Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair

INTRODUCTION

The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups.

OBJECTIVE

Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications.

STUDY DESIGN

We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days.

RESULTS

Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days.

DISCUSSION

Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period.

CONCLUSIONS

After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

[Caudal regional anesthesia: a safe anesthetic procedure for abdominal and inguinal surgery in newborns and toddlers]

OBJECTIVES

Caudal anesthesia is a safe and effective technique in children. Some surgical procedures, such as abdominal or inguinal surgeries, could be performed avoiding general anesthesia in newborns and babies, reducing the risk of respiratory depression and neurotoxicity. Our objective is to analyze the experience in a tertial referral center.

MATERIAL AND METHODS

We carried a retrospective study in patients under 1 year of age who underwent abdominal or inguinal procedures under caudal regional anesthesia, between 2016 and 2018. Demographics, diagnosis, comorbidity, surgical procedure, operation time, oral intake, perioperative complications and hospital stay were recorded.

RESULTS

We included 87 patients under 1 year of age. In 56 patients (23 males, 33 females) surgery was performed under caudal anesthesia (37 scheduled, 19 urgent). Mean age was 2 months (0-11). Comorbidity: 25 associated prematurity, 3 severe tracheomalacia, 1 apnea and 8 bronchopulmonary dysplasia. Surgical procedures: 34 inguinal hernia repair, 9 incarcerated inguinal hernias, 5 neonatal testicular torsions, 8 pyloromyotomies. Mean operation time was 35 min (15-80) and mean anesthetic time 30 min (20-60). Oral intake started 2 h after surgery in 55 patients. Discharge was given in 24 h (12-36). Complications were not noticed. Any patient needed conversion to general anesthesia.

CONCLUSIONS

Caudal anesthesia should be the anesthetic technique of choice in newborns and babies who undergo abdominal or inguinal surgeries, especially in those with comorbidity. This procedure could be performed safely, avoiding respiratory or neurological complications, with a fast recovery of patients and short hospital stay.

Analgesic Effect of Caudal Bupivacaine with or without Clonidine in Pediatric Patient

BACKGROUND

Caudal analgesia has long been the cornerstone to successful pain management in children undergoing abdominal and lower limb surgeries. Its analgesic duration with single shot injection is however limited. So adjuvants are used with local anesthetics in an attempt to increase the duration of caudal analgesia. This study aims to investigate the duration of analgesia provided by Clonidine when added to caudal Bupivacaine.

METHODS

A randomized, double blinded, comparative study was conducted on 64 patients, aged two to seven years, scheduled for unilateral inguinal hernia repair. Patients were randomly allocated into two groups of 32 each, with group A receiving bupivacaine two milligram/kilogram and group B receiving bupivacaine two milligram/kilogram with one microgram/kilogramclonidine, (total volume of injectate was one milliliter/kilogram). Duration of analgesia, hemodynamic response and adverse effects, if any were noted.

RESULTS

Mean duration of analgesia in group A was 264.12 ± 68.77 minutes and in group B was 520 ± 57.37 minutes, p-value <0.001.Incidence of vomiting was 9% in group A compared to 6% in group B.

CONCLUSIONS

Clonidineas an adjuvant to caudal bupivacaine prolongs the duration of analgesia without increasing the adverse effects.

Epidural hematoma after caudal epidural pulsed radiofrequency stimulation: A case report

RATIONALE

Epidural hematoma is a possible complication after neuraxial procedures. Recently, caudal epidural pulsed radiofrequency (PRF) stimulation was reported as an effective method for controlling several types of chronic pain. Herein, we report on a patient who developed a lumbar epidural hematoma after receiving caudal epidural PRF stimulation.

PATIENT CONCERNS

A 75-year-old woman, who was taking oral warfarin (2 mg/d), received caudal epidural PRF stimulation for symmetrical neuropathic pain in both legs due to chronic idiopathic axonal polyneuropathy. She did not discontinue warfarin use before undergoing the procedure. Three days and 12 hours after the procedure, motor weakness suddenly manifested in the right leg (manual muscle testing [MMT] = 2-3).

DIAGNOSES

Lumbar magnetic resonance imaging (MRI) performed 7 days after the PRF procedure showed a spinal epidural hematoma at the L1 to L5 levels, compressing the thecal sac. The international normalized ratio was 6.1 at the time of the MRI.

INTERVENTIONS

Decompressive laminectomy from L1 to L5 with evacuation of the hematoma was performed.

OUTCOMES

Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5.

LESSONS

This case suggests that clinicians should carefully check if patients are taking an anticoagulant medication and ensure that it is discontinued for an appropriate length of time before a caudal epidural PRF procedure is performed.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair

INTRODUCTION

Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence.

METHODS

All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed.

RESULTS

We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications.

CONCLUSIONS

In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

Awake caudal anaesthesia in neonates/young infants for improved patient safety

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.

