ± 1.31), respectively. The average pain score difference was 0.72 (sd ± 0.58) and was statistically significant (P < 0.05). In addition, when examined by procedure type, it was found that the difference in the average pain scores between the caudal and caudal/ilioinguinal block groups was statistically significant for the inguinal hernia repair patients (P < 0.05) but not for the other groin surgery patients (P = 0.13). For all groin surgery patients, six of the 23 patients in the caudal group and eight of the 25 patients in the caudal/ilioinguinal block group required pain rescue medications throughout their entire hospital stay or at home (P = 0.76). Overall, the caudal group received an average of 0.54 (sd ± 1.14) pain rescue medication doses, while the caudal/ilioinguinal block group received an average of 0.77 (sd ± 1.70) pain rescue medication doses; this was, however, not statistically significant (P = 0.58). Conclusions:, The addition of an US-guided ilioinguinal nerve block to a single-shot caudal block decreases the severity of pain experienced by pediatric groin surgery patients. The decrease in pain scores were particularly pronounced in inguinal hernia repair patients. [source] Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudalsPEDIATRIC ANESTHESIA, Issue 6 2007K. Raghavan Background:, Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods:, This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5,12 MHz linear array was used longitudinally with either midline or paramedian approach. Results:, We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions:, Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References, 1,Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333,339. 2,Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200,207. 3,Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671,676. [source] Postoperative shivering in children and causative factorsPEDIATRIC ANESTHESIA, Issue 12 2005AYNUR AKIN MD Summary Background:, The aim of this study is to investigate the incidence of shivering in children and to reveal the causative factors as well as any possible clinical implications. Methods:, This study was conducted on 1507 children who underwent surgery under general anesthesia. The patients were admitted to the postanesthesia care unit after the operation and their body temperatures measured from the tympanic membrane. The type of operation, operative time, method of anesthesia induction, age, and number of cases in which caudal block had been used were recorded. Results:, Of the 1507 children, 53 (3.5%) experienced shivering. The use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering. The type of the operation and gender had no effect. The frequency of shivering was lower in children who underwent caudal block with a statistical significance (P < 0.05). Conclusions:, The overall incidence of shivering in children is low (3.5%). Use of intravenous induction agents, age older than 6 years, and prolonged duration of surgery were associated with shivering; prophylaxis is not necessary in children, treatment is given only when shivering occurs. [source] Validation of a six-graded faces scale for evaluation of postoperative pain in childrenPEDIATRIC ANESTHESIA, Issue 8 2003A. Bosenberg MBChB Summary Background: The faces pain scales are often used for self-report assessment of paediatric pain. The aim of this study was to evaluate the validity of a six-graded faces pain scale after surgery by comparing the level of agreement between the children's report of faces pain scores and experienced nurses' assessment of pain by observation of behaviour. The faces pain scores before, at and after administration of analgesics were analysed. The study was performed in two South African hospitals, one with a mainly rural population and the other with an urban population. Methods: A total of 110 children aged 4,12 years, scheduled for inguinal surgery in the two South African hospitals, were included in the study. The anaesthetic technique was standardized. All patients received a caudal block preoperatively. Postoperative pain assessments were made every hour for 8 h after the caudal block was performed. A designated nurse assessed pain by using a four-graded descriptive scale (no, mild, moderate or severe pain) and thereafter the child reported pain by using the six-graded faces pain scale. Results: A high correlation was found between the two methods of assessment (, = 0.76, P < 0.0001). The correlation between methods was high in both hospital populations and in all age groups. The weakest correlation was found in children aged 8,12 years (, = 0.56, P < 0.01). Significantly lower faces pain scores were found after administration of analgesics compared with pain rating before analgesics (P < 0.0001). The proportion of patients with pain scores above 2 decreased from 86% to 31% (P < 0.001). Conclusions: The findings support this six-graded faces pain scale as a useful and valid instrument for measuring pain in the postoperative period in children aged 4,12 years. [source] Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofolPEDIATRIC ANESTHESIA, Issue 1 2003Ira Todd Cohen MD Summary Background: Emergence agitation in children is frequently associated with the use of the new highly insoluble volatile anaesthetics. Rapid emergence has been cited as one of the possible causes. Propofol also permits rapid emergence from general anaesthesia but is not associated with agitation. Methods: The emergence characteristics of children receiving sevoflurane and propofol anaesthesia were examined. After induction with sevoflurane, 53 children, aged 2,36 months, who were undergoing ambulatory surgery, were randomized to receive maintenance anaesthesia with either sevoflurane or propofol. Introperative