Thoracic Epidural Analgesia Via the Caudal Approach in Pediatric Patients Undergoing Fundoplication Using Nerve Stimulation Guidance

Abstract

Epidural catheter placement using electrical stimulation guidance is an alternative approach for positioning the catheter into the thoracic region via the caudal space. This easily performed clinical assessment provides optimization of catheter tip positioning for achieving effective pain control.

The threshold current in the intrathecal space to elicit motor response is lower and does not overlap that in the epidural space: a porcine model

“…[14][15][16] The use of ES to confirm the location of the epidural space (Tsui test) has only recently been described. [7][8][9][10][11][12] This test appears to reliably confirm caudal, lumbar and thoracic epidural catheter placement in pediatric, obstetric and postoperative patients. [7][8][9][10][11][12] None of the patients in these trials experienced any perioperative or postoperative discomfort or side-effects from ES.…”

“…[7][8][9][10][11][12] This test appears to reliably confirm caudal, lumbar and thoracic epidural catheter placement in pediatric, obstetric and postoperative patients. [7][8][9][10][11][12] None of the patients in these trials experienced any perioperative or postoperative discomfort or side-effects from ES. ES takes advantage of the distinct anatomic layers surrounding the spinal cord, each of which has its own conductive properties.…”

“…[7][8][9][10][11][12] These studies also hypothesized that when using ES, a motor response evoked by a low current (< 1 mA) could serve as a warning sign of a needle or catheter approaching a nerve root or entering the subarachnoid space. [7][8][9][10][11][12] Passannante et al reported a case of total spinal block and permanent neurological damage resulting from an accidental subarachnoid and intraneural local anesthetic injection at a low current (0.2 mA) when a nerve stimulatorguided interscalene brachial plexus block was performed during general anesthesia. 13 In previous case reports, using ES, we demonstrated that a motor response occurs with: a) subarachnoid catheter placement at 0.4 mA; 8 b) subdural catheter placement at 0.3 mA; 9 and c) catheter tip placement in close proximity to nerve roots at 0.5 mA.…”

Electrophysiological stimulation (Tsui test) is feasible for epidural catheter positioning in adults with chronic back pain: a cohort study

“…12 Their technique has also been used successfully to guide placement of thoracic epidural catheters via the caudal route in small infants and children. 28,30 In our study, the Tsui test elicited isolated sensory responses in only three patients (3/12), with no motor responses. Two of the patients required threshold currents of 10 mA to elicit a response.…”

From the Journal archives: Epidural anesthesia in young children: What have we learned in the past 60 years?

“…Subsequently, other workers have successfully employed a hybrid of the hanging drop and loss of resistance techniques, notably Masao Yamashita of Japan who describes the application of a microdrip infusion set to a Tuohy needle. 6 Other more recently described techniques for identifying the epidural space in children have included nerve stimulation guidance 7 and ultrasound. 8 Currently, it is safe to say that the loss of resistance technique using saline is the most widely accepted method of identifying the epidural space, at least in Canada.…”