[Central neuroaxial blocade and metabolic stress-answer in a newborn and babies in surgical diseases]

Investigation of markers of humoral stress was conducted in 25 babies (the main group), in whom a central neuroaxial blocade was performed while doing various surgical interventions. In a control group there were included 20 babies, in whom a standard atharalgesia was applied. The best efficacy was achieved while anesthesia using central neuroaxial blocade.

Effects of caudal sufentanil supplemented with levobupivacaine on blocking spermatic cord traction response in pediatric orchidopexy

PURPOSES

Caudal block is one of the most commonly used anesthetic techniques in subumbilical and genitourinary procedures. However, traditional administration of caudal levobupivacaine was inadequate on blocking peritoneal response during spermatic cord traction. The aim of this study was to evaluate whether the addition of caudal sufentanil to levobupivacaine provided better analgesia for children undergoing orchidopexy.

METHODS

Sixty-two patients, scheduled for right orchidopexy, received caudal block after induction. Group LS (n = 31) received levobupivacaine 0.25% 1 ml/kg plus sufentanil 0.5 μg/kg, and group L (n = 31) received levobupivacaine 0.25% 1 ml/kg only. HR or MAP fluctuation >20% or entropy increase >15% during spermatic cord traction was defined as inadequate anesthesia and was treated with increasing sevoflurane concentration. The number of children who needed sevoflurane rescue was counted, and postoperative side effects and quality of sleep were also recorded.

RESULTS

There were no statistically significant differences between the two groups in age, weight, and duration of surgery. Two (6.45%) children in group LS required inspired sevoflurane rescue to block hemodynamic fluctuation during spermatic cord traction, as compared with 12 (38.71%) patients in group L (P < 0.001). At the time of exerting spermatic cord traction, the median HR was, respectively, 134 and 145 (P < 0.001); the corresponding response entropy (RE) and state entropy (SE) was 65 and 54, respectively, in group LS versus 76 and 65 in group L (P < 0.001).

CONCLUSION

In pediatric orchidopexy, the addition of sufentanil to levobupivacaine for caudal blockade offers clinical benefit over levobupivacaine alone in blocking the spermatic cord traction response.

Prospective, randomized, double-blinded comparison of the effects of caudally administered levobupivacaine 0.25% and bupivacaine 0.25% on pain and motor block in children undergoing circumcision surgery

BACKGROUND

Caudal anesthesia is widely used as intraoperative and postoperative analgesia in children's subumbilical surgeries such as on the urogenital system, lower extremities and lower abdomen to reduce the stress response to surgery and to facilitate the general anesthesia.

AIM

The purpose of this study was to compare the effects of caudally administered bupivacaine and levobupivacaine of equal volume and concentration on motor block and postoperative pain in children undergoing circumcision surgery.

PATIENTS AND METHODS

The prospective, randomized, double-blind study included 60 patients with ages ranging from 1-10 years and ASA (American Society of Anesthesiologists) physical status of I-II who underwent elective circumcision surgery. The patients were divided into two groups: group B received 0.5 ml/kg of bupivacaine 0.25% caudally and group L received 0.5 ml/kg of levobupivacaine 0.25% caudally. Postoperative pain was assessed by children's and infant's postoperative pain scale and motor block was assessed by the Bromage scale.

RESULTS

The mean children's and infant's postoperative pain scale of group B was significantly lower than that of group L (p < 0.001). Three patients in group B and seven patients in group L needed additional analgesia after the incision. There was no significant difference between groups in terms of Bromage scores and in both groups the residual motor block was found to be zero at the 150th minutes.

CONCLUSION

According to these findings, bupivacaine has an adequate quality of analgesia than levobupivacaine. We suggest that bupivacaine for caudal block at the concentration of 0.25% (0.5 ml/kg) provides an adequate level of analgesia for outpatient circumcision surgery.

Caudal bupivacaine vs bupivacaine plus tramadol in post-operative analgesia in children

BACKGROUND

Caudal analgesia with bupivacaine is used commonly for pain relief in children and extradural administration of tramadol seemed to be a safe method of analgesia. The aim of the study is to compare the analgesic efficacy of caudal bupivacaine and bupivacaine and tramadol mixture for postoperative analgesia and to observe for side effects.

METHODS

Forty children, aged between 1- 6 years undergoing infra umbilical surgeries were selected for this randomized, control trial. They were randomly divided into two groups. Group A (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine and Group B (n = 20) received 0.5 ml/kg of 0.25 % bupivacaine with 1 mg/kg of tramadol as a single shot caudal block. In the postoperative period heart rate, respiratory rate, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects were noted and analyzed.

RESULTS

It was observed that the mean duration of pain relief was significantly longer in Group B (8.8 hrs Vs 7 hrs). Nausea and vomiting was observed in 25% of the patients in group B and 20 % of the patients in group A. None of the patients in both the groups had complication like motor weakness, urinary retention in the postoperative period.

CONCLUSIONS

The addition of tramadol to bupivacaine in the caudal analgesic technique provides longer analgesia and lesser need for rescue analgesic in the postoperative period compared to bupivacaine.

