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Yang W, Han D, Pan S, Zou S, Xie S, Ma Y, Huang G. Evaluation of sacral hiatus changes in children using ultrasound. Heliyon 2024; 10:e31526. [PMID: 38831844 PMCID: PMC11145470 DOI: 10.1016/j.heliyon.2024.e31526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Background and objectives The intercornual distance in the sacral hiatus has yet to be studied precisely in children. This age-stratified, observational study aimed to clarify the changes in sacral hiatus dimensions and to quantify the correlations between the intercornual distance of the sacral hiatus and age, height, weight, and head circumference by using real-time ultrasonography. Methods The patients were stratified into three groups: neonates and infants, toddlers, and schoolchildren. In the operating room, the ultrasonic probe was placed at the sacral cornua to obtain a transverse view of the sacral hiatus, and the intercornual distance was measured three times in millimetres. Results The study included a total of 156 patients. The mean ± SD (95%CI) of intercornual distance in neonates and infants (<12 months) was 11.58 ± 1.79 (11.11-12.04) mm, 13.29 ± 1.97 (12.71-13.86) mm in toddlers (13-36 months), and 13.36 ± 2.49 (12.64-14.08) mm in schoolchildren (>36 months).The mean values of neonates and infants were different from those of toddlers and schoolchildren (p < 0.001), but it was similar between toddlers and schoolchildren (p > 0.05, 95 % CI mean difference -1.10 to 0.95).Intercornual distance was correlated with age, height, weight, and head circumference before one year of age (Spearman's R values > 0.7), but there was no correlation thereafter (Spearman's p value > 0.05). Conclusion In the first year after birth, the intercornual distance increases rapidly with body growth; after one year of age, the sacral hiatus dimension changes significantly. Ultrasound is superior for assessing the gradually ossified cartilage components in older children.
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Affiliation(s)
- Wenshuang Yang
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Ding Han
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Shoudong Pan
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Shiya Zou
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Siyuan Xie
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Ya Ma
- Ultrasound Department, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Guimin Huang
- Big Data Centre, Capital Institute of Paediatrics, Beijing, China
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Portela F, Costa G, Cenicante T. Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical Center. Cureus 2023; 15:e48272. [PMID: 38054162 PMCID: PMC10695668 DOI: 10.7759/cureus.48272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2023] [Indexed: 12/07/2023] Open
Abstract
Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.
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Affiliation(s)
- Filipa Portela
- Anesthesiology, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
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Alansary AM, Badawy A, Elbeialy MAK. Ultrasound-guided trans-incisional quadratus lumborum block versus ultrasound-guided caudal analgesia in pediatric open renal surgery: a randomized trial. Korean J Anesthesiol 2023; 76:471-480. [PMID: 36704815 PMCID: PMC10562062 DOI: 10.4097/kja.22774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The caudal route is a common approach for postoperative analgesia; however, it is associated with limited duration of action. The quadratus lumborum block (QLB) may produce prolonged postoperative analgesia. Therefore, this study aimed to compare the postoperative analgesic efficacy of the ultrasound-guided caudal block with that of the ultrasound-guided transincisional QLB (TiQLB) in pediatric patients undergoing open renal surgery. METHODS Forty patients of both sexes, aged 2-11 years, were randomly assigned to receive either caudal analgesia with 1.25 ml/kg of bupivacaine 0.2% (Caudal group; n = 20) or a QLB with 0.5 ml/kg of bupivacaine 0.2% (TiQLB group; n = 20) in addition to standard general anesthesia. Time to first analgesia was the primary outcome. Total analgesic consumption in the first 24 h postoperatively, pain scores, and the incidence of side effects were the secondary outcomes. RESULTS The mean time to first analgesic requirement was significantly longer in the TiQLB group than in the Caudal group (18.8 ± 5.1 vs. 6.7 ± 0.7 h, P < 0.001). Total ketorolac consumption and pain scores were significantly lower in the TiQLB group (P < 0.001). A few cases of mild postoperative nausea and vomiting were noted among patients in both groups; however, the difference was not statistically significant. No incidence of pruritus, shivering, or respiratory depression was noted. CONCLUSIONS Analgesia after the ultrasound-guided TiQLB with bupivacaine was superior to that after the ultrasound-guided caudal block, with similar side effects.
