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Background Methods Results Conclusion Inguinal hernia repair is the most common operation in infants, with well recognized anesthetic and perioperative risks. The aim was to investigate if the combination of caudal block, high‐flow nasal oxygen insufflation and intravenous dexmedetomidine sedation is suitable for infants undergoing inguinal hernia surgery.A prospective multicenter international study was performed in three centers in Australia and New Zealand. Fifty infants less than 64 weeks post‐menstrual age undergoing inguinal hernia surgery were enrolled. Exclusion criteria were any condition that contraindicated the use of the anesthesia technique. The technique included intravenous dexmedetomidine with a loading dose of 1–2 mcg/kg over 10 min and maintenance of 0.2–3 mcg/kg/h, high‐flow nasal oxygen insufflation 2 L/kg/min with an oxygen blender, and a caudal block using 1 mL/kg 0.2% ropivacaine. The primary outcome was the successful completion of surgery without conversion to general anesthesia.Completion of surgery with the technique was successful in 41/50 (82%) infants. Care was provided by 22 anesthesiologists and 11 surgeons. Infants had a low incidence of intraoperative complications, including apnea [1 (2.4%)], bradycardia [2 (4.9%)], hypotension [2 (4.9%)], and desaturation [1 (2.4%)]. Postoperative complications included apnea [3 (7.3%)], bradycardia [3 (7.3%)], hypotension [3 (7.3%)], desaturation [4 (9.8%)]. No infants were intubated in the first 24 h postoperatively.Caudal block, high‐flow nasal oxygen insufflation and intravenous dexmedetomidine sedation is a potential alternative to general anesthesia for infant inguinal hernia surgery with a low rate of complications in this small cohort of infants. [ABSTRACT FROM AUTHOR]

Background and Objectives: The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic‐based techniques in premature and ex‐premature infants undergoing lower abdominal surgery. Methods: All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, abstracted data, and appraised quality. Results: Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of "awake" caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation. The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7–18.4), intermediate for awake caudal (6.6%, 5.26–9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48–7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%–24%), intermediate for awake caudal (7.62%, 0%–60%), and lowest for CSEA (5.53%, 0%–14.3%). High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals). Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high‐quality randomized controlled trials, and the eight single‐center retrospective data reviews lacked sufficient data to perform meta‐analysis. Conclusions: There is insufficient evidence to validate or refute the benefits of the use of "awake" caudal anesthesia in premature and ex‐premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block. [ABSTRACT FROM AUTHOR]

Background: Caudal block is a common regional anesthesia technique in pediatrics with landmark method predominantly being practiced. Ultrasound‐guided technique provides real‐time visualization of the structures and injection while performing caudal block. We performed this meta‐analysis to determine the utility of ultrasound in caudal blocks in children over the landmark‐based technique. Methods: Randomized controlled trials comparing ultrasound‐guided caudal blocks and landmark technique in pediatrics were searched from databases—PubMed, Embase, Scopus, and CENTRAL from inception until August 2020. The primary objective was success rate between the two techniques and secondary objectives included time to perform the block, first puncture success, and complications. Results: Five trials with 904 participants were included for this meta‐analysis. There was no difference in success rate between the two techniques (Risk ratio–1.07; 95% CI [0.97, 1.18]; p =.15). Time to perform the block was similar (Mean difference–8.88 s; 95% CI [−21.64, 39.40; p =.57) while first puncture success was higher with ultrasound‐guided technique (Risk ratio–1.31; 95% CI [1.15, 1.49]; p =.0001). Complications like vascular puncture and needle misplacement were lower in the ultrasound group, and no serious complications were seen in any patient. Needle visualization and sacral canal distension were seen in 82% and 97.5% of the cases, respectively, in ultrasound group. Conclusion: Ultrasound‐guided caudal injection does not improve the success rate or time to perform the block but results in higher first puncture success and lower incidence of complications compared to landmark technique. [ABSTRACT FROM AUTHOR]

Background: Despite being the most frequently used pediatric nerve block, certain aspects of the initial intraspinal spread of local anesthetics when performing a caudal block need further elucidation. The fact that injected volumes of 0.7–1.3 mL kg−1 initially only reach the thoraco‐lumbar junction, with only a few vertebral segments difference despite the huge difference in injected volume, still has no apparent explanation. We hypothesize that the narrowing of the epidural space caused by the lumbar spinal enlargement may provide an anatomical barrier causing this restriction of initial spread, alone or in combination with increased intrathecal pressure caused by the "cerebrospinal fluid rebound mechanism." The aim of this observational study was to find support for or refute this hypothesis. Methods: Twenty nine MRI scans of the vertebral column, performed in children 0–6 years of age, was identified from the radiographic imaging computer system and analyzed for the vertebral level of the maximum of the lumbar spinal enlargement (Associated anatomical data related to the spinal canal, the dura mater, and the spinal cord were also recorded. Results: The maximum of the lumbar spinal enlargement was found at a median vertebral level of Th 11 (IQR 11–11). Conclusion: The maximum of the lumbar spinal enlargement is located at the Th 11 vertebral level. Although not entirely conclusive, the findings of the present study do support the notion that the lumbar spinal enlargement, in combination with the CSF rebound mechanism, may be the factors limiting the initial spread of a caudal block to the thoraco‐lumbar junction. [ABSTRACT FROM AUTHOR]

