Effect of epidural anesthesia on the optic nerve sheath diameter in patients with pre-eclampsia: a prospective observational study

INTRODUCTION

Optic nerve sheath diameter (ONSD) reflects intracranial pressure and is increased in pre-eclampsia. Administrating a significant volume of epidural solution into the epidural space can potentially increase ONSD. We investigated the impact of epidural local anesthetic injection on ONSD in patients with pre-eclampsia.

METHODS

Patients with pre-eclampsia (n=11) and normotensive pregnant women (n=11) received de novo epidural anesthesia for cesarean delivery. We administered 21 mL of an epidural solution containing 2% lidocaine and 50 μg fentanyl into the lumbar epidural space in incremental doses. ONSD was measured at baseline, 3, 10, and 20 min after completing the epidural injection, after delivery, and at the end of surgery. Primary outcome was the change in ONSD from baseline to 3 min after epidural injection in patients with pre-eclampsia and normotensive pregnant women. Serial changes in the ONSD were analyzed using a linear mixed model.

RESULTS

At baseline and 3 min after epidural drug injection, ONSD was significantly larger in patients with pre-eclampsia than in normotensive mothers (5.7 vs 4.1 mm, p=0.001 and 5.4 vs 4.1 mm, p<0.001, respectively). However, there were no significant changes in ONSD at 3 min after injection from baseline in either group (p>0.999). Linear mixed model demonstrated that ONSD did not change after epidural anesthesia in either group (p=0.279 and p=0.347, respectively).

CONCLUSIONS

Despite a higher baseline ONSD in pre-eclampsia, epidural anesthesia did not further increase ONSD. Our findings indicate that epidural anesthesia can be safely administered in patients with pre-eclampsia at risk of increased intracranial pressure, without other intracranial pathology.

TRIAL REGISTRATION NUMBER

NCT04095832.

Methods of prolonging the effect of caudal block in children

Caudal epidural blockade is one of the most frequently administered regional anesthesia techniques in children. It is a supplement during general anesthesia and for providing postoperative analgesia in pediatrics for sub-umbilical surgeries, especially for genitourinary surgeries. However, the duration of the analgesic effect is occasionally unsatisfactory. In this review, we discuss the main advantages and disadvantages of different techniques to prolong postoperative analgesia for single-injection caudal blockade in children. A literature search of the keywords "caudal", "analgesia", "pediatric", and "children" was performed using PubMed and Web of Science databases. We highlight that analgesic quality correlates substantially with the local anesthetic's type, dose, the timing relationship between caudal block and surgery, caudal catheterization, and administration of epidural opioids or other adjuvant drugs.

EEG response to a high volume (1.5 mL/kg) caudal block in infants less than 3 months

INTRODUCTION

The substantial compression of the dural sac and the subsequent cranial shift of cerebrospinal fluid caused by a high-volume caudal block has been shown to significantly but transiently reduce cerebral blood flow. The aim of the present study was to determine whether this reduction in cerebral perfusion is significant enough to alter brain function, as assessed by electroencephalography (EEG).

METHODS

Following ethics approval and parental informed consent, 11 infants (0-3 months) scheduled to undergo inguinal hernia repair were included in the study. EEG electrodes (using nine electrodes according to the 10-20 standard) were applied following anesthesia induction. Following a 5 min baseline period, a caudal block was performed (1.5 mL/kg), whereafter the EEG, hemodynamic, and cerebral near-infrared spectroscopy responses were followed during a 20 min observation period that was divided into four 5 min segments. Special attention was given to alterations in delta power activity since this may indicate cerebral ischemia.

RESULTS

All 11 infants displayed transient EEG changes, mainly represented by increased relative delta power, during the initial 5-10 min postinjection. The observed changes had returned close to baseline values 15 min postinjection. Heart rate and blood pressure remained stable throughout the study.

CONCLUSION

A high-volume caudal block appears to increase intracranial pressure, thereby reducing cerebral blood flow, to the extent that it transiently will affect cerebral function as assessed by EEG (increased delta power activity) in approximately 90% of small infants.

TRIAL REGISTRATION NUMBER

ACTRN12620000420943.

A comparison of ultrafast and conventional spectral Doppler ultrasound to measure cerebral blood flow velocity during inguinal hernia repair in infants

BACKGROUND

Ultrafast cerebral Doppler ultrasound enables simultaneous quantification and visualization of cerebral blood flow velocity. The aim of this study is to compare the use of conventional and ultrafast spectral Doppler during anesthesia and their potential to show the effect of anesthesiologic procedures on cerebral blood flow velocities, in relation to blood pressure and cerebral oxygenation in infants undergoing inguinal hernia repair.

