Determining the extent of the dural sac for the performance of caudal epidural blocks in newborns

Schoor, Albert-Neels Van; Bosman, Marius C.; Venter, Gerda; Bösenberg, Adrian

doi:10.1111/pan.13483

Cited by 6 publications

(5 citation statements)

References 24 publications

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“…Neither had we intent to overlook the advantages provided by US as to the drug spread visualization as a surrogate of the LA spread in the neuraxial conduit. However, we do not assert this in neonates where the distance between the dural sac and the sacral hiatus can be as short as 4.94 mm17 and in children with anatomic variations or malformation 18. Anecdotally, the anesthesiologist should select the variation of block which provides the highest grade of safety according to his individual opportunities…”

Section: Discussionmentioning

confidence: 86%

Comparison of Landmark-guided, Nerve Stimulation–guided, and Ultrasound-guided Techniques for Pediatric Caudal Epidural Anesthesia

Ponde

Singh

Nair

et al. 2021

The Clinical Journal of Pain

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Objectives: Traditionally, caudal epidurals are performed by a landmark-guided approach using the loss of resistance technique. Improvisations to increase the success rate can be attained by implementing modalities, namely neurostimulation and ultrasound, but there is a paucity of literature comparing these 3 approaches. Here, we compare the 3 techniques in terms of the success rate. Materials and Methods:The primary outcome of this study was to compare the success rate of the 3 techniques, and the secondary outcome was the blood or cerebrospinal fluid aspiration during the procedure. It was a prospective, randomized, open-label parallel-group study. Three hundred children aged 1 to 5 years scheduled for circumcision, hypospadias repair, and minor lower extremity surgeries were enrolled after taking written informed consent from the parents.Results: Demographic profiles were comparable in terms of age, weight, sex distribution, and types of surgeries. Success rates in landmark-guided, neurostimulation-guided, and ultrasound-guided were 97%, 97%, and 98%, respectively which was comparable (P = 0.879). There was no significant difference in the incidence of blood or cerebrospinal fluid aspiration.Discussion: We found a similar success rate of the caudal epidural block by using landmark-guided, nerve stimulation-guided, or ultrasound-guided techniques in children aged 1 to 5 years with normal anatomy.

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Section: Discussionmentioning

confidence: 86%

Comparison of Landmark-guided, Nerve Stimulation–guided, and Ultrasound-guided Techniques for Pediatric Caudal Epidural Anesthesia

Ponde

Singh

Nair

et al. 2021

The Clinical Journal of Pain

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“…A previous cadaver study also documented a large variability in distance from the sacrococcygeal membrane to the dural sac in neonates reporting a mean distance of 10.45 mm in 39 neonatal cadavers with a range of 4.9 to 26.3 mm but no reference or correlation to weights making comparison difficult 5. In their study, measurements were taken in supine, dissected cadavers while our measurements were taken with infants positioned lateral with hip and knee flexion which is clinically more relevant.…”

Section: Discussionmentioning

confidence: 99%

“…This is the result of a shorter distance from the sacrococcygeal membrane (sacral hiatus) to dura secondary to a more caudad dural sac (S4 compared with S2 in older children and adults). Large variability in the distance from the sacrococcygeal membrane to the most distal dural sac has been demonstrated in neonatal cadavers with a mean of 10.45 mm and a range from 4.9 to 26.3 mm 5…”

