Ultrasound‐guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study

Abstract

Summary Data on safety and success rates of ultrasound‐guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block‐related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal‐plus‐sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain‐related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain‐related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035–1.092, p < 0.001) as well as with mid‐abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69–29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38–9.5, p = 0.009) for respiratory problems. Ultrasound‐guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid‐abdominal surgical procedures are risk factors for pain‐related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.

Ad-hoc preoperative management and respiratory events in pediatric anesthesia during the first COVID-19 lockdown–an observational cohort study

“…Respiratory complications are the most frequent critical events in pediatric anesthesia [ 25 ] in all age groups, given a 3.1% incidence reported across 261 European hospitals (APRICOT; Anesthesia Practice In Children Observational Trial [ 19 ]). The same study found a 1.9% incidence of hemodynamic instability, mainly in the wake of respiratory instability, in 61% of these events [ 19 ].…”

“…It is, however, important to understand that we never modified our strategy of intraoperative and postoperative management in this situation. As stated above, an ever-growing proportion of anesthetic techniques conducted under mild sedation with a natural airway has been evolving at our center over many years [ 25 – 30 ] and certainly was not a result of special requirements associated with the pandemic, let alone an outcome of modifying our processes under its pressure. Such modifications, therefore, also cannot explain our secondary finding of significantly longer anesthesia durations during the lockdown in early 2020, which most likely was due to constraints in medical staff and a lack of highly experienced pediatric anesthetists during some of those days.…”

“…Yet the APRICOT cohort cannot be readily compared to the cases herein reported, given its 0.9% share of surgical procedures managed by regional anesthesia and sedation without airway instrumentation versus 48.5% in the present study. This large proportion is due to an ongoing strong focus we have been placing over the past two decades on developing and implementing specific techniques of regional anesthesia that allow spontaneous breathing of pediatric patients to be never interrupted [25][26][27][28][29][30].…”

“…It is, however, important to understand that we never modified our strategy of intraoperative and postoperative management in this situation. As stated above, an evergrowing proportion of anesthetic techniques conducted under mild sedation with a natural airway has been evolving at our center over many years [25][26][27][28][29][30] and certainly was not a result…”

Perioperative management of infant inguinal hernia surgery; a review of the recent literature

“…This provides anesthesia and analgesia for a significantly longer time than spinal block and has the additional benefit of providing post operative as well as intraoperative analgesia. The utilization of ultrasound guidance for caudal block placement has the advantage of further increasing its success rate 38 . Its regular use in pediatric anesthesia and therefore increased clinician experience, high success rate and excellent safety profile make this a popular choice for infant inguinal hernia surgery.…”