Caudal epidural anesthesia for a 2-year old child with congenital myasthenia gravis

Myasthenia gravis is an autoimmune disease with antibodies directed against the acetylcholine receptor at the neuromuscular junction. Anesthetists have a special interest in myasthenia gravis because of its interaction with various anesthetic agents. Unlike adult myasthenic patients; very little report has been written about the anesthetic management in children, other than in relation to thymectomy. Although the use of caudal anesthesia in pediatric patients is common, have not seen any report concerning its use in a myasthenic child. In this case report, we represented a 2 year-old boy was performed caudal anesthesia for orchiopexy operation. He had presented difficulty in breathing, generalized weakness and droopy eyes due to congenital myasthenia gravis. In the operating room, following the routine monitoring, the patient was sedated with intravenous 1mg midazolam and 10 mg ketamine. Then caudal block was performed. 17 minutes later from the local anesthetic injection; operation was started and lasted 45 minutes. The patient did not require intraoperative supplemental analgesia and postoperative course was uneventful. Specific attention should be paid to voluntary and respiratory muscle strength in myasthenia gravis patients. Caudal anesthesia allowed airway control of myasthenia gravis patients without endotracheal intubations and muscle relaxant. In conclusion, we think that caudal anesthetic technique may be considered as a safe and suitable for the myasthenic child and it may represent a valid alternative to general anesthesia for these patients.

Rückenmarknahe Regionalanästhesieverfahren bei Kindern - Kaudalblock und Spinalanästhesie

Caudal anesthesia is a safe, simple and very effective method to provide excellent perioperative analgesia. It is used routineously in pediatric anesthesia and can be applied to nearly all children with surgery below the umbilicus. In contrast, spinal anesthesia is a very special technique for former preterm infants below the 50th postconceptive week who are prone to develop postoperative apnea. It has been suggested that some of the problems associated with general anesthesia in these patients may be avoided by the use of spinal anesthesia.

Caudal anesthesia in pediatric surgical practice

Prospective study was carried out on 100 patients since May 2005 in my private practice and in the department of pediatric surgery of MMCH. Under caudal anesthesia along with or without ketaminie induction and gas inhalation all the patients underwent different surgical procedure namely anorectal surgery (eg. anoplasty, rectal polyp), urogenital surgery (Circumcision, hypospadias, meatotomy), groin surgery (hernia, hydrocele) and foot & leg surgery. Calculated dose schedule of drugs used in anesthesia and volume were maintained. Time of giving anesthesia and time of starting analgesia were recorded. Per-operative and postoperative analgesia were evaluated. Every parent was explained regarding the merit of caudal anesthesia calculated and compared with that of general anesthesia. Application of caudal anesthesia with or without ketamine & diazepam induction can be used safely and cost effectively and may be put into protocol in many of the pediatric surgical practice both in institute and also in private practice.

[Information and consent sheet of caudal block in the University of Tokyo Hospital]

Caudal block with a local anesthetic through the hiatus sacralis has been performed in patients with chronic low back pain, lower limb pain, anal pain, and pelvic pain due to spinal canal stenosis, lumbar disc herniation, lumbar spondylolisthesis, postherpetic neuralgia, peripheral vascular disease, complex regional pain syndrome and so on. We prepar- ed an information and consent sheet on caudal block in The University of Tokyo Hospital. In the information sheet, we included disease, purpose, methods, outcome, accidental complications of caudal block, other treatments, progress on unperformed case, questions and answers, influence of rejection, and doctor's name. We experienced some cases of boring pain, deterioration of low back pain and lower limb pain, headache, nausea, hypertension, hypotension, and tachycardia as accidental complications of caudal block. In describing some accidental complications, we included boring pain, high intracranial pressure, dural puncture, nerve injury, infection, hemorrhage, embolism, allergy, and heart, lung, brain, liver, and kidney failures. Further, we could refer to the accidental complications of epidural block. However, the rate of each accidental complication has not been known in detail. We should survey the outcome and accidental complication of caudal block prospectively in multiple facilities and provide the patients with useful information.

Caudal block complication in a patient with trisomy 13

In this report we describe a complication of a caudal block in a 4-year-old child with trisomy 13. The patient's history was remarkable for microcephaly, developmental delay, seizures, apnea, and prolonged emergence times. Induction of anesthesia and tracheal intubation were uneventful. A caudal block was aborted after positive aspiration of cerebrospinal fluid. A radiogram suggestive of spinal dysraphism, found on subsequent review, was confirmed by a magnetic resonance imaging scan consistent with tethered cord and dural ectasia. Congenital abnormalities associated with trisomy 13 and cutaneous signs suggestive of spinal abnormalities are reviewed. Avoidance of neuraxial regional anesthesia in these patients is recommended.

