5/8/2013

PediatricNeuraxialAnesthesia
fromCaudals,toThoracic
Epidurals,toAwakeSpinals
MartinMller,MD
AssistantProfessor
DivisionofPediatricAnesthesia
IowaSymposiumXIII
May4,2013

Disclosure
Nofinancialties,compensationfromor
obligationtomanufacturersofbiomedical
productsordrugs

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Overview
Caudalsingleshot
Thoracicepiduralcatheter
Awakespinalblock

Introduction
Mostcommonblockinchildren
Easytolearn1
Minimalequipment
Favorablerisk/benefitratio
Surgicalstressresponse2
1 Schuepfer G; et al.: Reg Anesth Pain Med 2000; 25: 3858
2 Erol A; et al.: Pediatr Int. 2007;49:928-32

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Indications
AugmentationforGAandpostoperative
analgesia
Pediatricsurgeriesinvolvinglowerbody
Ureteralreimplantation,orchiopexy1,complex
hypospadiasrepair,inguinalherniorrhaphy,
clubfootrepair,etc.
1 Rice LJ; et al: Canadian Journal of Anesthesia 1990; 37:429-31

Contraindications

S1
Refusal,noparentalconsent
S2
Skininfection
Sepsis
Immunodeficiency
Coagulopathy/thrombocytopenia
Postoperativetestingofmotor/sensoryfunction
Anatomical sacraldimpleindicativeofmyelodysplasia
Ultrasoundtoconfirmanatomy1

1 Schwartz D; et al: Pediatric Anesthesia 2011; 21:10731088

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Anatomy

Anatomy:Pediatric
Sacrumnarrow,flat direct
routetoduralsac
Conusmedullaris@L3
Duralsac@S3
Incompleteossification
Thinligamentumflavum
Compliance&sizeof
epiduralspace
Intervertebralforamina
LAescape

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Physiology
RelativeCSFvolume1
CSFturnover
Hemodynamicstabilityinchildren<6yearswith
neuraxialblock2
Smallvenouscapacitanceoflower
extremities
Lackofrestingsympatheticperipheralvasculartone
1 Cutler RWP; et al.: Brain 1968;91:707-20
2 Dohi S; et al.: Anesthesiology 1979; 50: 31923

Dohi S; et al.: Anesthesiology 1979; 50: 31923

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Technique
Monitoring:standardASAmonitors(ECG)
Patientposition:lateraldecubitus,hipsand
kneesflexed
Operator:standingorsittingposteriorlyvs.
anteriorlybendingover
Goodlighting

Technique:Landmarks
Equilateraltriangle
posteriorsuperioriliac
spinesandsacralhiatus
Hiatusrostralofgluteal
crease
Effectofgravityonskin

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Technique:Needle
Shortbevel22G
straightneedle
(intravascular
injection)

Short Bevel

Regular Bevel

22GJelcoIVcatheter
Softtip:perforation
Kinking

Technique:PopandDrop
Palpationofhiatus
Needleinsertion45
Characteristicgive
through
sacrococcygeal
ligament
Dropangle

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Technique:Verification
Needlehubopentoair
Aspiration(clearfluid,blood)
Testdose
Lidocainewith1:200000epinephrine
Controversial
Sensitivityquestionedinchildren1
1 Fisher QA; et al.: Can J Anesth. 1997;44: 592-8

Technique:Injection
Slow,incremental
10ccsyringe
(comparable
resistance)
Subcutaneous
palpation
ECGmonitoring(ST
segment,Twave)

Normal

LA toxicity

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CaudalVideo

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Bupivacaine
0.175%idealforoutpatient
surgery(max.sensoryblockw/
minimalmotorblock)
Max.dose:2.5mg/kg
CNStoxicity:seizures
Cardiactoxicity:therapyresistant
arrhythmias,cardiacarrest
20%Intralipid,1.5ml/kgbolus,
theninfusion0.25ml/kg/h

Ropivacaine

Onset714min
Duration46h
Goodsensory/weakmotorblock
0.2%idealforcaudal
Moreexpensive
LessCNSandcardiactoxicity1

