Survey of paediatric epidural practice in the UK

Abstract

Introduction In infants and young children epidural catheterisation is technically more difficult than in older children and adults (1). Various solutions have been offered to make this difficult task easier (2–4). One of the suggested remedies is using the paramedian approach to the epidural space (5,6). The paramedian approach not only makes the procedure technically less difficult, but because of the angle of needle entry, the chance of dural puncture is low (7,8). The aims of this questionnaire were to investigate whether paediatric anaesthetists experienced any catheter related difficulties with epidural anaesthesia, what manoeuvres were used to overcome these difficulties and if a paramedian approach was used to place paediatric epidurals. Methods A postal questionnaire was sent to members of the Association of Paediatric Anaesthetists resident in the UK. There were five questions asked with an option of 2–4 replies. The questions pertained to frequency of use of epidural catheters in infants and young children, preferred approach, difficulties encountered, methods to overcome problems and use of paramedian approach. Results 203 questionnaires were sent between November 2000 and December 2000 and 145 replies were received making an overall response rate of 71.45%. From our survey we note that 66 out of 145(45.5%) paediatric anaesthetists regularly use epidural catheters in infants and children less than 15 kg, while 42(28.9%) are occasional users and 9(6.2%) use them infrequently. Thirty out of 145(20.66%) never use this technique in this age group at all. Therefore 115 respondents use the technique. As regards the preferred approach; 107 out of 115(77%) paediatric anaesthetists use the midline approach while only 5 members(4.34%) prefer the paramedian approach and a small percentage(2.6%) use other approaches i.e. caudal catheters. Some members (8/145) in the survey suggested that the reason for infrequent use of the paramedian approach was lack of training. 49/115(42.6%) paediatric anaesthetists occasionally encountered problems with catheter insertion and 69/115(60%) rarely had any problems. Therefore it was felt that, since there were no problems with the midline approach, a change was not warranted. In case of a problem with epidurals only 8 members(6.95%) would consider using the paramedian approach. Nearly 50% (57/115) of epidural users felt that they did not know/could not comment on the paramedian approach, as they never used the technique. Suggested methods to overcome problems with threading the catheter include: using 18 g Tuohy needle with 21 g catheter rather than 23 g catheters; inserting the needle in midline in a slightly cephalad direction in order to ‘open the angle’ for subsequent catheter insertion; using the blue introducer for feeding the catheter; injecting saline/local anaesthetic to ‘dilate’ the epidural space before inserting the catheter, etc. Summary In summary, this survey of epidural practices in young children shows that technical problems with epidural catheter insertio...

Pediatric epidurals

“…The lateral decubitus position with midline approach is commonly chosen though some advocate the paramedian approach. [ 7 ] In neonates, the intercristal line bisects L5 (unlike L3/4 interspace in adults) and the spinal cord ends at L3 (unlike L1 in adults). The epidural space is more superficial with a more subtle “give” as the ligamentum flavum is pierced.…”

“…[ 4 ] The pediatric epidural catheter also tends to kink or recoil and suggestions for facilitating catheter insertion include use of 21 G instead of 23 G catheters, increasing cephalad angulation of the epidural needle, flexing (or extending the spine), use of “blue” introducer, and injection of saline to open up the epidural space. [ 7 ]…”