analgesia with either 2 µg·kg,1 of intravenous fentanyl or a caudal block with 0.25% bupivacaine was supplied according to surgical procedure. An observer blinded to anaesthetic technique recorded the time to achieve extubation and recovery and assessed emergence behaviour. Data were analysed using Wilcoxon scores, Kruskal,Wallis test, chi-square and multiple regression analysis. Results: The results showed that the time to extubation and recovery were similar between the two study groups, but that emergence agitation was significantly higher in the sevoflurane group compared with the propofol group. No relationship between analgesic technique and agitation scores was found. Conclusions: Although both sevoflurane and propofol allow for rapid emergence from general anaesthesia, only sevoflurane is associated with a high incidence of emergence agitation in infants and young children. Rapid emergence does not fully explain this phenomena. [source] Comparison of recovery after intermediate duration of anaesthesia with sevoflurane and isofluranePEDIATRIC ANESTHESIA, Issue 4 2001Pierre-Yves Le Berre MD Background:,The purpose of this study was to compare recovery from anaesthesia after sevoflurane and isoflurane were administered to children for more than 90 min. Methods:,After parental informed consent and ethical committee approval, children aged between 2 months and 6 years, ASA I or II, were randomly allocated to sevoflurane (n=20) or isoflurane (n=20) groups. Halogenated agents were discontinued following skin closure and patients were ventilated mechanically with 100% oxygen until minimum alveolar concentration (MAC) values awake were obtained (endtidal concentrations 0.6 MAC for sevoflurane and 0.4 MAC for isoflurane). Effective perioperative analgesia was provided by a caudal block. Results:,The mean (± SD) duration of anaesthesia was 132 ± 38 min and 139 ± 49 min for sevoflurane and isoflurane, respectively. Early recovery occurred sooner in the isoflurane group (time to extubation was 16 ± 7 min and 11 ± 5 min, P<0.01; Aldrete's score at 0 min was 5.5 ± 1.5 and 7.4 ± 1.8, P<0.001, respectively). But the time to be fit for discharge from recovery room was similar at 136 ± 18 min and 140 ± 20 min, respectively. Conclusions:,After intermediate duration of anaesthesia administered to children for up to 90 min, isoflurane and sevoflurane allow recovery after approximatively the same lapse of time. [source] Minimum local analgesic concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age childrenANAESTHESIA, Issue 10 2010X. M. Deng Summary We compared the minimum local analgesia concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children. Fifty-one boys, undergoing hypospadius repair surgery, were stratified into pre-school or school age groups. After induction of anaesthesia, caudal block was performed with ropivacaine 1 ml.kg,1 of the desired concentration. The first child in each group received ropivacaine 0.125%, and subsequent concentrations were determined by the analgesic response of the previous patient using Dixon's up-and-down method. Under general anaesthesia with 0.7 minimum alveolar concentration of sevoflurane, the minimum local analgesia concentration of ropivacaine for intra-operative caudal block was 34% greater in school age than in pre-school age boys (0.143% (95% CI 0.132,0.157%) vs 0.107% (95% CI 0.089,0.122%), respectively; p < 0.001). This study indicates that a higher concentration of ropivacaine is needed for school age than pre-school age children to provide intra-operative caudal analgesia when combined with general anaesthesia. [source] The prevalence of anatomical variations that can cause inadvertent dural puncture when performing caudal block in Koreans: a study using magnetic resonance imagingANAESTHESIA, Issue 1 2010J. Joo Summary The purpose of this study was to investigate the prevalence of the anatomical abnormalities that can induce inadvertent dural puncture when performing caudal block. The anatomy of the lumbo-sacral area was evaluated using magnetic resonance imaging. In 2462 of the 2669 patients imaged, the dural sac terminal was located between the upper half of the 1st sacral vertebra and the lower half of the 2nd sacral vertebra. In 22 cases (0.8%), the dural sac terminal and the spinal canal were located at or below the 3rd sacral vertebra, and these were cases of simple anatomical variations. As regards pathologic conditions, there was one case of sacral meningocoele and 46 cases of sacral perineural cyst. In 21 cases (0.8%) out of the 46 perineural cyst cases, the cyst could be found at or below the 3rd sacral vertebra level. Inadvertent dural puncture may happen when performing caudal block in patients with such abnormal anatomy. [source] The effect of flexion on the level of termination of the dural sac in paediatric patientsANAESTHESIA, Issue 10 2009B-N. Koo Summary Although the anatomy of the spinal cord and its associated structures have been well defined, the effects of body position relevant to neuraxial blockade have not been elucidated. This study was designed to determine the effect of body position on the end of the dural sac in children. After induction of anaesthesia, ultrasound examination was performed to evaluate the location of the dural sac end in the lateral position with a straight back and knee, and in the lateral position with the knees, legs, and neck flexed. The level of the end of the dural sac was determined in relation to the vertebrae. Our data demonstrate that the dural sac shifts significantly cephalad in the lateral flexed position used for neuraxial blockade (p < 0.001). These results suggest that the safety margin to avoid dural puncture during hiatal or S2-3 approach for caudal block can be increased in younger children. [source] The optimum concentration of levobupivacaine for intra-operative caudal analgesia in children undergoing inguinal hernia repair at equal volumes of injectateANAESTHESIA, Issue 1 2009Y.