Section: Introductionmentioning

confidence: 99%

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

Ponde

Shah

Nagdev

et al. 2022

Reg Anesth Pain Med

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BackgroundCaudal epidural analgesia is the most common regional anesthetic performed in infants. Dural puncture, the most common serious complication, is inversely proportional to age. Measuring the distance from the sacrococcygeal membrane to the dural sac may prevent dural puncture. This study measures the sacrococcygeal membrane to dural sac distance using ultrasound imaging to determine feasibility of imaging and obtaining measurements.MethodsSacral ultrasound imaging of 40 preterm neonates was obtained in left lateral decubitus, a typical position for caudal blockade. No punctures were made. The sacrococcygeal membrane and termination of the dural sac were visualized, and the distance measured. The spinal levels of the conus medullaris and dural sac termination were recorded.Results20 males and 20 females former preterm neonates with an average weight (SD; range) of 1740 (290; 860–2350) g and average age (SD; range) of 35.0 (1.35; 32.2–39) weeks gestational age at the time of imaging. The average sacrococcygeal membrane to distal dural sac distance (SD; range) was 17.4 (3.1; 10.6–26.3) mm. Overall, the weights correlated positively with the distance but the coefficient of variation was large at 23%. The conus medularis terminated below the L3 level and dural sac below the S3 level in 20% and 10% of subjects respectively with hip flexion.ConclusionUltrasound can be used to measure the sacrococcygeal membrane to dura distance in preterm neonates prior to needle insertion when performing caudal block and demonstrates large variability. Ultrasound imaging may identify patients at risk for dural puncture. When ultrasound is not available, needle insertion less than 3 mm/kg beyond the puncture of the sacrococcygeal membrane should prevent dural contact in 99.9% of neonates.

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“…As an aside, this very low anatomy-related failure rate of 0.24% (95%CI 0.1–0.5%) (given 2547 cases overall) bears testimony to our experience that visualisation by ultrasound can effectively minimise the risk of misplacing punctures or of unexpectedly meeting with anatomical impediments. Ultrasound imaging is an increasingly used tool of advanced pediatric anesthesia and is extremely useful for caudal blocks in small children [ 9 , 13 ]. In the present series, all 2547 evaluable cases (100%) were successfully covered by ultrasound visualisation.…”

Section: Discussionmentioning

confidence: 99%

Sex differences in pediatric caudal epidural anesthesia under sedation without primary airway instrumentation

et al. 2023

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Study objective To identify sex differences associated with caudal epidurals, the most commonly used technique of pediatric regional anesthesia, based on individually validated data of ultrasound-guided blocks performed between 04/2014 and 12/2020. Methods Prospectively collected and individually validated data of a cohort of children aged between 0–15 years was analyzed in a retrospective observational study. We included pediatric surgeries involving a primary plan of caudal epidural anesthesia under sedation (without airway instrumentation) and a contingency plan of general anesthesia. Sex-specific rates were analyzed for overall failure of the primary anesthesia plan, for residual pain, for block-related technical complications and for critical respiratory events. We used Fisher´s exact tests and multivariable logistic regressions were used to evaluate sex-specific associations. Results Data from 487 girls and 2060 boys ≤15 years old (ASA status 1 to 4) were analyzed. The primary-anesthesia-plan failure rate was 5.5% (95%CI 3.8%-7.8%) (N = 27/487) among girls and 4.7% (95%CI 3.9%-5.7%) (N = 97/2060) among boys (p = 0.41). Residual pain was the main cause of failure, with rates of 4.5% (95%CI 2.9–6.6%) (N = 22/487) among girls and 3.0% (95%CI 2.3–3.8%) (N = 61/2060) among boys (p = 0.089). Block-related technical complications were seen at rates of 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls vs 2.5% (95%CI 0.5–2.7%) (N = 51/2060) among boys and, hence, significantly more often among male patients (p = 0.023). Male sex was significantly associated with higher odds (adjusted OR: 3.18; 95% CI: 1.12–9; p = 0.029) for such technical complications regardless of age, ASA status, gestational week at birth or puncture attempts. Critical respiratory events occurred at a 1.7% (95%CI 1.2%-2.3%) rate (N = 35/2060) twice as high among boys as 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls (p = 0.21). Conclusions While the the primary-anesthesia-plan failure rate was equal for girls and boys, technical complications and respiratory events are more likely to occur in boys.

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Determining the extent of the dural sac for the performance of caudal epidural blocks in newborns

Cited by 6 publications

References 24 publications

Comparison of Landmark-guided, Nerve Stimulation–guided, and Ultrasound-guided Techniques for Pediatric Caudal Epidural Anesthesia

Comparison of Landmark-guided, Nerve Stimulation–guided, and Ultrasound-guided Techniques for Pediatric Caudal Epidural Anesthesia

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

Sex differences in pediatric caudal epidural anesthesia under sedation without primary airway instrumentation

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