METHODS

A single-center prospective observational cohort study in infants up to six months of age. We evaluated conventional and ultrafast spectral Doppler cerebral ultrasound measurements in terms of number of successful measurements during the induction of anesthesia, after sevoflurane induction, administration of caudal analgesia, a fluid bolus and emergence of anesthesia. Cerebral blood flow velocity was quantified in pial arteries using conventional spectral Doppler and in the cerebral cortex using ultrafast Doppler by peak systolic velocity, end diastolic velocity and resistivity index.

RESULTS

Twenty infants were included with useable conventional spectral Doppler images in 72/100 measurements and ultrafast Doppler images in 51/100 measurements. Intraoperatively, the success rates were 53/60 (88.3%) and 41/60 (68.3%), respectively. Cerebral blood flow velocity increased after emergence for both conventional (end diastolic velocity, from 2.01 to 2.75 cm/s, p < 0.001) and ultrafast spectral Doppler (end diastolic velocity, from 0.59 to 0.94 cm/s), whereas cerebral oxygenation showed a reverse pattern with a decrease after the emergence of the infant (85% to 68%, p < 0.001).

CONCLUSION

It is possible to quantify cortical blood flow velocity during general anesthesia using conventional and ultrafast spectral Doppler cerebral ultrasound. Cerebral blood flow velocity and blood pressure decreased, while regional cerebral oxygenation increased during general anesthesia. Ultrafast spectral Doppler ultrasound offers novel insights into perfusion within the cerebral cortex, unattainable through conventional spectral ultrasound. Yet, ultrafast Doppler is curtailed by a lower success rate and a more rigorous learning curve compared to conventional method.

Effect of paediatric caudal injection volume on optic nerve sheath diameter and regional cerebral oximetry: A randomised trial

BACKGROUND

Caudal injections commonly used for neuraxial anaesthesia in children can displace cerebrospinal fluid cranially causing safety concerns in terms of raised intracranial pressure. Optic nerve sheath diameter (ONSD) is a noninvasive surrogate for the measurement of intracranial pressure. Regional cerebral oximetry (CrSO 2 ) can monitor brain oxygenation, which may decrease by a reduction in cerebral flow due to increased intracranial pressure.

OBJECTIVES

Comparing how caudal injection volumes of 0.8 and 1.25 ml kg -1 influence ONSD and CrSO 2 within the first 30 min after injection.

DESIGN

Prospective, randomised and parallel group trial.

SETTING

Operating room.

PATIENTS

Fifty-eight elective paediatric surgical patients between ages 1 and 7 years old, ASA class I or II, without previous intracranial or ocular pathology and surgery appropriate for single - shot caudal anaesthesia.

INTERVENTION

Single-shot caudal anaesthesia with 0.8 ml kg -1 (group L, n  = 29) and 1.25 ml kg -1 (group H, n  = 29) of 2 mg kg -1 bupivacaine solution.

MAIN OUTCOME MEASURES

Optic nerve sheath diameter measured with ultrasonography and regional cerebral oximetry measured by near - infrared spectroscopy before (NIRS), immediately after, 10, 20 and 30 min after the block.

RESULTS

Mean ONSD values increased from a baseline of 4.4 ± 0.2 mm to a maximum of 4.5 ± 0.2 mm 20 min after injection in group L and from a baseline of 4.5 ± 0.3 mm to a maximum of 4.8 ± 0.3 mm 10 min after injection in group H. Eight of 29 patients in group H and none in group L had an ONSD increase by more than 10%. Both groups had a reduction of less than 2.5% in CrSO 2 .

CONCLUSION

Caudal injection with 1.25 ml kg -1 increased ONSD, an indirect measurement of ICP, more than 0.8 ml kg -1 and neither volume caused a clinically important reduction in CrSO 2 .

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04491032.

