Search

BACKGROUND Caudal epidural injections are easy, effective, and safe methods and are good options for patients with low back pain and radicular lower extremity pain. Although various complications related to the technique of the procedure or the drugs used in the procedure have been described, Posterior Reversible Encephalopathy Syndrome (PRES) has not yet been defined for this intervention. CASE In this case report, we describe a case of PRES, which we supported with MRI findings in our patient who developed convulsions, changes in consciousness, and vision loss after being administered with caudal epidural steroid, and whose imaging findings regressed with the regression of clinical symptoms during the treatment process. CONCLUSION Although PRES is rarely reported, it should be kept in mind that it is a complication that can develop after caudal epidural steroid injection.

AimTo investigate total serum levobupivacaine concentrations after a caudal‐epidural loading dose followed by a maintenance infusion in infants aged 3‐6 months over 48 hours.BackgroundThe local anaesthetic, levobupivacaine, is the safer enantiomer of racemic bupivacaine. Present protocols for levobupivacaine are based on studies and pharmacokinetic modelling with racemic bupivacaine. This study will inform clinical practice in this age group and validate the pharmacokinetic model for levobupivacaine infusions in infants, aged 3‐6months.MethodsThe clinical trial was conducted in 8 infants aged 3‐6 months, undergoing bladder exstrophy repair. Pharmacokinetic modelling allowed optimisation of clinical sampling to measure total levobupivacaine and α1‐acid glycoprotein and prediction of the effect of α1‐acid glycoprotein on levobupivacaine plasma protein binding.ResultsThe observed median total levobupivacaine serum concentration was 0.30 mg.L−1 (range: 0.20‐0.70 mg.L−1) at 1 hour after the loading dose of 2 mg.kg−1. The median total levobupivacaine concentration after 47 hours of infusion, at 0.2 mg.h−1.kg−1, was 1.21 mg.L−1 (0.07‐1.85 mg.L−1). Concentrations of α1‐acid glycoprotein were found to rise throughout the study period. Pharmacokinetic modelling suggested that unbound levobupivacaine quickly reached steady state at a concentration of approximately 0.03 mg.L−1.ConclusionThis study examines the pharmacokinetics of levobupivacaine after a loading dose (given over 5 minutes) followed by a maintenance infusion in infants 3‐6 months. The study allows the development of a pharmacokinetic model, combining levobupivacaine and α1‐acid glycoprotein data. Modelling indicates that unbound levobupivacaine quickly reaches steady state once the infusion is started. Simulations suggest that it may be possible to continue the infusion beyond 48 hours.

A 9‐year‐old show pony mare became acutely lame following removal of a bone sequestrum of the distal phalanx of the right thoracic limb. The mare also suffered from ongoing right dorsal colitis secondary to previous long‐term nonsteroidal anti‐inflammatory drug (NSAID) use. To avoid further NSAID use, a protocol for caudal epidural administration of morphine and detomidine in an increased volume was used to provide analgesia to the thoracic limbs. A total volume of 50 mL (0.2 mL/kg bwt) was administered over approximately 90 s. Immediately following the injection, the pony collapsed into lateral recumbency and experienced an apparent generalised seizure characterised by loss of consciousness and frantic paddling of all four limbs. The pony recovered rapidly without intervention, and no residual neurological deficits were noted. The epidural analgesia resulted in a marked improvement in comfort levels. The speed of injection is thought to have caused a change in epidural and intracranial pressures resulting in a generalised seizure and highlights the importance of administering large volumes slowly.

SummaryBackground Caudo-lumbar and caudo-thoracic epidural anesthesia is an established technique that carries a low risk of dural puncture or spinal cord trauma in infants. Traditionally catheter advancement is based on external measurements. However, malpositioning of catheters are known to occur. We hypothesized that caudal-epidural catheters inserted under real-time ultrasound guidance may be more accurate than the accuracy of the measurements traditionally used for their placement. Methods We studied 25 patients, aged 2 days to 5 months, posted for abdominal or thoracic surgery, receiving general anesthesia followed by caudo-epidural continuous block. External measurement defined as the distance from the caudal space and the surgically congruent vertebral level was measured in centimeters with the back gently flexed. Subsequently, a caudo-epidural block was performed in the same position. The epidural catheter insertion was followed under real-time ultrasound guidance till the predetermined vertebral level was reached. The actual length placed under real-time ultrasound scan was defined as the actual length. The high-frequency probe was placed longitudinal and paramedian to the spine. The vertebral level was determined by identifying the lumbosacral junction in longitudinal saggital view and counting the vertebrae up from L5. The catheter length at the skin was compared with the length recorded by external measurement. Results The actual length placed under real-time ultrasound scan were consistently longer than the external distance between the caudal space and selected vertebral level. The mean values of ultrasound were higher than the mean values of external measurement with a difference of 4.28 cm. Accuracy was not affected by age or affected by the selected vertebral level in the age group we studied. Conclusion We conclude that catheters placed under ultrasound guidance are more accurate than the traditional method developed before the advent of ultrasound in young infants.

