Loss of resistance to normal saline is preferred to identify the epidural space: a survey of Canadian pediatric anesthesiologists

Abstract

P Pu ur rp po os se e: : Several methods have been described to locate the epidural space, but the loss-of-resistance (LOR) technique is the most commonly used. Expert opinion states that LOR to air is the best medium for neonates and infants. We conducted a Canadawide postal survey to determine the current state of practice for placement of epidural catheters in pediatric patients.M Me et th ho od ds s: : Two hundred and nine surveys were distributed to academic pediatric anesthesiologists across Canada. The survey was limited to six questions and was anonymous.

The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine Joint Committee Practice Advisory on Controversial Topics in Pediatric Regional Anesthesia

“…51 Despite these issues associated with the use of saline-LOR, the exclusive use of saline has been recommended by some experts and has become the general practice in some countries. 52,53 Air/Saline-LOR One publication involving 500 pediatric epidural blocks described the use of saline with a bubble of air in the syringe 44 (Evidence B3). This was reported to permit easy detection of the epidural space with a lower incidence of dural puncture (0.5%) than what has been reported for exclusive use of air or saline.…”

“…53 Therefore, the time to diagnosis of ACS is essential because a delay in treatment of more than 4 hours can lead to irreversible limb damage and possible limb loss.…”

Recent developments in paediatric neuraxial blocks

“…[37] Loss of resistance can be elicited with either air or saline. Although air is readily available and cannot be confused for another substance, and also may permit easier detection of a dural tap compared to saline in children, loss of resistance is elicited by saline instead of air.…”

From the Journal archives: Epidural anesthesia in young children: What have we learned in the past 60 years?

“…8 Currently, it is safe to say that the loss of resistance technique using saline is the most widely accepted method of identifying the epidural space, at least in Canada. 9 Ames et al present a detailed discussion of the arguments in favour of saline over air for identifying the epidural space in infants and children; perhaps the most important argument is minimizing the risk of venous air embolism. 9 Ruston was somewhat limited by the needles available to him.…”

“…9 Ames et al present a detailed discussion of the arguments in favour of saline over air for identifying the epidural space in infants and children; perhaps the most important argument is minimizing the risk of venous air embolism. 9 Ruston was somewhat limited by the needles available to him. The early design of Tuohy needles were both sharp and of wide diameter 10 and therefore would not have been suitable.…”