Optic Nerve Ultrasound Evaluation in Children: A Review

Managing patients with neurocritical illness requires monitoring and treating elevated intracranial pressure (ICP), especially in cases in children. In terms of precise and real-time measurements, invasive ICP measurements are presently the gold standard for the initial diagnosis and follow-up ICP assessments. As a rapid and non-invasive way to detect elevated ICP, point-of-care ultrasonography (POCUS) of optic nerve sheath diameter (ONSD) has been proposed. The utility of bedside POCUS of ONSD to detect elevated ICP with excellent diagnostic test accuracy in adults has already been demonstrated. Nonetheless, data on the relationship between POCUS of ONSD and ICP in children are scarce. Therefore, the purpose of this review is to point out the most recent findings from the pediatric published literature and briefly discuss what was assessed with ONSD ultrasound examination, and also to describe and discuss the diagnostic procedures available for optic nerve ultrasound appraisal. A search of the medical databases PubMed and Scopus was carried out. The terms such as "ocular ultrasonography", "ICP assessment", "children", "point-of-care ultrasound", and "POCUS" were searched. In conclusion, the use of the standardized A-scan technique coupled with the B-scan technique should be suggested to provide data that are as accurate, precise, repeatable, and objective as possible.

Effect of end-tidal carbon dioxide level on the optic nerve sheath diameter measured by transorbital ultrasonography in anesthetized pediatric patients: A randomized trial

BACKGROUND

Intraoperative hypercapnia and hypocapnia are common during pediatric anesthesia, and the cerebral blood flow and intracranial pressure may be affected by the partial pressure of arterial carbon dioxide. Transorbital ultrasound measurement of the optic nerve sheath diameter is a simple and non-invasive method for intracranial pressure assessment. The objective of this study was to evaluate the effect of end-tidal carbon dioxide (E_T CO₂ ) on optic nerve sheath diameter in a healthy anesthetized pediatric population.

METHODS

Pediatric patients scheduled for elective surgery under general anesthesia and mechanical ventilation in the supine position were enrolled and divided into four subgroups; age <2 years, 2-6 years, 6-12 years, and 12-18 years. Mechanical ventilation was adjusted to achieve target E_T CO₂ levels in a randomized sequence (40-35-45-40 mmHg or 40-45-35-40 mmHg). Three minutes after reaching each target E_T CO₂ level, transorbital ultrasound images of optic nerve sheath diameter were obtained and analyzed. The primary outcome was the optic nerve sheath diameter at each E_T CO₂ level.

RESULTS

Sixty-four pediatric patients were enrolled and analyzed. At E_T CO₂  = 40 mmHg, the optic nerve sheath diameter was 5.6 ± 0.6 mm, 6.4 ± 0.5 mm, 6.8 ± 0.6 mm, and 7.1 ± 0.5 mm in children aged <2 years, 2-6 years, 6-12 years, and 12-18 years, respectively. The overall percent decreases in the optic nerve sheath diameter was -5.6 ± -4.3% (95% CI; -6.7 to -4.5%) at E_T CO₂  = 35 mmHg while the overall percent increases of optic nerve sheath diameter (ONSD) was 4.9 ± 5.1% (95% CI; 3.6 to 6.1%) at E_T CO₂  = 45 mmHg compared with those at E_T CO₂  = 40 mmHg. Spearman rank correlation analysis indicated that there were weak to moderate correlation between E_T CO₂ and the optic nerve sheath diameter (correlation coefficient [p-value] = .355 [.004], .318 [.014], .373 [<.001], and .420 [<.001] in children aged <2 years, 2-6 years, 6-12 years, and 12-18 years, respectively).

CONCLUSIONS

The optic nerve sheath diameter measured by transorbital ultrasound showed rapid reactivity from E_T CO₂ 35 to 45 mmHg in healthy pediatric patients under inhalation general anesthesia.

The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided caudal block in anorectal surgery. A dose finding study

Background

Caudal epidural block (CEB) provides reliable anesthesia for adults undergoing anorectal surgery. Despite the widely utilization, the minimum effective concentration for 90% patients (MEC₉₀) of ropivacaine for CEB remains unknown.

Objective

To estimate MEC of ropivacaine for CEB in anorectal surgery.

Design

A prospective dose-finding study using biased coin design up-and-down sequential method.

Setting

Operating room and postoperative recovery area of Chengdu Shangjin Nanfu Hospital, from October 2019 to January 2020.

Patients

50 males and 51 females scheduled for anorectal surgery.

Interventions

We conducted two independent biased coin design up-and down trials by genders. The concentration of ropivacaine administered to the first patient of male and female were 0.25% with fixed volume of 14ml for male and 12ml for female patients based on our previous study. In case of failure, the concentration was increased by 0.05% in the next subject. Otherwise, the next subject was randomized to a concentration 0.05% less with a probability of 0.11, or the same concentration with a probability of 0.89. Success was defined as complete sensory blockade of perineal area 15 min after the block evidenced by the presence of a lax anal sphincter and pain-free surgery.