[Examination of the anesthesia on transperineal prostate biopsy--saddle block versus caudal block]

We examined the anesthesia of transperineal prostate biopsy under saddle block or caudal block. Between July 2003 and September 2004, we performed transperineal prostate biopsy under saddle block and caudal block, in 59 and 78 patients, respectively. We evaluated the pain score with the FACES Pain Rating Scale (0-5) and examined side effects on each anesthesia. There was no significant difference in the pain score of anesthesia prick between saddle block and caudal block (1.51 +/- 1.03 versus 1.39 +/- 0.98 respectively, P = 0.629), but the biopsy prick under saddle block revealed significantly (P < 0.0001) lower pain score (0.05 +/- 0.22) than caudal block (1.18 +/- 1.22). Saddle block caused post-operative retention more frequently than caudal block and required the patient to rest in bed for several hours after prostate biopsy. Saddle block was useful for relieving the pain of biopsy. In future, we need to consider using a method with fewer side effects.

Caudal Additives in Pediatrics: A Comparison Among Midazolam, Ketamine, and Neostigmine Coadministered with Bupivacaine

Single-shot "kiddie caudal" with bupivacaine alone is losing popularity because of its duration of 4-8 h. In a prospective randomized double-blind clinical study, we assessed and compared the efficacy of ketamine, midazolam, and neostigmine coadministered with bupivacaine in a caudal epidural to provide intraoperative and postoperative pain relief. Eighty children (ASA status I) aged 5-10 yr undergoing unilateral inguinal herniotomy were allocated randomly in equal numbers (n = 20) into 4 groups to receive a caudal injection of 0.25% bupivacaine (1 mL/kg) with or without ketamine (0.5 mg/kg), midazolam (50 microg/kg), and neostig-mine (2 microg/kg), after the induction of standardized general anesthesia without premedication. Monitoring for pain, sedation, postoperative nausea/vomiting, dizziness, and pruritus was performed by anesthesiologists blinded to the study allocation. The time to first analgesic administration (paracetamol syrup) was longer (P < 0.05) in the bupivacaine-neostigmine group and the bupivacaine-midazolam group than in the other groups. Undesirable effects, such as emesis, pruritus, and dizziness, were comparable in all groups. However, the incidence of hallucination was more frequent in the bupivacaine-ketamine group compared with the other groups. This study shows that single-shot caudal coadministration of bupivacaine-neostigmine and bupivacaine-midazolam was associated with an extended duration of postoperative pain relief.

A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade

BACKGROUND

The aim of our study was to compare postoperative analgesic efficacy, analgesic duration and motor blockade of levobupivacaine, ropivacaine and bupivacaine administered caudally in equal concentrations to children undergoing elective minor surgery.

METHODS

In the study, 182 children, aged 1-7 years, undergoing either inguinal hernia repair or orchidopexy, were randomly allocated to one of the three groups. They received via a caudal extradural either 1 ml x kg(-1) levobupivacaine 0.2% (Group L) or 1 ml x kg(-1) ropivacaine 0.2% (Group R) or 1 ml x kg(-1) bupivacaine 0.2% (Group B).

RESULTS

No statistically significant difference was noted in age, weight, duration of the operation or level of the caudal block between the groups. The onset of analgesia was significantly later after levobupivacaine. Postoperative pain scoring evaluated with Children's and Infant's Postoperative Pain Scale observational scale showed no statistical difference between groups. Median postoperative analgesia was 5.75 h (SEMed: +/- 0.65) in Group L, 5.7 h (SEMed: +/- 0.8) in Group R and 5.35 h (SEMed: +/- 1.3) in Group B the difference being statistically nonsignificant.

CONCLUSIONS

The degree of motor block was significantly less after ropivacaine and levobupivacaine during the first 2 h postoperatively.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children

PURPOSE

To evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery.

METHODS

In a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL.kg(-1) (Group I) or 0.25% plain bupivacaine 0.5 mL.kg(-1) with neostigmine (Groups II-IV) in doses of 2, 3 and 4 microg.kg(-1) respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded.

RESULTS

The duration of postoperative analgesia in Group I (5.1 +/- 2.3 hr) was significantly shorter than in the other three groups (II -16.6 +/- 4.9 hr; III - 17.2 +/- 5.5 hr; IV - 17.0 +/- 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group I (697.6 +/- 240.7 mg) than in the groups receiving caudal neostigmine (II - 248.0 +/- 178.4; III - 270.2 +/- 180.8 and IV -230.6 +/- 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed.

CONCLUSIONS

Caudal neostigmine (2, 3 and 4 microg.kg(-1)) with bupivacaine produces a dose-independent analgesic effect ( approximately 16-17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.

Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine

BACKGROUND

The aim of the present pilot study was to compare the analgesic efficacy of S(+)-ketamine either alone or in combination with neostigmine for caudal blockade in pediatric surgery.

METHODS

A total of 40 children were randomly assigned to receive after induction of general anesthesia either caudal S(+)-ketamine 1 mg.kg(-1) (group K, n = 20) or caudal S (+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1) (group KN, n = 20). Anesthesia was maintained with sevoflurane and a laryngeal mask airway (LMA), no additional analgesics were administered. Postoperative pain and sedation were assessed by the Children's Hospital of Eastern Ontario Pain Score and Ramsay scale for 24 h.

