Thoracic epidural catheters via the caudal and lumbar approaches using styletted multiple port catheters in pediatric patients: a report of three cases

Abstract

Advancing catheters from the lumbar and caudal epidural spaces to the thoracic level has been reported to be an alternative to the direct thoracic approach. However, as children grow, the threading of catheters in the epidural space becomes increasingly difficult. This report describes three cases of thoracic epidural placement using a multiport catheter threaded from the caudal and lumbar spaces using electrical stimulation guidance. In the first case, a multiport catheter was threaded 22 cm from the lumbar space to T8 following a failed attempt with a single-port catheter in a 9-year-old boy scheduled to undergo a right nephrectomy. In the second case, a multiport catheter was threaded 26 cm from the caudal space to T9 in a 3-year-old girl undergoing fundoplication. In the last case, a multiport catheter was inserted at the completion of a fundoplication in a 2-year-old girl after it had been confirmed that the single-port catheter inserted prior to surgery had not advanced to the desired thoracic level. The multiport catheter was threaded 17 cm without resistance from the caudal space to T9. In all cases, electrical stimulation was used to confirm the location of the catheter tip at the time of insertion. The position of the catheters was later confirmed by X-ray. The multiport catheter incorporates a stylet, which extends to a closed distal tip, within a catheter body that ejects fluid from three lateral holes in a direction perpendicular to the advancing catheter. These properties may facilitate the reliable advancement of catheters in the epidural space.

Major complications related to epidural analgesia in children: a 15-year audit of 3,152 epidurals

“…In infants and neonates, ultrasound enables visualization of epidural catheters that are inserted via the easily accessible caudal space and threaded to the desired vertebral level in the thoracic or lumbar regions. [33][34][35] The availability of ultrasound to guide placement of caudal-thoracic epidurals has resulted in an increased use of epidural analgesia in infants during the last three years of this review.…”

Low-dose intrathecal local anesthetic does not increase the threshold current for the epidural stimulation test: a prospective observational trial of neuraxial analgesia in labouring women

“…[8][9][10][11][12][13][14][15][16][17][18] The motor threshold current (MTC) achieved when using the EST can distinguish whether the catheter tip is positioned epidurally (medium MTC: 2-15 mA), subcutaneously (high MTC: [ 15 mA), or intrathecally (low MTC: \ 2 mA), although a low MTC might also conceivably be due to the catheter abutting a nerve root. It should be emphasized that these MTC ranges are somewhat arbitrary depending on the individual interpreting the EST results.…”

Keys to minimizing the risk of spinal cord trauma during a lumbar approach to thoracic epidural

“…Des décennies plus tard, De nombreux comptes rendus, particulièrement dans la littérature d'anesthésie pédiatrique, rapportent la réussite de techniques d'insertion péridurale caudales et l'insertion du cathéter jusqu'aux niveaux thoracique et lombaire. 9,[14][15][16][17][18][19][20][21][22][23][24][25] En revanche, seules quelques séries de cas décrivant l'insertion d'un cathéter depuis un point d'insertion lombaire ont été publiées. 11,25 Les raisons pour la popularité de l'approche caudale avec les anesthésiologistes pédiatriques sont multiples.…”

“…9,20,23,25,27 Enfin, et surtout, la facilité d'insertion du cathéter par approche caudale, par laquelle l'aiguille d'insertion est placée presque parallèlement à la dure-mère et à la moelle épinière, permet dans le fond à l'utilisateur de glisser le cathéter le long de la surface durale en exerçant une force de flexion négligeable.…”

“…14,26 Second, the use of the epidural stimulation test enables accurate targeting of catheter placement at a specific myotome level, as shown by an abundance of reports in the literature. 9,20,23,25,27 Last, but not least, the ease of catheter advancement with the caudal approach, where the introducer needle is placed almost parallel to the dura and spinal cord, enables the user essentially to slide the catheter along the dural surface with negligible bending force needed.…”