Background: Caudal epidural anesthesia is a frequently performed regional anesthesia block in infants and young children. Traditional landmark‐based blind needle insertion remains the norm with no immediate, objective method to determine the presence of local anesthetic in the epidural space. Increasingly, ultrasound‐imaging is used in pediatric regional anesthesia with demonstrated improvements in block efficacy and efficiency. The value of ultrasound‐imaging in confirming success rate of traditional caudal placement is not well defined. Aim: To assess the success rate of conventional landmark‐based caudal technique using ultrasound‐imaging. Methods: Prospective observational study of 30 children ages 1 month to 7 years undergoing surgical procedures with consent for caudal blockade. Provider success rate of caudal blockade placed by landmark technique was measured using ultrasound‐imaging of needle tip and local anesthetic flow in the epidural space. Results: Ultrasound‐imaging demonstrated 80% success to correct positioning of the needle tip and local anesthetic in the epidural space. Failure was associated with decreasing experience and presence of anatomic variances. All improperly positioned needles were subsequently successfully positioned using real‐time ultrasound‐imaging. Mean time for confirmatory ultrasound‐imaging (SD; range) was 1 minute (0.3; 1‐3). Conclusion: The use of ultrasound‐imaging can be used to identify proper needle placement in the sacral epidural canal and facilitate subsequent corrected placement. [ABSTRACT FROM AUTHOR]

Background: Recent publications from the United States, India, and Korea report that children undergoing hypospadias repair with caudal regional anesthesia/analgesia could have increased postoperative surgical complications. Aims: The purpose of this retrospective cohort study was to assess the impact between caudal regional anesthesia, other regional anesthesia, and no regional anesthesia on complications after hypospadias repair at a tertiary care children's hospital in Ottawa, Canada, with an expectation to changing practices if a link was found. Method: We reviewed the health records of 827 children with hypospadias undergoing penile surgery from January 1991‐June 2017. The final sample size for the analysis consisted of 764 patients and 825 procedures. Results: The overall complications were almost identical when considering anesthesia effects, and this similarity persisted when we assessed specifically for only surgical complications. We had 716, 94, and 15 subjects who had a caudal block, penile block, and general anesthesia only, respectively, and their complication rates were 28, 31, and 27%, respectively, and their fistula formation rates were 10, 6, and 0%, respectively, and their stricture formation rates were 8, 7, and 20%,, respectively. Hypospadias type and surgical repair technique were marked predictors of complications in the postoperative period. Conclusion: Anesthesia technique appears to have minor impact on complications after hypospadias repair, while surgical technique and type of hypospadias impact complications after hypospadias surgery in children. Based upon these results, we will not change our current practice of using a variety of regional anesthesia techniques for children undergoing hypospadias repair. [ABSTRACT FROM AUTHOR]

Background Caudal block has been widely used in children undergoing genitourinary surgery. However, the influence of caudal block on postoperative oliguria is unclear. Aim The aim of this study was to assess the effect of caudal block on urinary flow through the reimplanted ureter after ureteroneocystostomy and the incidence of postoperative oliguria in infants. Methods This retrospective study analyzed the medical records of 121 infants aged less than 12 months who underwent bilateral ureteroneocystostomy for vesicoureteral reflux at a tertiary medical center. In all study infants, a ureteral catheter was placed in one of the two ureters in order to relieve the clinical consequences of transient ureteral obstruction and a urethral catheter was placed at the end of the ureteroneocystostomy procedure. Urinary output was assessed separately for each catheter. Logistic regression analysis was performed to identify the risk factors for oliguria from the urethral catheter. Results Among the 121 patients, 63 (52%) received caudal block (caudal block group) and 58 (48%) did not (no caudal block group). Patient characteristics, preoperative vesicoureteral reflux grade and renal function, and intraoperative profiles were comparable between the groups. The incidence of oliguria from the urethral catheter for 8 h after the surgery was significantly higher in the caudal block group than in the no caudal block group. However, the incidence of oliguria from the ureteral catheter was comparable between the groups. In multivariate analysis, oliguria from the urethral catheter was associated with caudal block, anesthesia duration, and intraoperative dexamethasone administration. The odds for oliguria was 3.069-fold greater in patients who received caudal block than in those who did not (95% CI, 1.303-7.228, P = 0.010). On the other hand, intraoperative dexamethasone reduced the risk of oliguria. Conclusion Caudal block may be associated with postoperative oliguria in infants undergoing ureteroneocystostomy. [ABSTRACT FROM AUTHOR]

Background Caudal blocks are performed through the sacral hiatus in order to provide pain control in children undergoing lower abdominal surgery. During the block, it is important to avoid advancing the needle beyond the sacrococcygeal ligament too much to prevent unintended dural puncture. This study used demographic data to establish simple guidelines for predicting a safe needle depth in the caudal epidural space in children. Methods A total of 141 children under 12 years old who had undergone lumbar-sacral magnetic resonance imaging were included. The T2 sagittal image that provided the best view of the sacrococcygeal membrane and the dural sac was chosen. We used Picture Achieving and Communication System (Centricity® PACS, GE Healthcare Co.) to measure the distance between the sacrococcygeal ligament and the dural sac, the length of the sacrococcygeal ligament, and the maximum depth of the caudal space. Results There were strong correlations between age, weight, height, and BSA, and the distance between the sacrococcygeal ligament and dural sac, as well as the length of the sacrococcygeal ligament. Based on these findings, a simple formula to calculate the distance between the sacrococcygeal ligament and dural sac was developed: 25 × BSA (mm). Conclusion This simple formula can accurately calculate the safe depth of the caudal epidural space to prevent unintended dural puncture during caudal block in children. However, further clinical studies based on this formula are needed to substantiate its utility. [ABSTRACT FROM AUTHOR]