Main outcome measures

The MEC of ropivacaine to achieve a successful CEB in 90%(MEC₉₀) of the patients.

Results

The MEC₉₀ of ropivacaine for CEB were estimated to be 0.35% (95% CI 0.29 to 0.4%) for male and 0.353% (95%CI 0.22 to 0.4%) for female. By extrapolation to MEC in 99% of subjects (MEC99) and pooled adjacent violators algorithm (PAVA) adjusted responses, it would be optimal to choose 0.4% ropivacaine with a volume of 14ml for male and 12ml for female.

Conclusions

A concentration of 0.35% ropivacaine with a volume of 14ml provided a successful CEB in 90% of the male patients, while 0.353% ropivacaine with a volume of 12ml provided a successful CEB in 90% of the female patients. A concentration of 0.4% and a volume of 14ml for male and 12 ml for female would be successful in 99% of the patients.

Trial registration

Chictr.org.cn identifier: No. ChiCTR 1900024315.

Primary spread of caudal blockade in children: the possible limiting role of the lumbar spinal cord enlargement (tumenescence) in combination with the cerebrospinal fluid rebound mechanism

BACKGROUND

Despite being the most frequently used pediatric nerve block, certain aspects of the initial intraspinal spread of local anesthetics when performing a caudal block need further elucidation. The fact that injected volumes of 0.7-1.3 mL kg^-1 initially only reach the thoraco-lumbar junction, with only a few vertebral segments difference despite the huge difference in injected volume, still has no apparent explanation. We hypothesize that the narrowing of the epidural space caused by the lumbar spinal enlargement may provide an anatomical barrier causing this restriction of initial spread, alone or in combination with increased intrathecal pressure caused by the "cerebrospinal fluid rebound mechanism." The aim of this observational study was to find support for or refute this hypothesis.

METHODS

Twenty nine MRI scans of the vertebral column, performed in children 0-6 years of age, was identified from the radiographic imaging computer system and analyzed for the vertebral level of the maximum of the lumbar spinal enlargement (Associated anatomical data related to the spinal canal, the dura mater, and the spinal cord were also recorded.

RESULTS

The maximum of the lumbar spinal enlargement was found at a median vertebral level of Th 11 (IQR 11-11).

CONCLUSION

The maximum of the lumbar spinal enlargement is located at the Th 11 vertebral level. Although not entirely conclusive, the findings of the present study do support the notion that the lumbar spinal enlargement, in combination with the CSF rebound mechanism, may be the factors limiting the initial spread of a caudal block to the thoraco-lumbar junction.

Comparison of the effects of normal and low blood pressure regulation on the optic nerve sheath diameter in robot assisted laparoscopic radical prostatectomy

Background

Robot-assisted laparoscopic radical prostatectomy is an advanced and popular surgical technique. However, increased intracranial pressure which is caused by CO₂ pneumoperitoneum and Trendelenburg position is the main cerebrovascular effect. Measurement of optic nerve sheath diameter using ocular ultrasound is a noninvasive and reliable method for the assessment of intracranial pressure. The primary endpoint of this study was to identify whether low blood pressure regulation has any benefit in attenuating an increase of optic nerve sheath diameter during robot-assisted laparoscopic radical prostatectomy.

Methods

Optic nerve sheath diameter and cerebral oxygen saturation were measured at baseline (supine position), one and two hours after pneumoperitoneum and Trendelenburg position respectively, and after return to supine position in normal (n = 27) and low blood pressure groups (n = 24).

Results

Mean optic nerve sheath diameter values measured at one and two hours after pneumoperitoneum and Trendelenburg position were significantly increased compared to the baseline value (P < 0.001 in normal blood pressure group; P = 0.003 in low blood pressure group). However, the mean optic nerve sheath diameter and cerebral oxygen saturation measured at any of the time points as well as degrees of change between the two groups did not show any significant changes. The peak values of optic nerve sheath diameter in normal and low blood pressure groups demonstrated 14.9% and 9.2% increases, respectively.

Conclusions

Low blood pressure group demonstrated an effect in maintaining an increase of optic nerve sheath diameter less than 10% during CO₂ pneumoperitoneum and Trendelenburg position.