RESULTS

No statistical difference in duration of analgesia and sedation was found. Mean duration of postoperative analgesia was 18 +/- 9.4 h in group K and 21.8 +/- 6.7 h in group KN. There was a significantly higher incidence of postoperative vomiting after administration of caudal ketamine with neostigmine (30% group KN Vs 0% group K; P < 0.05).

CONCLUSIONS

This pilot study demonstrates equianalgesic effects on postoperative pain relief in children with both caudal S(+)-ketamine 1 mg.kg(-1) and caudal S(+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1). Further studies are required to confirm adoption of caudal neostigmine into routine clinical practice.

Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine

BACKGROUND

The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic.

METHODS

Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg x kg(-1) (group K) or S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h.

RESULTS

No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant.

CONCLUSIONS

Caudal S(+)-ketamine 1 mg x kg(-1) and S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects.

Is tissue coring a real problem after caudal injection in children

BACKGROUND

The aim of this study was to determine whether tissue coring occurs with 22-G hollow needle and 22-G caudal block needle during caudal injection in children, as well as evaluating the nature of the coring material if it did occur.

METHODS

Seventy children were randomly allocated to two groups and caudal block was performed with either 22-G hollow (group I) or 22-G caudal block (group II) needle under general anesthesia. The needles and guides were washed with 0.5 ml of 70% ethanol in a sterile tube and were evaluated by a pathologist blinded to the type of needle used, for the type and number of cells.

RESULTS

Nucleated cells, which have no mitotic activity, were present in 8.5% in each study group and bloody material was present in 8.5 and 2.8%, in group I and II, respectively. Non-nucleated epidermal cells were detected in 94.2 and 97.1% of the patients in group I and II, respectively. However, cells with mitotic activity from the stratum basale were not detected in any slides.

CONCLUSIONS

The incidence of transporting nucleated epidermal cells with no mitotic activity from stratum spinosum during puncture for caudal block is low and no differences exist between different types of needle used. However, it may also suggest that transporting nucleated cells with mitotic activity from the stratum basale may be possible during caudal puncture.

Analgesic effect of clonidine added to bupivacaine 0.125% in paediatric caudal blockade

BACKGROUND

Caudals are a common method of providing pain relief in children undergoing surgery. Clonidine, an alpha(2) agonist, exhibits significant analgesic properties. The current investigation sought to determine whether caudal clonidine added to caudal bupivacaine would decrease pain in paediatric patients undergoing surgery.

METHODS

Thirty-six children undergoing elective surgery were studied. Following anaesthetic induction, a caudal was placed (1 mg.kg(-1) bupivacaine 0.125%) with an equal volume of either clonidine (2 microg.kg(-1)) or saline. Perioperative analgesic requirements in the postanaesthesia care unit (PACU) and at home following hospital discharge, and parental pain scores were evaluated.

RESULTS

There were no significant demographic, haemodynamic, or pain score differences between the groups. There was no difference in analgesic duration between groups. There were significantly more children who vomited during the first 24 postoperative hours in the clonidine group than in the saline group (eight in clonidine, two in saline; P < 0.05).

CONCLUSION

We do not recommend adding clonidine (2 microg.kg(-1)) to a bupivacaine (0.125%) caudal block in children undergoing surgery.

[Regional anesthesia in newborn infants, infants and children--what prerequisites must be met?]

In general, every anaesthetic technique should only be used with a given indication after a careful risk-benefit evaluation, when there are no contraindications and when the physician has sufficient knowledge and skill to safely perform the technique.

INDICATION

the great advantage of regional blocks is that they can be administered without the risks of opioids, e.g. respiratory depression, nausea, vomiting and delayed gastric emptying. Regional anaesthesia is rarely indicated instead of general anaesthesia: even ex-premature babies can safely undergo general anaesthesia supplemented with a regional block. Special risks occur when regional blocks are performed in anaesthetised children, and special care is needed. However, in contrast to adult practice, this is a generally accepted modality of paediatric anaesthesia worldwide. In addition, perfect analgesia may obscure the signs of compartment syndrome and beginning pressure sores. Preoperative evaluation: the preoperative evaluation relies mainly on the patient's history. Coagulation tests are not performed as routine screening. However, even with a careful history, bleeding disorders can be overlooked, especially in neonates and infants. Mastering the technique: caudal anaesthesia can be used for a large variety of interventions below the umbilicus; therefore, a sufficient caseload can be achieved by most anaesthetists, and the technique can be easily learned. It should belong, together with wound infiltration, ilioinguinal and penile block, to the armamentarium of all anaesthetists caring for children. However, regional blocks are of limited duration and are therefore only part of a concept of balanced analgesia, which also involves nonsteroidals, paracetamol and opioids.

Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review

BACKGROUND

Caudal epidural injection with local anaesthetics is a popular regional technique used in infants and children. A disadvantage of caudal blockade is the relatively short duration of postoperative analgesia. Opioids have traditionally been added to increase the duration of analgesia but have been associated with unacceptable side-effects. A number of nonopioid additives have been suggested to increase the duration of analgesia.

METHODS

A systematic review was conducted to identify randomized control trials comparing the use of local anaesthetic to local anaesthetic with nonopioid additives for caudal blockade in children. The increase in duration of analgesia and side-effects were compared.

RESULTS

The addition of clonidine to the local anaesthetic solution produces an increase in the duration of analgesia following caudal blockade in children (pooled weighted mean difference of 145 min with 95% confidence interval of 132-157 min). Side-effects include sedation and the potential for neonatal respiratory depression. Ketamine and midazolam further increase the duration of analgesia, however, the potential for neurotoxicity remains a concern.

CONCLUSION

The evidence examined shows an increased duration of analgesia with clonidine, ketamine and midazolam. However, we are not convinced that the routine use of these adjuvants in the setting of elective outpatient surgery shows improved patient outcome. It is unclear if the potential for neurotoxicity is outweighed by clinical benefits. Further testing, including large clinical trials, is required before recommending routine use of nonopioid additives for caudal blockade in children.

Distant skip level discitis and vertebral osteomyelitis after caudal epidural injection: a case report of a rare complication of epidural injections

STUDY DESIGN

A case report of distant discitis and vertebral osteomyelitis involving skip levels after caudal epidural steroid injection.

OBJECTIVES

To report and investigate the occurrence of distant infective discitis and vertebral osteomyelitis involving skip levels after epidural injection.

SUMMARY OF THE BACKGROUND DATA

Distant discitis and vertebral osteomyelitis is a serious but rare complication after epidural injection. A case involving skip levels and without the occurrence of epidural abscess formation has apparently not been previously reported in the literature.

METHODS

An elderly woman presenting with clinical, radiologic, and magnetic resonance imaging evidence of spinal canal stenosis involving L3/4 and L4/5 levels and degenerative spondylolisthesis of the L4/5 level was given an epidural injection of steroids and lignocaine via the caudal route. A month later, she presented with worsened low back pain, elevated serum acute phase reactants, and plain radiographic evidence of L4/5 infective discitis. Magnetic resonance imaging and microbiologic examination of computed tomographically guided biopsy specimens confirmed infective discitis involving L2/3 and L4/5 intervertebral levels, together with adjacent vertebral osteomyelitis.

RESULTS

The patient was successfully treated with antibiotics targeted at Pseudomonas aeruginosa, which was isolated in the culture of the biopsy specimens. Follow-up improvements in the clinical condition, serum acute phase reactants levels, radiographs, and magnetic resonance imaging were noted.

CONCLUSIONS

Distant discitis and vertebral osteomyelitis involving skip levels and without the occurrence of epidural abscess formation is a serious but rare complication after epidural injection.

Efficacy and safety of caudal injection of levobupivacaine, 0.25%, in children under 2 years of age undergoing inguinal hernia repair, circumcision or orchidopexy

BACKGROUND

Levobupivacaine is the S(-)-enantiomer of racemic bupivacaine. Evidence suggests that it is less cardiotoxic than racemic bupivacaine and the R(+)-enantiomer, dexbupivacaine, while retaining similar local anaesthetic properties and potency to racemic bupivacaine.

METHODS

This was an open study designed to assess the efficacy and safety of 0.25% levobupivacaine administered as a caudal injection at a dose of 2 mg.kg(-1) to 49 paediatric patients aged less than 2 years old undergoing circumcision (group 1), or hernia repair or orchidopexy (group 2).

RESULTS

Adequate analgesia (an increase of <20% in pulse or respiratory rate compared with baseline and an absence of gross movement on application of surgical stimulus) was achieved in 43/48 patients evaluable for efficacy (89.6%). All 22 patients in the circumcision group had adequate analgesia, and two of these patients did not require additional analgesia. The mean time to the use of additional analgesia was 7.3 h. Only one event (a mild rash) was considered possibly related to study medication.

CONCLUSIONS

Levobupivacaine is a promising new local anaesthetic agent for pain management in paediatric patients and appears to offer similar anaesthetic efficacy to racemic bupivacaine with a potentially improved tolerability profile.

[The choice of drugs for caudal anaesthesia in children. An overview]

Caudal anaesthesia is the most frequently used regional technique in paediatric anaesthesia. Caudal in combination with general anaesthesia is usually performed in healthy children (i.e. for herniotomy or hypospadias). Therefore every complication of this method is a catastrophe, even when the incidence of these complications is very low. Some of the documented complications of caudal anaesthesia in children are caused by the local anaesthetic solutions and/or by additives. Thus, the choice of substances for paediatric caudal blocks should minimize the risk associated with the substances used for this indication. Over the last decades the standard was bupivacaine but because of serious cardiovascular and central-nervous toxicity following inadvertent intravascular injection of bupivacaine during caudal puncture, the less toxic ropivacaine should be favoured for this indication. A huge number of clinical studies have proven the clinical effectiveness and safety of ropivacaine also for this indication. In addition, levobupivacaine, the L-enantiomere of bupivacaine, will also be an interesting local anaesthetic in the future for paediatric caudal anaesthesia. By using additives to local anaesthetics better analgesic properties should be obtained. Following an exact review of the literature, only clonidine and S(+)-ketamine are useful additives to local anaesthetics in paediatric caudal anaesthesia.