Aim: Caudal epidural anesthesia has been shown to reduce stress response and shorten the time to extubation in children after cardiac surgery. Combined with general anesthesia, regional anesthesia has been proven to be safe and efficacious in the pediatric population. It is not known, however, whether the use of caudal anesthesia actually reduces postoperative pain scores and decreases postoperative opioid use. Methods: We retrospectively analyzed the charts of 199 children who underwent repair for atrial septal defect (ASD), ventricular septal defect (VSD), and Tetralogy of Fallot (TOF) at a major academic children's hospital between 2010 and 2013. Results: Eighty-six patients underwent preoperative placement of caudal anesthesia (bupivacaine 0.25% 1 ml·kg-1 up to 20 ml + clonidine 2mcg·kg-1 + Duramorph 40 mcg·kg-1 up to 2.5 mg) and 113 patients did not have a caudal block. Postoperative cardiac intensive care pain scores were analyzed according to standard nurse-recorded patient-appropriate pain scales ranging from 0 to 10 (CRIES for neonates and FLACC for 2 months–7 years). There was no statistical difference between caudal and noncaudal groups with respect to postoperative pain scores or with postoperative opioid requirements. There was a statistical significance with regard to intraoperative opioid use as noncaudal patients invariably received more opioid during the procedure. Conclusion: Although regional anesthesia reduced intraoperative opioid usage, there was no difference in postoperative opioid usage or pain scores. [ABSTRACT FROM AUTHOR]

Background: Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain. Aim: To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques. Methods: Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'--single-shot caudal; (iii) 'epidural'-- epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 lg ml -1; (iv) 'caudal catheter'--caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain. Results: Over the study period, the caudal catheter technique (mean interventions/ patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload. Conclusions: Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required. [ABSTRACT FROM AUTHOR]

Background There is a need for an adjuvant agent of caudal block that prolongs its duration and improves the analgesic efficacy to fasten functional recovery. Magnesium is an N-methyl-D-aspartate receptor antagonist that functions as an analgesic. This study was aimed to evaluate whether magnesium as an adjuvant for caudal block in children can improve postoperative analgesia and functional recovery. Methods Eighty children, 2-6 years of age, undergoing inguinal herniorrhaphy, were included in this prospective, randomized, double-blinded study. For caudal block, Group R received ropivacaine 1.5 mg·ml−1, 1 ml·kg−1 and Group RM received the same dose of ropivacaine mixed with 50 mg of magnesium. The Parents' Postoperative Pain Measure ( PPPM) score, analgesic consumption, functional recovery, and adverse effects were evaluated at 6, 24, 48, and 72 h after surgery, as well as daily thereafter until the child showed full functional recovery. Results The PPPM score after hospital discharge was significantly lower for Group RM than for Group R at all times ( P < 0.05). Children in Group RM required less fentanyl for rescue analgesia in the recovery area (16.2% vs 39.5%, P = 0.034) and less oral analgesics after discharge (20.5% vs 52.6%, P = 0.007). The time to return of normal functional activity was shorter in Group RM ( P < 0.05). The incidence of adverse effects did not differ between groups. Conclusions As an adjuvant for caudal analgesia, 50 mg magnesium provided superior quality of analgesia and faster return of normal functional activity than local anesthetic alone in children. [ABSTRACT FROM AUTHOR]

Background and Objectives: Dexmedetomidine (D) can prolong the duration of local anesthetics, but the effect of caudal dexmedetomidine on the potency of levobupivacaine (L) for caudal block has not been investigated. This study was designed to determine the effect of caudal dexmedetomidine on levobupivacaine for caudal block in pediatric patients. Methods: Eighty-nine children scheduled for elective inguinal hernia repair or hydrocele were randomly assigned to one of the three groups: Group L (caudal levobupivacaine), Group LD1 (levobupivacaine plus 1 μg·kg-1 dexmedetomidine), or Group LD2 (levobupivacaine plus 2 μg·kg-1 dexmedetomidine). The primary endpoint was the minimum local anesthetic concentration (MLAC), which was determined using the Dixon up-and-down method. The secondary endpoints were the duration of analgesia and sedation. Results: The MLAC values (sd) of caudal levobupivacaine were 0.103 (0.01)%, 0.068 (0.02)%, and 0.055 (0.03)% in Groups L, LD1, and LD2, respectively. The values of EC50 and EC95 (95% CI) of caudal levobupivacaine from logistic regression analysis were 0.094 (0.083-0.105)% and 0.129 (0.1-0.159)%, 0.058 (0.044-0.072)% and 0.106 (0.067-0.144)%, and 0.046 (0.033-0.059)% and 0.091 (0.055-0.127)% in Groups L, LD1, and LD2, respectively. The mean durations of analgesia in the postoperative period were 141, 378, and 412 min in Groups L, LD1, and LD2, respectively (L vs LD1 or LD2, P < 0.001). The mean durations of sedation in both Groups LD1 and LD2 also were significantly prolonged, compared with Group L (P < 0.01). Conclusions: Caudal dexmedetomidine reduces the MLAC values of levobupivacaine and improves postoperative analgesia in children without any neurological side effects. [ABSTRACT FROM AUTHOR]

