Caudal epidural block in children and infants: retrospective analysis of 2088 cases

Agony of Choice: Caudal Block versus Ilioinguinal/Iliohypogastric Nerve Block in Unilateral Orchidopexy

Objective: This prospective study aimed to compare the efficacy of caudal block (CB) and ilioinguinal/iliohypogastric nerve block (IINB) for providing additional analgesia during unilateral orchidopexy. Methods: Seventy-one boys aged <48 months, classified as ASA I/II, were assigned into CB (n = 37) and IINB (n = 34) groups. Outcome measures included intra- and postoperative analgesic requirements, pain scores, and administration duration. Additional intraoperative analgesia was administered for a 10% increase in heart rate, while postoperative pain was assessed using the Children's and Infants Postoperative Pain Scale (CHIPPS), with scores >4 prompting supplementary analgesia. Monitoring was extended for 24 h post-surgery. Results: CB significantly reduced the need for intraoperative (p < 0.001) and early postoperative (p = 0.008) analgesia compared to IINB. However, the CB group exhibited a slightly higher but non-significant analgesic requirement on the ward. No clinically relevant side effects were observed in either group. Conclusions: Both CB and IINB are effective and safe methods for providing regional analgesia during orchidopexy. CB demonstrates superior efficacy intraoperatively and in the early postoperative period, while IINB may offer advantages in the later recovery phase. However, additional analgesia is often required for orchidopexy, especially in outpatient settings.

Review of clinical evidence of caudal block for postoperative analgesia in children with ketamine added local anesthetics

Background

Adding ketamine to local anesthetics used for caudal block in children is an emerging clinical practice. This review aims to resolve controversies related to this adjuvant for a caudal block in children who underwent sub-umbilical surgeries.

Methods

Between January 2010 and November 2021, PubMed, Cochrane Review, and Google Scholar were searched for a caudal block with ketamine added local anesthetics for children. After screening for eligibility and removing duplicates, 38,187 articles were found, 13 reviewed.

Discussion

Despite adding ketamine to local anesthetics used for a caudal block, it is a recent technique practiced worldwide. Ketamine showed equi-efficacious as other adjuvants used for the caudal block to control postoperative pain in children.

Conclusion

Ketamine with a 0.5 mg/kg dose is safe and effective to manage postoperative children's pain when used as an adjuvant to local anesthetics used for caudal block.

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Caudal additives prolong the length of analgesia than local anesthetics alone

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Ketamine is an alternative to be added for local anesthetics in a caudal block for children

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Ketamine in caudal block prolongs analgesia and reduces opioid intake.

Inadvertent life-threatening total spinal anesthesia following caudal block in a preschool child underwent urologic surgery: A rare case report

INTRODUCTION AND IMPORTANCE

Caudal block is considered to be safe and provide optimal analgesia for pediatric patients undergoing sub-umbilical operations. It overcomes opioid-related side effects, particularly the dangers associated with respiratory depression in small children.

CASE PRESENTATION

A 5-year-old male underwent uneventful hypospadias surgery under general endotracheal anesthesia. Caudal block planned to be administered postoperatively for postoperative analgesia then performed after palpation of sacral cornu with 8 ml of 0.25% bupivacaine. A few minutes later, the patient became apneic, heart rate, blood pressure, and oxygen saturation dropped abruptly-immediate resuscitation with ventilatory support, fluid bolus, and atropine administration. After a minute patients' vital signs returned to the normal range then 2 h later patient started to breathe spontaneously and consciousness is regained. After close follow-up for 24 h in the post-anesthesia care unit patient was discharged to the pediatric ward then discharged to home without any neurologic sequelae after 3 days.

CLINICAL DISCUSSION

Total spinal anesthesia in a very infrequent incident during central neuraxial blocks, especially in the pediatrics population where a caudal block is usually performed. Manifestation of this event can be detected by loss of consciousness, cessation of respiratory effort, hemodynamic instability, and dilated pupils. Delayed treatment can result in cardiopulmonary arrest.