Caudal epidural catheters provide exceptional analgesia while avoiding or minimizing opioids. Historically, the catheter tip location (dermatomal level) was estimated or verified via epidurogram. According to the Pediatric Regional Anesthesia Database, the majority of caudal-to-thoracic epidural catheters are placed without imaging guidance or verification of the position of the catheter tip. Ponde et al demonstrated that catheter insertion depth was longer when using ultrasound guidance than when estimated by external measurement. We report a simple yet novel ultrasound approach for catheter localization.

OBJECTIVES The aim of this study was to clarify differences in the anatomic structure of the sacral hiatus and angle of needle insertion during caudal epidural steroid injection using ultrasound guidance in patients according to sex and age. METHODS A total of 237 patients with low back pain with or without sciatica were included. Sonograms of the sacral hiatus were obtained, and caudal epidural steroid injection using ultrasound guidance was performed in all patients. The intercornual distance, diameter of the sacral canal, thickness of the sacrococcygeal ligament, optimal angle for needle insertion, and actual angle of needle insertion were measured. RESULTS Between men and women, significant differences were observed for the intercornual distance (17.7 versus 16.5 mm; P< .01) and thickness of the sacrococcygeal ligament (4.3 versus 3.9 mm; P = .02). In all patients, the thickness of the sacrococcygeal ligament (r= 0.28) and diameter of the sacral canal (r= 0.40) were positively correlated with the optimal angle for needle insertion (P < .01). In women, the thickness of the sacrococcygeal ligament (r = -0.24), diameter of the sacral canal (r = -0.27), optimal angle for needle insertion (r = -0.29), and actual angle of needle insertion (r = -0.18) were negatively correlated with age. In men, only the diameter of the sacral canal was negatively correlated with age (r = -0.30). CONCLUSIONS We found that the sacral hiatus has anatomic differences between patients of different sexes and ages. Understanding these differences, especially in women, may improve the safety and reliability of caudal epidural steroid injection.

Summary The anatomy of the sacral hiatus and caudal canal is prone to significant variation, yet studies assessing this in the pediatric population remain limited. Awareness of the possible anatomical variations is critical to the safety and success of caudal epidural blocks, particularly when image guidance is not employed. This systematic review analyzes the available evidence on the clinical anatomy of the caudal canal in pediatric patients, emphasizing surface anatomy and internal anatomical variations. A literature search using three electronic databases and standard pediatric and anatomy reference texts was conducted yielding 24 primary and seven secondary English-language sources. Appreciating that our current landmark-guided approaches to the caudal canal are not well studied in the pediatric population is important for both clinicians and researchers.

Summary A caudal epidural injection was performed on a middle-aged woman for pain in her right foot. Although the procedure was uncomplicated and a good epidurogram was obtained, the patient went on to develop an orthostatic headache with generalised weakness and syncopal episodes that were treated successfully by epidural blood patching. We describe the aetiology, presentation and treatment of spontaneous intracranial hypotension and review the similarities with our patient’s clinical presentation. We hypothesise as to how our intervention may have resulted in a dural tear.