1 Scott DB; et al.: Anesth Analg 1989;69:563-9

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2,3Chloroprocaine

Denserblock
Esterhydrolysis
Lessriskoftoxicaccumulationinneonates
Continuousinfusion1
Cheap
Neurotoxicwithsubduraladministration
1 Tobias JD; et al.: Can J Anesth 1996; 43: 69-72

Adjuvants
Clonidine
Optimaldose12mcg/kg
Sedation
Bradycardia,hypotension,apneainneonates

Ketamine
PreservativefreeketaminenotavailableinUS

Neostigmine
PONV30%

Opioids
Delayedrespiratorydepression

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Caudal:
Complications
Intravascular/intraosseousinjection
Epiduralhematoma
Neuralinjury
Subarachnoidinjection
Epiduralabscess
Urinaryretention(opioids)

ThoracicEpiduralCatheter:
Indication/Goals
Abdominal/thoracicsurgery
Postoperativeanalgesia
Olderchildren

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ThoracicEpidural:Technique
Undergeneralanesthesia
Lateraldecubitusposition
Midlinevs.paramedianapproach
LORwithNS(avoidairembolism)
Ligamentumflavumnotasprominent
Depthofepiduralspace:ca.1cm/10kg

ThoracicEpidural
Complications
Drugs
CNS/cardiotoxicity
Intravascular/subarachnoidinjection

Catheterplacement
Traumatoepiduralstructures(nerves,spinalcord,
vessels)
Cathetermigrationspinalblock1
Infection
1 Taenzer AH: Anesthesiology 2003; 98:1014-15

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AwakeSpinalAnesthesia

Indications
Preferabletoavoidgeneralanesthesia
Muscularhypotonia(postopventilation)
Postopapnea
?Neurotoxicity
DifficultAW(PierreRobin)

Inguinalherniarepair,musclebiopsy

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Spinal:Technique
PIV(timingvariable)
ASAmonitors
Sittingposition
Needsagoodbabysitter:restrainall4
extremities,lumbarlordosis,avoidneckflexion
(AWobstruction)
pacifier

Spinal:Technique
22g1inchspinal
needle
TBsyringe(sliptip)
Sterileprep
iodine/alcohol

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Spinal:Technique
Barbotage
Supine
positioning
Softrestraints
Immediate
startof
surgery

L3-4

Spinal:Drugs
Drug

Lidocaine

Bupivacaine

Tetracaine

Concentration
%

Dose
mg/kg

Duration
min

56

0.5

70

0.5

80

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Spinal:Complications1

Desaturation
Highspinal
Bradycardia(<100bpm)
Apnea
Rarely:infection,bleeding,nervedamage,
spinalcordinjury
CSFleak
1 Williams RK; et al.:Anesth Analg. 2006; 102:67-71

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CommonProblems
Incompleteblock(failedspinal)
Rare(520%)
RepeatSAB,docaudalblock,i.v.supplementation,
cancelsurgery

Agitation
Fromheat,covers,physicalrestraints
Solution:sweetenedpacifier,padding,ventilation,
i.v.sedation(benzodiazepines,propofol)

CommonProblems
Timerunningout:
Avoiddelaysduringprepandintraop
Havegoodcommunicationwithsurgeon
Additionofepinephrine
Combinationwithcaudalblock:
Totaldose2.5mg/kgbupivacainedividedinto
SAB:
Caudal:

1mg/kg(0.2cc/kgof0.5%bupivacaine)
1.5mg/kg(0.6cc/kgof0.25%bupivacaine)

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Summary
Caudal:mostcommonblock,easytolearn
Intralipidneedstobeimmediatelyavailable
Thoracicepidural:potentialforserious
complications,LORwithNS,asleepvs.awake
Awakespinal:wonderfulalternativetoGA,
potentialtoavoidsuspectedneurotoxic
effectsofGA,timelimitations

Questions?

martin-mueller@uiowa.edu

www.anesth.uiowa.edu

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