CONCLUSION

Unanticipated total spinal anesthesia following central neuraxial blocks can potentially cause severe adverse consequences. Preventive modalities must be employed to avoid this incident. Early recognition and instant management should be instituted to avoid dangerous complications following the total spinal blockade.

[Effects of caudal block in pediatric surgical patients: a randomized clinical trial]

BACKGROUND

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

OBJECTIVES

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

METHODS

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

RESULTS

Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

CONCLUSIONS

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Effects of caudal block in pediatric surgical patients: a randomized clinical trial

Background

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

Objectives

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

Methods

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

Results

Children who received a caudal block had significantly lower serum glucose (p <  0.01), cortisol concentrations (p <  0.01) and pain scores 3 h (p =  0.002) and 6 h (p =  0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

Conclusions

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit

Introduction

Caudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia.

Materials and methods

Data of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained.

Results

Data of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001).

Conclusion

Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

Neuraxial Anesthesia in Children With Ventriculoperitoneal Shunts

Neuraxial anesthesia has been demonstrated to be safe and effective for children undergoing subumbilical surgery. There is limited evidence regarding the safety of neuraxial anesthesia in pediatric patients with a ventriculoperitoneal shunt. We evaluated a series of 25 patients with indwelling ventriculoperitoneal shunts for complications within 30 days of any procedure performed with a neuraxial technique. One patient required a ventriculoperitoneal shunt revision 5 days after a lumbar catheter placement. The neurosurgeon determined the revision to be likely unrelated to the patient's lumbar catheter. Concerns about the use of neuraxial anesthesia in patients with an indwelling ventriculoperitoneal shunt may be overstated.

Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery?

BACKGROUND

Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations.

OBJECTIVE

The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block.

STUDY DESIGN

A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis).

RESULTS

Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure).

DISCUSSION

Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias.

CONCLUSION

The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.

Nonopioid (Dexmedetomidine, Dexamethasone, Magnesium) Adjuvant to Ropivacaine Caudal Anesthesia in Pediatric Patients Undergoing Infraumbilical Surgeries: A Comparative Study

Background:

Desirable adjuvants to caudal ropivacaine are the one which prolongs analgesia and free of side effects. We compared nonopioid drugs dexmedetomidine, dexamethasone, and magnesium as adjuvants to ropivacaine caudal analgesia in pediatric patients undergoing infraumbilical surgeries.

Materials and Methods:

This study was done on 128 pediatric patients (3–12-year olds) undergoing infraumbilical surgeries; they were randomly allocated to four groups to receive normal saline, dexmedetomidine 1 μg/kg, dexamethasone 0.1 mg/kg, and magnesium sulfate 50 mg with injection ropivacaine 0.2% in the dose 0.5 ml/kg caudally. Modified Objective Pain Score and Ramsay Sedation Score, duration of analgesia, hemodynamic changes, and side effects were assessed. ANOVA test was used for numerical values as data were expressed in mean and standard deviation. Kruskal–Wallis test was used for postoperative pain and sedation score as data were expressed as median and range.

Results:

The demographic data and hemodynamics were comparable. There was a significant prolongation of duration of analgesia in all study groups, dexmedetomidine (406.2 ± 45.5 min), dexamethasone (450.0 ± 72.6 min), and magnesium (325.0 ± 45.8 min) as compared to ropivacaine (285.9 ± 52.7 min) group. None of the adjuvants resulted in either excess or prolonged sedation. No side effects were encountered.

Conclusion:

The adjuvants dexmedetomidine, dexamethasone, and magnesium added to ropivacaine prolong caudal analgesic duration without any sedation or side effect.

Dexmedetomidine as an Adjuvant to Pre-Emptive Caudal Epidural Ropivacaine for Lumbosacral Spine Surgeries

INTRODUCTION

Pre-emptive caudal epidural is a proven technique for providing analgesia for spinal surgeries. Prolonged pain relief with no motor blockade is desired for early mobilisation.

AIM

Present study aimed to evaluate the effect of addition of Inj dexmedetomidine to caudal ropivacaine on the duration of analgesia, haemodynamic profile and the associated side effects.