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Affiliation(s)
- Amin M. Alansary
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Atef Badawy
- Department of Urology, Menoufia University, Cairo, Egypt
| | - Marwa A. K. Elbeialy
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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Quan S, Lu Y, Huang Y. Analgesic effect of ropivacaine combined with dexmedetomidine in the postoperative period in children undergoing ultrasound-guided single-shot sacral epidural block: A systematic review and meta-analysis. Front Pediatr 2023; 11:1099699. [PMID: 37063658 PMCID: PMC10090670 DOI: 10.3389/fped.2023.1099699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Objective This study aims to evaluate the efficacy of dexmedetomidine as an adjuvant to ropivacaine in prolonging postoperative analgesia and reducing pain scores in children undergoing surgery. Methods Five online databases were searched for RCTs on postoperative analgesia of pediatric patients undergoing ultrasound-guided single-shot sacral epidural block with dexmedetomidine as an adjuvant to ropivacaine up to January 2, 2023. Pain score and sedation score at 2, 4, 8, 12, and 24 h after the operation, the time of first receiving additional analgesic drugs, and the number of postoperative adverse effects were selected to compare the efficacy and safety of combined treatment with ropivacaine alone for pediatrics. The standard mean difference (SMD) or odds ratio (OR) and the corresponding 95% confidence interval (95%CI) were calculated by using a random-effects model. Results A total of 295 articles were retrieved, but only 20 records were included in this meta-analysis. The results showed that dexmedetomidine combined with ropivacaine for sacral epidural block in children undergoing ultrasound-guided single-shot sacral epidural block had a more prolonged analgesia effect (SMD = 3.47, 95%CI: 2.80, 4.14). There were lower analgesia scores at 2 h(T1), 4 h(T2), 8 h(T3), 12 h(T4), and 24 h(T5) in postoperative period (T1 : SMD = -1.02, 95%CI: -1.31, -0.72; T2 : SMD = -1.02, 95%CI: -1.32, -0.72; T3 : SMD = -0.84, 95%CI: -1.12, -0.56; T4 : SMD = -0.61, 95%CI: -1.03, -0.20; T5 : SMD = -1.03, 95%CI: -1.28, -0.78). And the incidence of adverse effects was similar between the two groups (OR = 0.84, 95%CI: 0.59, 1.18). Conclusions The results of this review and meta-analysis support that dexmedetomidine, as an adjuvant to ropivacaine, can improve postoperative analgesia of surgery and significantly prolong the analgesic time in children, with a similar incidence rate of adverse symptoms when compared with ropivacaine alone.
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Affiliation(s)
- Shoubo Quan
- Department of Anesthesiology, Songshan Lake Central Hospital of Dongguan City, Dongguan, China
| | - Yuexia Lu
- Department of Anesthesiology, Haikou Hospital of Traditional Chinese Medicine, Haikou, China
| | - Yujie Huang
- Department of Anesthesiology, Nantong Haimen District People's Hospital, Nantong, China
- Correspondence: Yujie Huang
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Xie G, Zhao J, Chu L, Song S, Wang Y, Lai D, Cheng B, Fang X. Establishment of Difficult Caudal Epidural Blockade Prediction Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:2037904. [PMID: 36387347 PMCID: PMC9652077 DOI: 10.1155/2022/2037904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 07/29/2023]
Abstract
Background We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verified the role of ultrasound in difficult caudal epidural blockade (CEB). Methods From October 2018 to March 2019, this study consisted of three phases. First, we prospectively enrolled 202 patients scheduled to undergo caudal epidural anesthesia and assessed risk factors by binary logistic regression to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction model. Youden-index was used to determine the cut-off value. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound. Result The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation between unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), the number of the sacral hiatus by palpation ≥1 (OR 4.451), and history of difficult CEB (OR 39.282) with a higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥3, a preprocedure ultrasound scan could reduce the incidence of difficult CEB (55.56% in the Landmark group vs. 9.38% in the ultrasound group, p < 0.001). Conclusion This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥3. Trial registration: No: ChiCTR1800018871, Site URL: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4; Principal investigator: Jialian Zhao, Date of registration: 2018.10.14.
