Caudal epidural blocks in paediatric patients: a review and practical considerations

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.

The analgesic effect of bilateral ultrasound-guided erector spinae plane block in paediatric lower abdominal surgeries: A randomised, prospective trial

“…Although a simple technique in infants and young children, the development of sacral fat pad in older children makes palpation of sacral cornua difficult. [ 13 14 ]…”

A Randomized Controlled Double-Blind Comparative Study between Bupivacaine 0.25% Plus Fentanyl and Bupivacaine 0.25% Plus Dexmedetomidine for Caudal Epidural Postoperative Analgesia in Pediatric Lower Abdominal and Urogenital Surgeries in Indian Genotype

“…In phase 2, the intracranial and spinal pressure gradient shifts the CSF in the caudal direction, forcing the local anesthetic drug to spread cranially. 7,8 Consider this and the adjuvant we have taken (0.25% bupivacaine 0.75 mL/kg) as the caudal dose, although the recommended dose for lower abdominal surgeries is 1 mL/kg.…”

Pain management with ultrasound-guided lidocaine-ropivacaine caudal block in hypospadias repair: A single-surgeon comparative study

“…Systemic toxicity in children also continues to be a topic of concern. The consensus is that the traditional method of general anesthesia can be improved with reduced use of opioids or opioid-free therapy [6,12,13].…”

“…The conventional landmark-based technique of caudal injection in children was reported with a success rate in the range of 75-96% [6,7]. Performed with visualization tools such as the ultrasound, which is quickly becoming commonplace practice, caudal blocks can improve block efficacy and patient safety.…”

“…Performed with visualization tools such as the ultrasound, which is quickly becoming commonplace practice, caudal blocks can improve block efficacy and patient safety. Ultrasound can clearly show the sacral foramen, sacrococcygeal ligament and the sacral space; it also makes it possible for real-time monitoring of the spread of injectate and expansion of the epidural cavity upon injection of medication [6].…”