Caudal epidural

Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip.

Diab. DCA, Dip. Software statistics – Ph D physiology.

Mahatma gandhi medical college and research institute, puducherry, India

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Introduction

• easiest and safest approach to the epidural space

• sole anaesthetic for some procedures, or it may be combined with general anaesthesia.

• peri and post operative analgesia in adults and children 

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History

• Cathelin 1901 • Hingson 1943 (labour pain )• Brazilian anaesthetists 1962 popularized for

paediatrics • Failures??

• 5 % failure if selection of cases is commonsense based

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INDICATIONS

• Anaesthesia and analgesia below the umbilicus• Obstetric analgesia for the 2nd stage or

instrumental deliveries• Chronic pain problems such as leg pain after

prolapsed intervertebral disc, or post shingles pain below the umbilicus.

• Common in paediatrics – circumcision, hernia, orchiopexy, hypospadias

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Newer adult indications

• vasospastic or vasocclusive disease, including frostbite and ergotamine toxicity

• Cancer pain management

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Newer adult indications

• percutaneous epidural neuroplasty• the use of caudal analgesia following lumbar

spinal surgery

• caudal analgesia after emergency orthopedic

lower extremity surgery;

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And extra

• Better post op period • Preemptive analgesia • Only technique for premature

infants

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Contraindications

• Infection near the site of the needle insertion.• Coagulopathy or anti coagulation. • Pilonidal cyst • Congenital abnormalities of the lower spine or

meninges,• Hydrocephalus and intracranial tumors

decrease intracranial compliance

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Anatomy

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Triangle

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• The sacral hiatus is a defect in the lower part of the posterior wall of the sacrum formed by the failure of the laminae of S5 and/or S4 to meet and fuse in the midline

• The sacral canal is a continuation of the lumbar spinal canal which terminates at the sacral hiatus.

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The sacral canal contains

• The terminal part of the dural sac, ending between S1 and S3.

• The five sacral nerves and coccygeal nerves making up the cauda equina

• The filum terminale• Epidural fat, the character of which changes from a

loose texture in children to a more fibrous close-meshed texture in adults.

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So the problem is puberty

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Technique

• There are three main approaches:

• prone, • semi-prone, • lateral

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Practical problems in anatomy

• Size, position of sacral hiatus :• Semi closed, closed or asymmetrical• AP diameter • 2 mm to 1.5 cm• Lateral width

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Practical problems in anatomy

• Volume of sacral canal :• 12 ml to 65 ml • Sacral foramina • Posterior sacral foramina – sacro

spinalis muscles.• Anterior sacral foramina unobstructed • Curvature :• Less – more straight needle – females

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Practical problems in anatomy

• Lordosis and lumbosacral angle

• Cephalad flow less in lordotics • Epidural fat • Loose wide meshed to tight

fibrous in adults • Predictable in children to

unpredictable spread in adults

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Equipment

• A Crawford needle similar to Touhy needle

• Crawford needle's bevel is in alignment with

the shaft of the needle so that a catheter

exits the needle in a straight line.

• The Crawford needle is ideal for either

single-shot local anesthetic injection or for

placement of a caudal epidural catheter.

• Routine needles of 21 to 25 G

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Adults –prone ok -internal rotation of ankle -not sedated

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Semiprone & lateral

• Sedation is ok • Children - lateral is fine • Easy to find landmarks • Don’t overflex knees as in lumbar epidural

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Palpate up from down coccyx feel hiatus

depression- distance

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Technique

• Local anaesth.• Less than 0.5 ml • 45 * from the sacrum • Pierce sacro coc. Mem• Angle to 30 - 15 degrees • Two methods

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Aspirate Midline lump??Whoosch test

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Gauge needle

• 22 or 23 or 21 • 21 = feel good • Easy

• 23 or 24 good in infants

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Flouroscopy

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USG guided

• Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound.

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Dose ??

• Segment • Age • Weight • Local anaesthetics

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Dose

• 0.25 mg / kg / segment of 0.25 % bupivacaine

• T 10 level , 10 kg

• 13 * 10 * 0.25 = 32.5 mg of bupivacaine • = 6.5 ml of 0.5 % bupi or 13 ml of 0.25 %

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Armitage schedule

• Armitage recommends bupivacaine

• 0.5ml/kg for a lumbosacral block, • 1 ml/kg for a thoraco-lumbar block,• 1.25 ml/kg for a mid thoracic block• one part of 0.9% NaCl to three parts local

anaesthetic to produce a 0.19%

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Verghese

• Sacral : 0.5 ml/kg

• Lumbar : 1 ml/kg

• Thoracolumbar : 1.25 ml/kg

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Schrock

• Sacral : 0.7 ml/kg

• Lumbar : 1 ml/kg

• Thoracolumbar : 1.3 ml/kg

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Dose with age

0.1 mL/ segment/year of age

1% lidocaine or 0.25% bupivacaine.

Dose : adults = 3 ml /segment

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Other drugs

• 1 mL/kg of 0.2% ropivacaine,

• 1 ml/kg of 1% lignocaine

• Levobupi 0.25 % 1 mg /kg •

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Tingling is OK

• Tingling or a feeling of fullness that extends from the sacrum to the soles of the feet is common during injection.

• The injection should never be more than 10 ml/30 seconds.

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Additives

• Epinephrine : 1 in 2 lakh • Ketamine : 0.5 mg/kg• Clonidine at 1 to 2 mcg/kg • Tramadol 1 mg/kg • Neostigmine 2 mcg/kg • Morphine 30 mic/kg --

others??

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The large capacity of the sacral canal

• significant volumes may be lost through the wide

anterior sacral foramina.

• the caudal dose requirements of local anaesthetics are

significantly larger to effect the same segmental

spread. Roughly twice

• Drugs injected in the caudal space take longer to

spread

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Caudal catheters

• Intraop and postop analgesia and stress reduction in major cases

• 0.1 % bupi - 0.4 mL/kg per hr • Add opioids – if necessary - fentanyl sos

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Complications

• Intravascular or intraosseous injection. This may lead to grand mal seizures and/or cardio-respiratory arrest.

• Test dose & aspiration• Perforation of the rectum – beware

of infection than needle prick

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Complications- continued

• Sepsis – very rare • Urinary retention.• Subcutaneous injection• Inadequate block • Haematoma • Unpredictability • Hypotension ??

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Some examples

• 2 kg infant for herniotomy

• 0.25 mg / kg / segment

• 13 * 2 * 0.25 = 6.5 mg = 2.6 ml of 0.25% bupi

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Some examples what to follow ??

• 15 kg 4 years child - club foot • 0.25 mg / kg / segment • 0.25 * 15 * 10 = 37.5 mg • 15 ml of 0.25 % BUPI • OR 0.1 mL/ segment/year of age • 0.1 * 10 * 4 = 4 ml

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