Background Regional blocks have been shown to decrease the requirement of anesthetic agents. This study was conducted to determine the optimal endtidal concentrations of desflurane for removal of Laryngeal mask airway in children in presence of caudal block. Methods Twenty-two children of ASA status I between the age group of 2-10 year undergoing infraumbilical surgery were enrolled in the study. General anesthesia was induced with sevoflurane and oxygen given via mask and laryngeal mask airway inserted. Caudal injection of bupivacaine 0.25%, 1 ml·kg−1 was administered according to Armitage regimen. Desflurane was used for maintenance of anesthesia. Predecided endtidal concentration of desflurane was maintained for 10 min at the end of surgery and laryngeal mask airway removed. Target concentration in the next patient was thereafter determined by the Dixon up-down method (with 0.5% as a step size). 5% endtidal concentration was kept as the starting concentration. If removal of laryngeal mask airway was not associated with any coughing, teeth clenching, gross purposeful movement, breath holding or laryngospasm, during or within 1 min after removal, it was considered as successful. Results In the presence of caudal analgesia, endtidal concentration of desflurane required for successful laryngeal mask airway removal in 50% ( ED50) children was 3.39 ± 0.38% by Dixon's method. Conclusion Laryngeal mask airway can be successfully removed in 50% of anesthetized children without coughing, moving, or any other airway complications at an endtidal desflurane concentration of 3.4% in the presence of caudal analgesia. [ABSTRACT FROM AUTHOR]

Background There is a risk of inadvertent dural or vascular puncture for the traditional single-shot caudal block performed by inserting the needle into the sacral canal through the sacral hiatus. This prospective, randomized study was to evaluate the clinical feasibility of the hiatus injection under ultrasound guidance for caudal block in children. Methods 140 ASA I-II children undergoing inguinal hernia repair were randomly allocated to one of two groups (Group C or Group H, n = 70). 1 ml·kg−1 of 0.25% ropivacaine was injected after the needle was inserted into the sacral canal in Group C, or after the needle pierced the sacrococcygeal ligament under a transverse ultrasound view in Group H. Success rate of block, puncture frequency, complications, and durations of block were recorded. Results The success rate of block was similar between two groups (95.7% in Group C vs 92.8% in Group H, P > 0.05). The first puncture success rate was higher, and the durations of block were shorter in Group H than in Group C (92.8% vs 60% and 145 ± 23s vs 164 ± 31s, respectively P < 0.05). Bloody puncture had an incidence of 18.6% in Group C and 5.7% in Group H ( P < 0.05). Subcutaneous bulging occurred in six patients (7.1%) in Group C but none in Group H ( P < 0.05). Conclusions Sacral hiatus injection offers a reliable caudal block for pediatric inguinal hernia repair with the advantages of easier performance and fewer complications compared with traditional sacral canal injection. [ABSTRACT FROM AUTHOR]

The aim of this prospective, age-stratified, observational study was to determine the cranial extent of spread of a large volume (1.5 ml·kg, ropivacaine 0.2%), single-shot caudal epidural injection using real-time ultrasonography. Fifty ASA I-III children were included in the study, stratified in three age groups; neonates, infants (1-12 months), and toddlers (1-4 years). The caudal blocks were performed during ultrasonographic observation of the spread of local anesthetic (LA) in the epidural space. A significant inverse relationship was found between age, weight, and height, and the maximal cranial level reached by 1.5 ml·kg of LA. In neonates, 93% of the blocks reached a cranial level of ≥Th12 vs 73% and 25% in infants and toddlers, respectively. Based on our data, a predictive equation of segmental spread was generated: Dose (ml/spinal segment) = 0.1539·(BW in kg)-0.0937. This study found an inverse relationship between age, weight, and height and the number of segments covered by a caudal injection of 1.5 ml·kg of ropivacaine 0.2% in children 0-4 years of age. However, the cranial spread of local anesthetics within the spinal canal as assessed by immediate ultrasound visualization was found to be in poor agreement with previously published predictive equations that are based on actual cutaneous dermatomal testing. [ABSTRACT FROM AUTHOR]

Clonidine has the potential to significantly prolong the duration of caudal epidural anesthesia. We investigated the effect of the addition of clonidine to the MLAC of levobupivacaine in a randomized controlled dose-response trial. A group of 120 children aged <6 years of age received caudal anesthesia with levobupivacaine and 1, 2, or 3 μg·kg of clonidine. The MLAC was determined according to a Dixon-Massey protocol. The primary outcome was effective surgical anesthesia. Secondary outcomes were the duration of postoperative analgesia, postoperative pain scores, clonidine side effects, and time to hospital discharge. The MLAC of caudal levobupivacaine was 0.106%, 0.077%, and 0.035% with 1, 2, and 3 μg·kg of clonidine, respectively. There were significant dose-dependent increases in median duration of analgesia. The incidence of delayed discharge, somnolence, and PONV was significantly increased in the 3 μg·kg of clonidine group. Clonidine produces a local anesthetic sparing effect with a dose-dependent decrease in levobupivacaine MLAC for caudal anesthesia. In addition, there is a dose-dependent prolongation of postoperative analgesia following lower abdominal surgery in children. A dose of 2 μg·kg of clonidine provides the optimum balance between improved analgesia and minimal side effects. [ABSTRACT FROM AUTHOR]