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Affiliation(s)
- Guohao Xie
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jialian Zhao
- Departments of Anesthesiology, The Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lihua Chu
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shengwen Song
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ya Wang
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Dengming Lai
- Departments of Neonatal Surgery, The Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Baoli Cheng
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Hüppe T, Pattar G, Maass B. Kaudalanästhesie: Übersicht und praktische Handlungsempfehlungen. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:724-736. [DOI: 10.1055/a-1467-8624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Mahrous RSS, Ahmed AAA, Ahmed AMM. Comparison Between Ultrasound-guided Caudal Analgesia versus Peripheral Nerve Blocks for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Prospective Study. Local Reg Anesth 2022; 15:77-86. [PMID: 36117554 PMCID: PMC9480592 DOI: 10.2147/lra.s372903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aim Ultrasound (US) guided regional analgesia is a safe and effective method in providing perioperative analgesia in pediatrics with a high success rate rapid onset and fewer side effects. The aim of this study was to compare the efficacy of US-guided caudal block versus US-guided peripheral nerve blocks (femoral and sciatic nerve blocks) in providing perioperative analgesia in pediatrics undergoing unilateral lower limb surgery. Methods Children aged 1–12 years scheduled for unilateral lower limb surgery during the period from January 2020 to December 2021 were randomly allocated into two groups. Group C where pediatrics received US-guided caudal block, while in group P, pediatrics received US-guided femoral and sciatic nerve blocks after the induction of general anesthesia (GA). The primary aim was to compare the postoperative pain (evaluated by the COMFORT pain score) between the two groups. Secondary aims were to compare perioperative opioids used parents’ satisfaction and occurrence of side effects. Results Pediatrics who underwent unilateral lower limb surgeries were allocated into two groups (group C and group P). There was no significant difference between patients’ baseline characteristics and the postoperative pain score at 2, 4, 16, and 20 h.’ However there was a statistical significance at 6, 8, 12, and 24 h postoperatively, frequency of analgesia as well as the total postoperative dose of opiates (nalbuphine). Time to first analgesic (nalbuphine) requirement was significantly less in group C with a mean of (9.6±2.9 h) than in group P with a mean of (15.1±3.5 h). Parents of children in group P were more satisfied than those in group C with no recorded complications for both techniques. Conclusion US-guided lower limb peripheral nerve block is a simple and safe method to provide adequate and more prolonged analgesia compared to US-guided caudal block for lower limb surgeries in pediatrics.
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Affiliation(s)
- Rabab S S Mahrous
- Department of Anaesthesia and Surgical Intensive Care Alexandria University Alexandria Egypt
| | - Amin A A Ahmed
- Department of Orthopedic Surgery and Traumatology Alexandria University Alexandria Egypt
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Jain D, Hussain SY, Ayub A. Comparative evaluation of landmark technique and ultrasound-guided caudal epidural injection in pediatric population: A systematic review and meta-analysis. Paediatr Anaesth 2022; 32:35-42. [PMID: 34752689 DOI: 10.1111/pan.14332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 08/17/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound-guided technique provides real-time visualization of the structures and injection while performing caudal block. We performed this meta-analysis to determine the utility of ultrasound in caudal blocks in children over the landmark-based technique. METHODS Randomized controlled trials comparing ultrasound-guided caudal blocks and landmark technique in pediatrics were searched from databases-PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. RESULTS Five trials with 904 participants were included for this meta-analysis. There was no difference in success rate between the two techniques (Risk ratio-1.07; 95% CI [0.97, 1.18]; p = .15). Time to perform the block was similar (Mean difference-8.88 s; 95% CI [-21.64, 39.40; p = .57) while first puncture success was higher with ultrasound-guided technique (Risk ratio-1.31; 95% CI [1.15, 1.49]; p = .0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. CONCLUSION Ultrasound-guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique.