[Caudal epidural anesthesia for transurethral resection of benign hyperplasia of prostate]

Caudal epidural anesthesia was used as a basic method of anesthesia in 300 elderly patients for transurethral resection of prostate adenoma. There were no complications during and after operation in spite of frequent concomitant diseases in these patients.

Use of ultrasound bladder monitoring in children after caudal anaesthesia

Urinary retention occurring after caudal anaesthesia in children has a low incidence. Most children will void within 12 h of surgery, although the incidence of retention is higher after hypospadias repair. However, overdistention causing bladder atony that is temporary, or may become permanent, is described in adults. Long-term effects of overdistention in children have not been described. Urine volume, used to describe overdistention, is traditionally measured after catheterization. We report two children suffering from urine retention after caudal anaesthesia (bupivacaine 0.25%) was used to supplement a general anaesthetic. Ultrasound bladder monitoring was used to assist with the clinical diagnosis of bladder distension in the postanaesthesia care unit (PACU) and subsequent management. In-out catheterization was required in a 1-year-old-girl with a bladder volume of 12 ml.kg-1 after external manual compression over the bladder was unable express urine. Spontaneous micturation occurred within the subsequent 8 h. A 10-year-old boy suffered distress in PACU with a bladder volume, measured by ultrasound, of 5 ml.kg-1. Catheterization relieved distress and spontaneous micturation returned 18 h after surgery. Measured urine volumes were similar to those estimated by ultrasound. Ultrasound bladder monitoring is a simple, noninvasive technique that can be used to assist with the diagnosis and management of urinary retention in children. It may replace catheterization as the prefered technique to measure urine volume. The correlation between measured bladder volumes and urine volume appears reasonable. A volume of approximately 10 mg.kg-1 may be considered as causing overdistension.

Apnoea in a former preterm infant after caudal bupivacaine with clonidine for inguinal herniorrhaphy

Awake regional anaesthesia for inguinal hernia repair in former preterm infants is suggested to avoid life-threatening respiratory complications known to occur after general anaesthesia. Caudal anaesthesia is becoming a more popular technique for this purpose. To prolong duration of anaesthesia and to reduce postoperative need for analgesics in these infants, caudal clonidine has been considered useful. We report a former preterm infant, who had two awake caudal anaesthetics for herniotomy within 3 weeks. The first was uneventful with bupivacaine 0.25% at 35 weeks postconceptional age. At 38 weeks, the baby suffered form intra- and postoperative apnoeas after inadvertent administration of bupivacaine 0.125% plus clonidine.

Decreased risk of catheter infection in infants and children using subcutaneous tunneling for continuous caudal anesthesia

Continuous caudal anesthesia has been commonly used for intra- and post-operative analgesia in infants and children. However, it has a potential risk of bacterial infection, especially in infants in whom the catheter site is easily contaminated with loose stool. To avoid infection, the authors applied a new procedure using subcutaneous tunneling for continuous caudal anesthesia. In the 18 cases studied with subcutaneous tunneling, clinical signs of infection were absent and bacterial colonization was not found on the catheter tip after 3.9 +/- 1.4 days of catheterization. The incidence of catheter colonization after continuous caudal anesthesia without tunneling had been reported. In their reports, the incidence of catheter colonization ranged from 20% to 37%. Therefore, caudal catheterization with subcutaneous tunneling is a simple and safe method, and has proved very effective to reduce the risk of epidural infection.

[Caudal block in pediatrics]

Caudal block is the single most popular regional anesthetic technique used in infants and children. A review of the literature concerning complications related to this technique reveals that it is safe and it has a low failure rate. Probably the incidence of complications of caudal block is 7/10.000, the lowest of all the central blocks. High success rates in performing caudals in children are achieved after a lower caseload than for other regional anesthetic procedures. The success rate in children under 7 years of age is 99%, but most failures occur in the oldest. Caudal anaesthesia can be used for anything surgical under the umbilicus and is an acceptable alternative to general or spinal anaesthesia in premature and high-risk infants, where a regional anaesthesia alone may be preferable. Caudal morphine has been used successfully for postoperative analgesia in children of all ages, including neonates after open-heart surgery. Possible complications of this technique are: local anesthetics overdose, vascular penetration and intravascular injection of local anesthetics, dural puncture and total spinal anaesthesia, intraosseous injection, infections, meningitis, respiratory depression (when morphine is used). Authors analyze all these complications and the safety rules for their prevention.