To examine the anatomic spread of caudal local anesthetic solution in children aged 1-7 years. To determine whether incremental increases in the volume of caudal injections of 0.5, 0.75, and 1.0 ml·kg result in reliable (>90%) and potentially clinically significant increases in the number of vertebral segments reached. Caudal block is one of the most frequently performed pediatric regional analgesic techniques. Traditional formulae suggest that changes in the volume of caudal injectate in the range 0.5-1.0 ml·kg would have clinically useful effects. In a single blind design, 45 children aged 1-7 years undergoing caudal block received one of the three predetermined volumes (0.5, 0.75, and 1 ml·kg) of local anesthetic solution containing radio-opaque contrast under controlled conditions. Following X-ray examination, the anatomic spread of the block was reported by a radiologist blinded to the volume of solution received. There were 15 children in each group, and they were similar in terms of age, height, and weight. Spread was observed between the 5th lumbar (L5) and 12th thoracic (T12) vertebral levels. A volume of 1 ml·kg results in a small but significantly greater spread of solution than 0.5 ml·kg ( P < 0.05), but there was no difference between 0.5 and 0.75 ml or between 0.75 and 1.0 ml. No volume reliably reached a level higher than the second lumbar vertebra (L2). Incrementally increasing the volume of injectate between 0.5 and 1.0 results in a modest increase in the spread of the caudal solution. It is unlikely that volumes of <1 ml will reliably reach a vertebral level that is higher than L2. [ABSTRACT FROM AUTHOR]

Background: Spinal anesthesia (SA) is widely used for awake regional anesthesia in ex-preterm infants scheduled for herniotomy. Awake caudal anesthesia (CA) is suggested as an alternative approach for these patients and type of surgery. The aim of this study was to compare efficacy and complications of the two different techniques. Methods: Two historical populations of 575 ex-preterm infants undergoing herniotomy under awake SA ( n = 339; 1998–2001) and under awake CA ( n = 236; 2001–2009) were investigated. Data are compared using t-test and chi-square tests ( P < 0.05). Results: The SA group consisted of 339 patients, they were born after 32.0 (3.3) weeks of gestation on average with a mean birth weight of 1691 g (725). The CA group consisted of 236 patients born after 32.1 weeks (3.7) with a mean birth weight of 1617 g (726). At the time of operation, the total age was 41.37 (3.6) and 41.28 (4.0), respectively, for SA and CA patients, and the corresponding weights were 3326 (1083) g and 3267 (931) g for SA and CA patients, respectively. For SA, significantly more puncture attempts were needed (1.83 vs 1.44, P < 0.001). Surgery was performed under pure regional anesthesia in 85% (SA) and 90.1% (CA) (ns). A change to general anesthesia was necessary in 7.7% (SA) and 3.9% (CA) (ns). Overall, intra- and postoperative complications were not statistically different. Conclusions: Caudal anesthesia was shown to be technically less difficult than SA and to have a higher success rate. Its application as awake regional anesthesia technique in these patients seems more appropriate than SA. [ABSTRACT FROM AUTHOR]