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Affiliation(s)
- Dhruv Jain
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sana Yasmin Hussain
- Department of Anaesthesiology, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Arshad Ayub
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Ozen V. Comparison of the postoperative analgesic effects of US-guided caudal block and US-guided pudendal nerve block in circumcision. Int J Clin Pract 2021; 75:e14366. [PMID: 33993633 DOI: 10.1111/ijcp.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/09/2021] [Indexed: 11/29/2022] Open
Abstract
AIM To compare the postoperative analgesic efficacy and postoperative complications of the pudendal nerve block (PNB) and caudal block (CB) with ultrasound (US). STUDY DESIGN A prospective observational study. METHODS This study was included male patients aged between 4 and 12 years in the ASA I-II group and scheduled for circumcision. A low-dose CB or US-guided PNB was administered under general anaesthesia before the operation. Postoperative pain was evaluated using the Children's Hospital Eastern Ontario Pain Scale (CHEOPS) and Faces Pain Scale-Revised. Postoperative analgesic need was also noted. RESULTS The study was completed with a total of 100 patients consisting of 50 patients who received a CB and 50 who received a PNB. Intraoperative block failure was not seen in any patient. The mean CHEOPS score (P < .001) and the 6th (P = .003) and 12th hours (P < .001) CHEOPS scores were found to be statistically significantly higher in the CB group. There were no postoperative side effects in the PNB group with a statistically significant difference compared with the CB group (P = .027). CONCLUSION This first prospective study in the literature shows that US-guided PNB provided a more pronounced and longer analgesic effect and resulted in less requirement for postoperative analgesics than US-guided CB.
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Affiliation(s)
- Volkan Ozen
- Department of Anesthesiology and Reanimation, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
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Nair N, Sreenivas M, Gupta AK, Kandasamy D, Jana M. Neonatal and infantile spinal sonography: A useful investigation often underutilized. Indian J Radiol Imaging 2021; 26:493-501. [PMID: 28104945 PMCID: PMC5201081 DOI: 10.4103/0971-3026.195788] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Sonography is an ideal, effective, noninvasive tool for evaluation of the spinal cord in neonatal and early infantile age groups owing to lack of ossification of the posterior elements of spine. Understanding normal anatomical appearances is a prerequisite for the interpretation of various pathologies of the spinal canal and its contents. This review elucidates normal appearances of the spinal cord in this age group, in both axial and sagittal planes. Usefulness of Doppler sonography is briefly discussed, and special emphasis is placed on normal anatomical variants that may mimic spinal abnormalities. Sonographic appearances of common intraspinal pathologies, both congenital and acquired, are exhaustively described. Key points regarding sonographic diagnosis of important spinal anomalies are emphasized and explained in detail. To conclude, spinal ultrasound is a reliable and widely available screening tool, albeit the usefulness of which is often underestimated.
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Affiliation(s)
- Nikhil Nair
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - M Sreenivas
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Arun K Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | | | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Jain A, Barasker SK, Jain S, Waindeskar V. Correlation of correct needle placement in caudal epidural space and anatomical structures of sacral canal in paediatric patients: An observational study. Indian J Anaesth 2021; 65:S74-S79. [PMID: 34188259 PMCID: PMC8191192 DOI: 10.4103/ija.ija_1599_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/15/2021] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background and Aims: Caudal epidural block (CEB) is commonly performed using surface landmark-based technique in the paediatric patients, with a good success rate. Failure to perform CEB is usually attributable to anatomic variations. The aim of this study was to perform measurements of the anatomical landmarks that are generally used to perform CEB and find a relation between these measurements and successful needle placement. Methods: This was an observational study that included 114 patients, aged up to 15 years. Ultrasonography (USG) scan of the sacrococcygeal region with measurement of cornu height, skin to cornu distance, inter-cornu distance (ICD), vertical and oblique size of hiatus were done. Needle placement for CEB was done using the usual palpatory hiatal approach. Needle position was checked by using ultrasound. Spearman correlation coefficient and multi-variate logistic regression were used for measuring the correlation and predictors of correct needle placement, respectively. Results: Correct placement of needle was found in 84% patients. Statistically significant correlation was found between all the anatomical parameters. Regression analysis revealed that only ICD had a statistically significant contribution (OR1.67, 95% CI 1.024–2.7; P = 0.04) in predicting an incorrect needle placement. If ICD was less than 12.5 mm, it predicted a difficult needle placement; all the children were less than 1.5 years in age; AUC was 77%, P = 0.001, sensitivity 83% and specificity 76.5%. Conclusion: ICD can be used as predictor of difficult needle placement for CEB. USG guidance may be of help while performing CEB in children less than 1.5 years.
