Confirmation of success rate of landmark‐based caudal blockade in children using ultrasound: A prospective analysis

Abstract

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.

Morphological and morphometric features of sacral hiatus and its clinical significance in caudal epidural anaesthesia

“…The sacral hiatus can be located by palpating the sacral cornua, approximately at the level of the skin folds of the buttocks. After infiltrating with local anesthetic, the epidural needle is inserted in the caudal canal by using the loss of resistance technique and its position is ascertained by fluoroscopy or ultrasound [3,7]. After the correct placement of the needle is confirmed, a catheter is inserted to the desired depth.…”

Pediatric regional anesthesiology: a narrative review and update on outcome-based advances

“…Pediatric caudals can be performed through a single injection but are frequently utilized by means of a continuous catheter approach, which allows more cranial dermatomes to be covered and extends the duration of the epidural block. Indeed, caudal blocks provide excellent analgesia for a variety of lower extremity, pelvic, abdominal, and thoracic procedures and allow for improved ventilator tolerance and earlier extubation compared with peripheral or facial plane techniques 24,131–134 . Similar to epidural anesthesia in adults, caudal dermatomal coverage corresponds with the volume of LA used.…”

“…Recently, there has been increasing evidence for performing caudal blocks using ultrasound to improve accuracy and success rates. Pediatric anatomy lends itself well to this technique, and it can be used as a radiation-sparing technique to precisely identify catheter tip location if it is threaded cranially 131,132,134,135 . Finally, ultrasound of the sacral and low lumbar spaces can identify underlying anatomic abnormalities such as spina bifida or tethered cord.…”

“…There is an emerging body of evidence supporting the use of ultrasound for placement as it helps to identify bony landmarks, level, and target depth. Furthermore, ultrasound use improves success rate and minimizes complications 131,132,136–141 . Catheter tip position can be confirmed using a variety of techniques, including ultrasound, fluoroscopy, stimulating catheters, or epidurograms.…”

Ultrasound determination of the dural sac to sacrococcygeal membrane distance in premature neonates

“…Ultrasound has been used to identify low lying dural sacs 6 7. Visualization of the neonatal sacral anatomy improves caudal success rates but no systematic studies have determined the feasibility of locating the dural sac using real-time imaging 8 9. The primary goal of this study was to determine the feasibility of measuring the distance from the sacrococcygeal membrane at the cephalad most edge of the sacral hiatus to the caudal edge of the dural sac in a preterm neonatal population using ultrasound-imaging.…”