Background: The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg·kg−1 and mixture of both in children undergoing day-case surgery. Methods: Sixty-three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg·kg−1 (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml·kg−1). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children’s and Infants’ Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was ≥4. Results: No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 ± 160 min vs 322 ± 183 min and 248 ± 188 min, respectively) ( P < 0.01). There were no significant differences between the group L and group T for duration of analgesia ( P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation ( P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. Conclusion: Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single-shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double-blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. Methods: Fifty children ages 1–6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US-guided ilioinguinal nerve block with 0.1 ml·kg−1 of preservative-free normal saline and Group B that received an US-guided nerve block with 0.1 ml·kg−1 of 0.25% bupivacaine with 1 : 200 000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml·kg−1 of 0.125% bupivacaine with 1 : 200 000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. Results: Forty-eight patients, consisting of 46 males and two females, with a mean age of 3.98 (sd ± 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (sd ± 1.59) and 1.18 (sd ± 1.31), respectively. The average pain score difference was 0.72 (sd ± 0.58) and was statistically significant ( P < 0.05). In addition, when examined by procedure type, it was found that the difference in the average pain scores between the caudal and caudal/ilioinguinal block groups was statistically significant for the inguinal hernia repair patients ( P < 0.05) but not for the other groin surgery patients ( P = 0.13). For all groin surgery patients, six of the 23 patients in the caudal group and eight of the 25 patients in the caudal/ilioinguinal block group required pain rescue medications throughout their entire hospital stay or at home ( P = 0.76). Overall, the caudal group received an average of 0.54 (sd ± 1.14) pain rescue medication doses, while the caudal/ilioinguinal block group received an average of 0.77 (sd ± 1.70) pain rescue medication doses; this was, however, not statistically significant ( P = 0.58). Conclusions: The addition of an US-guided ilioinguinal nerve block to a single-shot caudal block decreases the severity of pain experienced by pediatric groin surgery patients. The decrease in pain scores were particularly pronounced in inguinal hernia repair patients. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to compare two confirmatory tests - the ‘swoosh’ test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block. Methods/Materials: This was a retrospective observational study of caudal injections administered to 83 pediatric patients (0–11 years) presenting for elective surgery over a 4 month time period. While injecting small aliquots of local anesthetic, a standard stethoscope was placed over the lower lumbar spine to auscultate for the ‘swoosh’ test. An ultrasound machine (Sonosite Titan, Sonosite Inc., Bothell, WA, USA) was then utilized for real-time visualization of caudal injectate. Each test performed during the caudal injection (swoosh, turbulence on 2D imaging, or color flow on Doppler imaging) was recorded as positive, negative or equivocal. Results: Eighty out of 83 patients (96.4%) had a successful caudal block based on minimal or no perioperative narcotic use, minimal or no response to surgical stimulation, the presence of motor blockade and patient comfort in the PACU. Ultrasound was significantly superior to ‘swoosh’ for sensitivity (96.3% vs 57.5%), negative predictive (40% vs 5.6 value) % and likelihood ratio (2.89 vs 1.73). Specificity and positive predictive value were not different between ‘swoosh’ and ultrasound. Of the ultrasound tests, turbulence was more sensitive than color flow Doppler (95.0% vs 78.8%). Conclusion: Ultrasonography is superior to the ‘swoosh’ test as an objective confirmatory technique during caudal block placement in children. We found the presence or absence of turbulence during injection within the caudal space to be the best single indicator of caudal success. We think ultrasonography should be used, if available, when teaching this technique. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to investigate whether a supplemental dose of rectal paracetamol at the third or fourth hour would enhance the quality of analgesia provided by caudal epidural blockade in children. Methods: Two hundred and two ASA I patients aged 1–12 years undergoing inguinal surgery were randomized into three groups in the postanesthesia care unit by drawing lots. Patients in the control group did not receive any analgesic until they had a pain score of 5 or higher, patients in the group P3 received rectal paracetamol (20–25 mg·kg−1) at the third hour, and patients in the group P4 received the same dose of rectal paracetamol at the fourth hour after caudal epidural injection. Pain was assessed by VAS (Visual Analog Scale) and supplementary rescue analgesic need was recorded. Results: There was no difference between the demographic data or the duration and variety of surgery among the groups. A significantly lower number of patients required rescue analgesia at the sixth postoperative hour in group P3 and also lower pain scores were again obtained in group P3 at the sixth and eighth postoperative hours. Conclusions: Supplemental rectal paracetamol at the third hour of caudal blockade enhances the quality of postoperative analgesia better than its addition at the fourth hour in children undergoing inguinal surgery. [ABSTRACT FROM AUTHOR]

Background : The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile. Methods : One hundred and thirteen healthy children aged <10 years, scheduled for general or urological surgical procedures were randomly allocated to receive either propofol or sevoflurane induction and maintenance. Children received caudal or lumbar epidural block depending on their weight and expected surgery. Time to onset of surgical anesthesia, intraoperative analgesic effectiveness, residual motor blockade, postoperative pain, and adverse effects were evaluated. To assess the influence of age on these measures children were further divided into three age groups: 0–24, 25–60 and >60 months. Results : The mean time to onset of surgical anesthesia was significantly shorter in the sevoflurane group than the propofol group (3.1 vs 4.7 min, P < 0.01), independent of the type of regional technique employed. Distress on arousal in recovery was increased in children receiving sevoflurane ( P = 0.03). There was no significant difference in residual motor blockade between the groups but children between 0 and 24 months receiving sevoflurane had a higher incidence of residual motor blockade 3 h after local anesthetic injection ( P = 0.01). Conclusions : This study has demonstrated that general anesthesia with sevoflurane decreases the time to onset of surgical anesthesia relative to propofol anesthesia. This effect was most marked when sevoflurane anesthesia preceded caudal epidural blockade. The basis for this effect is most likely to be related to differential binding of the two anesthetic agents to receptors in the spinal cord that mediate immobility in response to surgical stimuli. [ABSTRACT FROM AUTHOR]

Background: Peripheral deafferentation induced by epidural or spinal anesthesia reduces the degree of cortical arousal in adults. This study aimed at determining if caudal blockade decreases the level of arousal, as measured by Bispectral Index (BIS) in unstimulated children, and to determine if this effect differed between age groups. Methods: Hospital ethics committee approval and parental consent was obtained. Children (age between 24 months and 5 years) and infants (between 6 and 24 months of age) were recruited if they were scheduled for below umbilical surgery that would usually require caudal local anesthesia blockade. Before the procedure, subjects within each age group were randomized to either caudal group (1 ml·kg−1 0.25% bupivacaine), or control group (no caudal). In all groups, anesthesia was induced with sevoflurane and maintained at a constant endtidal concentration of 1.5% sevoflurane without N2O. Five minutes after induction a baseline BIS was recorded (BIS1). In the caudal groups, a caudal block was then performed while in the control groups no block was performed. Fifteen minutes later, the BIS was again recorded (BIS2). The change in BIS over this time period was the primary outcome (BISΔ). After measurement, subjects in the control groups received a caudal block before the start of surgery. Results: Twenty-nine infants and 18 children completed the study protocol. In children, BISΔ was significantly different between the caudal group and control (−5.7 vs −0.7, P = 0.04). In infants, no significant difference was detected in BISΔ between caudal and control groups. Conclusions: Caudal blockade decreased the degree of arousal, as measured by BIS, in unstimulated children aged 2–5 years. No change in arousal was detected in infants. [ABSTRACT FROM AUTHOR]