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Affiliation(s)
- Anuj Jain
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Swapnil K Barasker
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Suruchi Jain
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vaishali Waindeskar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Ponde VC, Puri K, Nagdev T. Regional anaesthesia in neonates: a narrative review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The benefits of regional anaesthesia and the accompanying concerns of general anaesthesia in newborns make the former a safe and valuable addition. Multiple regional anaesthesia techniques, ranging from the central neuraxial blocks, truncal blocks, and peripheral nerve blocks are available. Empowering us to make the case to case decision to choose the most beneficial and safe block for the neonate. The applications of regional anaesthesia, over the period, have encompassed perioperative analgesia and therapeutic uses. With the addition of ultrasonography, neonatal regional anaesthesia has reached a fine amount of objectivity and accuracy. A trend of utilising regional blocks as the sole anaesthetic as against an adjuvant to general anaesthesia is setting in. In this review, we take a look at recent developments in this field in a generalised manner followed by dwelling into most of the commonly used blocks in daily practice. However, a detailed description of each block is beyond the scope of this review.
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Adler AC, Belon CA, Guffey DM, Minard CG, Patel NV, Chandrakantan A. Real-Time Ultrasound Improves Accuracy of Caudal Block in Children. Anesth Analg 2020; 130:1002-1007. [DOI: 10.1213/ane.0000000000004067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Botham SJ, Fillmore EP, Grant TS, Davies H, Hutchinson C, Tunstall R. Age-related changes in inguinal region anatomy from 0 to 19 years of age. Clin Anat 2019; 32:794-802. [PMID: 31066950 DOI: 10.1002/ca.23402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 11/10/2022]
Abstract
Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Sean J Botham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Erin P Fillmore
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Thomas S Grant
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Harvey Davies
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Charles Hutchinson
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Richard Tunstall
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev 2019; 2:CD011436. [PMID: 30820938 PMCID: PMC6395955 DOI: 10.1002/14651858.cd011436.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of ultrasound guidance for regional anaesthesia has become popular over the past two decades. However, it is not recognized by all experts as an essential tool, perhaps because it is unclear whether ultrasound reduces the risk of severe neurological complications, and the cost of an ultrasound machine (USD 22,000) is substantially higher than the cost of other tools. This review was published in 2016 and updated in 2019. OBJECTIVES To determine whether ultrasound guidance offers any clinical advantage when neuraxial and peripheral nerve blocks are performed in children in terms of decreasing failure rate or the rate of complications. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trial registers up to March 2018 together with reference checking to identify additional studies and contacted study authors to obtain additional trial information. SELECTION CRITERIA We included all parallel randomized controlled trials that evaluated the effects of ultrasound guidance used when a regional blockade technique was performed in children. We included studies performed in children (≤ 18 years of age) undergoing any type of surgical procedure (open or laparoscopic), for which a neuraxial (spinal, epidural, caudal, or combined spinal and epidural) or peripheral nerve block (any peripheral nerve block including fascial (fascia iliaca, transversus abdominis plane, rectus sheath blocks) or perivascular blocks), for surgical anaesthesia (alone or in combination with general anaesthesia) or for postoperative analgesia, was performed with ultrasound guidance. We excluded studies in which regional blockade was used to treat chronic pain.We included studies in which ultrasound guidance was used to perform the technique in real time (in-plane or out-of-plane), as pre-scanning before the procedure or to evaluate the spread of the local anaesthetic so the position of the needle could be adjusted or the block complemented. For control groups, any other technique used to perform the block including landmarks, loss of resistance (air or fluid), click, paraesthesia, nerve stimulator, transarterial, or infiltration was accepted. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were failed blocks, pain scores at one hour after surgery, and block duration. Secondary outcomes included time to perform the block, number of needle passes, and minor and major complications. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 33 trials with a total of 2293 participants from 0.9 to 12 (mean or median) years of age. Most trials were at low risk of selection, detection, attrition, and reporting bias, however the lack of blinding of participants and personnel caring for participants resulted in 25 trials being judged as at high or unclear risk of bias. We identified five ongoing trials.Ultrasound guidance probably reduces the risk of failed block (risk difference (RD) -0.16, 95% confidence interval (CI) -0.25 to -0.07; 22 trials; 1789 participants; moderate-quality evidence). When ultrasound guidance was used, there was a small to moderate reduction in pain one hour after surgery, equivalent to a reduction of 1.3 points on the revised Bieri FACES pain scale (scale; 0 = no pain, 10 = maximal pain) (standardized mean difference (SMD) -0.41, 95% CI -0.74 to -0.07 (medium effect size); 15 trials; 982 participants; moderate-quality evidence). Ultrasound guidance increases block duration by the equivalent of 42 minutes (SMD 1.24, 95% CI 0.72 to 1.75; 10 trials; 460 participants; high-quality evidence).There is probably little or no difference in the time taken to perform the block (SMD -0.46, 95% CI -1.06 to 0.13; 9 trials; 680 participants; moderate-quality evidence). It is uncertain whether the number of needle passes required is reduced with the use of ultrasound guidance (SMD -0.63, 95% CI -1.08 to -0.18; 3 trials; 256 participants; very low-quality evidence).There were no occurrences of major complications in either the intervention or control arms of the trials (cardiac arrest from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence); lasting neurological injury (19 trials; 1250 participants; low-quality evidence)).There may be little of no difference in the risk of bloody puncture (RD -0.02, 95% CI -0.05 to 0.00; 13 trials; 896 participants; low-quality evidence) or transient neurological injury (RD -0.00, 95% CI -0.01 to 0.01; 18 trials; 1230 participants; low-quality evidence). There were no occurrences of seizure from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence) or block infections without neurological injury (18 trials; 1238 participants; low-quality evidence). AUTHORS' CONCLUSIONS Ultrasound guidance for regional blockade in children probably decreases the risk of failed block. It increases the duration of the block and probably decreases pain scores at one hour after surgery. There may be little or no difference in the risks of some minor complications. The five ongoing studies may alter the conclusions of the review once published and assessed.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
- University of Quebec in Abitibi‐TemiscamingueTeaching and Research Unit, Health SciencesRouyn‐NorandaQCCanada
- Faculty of Medicine, Laval UniversityDepartment of Anesthesiology and Critical CareQuebec CityQCCanada
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoILUSA60611
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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Wiegele M, Marhofer P, Lönnqvist PA. Caudal epidural blocks in paediatric patients: a review and practical considerations. Br J Anaesth 2019; 122:509-517. [PMID: 30857607 DOI: 10.1016/j.bja.2018.11.030] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022] Open
Abstract
Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.
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Affiliation(s)
- Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.
| | - Per-Arne Lönnqvist
- Department of Paediatric Anesthesia and Intensive Care, Section of Anaesthesiology and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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17
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Abstract
Paediatric regional anaesthesia today is one of the fastest growing and exciting aspects of paediatric anaesthesia, which requires an ongoing fervour to learn. Application of paediatric regional anaesthesia in neonates, infants, toddlers and children is undertaken to treat perioperative pain without disturbing the physiological milieu with additional advantages elaborated in the review. The available choices, traditional methods and the most recently described methods are discussed with emphasis on their advantages and disadvantages. Clear pointers for selection of the blocks are also discussed. To present a holistic overview of this rapidly growing subject, a comprehensive literature search was performed in May 2019 in MEDLINE, PubMed and Google Scholar to retrieve articles pertaining to all the above topics. The keywords used in various combinations included 'Central neuraxial, blocks, Paediatric(s)', 'Peripheral Nerve blocks', 'Safety, controversies, regional, anaesthesia'.