Evaluation of the effect of the mouth gag use on optic nerve sheath diameter of pediatric patients undergoing tonsillectomy or Adenotonsillectomy: An observational study

BACKGROUND

A mouth gag is usually used during tonsillectomy and adenotonsillectomy surgeries, cleft palate repair, obstructive sleep apnea surgery, and intraoral tumor excision. The placement of the gag causes hemodynamic changes similar to laryngoscopy. The aim of this study was to evaluate the effect of mouth gag placement on the optic nerve sheath diameter (ONSD) of pediatric patients. The secondary aim was to assess the relationship between neck extension and changes in ONSD.

METHODS

The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291) on 12.04.2018. This prospective, observational study was performed in a tertiary university hospital operating room between 01.05.2018-01.07.2018. Thirty-five children aged < 18 years, with ASA I status, who were scheduled for tonsillectomy and adenotonsillectomy surgeries were prospectively included in the study. Measurements of ONSD were performed (T0) after induction of anesthesia, (T1) after endotracheal intubation, (T2) after mouth gag placement, and (T3) 20 min after mouth gag placement. After the mouth gag was placed and the head was positioned for surgery, the degree of neck extension was calculated.

RESULTS

All participants completed the study. There were significant differences in ONSD values at time points T1, T2, and T3 (p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.05,-0.02; respectively). The maximum increase in ONSD was after intubation (0.69 ± 0.06 mm) and immediately after mouth gag placement (0.67 ± 0.07 mm). ONSD values continued to increase 20 min after gag placement (0.36 ± 0.04). There was no relation between the degree of neck extension and ONSD values (β = 0.63, p = 0.715).

CONCLUSIONS

The use of a mouth gag causes significant increases in ONSD measurements of children. Therefore, attention to the duration of mouth gag placement should be considered during surgery.

TRIAL REGISTRATION

The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291 ) on 12.04.2018.

Epidural bolus versus continuous epidural infusion analgesia on optic nerve sheath diameter in paediatric patients: A prospective, double-blind, randomised trial

The use of programmed intermittent epidural bolus for postoperative analgesia may have greater analgesic efficacy than continuous epidural infusion. However, the rapid delivery speed used with an epidural bolus is more likely to increase intracranial pressure. We compared the effects of lumbar epidural bolus versus continuous infusion epidural analgesia on intracranial pressure in children using optic nerve sheath diameter as a marker. We randomly assigned 40 paediatric patients to bolus or infusion groups. Epidural analgesia (0.15% ropivacaine 0.3 ml·kg⁻¹) was administered via bolus or infusion. Ultrasonography was used to measure the optic nerve sheath diameter before (T0), at 3 min (T1), 10 min (T2), and 70 min (T3) after starting the pump. There were statistically significant between-group differences in optic nerve sheath diameter over time (P_{Group x Time} = 0.045). From T0–T3, the area under the curve values were similar between the two groups. Although there were differences in the patterns of optic nerve sheath diameter change according to the delivery mode, the use of lumbar epidural bolus did not increase the risk of intracranial pressure increase over that of continuous infusion. Further research is needed to investigate intracranial pressure changes after continuous application of each delivery mode.

Comparison of quadratus lumborum block and caudal block for postoperative analgesia in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries: a randomized controlled trial

Background and objectives

Caudal epidural anesthesia is a widely used popular technique for postoperative analgesia but it has potential side effects and duration of analgesia is short. Quadratus lumborum block (QLB) was found to be an effective method for postoperative analgesia in lower abdominal surgeries. In this double-blind prospective randomized trial, we aimed to compare the postoperative analgesic efficacies of QLB and the caudal block in pediatric patients undergoing inguinal hernia repair and orchiopexy surgeries under general anesthesia.

Materials and methods

After approval was obtained from the ethics committee, in this prospective randomized double-blind trial, 53 patients under general anesthesia undergoing inguinal hernia repair and orchiopexy surgeries randomly received caudal block or QLB. Demographic data, postoperative analgesic requirement, Face, Legs, Activity, Cry, and Consolability (FLACC) scores at 30 min, 1, 2, 4, 6, 12 and 24 hours, parent satisfaction scores and complications were recorded.

Results

The study included 52 patients, after excluding one patient because of a failed caudal block. There were no significant differences between the groups based on demographic data (p>0.05). The number of patients who required analgesics in the first 24 hours was significantly lower in QLB group (p=0.001). Postoperative 4, 6, 12 hours FLACC scores were significantly lower in the QLB group (p<0.001, p=0.001 and p<0.001, respectively). Parent satisfaction scores were higher in the QLB group (p=0.014).