A 7-year-old girl having posterior spinal fusion for Grade 3 anterior spondylolisthesis at the L5/S1 level was administered 2.5 mg of morphine in 10 ml saline via the caudal epidural route before surgery. Motor-evoked responses were markedly diminished in her lower limbs for 1 h following this but returned spontaneously. She suffered no neurological injury. The cause for this is postulated to be transient cauda equina compression from the volume of injectate. This complication of caudal injection has not been reported before. The possible mechanisms for this are discussed. We believe that significant L5/S1 spondylolisthesis should be considered a contraindication to the use of caudal epidural injections. [ABSTRACT FROM AUTHOR]

Background : The aim of this study was to compare the effectiveness of caudal morphine and bupivacaine usage on surgical stress response in children undergoing abdominal and genitourinary surgery while keeping anesthesia depth constant utilizing the bispectral index analysis (BIS). Methods : Following the approval of Institutional Review Board and informed parental consent, 28 children with ages ranging between 4 and 16 years with ASA physical status I and II , undergoing elective lower abdominal and genitourinary surgery were included in this study. Patients were randomized and separated into two subgroups. Before induction of anesthesia, patients were monitored for BIS. Epidural injection of 30 μg·kg−1 morphine in 1 ml·kg−1 saline for the first group (group M) and the same volume of (0.25%) bupivacaine for second group (group B) were administered via the sacral hiatus. We analyzed serum cortisol and glucose concentrations for evaluation of the stress response in the patients. Blood samples for cortisol and glucose were withdrawn at the beginning of induction (first samples), 40 min after surgical incision (second samples), and 40 min after end of the surgery (third samples). BIS scores of the patients were kept between 40 and 60 during the surgical procedure. Results : Group B had significantly lower levels of cortisol than group M in the second samples. There was a significant increase in serum glucose level in group M compared with group B during the intraoperative and postoperative periods. Conclusions : We conclude that, caudal administration of bupivacaine is more effective than morphine for attenuating intraoperative and postoperative stress response to surgery in children. [ABSTRACT FROM AUTHOR]

Background : Caudal analgesia is widely used in pediatric anesthesia practice. The ‘whoosh’ test which uses air to identify the epidural space, has been recommended as a guide for successful needle placement. However, the use of air may be associated with an incidence of neurological complications. The ‘swoosh’ test avoids the injection of air and was originally performed using injection of a local anesthetic solution. A comparison was made between the ‘whoosh’ test and a modified ‘swoosh’ test using saline to identify the caudal epidural space in children. Methods : We studied 60 children of either sex in the age group of 2–8 years undergoing inguinal herniotomy. During insertion of the caudal block, a stethoscope was placed over the lower lumbar spine to note the presence or absence of ‘whoosh’ or ‘swoosh’, by an independent observer who was blinded to the injection of 1 ml of air or saline which was given simultaneously by the operator into the caudal space. The operator's clinical impression of successful insertion of the needle was also recorded and correlated with the presence or absence of ‘whoosh’ or ‘swoosh’. In addition, the need for supplemental intraoperative analgesia was noted. Results : Overall success rate of caudal block using the ‘whoosh’ and modified ‘swoosh’ tests was found to be 96.6% and 93.3%, respectively as judged by the lack of supplementary perioperative analgesia. The sensitivity, specificity and positive predictive value of the ‘whoosh’ test and clinical predictors of caudal placement was found to be 100% whereas the modified ‘swoosh’ test had a sensitivity of 93%, specificity of 50% and a positive predictive value of 96%. However, statistically there was no significant difference between the clinical predictors, ‘whoosh’ and the modified ‘swoosh’ test for identification of the caudal epidural space. Conclusions : The modified ‘swoosh’ test is as reliable as the ‘whoosh’ test and we recommend it for identification of the caudal epidural space in children as it avoids injection of air into the caudal space. [ABSTRACT FROM AUTHOR]

Background : Correct caudal cannula placement is essential for block success and the avoidance of complications. The aim of this study was to assess the use of a saline injection test bolus with ultrasound (US) imaging to identify correct cannula placement for caudal anesthesia. Methods : A prospective observational study of 60 children undergoing caudal anesthesia. A Sonosite 180 Plus (Sonosite Inc., Bothwell, WA) was used to image the spine and look for caudal space expansion secondary to saline injection. Results : Saline test bolus correctly identified position in 96.5% of all subjects, and was 100% successful in children under 2 years of age. Conclusions : These preliminary results suggest saline test bolus under US imaging is a reliable indicator of correct cannula position for caudal block. We found it safe, quick to perform, and provided additional useful information. [ABSTRACT FROM AUTHOR]