Caudal epidural anesthesia is commonly utilized in veterinary medicine to allow diagnostic, obstetrical, and surgical intervention, in the perineal region of large animal. The aim of this study is to directly compare the time of onset and duration of analgesia produced by a tramadol and lidocaine-tramadol combination with that produced by lidocaine administration in the epidural space of Cattle. Five healthy adult Holstein dairy cows were selected to this study. Epidural anesthesia was produced in all cows by lidocaine, with 2 weeks intervals repeated by a combination of lidocaine-tramadol and tramadol. Time to onset and duration of analgesia were recorded. Heart rate, respiratory rate and body temperature were recorded at 0 min and at 5, 10, 15, 30, 60, and 75 min after the epidural administrations of each treatments. The tramadol produced a significant (P < 0.05) longer duration of analgesia (306.8 ± 8.58 min) than lidocaine (69.40 ± 8.96 min) alone and lidocaine-tramadol combination (174 ± 4.84 min). Also, lidocaine-tramadol combination produced a significant (P < 0.05) longer duration of analgesia than lidocaine alone. Complete analgesia began at 14.10 ± 1.57 min in the tramadol treatment, being more delayed than in the treatments with lidocaine-tramadol (4.84 ± 0.68 min) and lidocaine (3.90 ± 0.89 min). Body temperatures, heart rates, and respiratory rates were not significantly different in comparison with baseline values throughout the study in the all treatments. The combination of lidocaine-tramadol produced anesthesia of longer duration than lidocaine and the onset time was approximately same as for the lidocaine group. Utilizing this combination, long duration of anesthesia could commence relatively soon after epidural injection and might be used without re-administration of anesthetic agent in long-duration obstetrical and surgical procedures.

The purpose of this study was to evaluate the pharmacokinetics of lidocaine in mature Holstein cows following an inverted L and caudal epidural nerve block. Plasma and milk concentrations were determined using high-performance liquid chromatography assay. Pharmacokinetic parameters were estimated using a noncompartmental method. Following administration via inverted L nerve block, serum T(max) was 0.521 +/- 0.226 h and serum C(max) was 572 +/- 207 ng/mL. Serum AUC was 1348 +/- 335 ng.h/mL. Apparent serum t((1/2)beta) was 4.19 +/- 1.69 h and MRT was 5.13 +/- 2.33 h with clearance uncorrected for the extent of absorption of 2.75 +/- 0.68 L/kg/h. The last measurable time of lidocaine detection in serum was 8.5 +/- 1.4 h with a mean concentration of 51 +/- 30 ng/mL. Milk T(max) was detected at 1.75 +/- 0.46 h with C(max) of 300 +/- 139 ng/mL. Milk AUC till the last time was 1869 +/- 450 ng.h/mL with the mean AUC milk to AUC serum ratio of 1.439 +/- 0.374. The last measurable time of lidocaine detection in milk was 32.5 +/- 16.2 h with a mean concentration of 46 +/- 30 ng/mL. There was no detectable lidocaine concentration in any samples following caudal epidural administration.

Summary Background: This study was designed to investigate whether a fall in heart rate (HR) with injection of local anesthetic into the caudal space can be used as a predictor of correct needle placement. Methods: Two hundred and twenty pediatric patients undergoing infraumbilical surgery were recruited to the study. After induction of general anesthesia, baseline HR was recorded and caudal block was performed using 0.75–1 ml·kg−1 0.25% bupivacaine, which was injected at a rate of 1 ml·3 s−1. The change in HR while injecting an initial 0.2 ml·kg−1 of drug and during total drug injection was recorded. HR reduction of ≥3 b·min−1 was considered a positive test for correct needle placement. The success of block was judged by HR response to skin incision, endtidal halothane concentration required for maintenance of anesthesia and postoperative pain scores. Results: Caudal block was successful in 209/220 (95%) patients. Mean HR following the initial drug injection (111 ± 17.7, P

Six male buffalo calves aged from six to eight months and weighing 100 to 120 kg were used to evaluate the efficacy and safety of caudal epidural analgesia produced by doses of 37.5 mg (5 ml) and 75 mg (10 ml) ropivacaine (0.75 per cent). The study was completed in two phases. In phase 1, all the animals were used twice to evaluate the analgesic and clinical effects of two doses of ropivacaine. In phase 2, the animals were divided into two groups of three to evaluate the effects of two doses of ropivacaine on some haemodynamic and acid-base parameters. Signs of analgesia, as evidenced by a loss of response to pinprick stimulation, were recorded only at the tail, perineum and hindlimbs of the animals given 5 ml ropivacaine, but they extended from the tail to the thorax (T9) in the animals given 10 ml ropivacaine. The duration of analgesia was five to six hours in the animals given 5 ml ropivacaine and seven to eight hours in the animals given 10 ml ropivacaine. Animals of both groups became recumbent, but the score for ataxia was higher in the animals given 10 ml ropivacaine. The respiratory rate decreased significantly (P0.05) below the baseline in the animals given 10 ml ropivacaine, but the rectal temperature, heart rate, mean arterial pressure, central venous pressure and acid-base and electrolyte parameters did not change significantly in either group.

Summary 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.