Conclusion

According to the results of this study, QLB can provide much more effective analgesia than caudal block without adjuvants in multimodal analgesia management of children undergoing inguinal hernia repair and orchiopexy surgeries.

Trial registration number

NCT03294291.

Effect of neck extension on ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in patients undergoing palatoplasty: A prospective observational study

Palatoplasty is performed with neck extension in patients with a cleft palate. The neck extension required for a better surgical view during palatoplasty can affect intracranial pressure. We evaluated the effect of neck extension on intracranial pressure by measuring the optic nerve sheath diameter using ultrasonography during palatoplasty. The optic nerve sheath diameter was measured in 30 patients at 10 min after anesthetic induction in the supine position (T1), at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4). Hemodynamic and respiratory variables such as systolic blood pressure, heart rate, end-tidal carbon dioxide partial pressure, and peak airway pressure were also measured at the same time points. In comparison with the optic nerve sheath diameter measured at 10 min after anesthetic induction in the supine position (T1), the mean optic nerve sheath diameters were significantly increased at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4; 4.19 ± 0.26, 5.20 ± 0.29, 4.38 ± 0.36, and 4.35 ± 0.30 mm, respectively). However, hemodynamic and respiratory variables were not significantly different at all time points. We found that the optic nerve sheath diameter, an indicator of intracranial pressure, was increased during palatoplasty with neck extension, which suggests that the position may affect the intracranial pressure of patients with a cleft palate.

The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: A systematic review with meta-analysis

BACKGROUND

The aim of the study was to compare the analgesic efficacy of epidural analgesia and transverse abdominis plane (TAP) block. TAP block has gained popularity to provide postoperative analgesia after abdominal surgery but its advantage over epidural analgesia is disputed.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. Only trials comparing TAP block with epidural analgesia were included. The primary outcome was pain score at rest (analog scale, 0-10) on postoperative day 1 analyzed in subgroups according to the population (children and adults). Secondary outcomes included rate of hypotension, length of stay, and functional outcomes (time to first bowel sound, time to first flatus).

RESULTS

Ten controlled trials, including 505 patients (195 children and 310 adults), were identified. Pain scores at rest on postoperative day 1 were equivalent for TAP block and epidural analgesia groups in children (mean difference: 0.3; 95% confidence interval [CI]: -0.1 to 0.6; I = 0%; P = .15) and in adults (mean difference: 0.5; 95% CI: -0.1 to 1.0; I = 81%; P = .10). The quality of evidence for our primary outcome was moderate according to the GRADE system. The epidural analgesia group experienced a higher rate of hypotension (relative risk: 0.13; 95% CI: 0.04-0.38; I = 0%; P = .0002), while hospital length of stay was shorter in the TAP block group (mean difference: -0.6 days; 95% CI: -0.9 to -0.3 days; I = 0%; P < .0001), without impact on functional outcomes.

CONCLUSION

There is moderate evidence that TAP block and epidural analgesia are equally effective in treating postoperative pain in both pediatric and adult patients, while TAP block is associated with fewer episodes of hypotension and reduced length of stay.

Role of ultrasound guided epidural anesthesia for lower limb surgery in children with previously repaired meningomyelocele

BACKGROUND

Children that have had a meningomyelocele repair often present for hip and bilateral lower limb surgeries. Due to vertebral, epidural, and nerve root abnormalities, placement of epidural catheter is difficult.

AIMS

We aim to describe the potential role of ultrasound in delineating the most appropriate intervertebral space for central neuroaxial blocks in these patients.

METHODS

Twelve children with previous meningomyelocele repair, in the age group of 6-12 years posted for hip or bilateral lower limb surgeries were included. After induction of anesthesia, an ultrasound scan was done with the patient in the left lateral position. The central neuroaxial block was performed in the most appropriate intervertebral space seen on transverse scan of spine. These patients were studied with regard to visibility of the osseous framework of the spine, the anterior and posterior dural complexes, ease of insertion of catheter, evidence of dural puncture, and possibility of identification of the extent of peri-incisional fibrosis.

RESULTS

One case required 2 attempts. There was no evidence of dural puncture. We could confirm the soft tissue shadow, the osseous framework, and the anterior and posterior dural complexes in all 12 patients. Ultrasonography guided in selecting the most appropriate space for epidural catheter placement.

CONCLUSION

Ultrasound guidance aids in identification of normal intervertebral space and explicitly shows the abnormal space. It can be used as an aid to differentiate between normal and abnormal space in post-meningomyelocele repair.