MATERIALS AND METHODS

In this prospective double-blind study a total of 60 patients undergoing lumbosacral spine surgery were randomised to receive 20 cc of pre-emptive caudal epidural injection of either inj ropivacaine 0.2% (Group R, n =30) or a mixture of Inj ropivacaine 0.2% and Inj dexmedetomidine 1 μg/kg (Group RD, n =30) under general anaesthesia after the patient was positioned prone for surgery. VAS scores, heart rate, blood pressures and time to rescue analgesia were recorded at regular intervals for the first 24 hours. Data analysis was carried out using Statistical Package for Social Science (SPSS, V 10.5 package).

RESULTS

Mean VAS scores were significantly lower in the RD group for up to 12 hours following the caudal block. No clinically significant haemodynamic changes were noted in either of the groups. No other side effects were seen in both the groups.

CONCLUSION

These results suggest that inj dexmedetomidine is an effective additive to inj ropivacaine for pre-emptive caudal epidural analgesia in lumbosacral spine surgeries.

Rectal puncture complicating caudal blockade in a child with severe rectal distension

We describe a case of unrecognized rectal puncture following unsuccessful caudal blockade in a patient later found to have marked rectal distension on MRI. This may have contributed to the rectal injury.

The Effects of Different Doses of Caudal Morphine with Levobupivacaine on Postoperative Vomiting and Quality of Analgesia after Circumcision

The study aim was to investigate the effect of three different morphine doses added to levobupivacaine 0.125% for caudal analgesia after circumcision surgery in children, particularly in relation to the frequency of postoperative vomiting within the first 24 hours following surgery. Two hundred and forty patients aged 5 to 12 years undergoing circumcision were included in the study. Following induction, caudal 0.125% levobupivacaine 0.5 ml/kg was given after adding 7.5, 10 or 15 μg/kg morphine. The postoperative incidence of vomiting was 5%, 12.5% and 17.5% in the groups 7.5, 10 and 15 μg/kg morphine, respectively ( P=0.012, 7.5 versus 15 μg/kg groups). Five percent of the 7.5 μg/kg group and none of the patients in the other groups required paracetamol within the first 12 hours, and there was a significantly greater need for rescue paracetamol over the 24 hours in the 7.5 group versus the 15 μg/kg group ( P=0.013). Postoperative analgesic durations were long and did not differ between groups (1273±338, 1361±192 and 1426±48 minutes, respectively, P=0.08). In conclusion, because the incidence of vomiting is very low, the duration of postoperative analgesia is long and a dose of 7.5 μg/kg caudal morphine is much lower than doses previously reported to be associated with respiratory depression, this study supports the use of 7.5 μg/kg caudal morphine added to 0.125% levobupivacaine for circumcision surgery.

Assessment of pulse oximeter perfusion index in pediatric caudal block under basal ketamine anesthesia

Whether pulse oximeter perfusion index (PI) may be applied to detect the onset of caudal block in pediatric patients under ketamine intravenous basal anesthesia is investigated. 40 ASA I, 2–8-year-old boys scheduled for elective circumcision surgery were randomized into two groups. Group I: 20 patients were anesthetized by 2 mg·kg⁻¹ ketamine intravenous injection (IV) followed by caudal block using 1 mL·kg⁻¹ lidocaine (1%); Group II: 20 patients were anesthetized by 2 mg·kg⁻¹ ketamine IV only. PI on the toe in Group II decreased by 33 ± 12%, 71 ± 9% and 65 ± 8% at 1 min, 15 min, and 30 min after ketamine injection. The maximum increase in MAP and HR after ketamine IV was 11 ± 6% at 3 min and 10 ± 6% at 2 min. Compared to the PI value before caudal injection of lidocaine, PI in Group I increased by 363 ± 318% and 778 ± 578% at 5 min and 20 min after caudal block, while no significant changes in MAP and HR were found compared to the baseline before caudal block. Thus, PI provides an earlier, more objective, and more sensitive indicator to assess the early onset of caudal block under basal ketamine anesthesia.