Bupivacaine is available as a racemic mixture of its enantiomers, d-bupivacaine and l-bupivacaine (LB). The aim of this randomized, double-blind study was to investigate the clinical efficacy and safety of S(-)-bupivacaine compared with standard racemic bupivacaine (RB) in horses under caudal epidural analgesia. Two treatments were administered to each horse, with a 2-week interval between subsequent treatments. Treatment 1 consisted of 0.5% LB at a dose of 0.06 mg/kg of body weight, and treatment 2 consisted of 0.5% RB at a dose of 0.06 mg/kg of body weight. Epidural injections were given in all animals between the first and second coccygeal vertebra. Heart rate (HR), arterial pressures, respiratory rate (RR), rectal temperature (RT), analgesia, and motor blocking were determined before drug administration (basal) and 5, 10, 15 and 30 min after drug administration, and at 30 min intervals thereafter. There were no significant differences between the two treatments in the quality of sensory and motor block. The duration of analgesia was 320 +/- 30 min (mean +/- SD) for RB and 360 +/- 42 min for LB. HRs and RRs, arterial pressures and RT did not change (P < 0.05) significantly from basal values after epidural administration of LB or RB. This study supports that 0.5% LB is an effective alternative to RB in caudal epidural analgesia in conscious, standing horses. The use of LB vs. RB warrants further investigation, particularly for long-lasting surgery in the perineal region.

We report a case of bupivacaine-induced cardiotoxicity in a neonate following caudal epidural block under general anesthesia for urologic surgery. Prompt recognition of the complication allowed early intervention with both standard resuscitative measures and administration of 20% Intralipid(®) , resulting in a good outcome.

The working conditions in the developing world necessitate the development of many adaptations and improvizations of accepted anaesthetic techniques to improve patient care. Subcutaneous tunnelling of caudally placed epidural catheters is one such improvization to prevent the soiling of the catheter by urine and faeces. This study compares the duration of retention of catheter in a group with tunnelled catheters with an untunnelled group. The absence of a catheter emerging through skin at the site of catheter insertion hastens healing thus prolonging the retention of catheter in the tunnelled group and soiling ceases to be a major problem.

Aim: We performed a small study to examine the efficacy of caudal epidural analgesia in our patients with lumbosacral radicular pain, to assess the patient's tolerance of the procedure and to assess the willingness of patients to have the procedure repeated in future if offered. Method: Patients with low back pain/sciatica being examined by rheumatology consultants were selected for caudal epidural injection. The procedure was done in the rheumatology ward as a day procedure. Bupivacaine 0.25% (15–25 mL) and triamcinolone (40 mg) were used. Results: The majority of patients found improvement in pain. We did not come across any major side effects. A majority of patients were willing to have further injections. Conclusion: Caudal epidural analgesia for sciatica and low back pain is a relatively safe and straightforward procedure.

Summary The effectiveness of post-operative analgesia and the frequency of side effects of caudal epidural sufentanil with bupivacaine plus adrenaline was compared with bupivacaine plus adrenaline alone and morphine with bupivacaine plus adrenaline. One hundred and four children scheduled for subdiaphragmatic surgery were studied and divided in three groups. The results showed that epidural sufentanil with bupivacaine provided better analgesia than bupivacaine alone with fewer side effects compared with the group who received morphine and bupivacaine.

Summary Children with any of the mucopolysaccharidoses are at a high risk of developing significant morbidity and mortality when a general anaesthetic is administered. This case report describes the use of a caudal epidural technique for the repair of bilateral inguinal herniae in a 10-month-old infant with Hurler syndrome (mucopolysaccharidosis type I).

The venous blood concentrations of lidocaine, mepivacaine and bupivacaine were measured in children following the caudal epidural administration of these local anaesthetic solutions with adrenaline. The mean maximum concentrations of lidocaine and mepivacaine were 2.20 micrograms/ml and 2.53 micrograms/ml, respectively, which occurred at 45 min after injection of lidocaine or mepivacaine 11 mg/kg. By combined administration of 5.5 mg/kg equally of lidocaine and mepivacaine, the blood concentration of mepivacaine was significantly higher than that of lidocaine. The mean maximum concentration of bupivacaine was 0.67 micrograms/ml and occurred at 45 min after injection of bupivacaine 3.7 mg/kg. The blood concentration of bupivacaine was consistently significantly lower than that of lidocaine or mepivacaine. These results demonstrate that the blood concentrations of the three local anaesthetics following caudal administration are all below the toxic levels in spite of application of the maximum dosage recommended for adults.