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Affiliation(s)
- Vrushali Ponde
- Children Anaesthesia Services and Surya Children Hospital, Holy Spirit Hospital, Holy Family Hospital, Breach Candy Hospital, Mumbai, Maharashtra, India
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18
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Selkirk GD, Mclaughlin AC, Mirjalili SA. Revisiting the surface anatomy of the sciatic nerve in the gluteal region in children using computed tomography. Clin Anat 2015; 29:211-6. [PMID: 26379096 DOI: 10.1002/ca.22628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/06/2015] [Accepted: 09/11/2015] [Indexed: 12/25/2022]
Abstract
No anatomy text specifically describes the course of the sciatic nerve (SN) in the gluteal region in children. Anatomical information is largely derived from cadaveric studies of adults, so accurate anatomical information about the location of the SN in children is required. The aim of this study is to assess the surface anatomy of the SN in children using computed tomography (CT). After excluding studies with pelvic pathology, 75 CT scans were analyzed. Three groups were selected for analysis (0-2, 4-6, and 8-10 years). The position of the SN was measured between the posterior superior iliac spine (PSIS) and the ischial tuberosity (IT) and between the IT and the greater trochanter (GT) using 3-dimensional images. In the 0-2 age group, the SN crossed the middle third of a line between the PSIS and the IT in 94% and the GT and the IT in 80% of cases. In the 4-6 age group, the SN crossed the middle third of a line between the PSIS and the IT in 96% and the GT and the IT in 87%. In the 8-10 age group, the SN crossed the middle third of a line between the PSIS and the IT in 100% and the GT and the IT in 71%. The findings indicate that the SN in children is most accurately located in the middle third along a line drawn from the PSIS to the IT and the GT to the IT. Our study is the first to provide anatomical CT data from living children to guide interventions in the gluteal region.
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Affiliation(s)
| | - Andrew C Mclaughlin
- Department of Radiology, Starship Children's Hospital, Auckland, New Zealand
| | - S Ali Mirjalili
- Department of Anatomy with Radiology, University of Auckland, New Zealand
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Ultrasound versus anatomical landmarks for caudal epidural anesthesia in pediatric patients. BMC Anesthesiol 2015; 15:102. [PMID: 26169595 PMCID: PMC4499894 DOI: 10.1186/s12871-015-0082-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/24/2022] Open
Abstract
Background Caudal block is easily performed because the landmarks are superficial. However, the sacral hiatus is small and shallow in pediatric patients. In the present study, we evaluated under general anesthesia whether the distance between the bilateral superolateral sacral crests increased with growth, whether an equilateral triangle was formed between the apex of the sacral hiatus and the bilateral superolateral sacral crests, and whether expansion of the epidural space could be confirmed by ultrasound. Methods This prospective observational study included 282 children who were ASA I–II. Under general anesthesia, each patient was placed in the lateral bent knees position, and the attending anesthesiologist drew an equilateral triangle and measured the distance between the bilateral superolateral sacral crests along a line forming the base of the triangle. Then the sacral hiatus was identified by ultrasound. Differences of the distance between the anatomical landmarks measured by the anesthetist and by ultrasound were evaluated. Results Two patients were excluded because the superolateral sacral crests and sacral hiatus could not be palpated. The base of the triangle increased in proportion to age up to 10 years old, with a significant correlation between age and the length of the base (Spearman’s r value = 0.97). The triangle was not an equilateral triangle under 7 years old. The sacral hiatus could be identified by ultrasound and we could confirm expansion of the epidural space in all patients. Conclusion We observed a correlation between age and the length of the triangle base in children under 10 years old. Although detection of the anatomical landmarks by palpation differed from identification by ultrasound in pediatric patients, performing ultrasound is important. Epinephrine should be added to the anesthetic to avoid complications. Trial registration Current Controlled Trials UMIN000017898. Registered 14 June 2015. Date of protocol fixation was 1st December, 2008 and Anticipated trial start date was 5th January, 2009.
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