-S. Yao Summary Probit analysis was used to predict the median effective concentration (EC50) and the 95% effective concentration (EC95) values of levobupivacaine for caudal analgesia in children at equal volumes of injectate. Sixty children scheduled for inguinal herniorrhaphy were recruited. Anaesthesia was induced with sevofurane and nitrous oxide. Then caudal block (total volume of local anaesthetic 1 ml.kg,1) was performed. Patients randomly received one of six concentrations (0.08%, 0.10%, 0.12%, 0.14%, 0.16% or 0.18%) of levobupivacaine. Thereafter, inhalational anaesthetics were discontinued and intravenous midazolam 0.1 mg.kg,1 was administered to maintain sedation. The effective caudal analgesia was defined as an absence of gross movements and a haemodynamic (heart rate or blood pressure) reaction < 20% compared with baseline in response to surgical incision. Our data indicated that the EC50 and EC95 values of levobupivacaine for caudal analgesia were 0.109% (95% confidence intervals 0.098,0.120%) and 0.151% (95% confidence intervals 0.135,0.193%) when using the same volume (1 ml.kg,1), respectively. [source] DOSE,RESPONSE OF ROPIVACAINE ADMINISTERED CAUDALLY TO CHILDREN UNDERGOING SURGICAL PROCEDURES UNDER SEDATION WITH MIDAZOLAMCLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 7 2004F Tonatiu Aguirre-Garay SUMMARY 1.,In a double-blind randomized controlled design, 50 children were allocated to receive bupivacaine 0.25% or ropivacaine 0.25%, 0.32%, 0.40% or 0.50% by caudal block. 2.,Caudal block was performed after induction of anaesthesia with 2,5% sevoflurane, atropine 10 µg/kg and midazolam 100,300 µg/kg. During the surgical procedure, patients were maintained under spontaneous ventilation and no intravenous or inhalatory anaesthetic agent was administered. For transoperative sedation, midazolam 100,300 µg/kg was administered every 0.5,1.0 h. Transoperative cardiovascular response, postoperative analgesia and local and systemic complications were evaluated. 3.,Groups were similar (P > 0.05) in sex, age, weight and in the time elapsed from caudal block to the beginning of the surgical procedure. The surgical time was significantly lower in the ropivacaine 0.25% group. The duration of analgesia was 24 h with ropivacaine 0.25% and approximately 10 h in the other four groups (P < 0.001). Linear regression analysis revealed a significant relationship between the postoperative analgesic period produced by ropivacaine and the surgical time (r = , 0.48, two-sided P = 0.002). Systolic and diastolic blood pressures remained in the physiologically normal range for the duration of the transoperative period. Vomiting was present in only one patient receiving ropivacaine 0.50%. 4.,In children, the duration of analgesia produced by caudal block with ropivacaine may be affected by surgical time. At surgical times of 0.5,1 h, ropivacaine 0.25% produced at least 24 h postoperative analgesia. At similar surgical times, ropivacaine 0.32%, 0.40% and 0.50% produced similar analgesic times to bupivacaine 0.25%. [source] Lipophilicity affects the pharmacokinetics and toxicity of local anaesthetic agents administered by caudal blockCLINICAL AND EXPERIMENTAL PHARMACOLOGY AND PHYSIOLOGY, Issue 1-2 2004Alejandro A Nava-Ocampo Summary 1.,Drugs administered into the epidural space by caudal block are cleared by means of a process potentially affected by the lipophilic character of the compounds. 2.,In the present study, we examined the relationship between the octanol,water partition coefficient (log Poct) and the time to reach the maximum plasma drug concentration (tmax) of lignocaine, bupivacaine and ropivacaine administered by caudal block in paediatric patients. We also examined the relationship between log Poct and the toxicity of these local anaesthetic agents in experimental models. The tmax and toxicity data were obtained from the literature. 3.,Ropivacaine, with a log Poct of 2.9, exhibited a tmax of 61.6 min. The tmax of lignocaine, with a log Poct of 2.4, and bupivacaine, with a log Poct of with 3.4, were approximately 50% shorter than ropivacaine. At log Poct of approximately 3.0, the toxicity of these local anaesthetic agents was substantially increased. The relationship between log Poct and the convulsive effect in dogs was similar to the relationship between log Poct and the lethal dose in sheep. 4.,With local anaesthetic agents, it appears that the relationship between log Poct and drug transfer from the epidural space to the blood stream is parabolic, being the slowest rate of transference at log Poct 3.0. Toxicity, due to plasma availability of these local anaesthetic agents, seems to be increased at log Poct equal or higher than 3.0 secondary to the highest transfer from plasma into the central nervous system. [source] Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudalsPEDIATRIC ANESTHESIA, Issue 6 2007K. Raghavan Background:, Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods:, This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5,12 MHz linear array was used longitudinally with either midline or paramedian approach. Results:, We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions:, Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References, 1,Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333,339. 2,Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200,207. 3,Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671,676. [source] Ultrasound and caudal blocks in childrenPEDIATRIC ANESTHESIA, Issue 8 2006Donald A. Schwartz MD No abstract is available for this article. [source] | ||||||||||