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PEDIATRIC EPIDURALS VIA THE CAUDAL ROUTE USING NERVE STIMULATION

Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, 8440-112 Street, Edmonton, Alberta, T6G 2B7

INTRODUCTION

Cephalad advancement of epidural catheters to the thoracic region via the caudal route is feasible in neonates and small infants. However, it has been recommended that catheter insertion be guided radiographically. We examined the success rate and complications of epidurals since the routine use of the Epidural Stimulation Test¹ at our institution.

METHODS

After IRB approval, we retrospectively reviewed children who had thoracic or lumbar epidural analgesia via the caudal route between January 1999 and November 2002 using our pediatric pain service database, which prospectively collected information on all children receiving epidurals. A commercial product (Epidural Positioning System using Tsui Test, Arrow International, Inc, USA) was used. Most epidural infusions were 0.05-0.1% Bupivacaine with 1 mcg/ml Fentanyl.

RESULTS

A total of 285 children were identified as having received caudal placement of a lumbar or thoracic catheter. In 5 patients (ages 0.4 - 6.1yrs) the catheter could not be threaded to the desired level and was abandoned. Adequate pain control (success rate) in the remaining 280 patients was 85%. Side-effects occurred as follows: pruritis 26.4%, nausea and vomiting 17.1%, urinary retention 8.9%, respiratory depression 4.3%, and excessive block 1.8%. One possible seizure and 1 dural puncture also occurred. No patients received Naloxone, developed epidural abscesses, or developed neurological deficit related to the epidural.

DISCUSSION

Successfully advancing epidural catheters from the caudal to the thoracic level depends on the presence of a styleted catheter and patient size. It has been suggested that the development of the lumbar curve during infancy prevents easy threading of the catheter to the thoracic region. However, we have shown similar success rates in both infants (0-1 years) and in older children (>1 year) of 85.7% (162/189) and 84.6% (77/91), respectively. In this study, the high clinical success of approximately 85% in all age categories was likely due to the stimulation test to identify catheter tip position, and to the catheter setup simultaneously using a stylet and saline injection to permit catheter advancement.

REFERENCES

1 Anesth Analg 2001 93:1152–5.[Abstract/Free Full Text]

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