Clonidine in preterm-infant caudal anesthesia may be responsible for postoperative apnea

OBJECTIVE

Regional anesthesia without adjunctive general anesthesia or sedation has been recommended for preterm infants to decrease the risk of postoperative apnea. Single-dose caudal local anesthetic has a limited duration, which may be insufficient for long surgery. Addition of clonidine to local anesthetics has been shown to prolong the duration of surgical analgesia. However, respiratory depression related to clonidine may occur in adults. Respiratory depression has not been reported after caudal administration of clonidine in preterm infants. Here we report a case of early postoperative apnea in a waking preterm infant after caudal anesthesia performed with lidocaine, bupivacaine, and clonidine.

CASE REPORT

A male infant, 39 postconceptual weeks old, was administered a single-injection caudal anesthesia without sedation with 5 mg/kg lidocaine plus 2.5 mg/kg bupivacaine and 1.25 microg/kg clonidine for bilateral inguinal hernia repair, and had early postoperative apneic events. Except for gestational age, the patient showed no apparent risk factors for postoperative apnea. The infant was monitored 24 hours in a neonatal intensive care unit, and no other apnea was recorded.

CONCLUSIONS

Our report suggests that clonidine may be responsible for postoperative apnea in a preterm neonate. Further studies are required to determine the useful safe dose of clonidine for single-injection caudal anesthesia in those infants.

The pharmacokinetics of caudal ropivacaine 0.2% in children. A study of infants aged less than 1 year and toddlers aged 1-5 years undergoing inguinal hernia repair

This study evaluates the pharmacokinetics of ropivacaine in children after caudal epidural injection. Twenty male children undergoing inguinal hernia repair were enrolled after ethics committee approval and informed parental consent, and were grouped according to age (10 'infants' aged less than 1 year and 10 'toddlers' aged 1-5 years). After induction of general anaesthesia, caudal epidural injection using ropivacaine 0.2% 1 ml.kg-1 was performed. Plasma concentrations of ropivacaine in the first 2 h after injection were determined by reversed-phase high-pressure liquid chromatography. Caudal blockade with ropivacaine 2 mg.ml-1 resulted in mean (SD) peak plasma concentrations of 0.73 [0.27] microg.ml-1 in infants and 0.49 [0.21] microg.ml-1 in toddlers (p < 0.01). Maximum plasma concentrations occurred after a median [range] period of 60 [15-90] min and 52.5 [30-120] min in infants and toddlers, respectively. Two infants (weighing 3.8 and 5.0 kg) showed the highest individual maximum plasma concentrations: 1.31 and 1.11 microg.ml-1. No clinical signs of local anaesthetic toxicity were observed. The results of the present investigation suggest that, from a pharmacokinetic point of view, caudal blockade using ropivacaine 0. 2% 1 ml.kg-1 can be regarded as a safe technique in children, i.e. in infants as well as in toddlers.

Caudal anaesthesia in the clinical assessment of painful anal lesions

The clinical evaluation of patients who present with painful anal conditions is often incomplete because of the need to avoid distress that digital examination engenders. Diagnosis is then based on the history and other findings on clinical examination. This is associated with a risk of missed and delayed diagnosis, delay in the initiation of appropriate therapy and the use of alternative investigation modalities which may not be necessary if full clinical evaluation had been done. In this communication, the experience with the use of caudal anaesthesia in the outpatient and ward setting to evaluate painful anal conditions is presented. The result shows that the technique is safe, and allows the immediate and complete evaluation of these conditions. The anaesthesia is short lasting and no morbidity was observed in this study.

A report of two hundred twenty cases of regional anesthesia in pediatric cardiac surgery

The use of regional anesthesia (ie, epidural, spinal, or caudal) has been reported in a few small series of children undergoing cardiac surgery, but not in larger studies. In this retrospective, descriptive study, we report the results of the use of regional anesthesia in 220 pediatric cardiac operations. We reviewed the records of children receiving a regional anesthetic for cardiothoracic surgery at Stanford Medical Center between January 1993 and February 1997. All patients were targeted for early tracheal extubation. A variety of regional techniques were used. Time to extubation, control of pain, incidence of respiratory depression and other complications, and length of hospital stay were determined. There were no deaths. Eighty-nine percent of the patients were tracheally extubated in the operating room; 4.1% of whom required reintubation within 24 h. Ninety-five percent +/-2.5% of the patients had pain scores < or =4.0 at all intervals postoperatively. Adverse effects of regional anesthesia included emesis (39%), pruritus (10%), urinary retention (7%), postoperative transient paresthesia (3%), and respiratory depression (1.8%). The incidence of peridural hematoma was zero. The rate of adverse effects was lower in the thoracic catheter epidural approach as compared with various caudal, lumbar epidural, and spinal approaches. Hospital duration of stay was not effected by the presence of regional anesthetic complications. In this study, regional anesthesia was safe and effective in the management of pediatric patients undergoing cardiac surgery.