: Previous published data comparing ropivacaine 0.2% with levobupivacaine 0.25% have suggested that ropivacaine might be associated with less early postoperative motor blockade compared with levobupivacaine. The aim of the present study was to further investigate this issue comparing equal concentrations (0.2%) of ropivacaine and levobupivacaine in children undergoing minor subumbilical surgery.: Following induction of a standardized anesthetic, patients (1–7 years) were randomized in a double-blind manner to receive a caudal block with either ropivacaine 0.2% (group R,n = 30) or levobupivacaine 0.2% (group L,n = 30), total volume 1 ml·kg−1. Motor blockade (modified Bromage scale; primary end-point) and analgesia [Children and Infants Postoperative Pain Scale (CHIPPS) score] were assessed at predetermined time points during the first 24-postoperative hours.: Motor blockade was only registered during the first postoperative hour with no significant differences between the groups (group Rn = 5, group Ln = 8). Postoperative CHIPPS scores were almost identical in both groups with only seven and six patients requiring supplemental analgesia (CHIPPS score≥4) in the R and L groups, respectively.: A 0.2% concentrations of ropivacaine or levobupivacaine are clinically very similar with regard to postoperative analgesia and unwanted postoperative motor blockade in children undergoing minor subumbilical surgery. [ABSTRACT FROM AUTHOR]

The positioning of caudally inserted epidural catheters is crucial to their effectiveness. However, level assessment can be difficult and time consuming. We report the use of ultrasound to assess the catheter position in three patients aged between 1 and 10 months. The advantages and disadvantages of this technique are discussed in relation to other methods of assessing caudal catheter placement. [ABSTRACT FROM AUTHOR]

: In order to decrease the rate of adverse effects, we aimed to identify the lowest analgesic dose of epidural morphine administered to patients undergoing hip surgery.: Forty-five ASA I-II children undergoing surgical correction of hip dysplasia under caudal or epidural anesthesia with bupivacaine were randomized to receive epidural morphine 11.2, 15 or 20 μg·kg−1 (groups 1, 2 and 3, respectively; 15 patients per group) immediately after completion of surgery. Postoperative pain control, sedation, motor block, urinary retention, pruritus and vomiting were evaluated.: In the recovery room, 46.7% of patients from group 1, 33.3% from group 2, and 93.3% from group 3 were sleeping but were easy to arouse (x2 = 12.2;P < 0.005). The rest of the patients from each respective group were completely asleep. The cardiovascular and respiratory parameters were within normal limits. The ability to move the legs returned approximately 1 h after surgery in all three groups. Seven patients (46.7%) from group 1, nine (60%) from group 2, and 13 patients (86.7%) from group 3 vomited (x2 = 5.4;P = 0.06). One patient receiving 20 μg·kg−1 morphine experienced urinary retention. One patient receiving 15 μg·kg−1 morphine suffered from pruritus. The duration of analgesia was similar, 12–14 h, in all three groups.: In patients undergoing hip surgery under regional anesthesia with bupivacaine, epidural morphine at a dose of 11.2 μg·kg−1 administered immediately after completion of the procedure resulted in adequate pain relief for more than 12 h. Explanation of the high rate of patients vomiting (>45%) remains to be elucidated. [ABSTRACT FROM AUTHOR]

: In this study we compared caudal with intravenous (i.v.) tramadol given pre- or postoperatively for pain relief in boys having hypospadias repair. : The study was approved by the Ethics Committee and informed written consent was obtained from the parents of each patient. Patients ( n = 134), aged 1–3 years, American Society of Anesthesiologists (ASA) physical status I, scheduled for hypospadias surgery were recruited. The patients were randomly allocated to one of the four groups: group I ( n = 33), received 2 mg·kg−1 (0.5 ml·kg−1) of caudal tramadol after the surgical procedure was completed, group II ( n = 33) received 2 mg·kg−1 (0.5 ml·kg−1) of caudal tramadol before incision, group III ( n = 34) received 2 mg·kg−1 tramadol intravenously, after surgery and group IV ( n = 34) received 2 mg·kg−1 tramadol intravenously, after anaesthesia induction. When the patients were fully awake in the recovery area, heart rate, arterial pressure, peripheral oxygen saturation, respiratory rate, pain and sedation scores were recorded at 5, 10, 15, 30, 60 min, and 2, 3, 4, 6, 12 and 24 h postoperatively and side-effects were noted. Pain was assessed using an objective pain score (OPS). : The OPS were lower in caudal tramadol groups than in i.v. tramadol groups only at 3 h ( P < 0.05). The duration of postoperative analgesia was longer in the caudal groups than in the i.v. groups ( P = 0.001). However, the duration of postoperative analgesia was unaffected by the timing of administration. : Caudal tramadol provides better and longer lasting postoperative analgesia than i.v. tramadol. These results also suggest that preoperative caudal tramadol did not provide any clinically perceptible benefits compared with postoperative caudal tramadol. [ABSTRACT FROM AUTHOR]

We describe a case of unrecognized rectal puncture following unsuccessful caudal blockade in a patient later found to have marked rectal distension on MRI. This may have contributed to the rectal injury. [ABSTRACT FROM AUTHOR]

We report a 2-year-old patient with Opitz- GBBB syndrome scheduled for a posterior sagittal anorectoplasty ( PSARP). The ultrasound scan revealed the inferior end of dural sac just below sacrococcygeal membrane, although the patient had previously two successful caudal epidural blocks. Consequently, the epidural catheter was inserted under a real-time ultrasound guidance without dural puncture. Our patient had excellent pain relief without any side effects. [ABSTRACT FROM AUTHOR]

We report three sequential cases in which children received 100 times the intended dose of clonidine in their single shot caudals. Although all experienced excessive somnolence for up to 24 h, none had respiratory depression, oxygen desaturation, supplemental oxygen requirement, or hemodynamic instability. These cases suggest a large margin of safety exists for caudally administered clonidine in healthy children. [ABSTRACT FROM AUTHOR]