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Caudal Anaesthesia - Part 2 Notes

Caudal anaesthesia is a common and effective technique for providing pain relief in pediatric patients. It provides anaesthesia to the lower abdomen, perineum, and lower limbs with a high success rate and low risk of complications. Several local anaesthetics including bupivacaine, ropivacaine and levobupivacaine are effective options that produce similar onset of block and postoperative analgesia when used for caudal anaesthesia. The addition of certain drugs like clonidine or low doses of ketamine can increase the duration of the block without significant adverse effects. While caudal anaesthesia is low risk, inadvertent intravascular injection remains a potential complication, so careful administration and monitoring techniques are important.

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86 views3 pages

Caudal Anaesthesia - Part 2 Notes

Caudal anaesthesia is a common and effective technique for providing pain relief in pediatric patients. It provides anaesthesia to the lower abdomen, perineum, and lower limbs with a high success rate and low risk of complications. Several local anaesthetics including bupivacaine, ropivacaine and levobupivacaine are effective options that produce similar onset of block and postoperative analgesia when used for caudal anaesthesia. The addition of certain drugs like clonidine or low doses of ketamine can increase the duration of the block without significant adverse effects. While caudal anaesthesia is low risk, inadvertent intravascular injection remains a potential complication, so careful administration and monitoring techniques are important.

Uploaded by

Gareth Symons
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© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Caudal Anaesthesia – Part 2 Notes

Caudal Anaesthesia: Acute Pain Management 2010

 Single shot caudal anaesthesia is one of the most widely used techniques
in paediatrics
 Provided anaesthesia for lower abdomen, perineum and for lower limbs
 High success rate and low rate of complications (in large case series)
 Bupivacaine, Ropivacaine and Levobupivacaine all produce similar times
to onset of block and comparable post operative analgesia
 Concentration affects effect. 0.175% Ropivacaine provided better
analgesia than lower concentrations but less motor block than higher
doses
 Addition of adrenaline to bupivacaine has minimal effect on duration of
analgesia (particularly in older children)
 Additives: Morphine does increase duration of block but is associated
with dose dependent adverse effects, the most significant being
respiratory depression. Fentanyl slightly increases duration with less risk
of respiratory depression
 Supplementation of GA with caudal block for cardiac surgery decreases
time to extubation and duration of mechanical ventilation but showed no
difference in hospital stay or pain relief
 Clonidine @ 1 mcg/kg increased duration of block without adverse
sedation associated with higher doses
 Ketamine 0.25 – 0.5 mg/kg provided analgesia without adverse effects
but higher doses causes behavoural problems
 There is limited evidence that spinal anaesthesia in place of GA may
reduce the incidence of respiratory complications in premature infants
 There is evidence that time to discharge from hospital is reduced with
epidural in place of systemic opioids in fundoplication and patent ductus
arteriosus surgery

Complications: Inadvertent intravascular injection remains the most significant


risk of epidural techniques. There is a risk of injecting into the vascular
medullary space of the sacrum in infancy and childhood due to the cartilaginous
nature of the bone. A UK Audit revealed 5 serious complications in 10633
paediatric epidurals. 2 cases of epidural abscess, 1 case of meningism, severe
postdural puncture headache and a cauda equina syndrome associated with
incorrect drug volume error. Peripheral or Nerve Root Damage was also
reported in 6 additional cases. 3 resolved spontaneously, 2 required gabapentin
and ongoing review but resolved within 12 months, and 1 continued to be
symptomatic beyond 1 year.
Choice of Local Anaesthetic agent1:

 Ropivacaine, Levobupivacaine & Bupivacaine are equally efficacious


 Bupivacaine is associated with the greatest motor block, whilst
Ropivacaine is associated with the least motor block
 Adverse effects are rare and not associated with choice of LA

Caudal in Circumcision2:

 There was no difference between requirement for rescue analgesia


between patients receiving parenteral, DNPB or caudal anaesthesia
 There was no difference in PONV
 Those receiving caudal were much more likely to have motor block and as
such it may be more appropriate for children who are not walking yet

Epidural Test dose in Paediatrics3:

The criteria used for identification of intravascular needle/catheter placement in


adults are not sensitive in paediatrics.
A solution containing 0.5 mcg/kg of adrenaline should be injected slowly and the
following changes should be considered evidence of IV injection:
 a HR increase of 10 bpm

 an increase of SBP of 15 mmHg or more

 an increase of T Wave amplitude of >=25%

1
Canadian Journal of Anaesthesia. 57(12):1102-10, 2010 Dec.
Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy
with the fewest side effects [Review] Dobereiner, Elisabeth F A. Cox, Robin G. Ewen, Alastair. Lardner, David R.

2
Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003005. DOI: 10.1002/14651858.CD003005.pub2
Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cyna AM,
Middleton P.

3
1156 Anesth Analg 2001;93:1156–61
Caudal Epidural Block: A Review of Test Dosing and Recognition of Sytemic Injection in Children. Joseph D.
Tobias, MD

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