Ultrasound versus anatomical landmarks for caudal epidural anesthesia in pediatric patients

Abstract

BackgroundCaudal block is easily performed because the landmarks are superficial. However, the sacral hiatus is small and shallow in pediatric patients. In the present study, we evaluated under general anesthesia whether the distance between the bilateral superolateral sacral crests increased with growth, whether an equilateral triangle was formed between the apex of the sacral hiatus and the bilateral superolateral sacral crests, and whether expansion of the epidural space could be confirmed by ultrasound.MethodsThis prospective observational study included 282 children who were ASA I–II. Under general anesthesia, each patient was placed in the lateral bent knees position, and the attending anesthesiologist drew an equilateral triangle and measured the distance between the bilateral superolateral sacral crests along a line forming the base of the triangle. Then the sacral hiatus was identified by ultrasound. Differences of the distance between the anatomical landmarks measured by the anesthetist and by ultrasound were evaluated.ResultsTwo patients were excluded because the superolateral sacral crests and sacral hiatus could not be palpated. The base of the triangle increased in proportion to age up to 10 years old, with a significant correlation between age and the length of the base (Spearman’s r value = 0.97). The triangle was not an equilateral triangle under 7 years old. The sacral hiatus could be identified by ultrasound and we could confirm expansion of the epidural space in all patients.ConclusionWe observed a correlation between age and the length of the triangle base in children under 10 years old. Although detection of the anatomical landmarks by palpation differed from identification by ultrasound in pediatric patients, performing ultrasound is important. Epinephrine should be added to the anesthetic to avoid complications.Trial registrationCurrent Controlled Trials UMIN000017898. Registered 14 June 2015. Date of protocol fixation was 1st December, 2008 and Anticipated trial start date was 5th January, 2009.

Anatomy and clinical significance of sacral variations: a systematic review

“…In addition, the available caudal epidural space volume must be estimated preoperatively, so that high block complications are avoided [6]. Ultrasound is a safe, non-invasive and simple method of examination of the exact sacral anatomy, identification of sacral variations and accurate estimation of the volume of epidural space [1]. The use of ultrasonography for the navigation of needle placement into the caudal epidural space increases success rates by 100% [20].…”

Intravertebral Anaesthesia For cesarean section

“…Caudal anesthesia as a supplementary mode of analgesia has been considered more appropriate for gynecological surgery, and many studies have shown that the application of ultrasound has increased the safety, ease, and consistency of a caudal block analgesia [9][10][11][12] . The blockade level is an important factor to determine adequate intraoperative analgesia during regional blocks in cesarean section 29 .In our study, we changed the epidural puncture point L 2-3 or L 3-4 to T 11 -T 12 for epidural anesthesia combined with caudal anesthesia, and 10 mL of 0.75% ropivacaine and 20 ml of 0.25% ropivacaine were administrated in epidural and sacral canal respectively.…”

“…A single point epidural block can't achieve such a wide range of nerve blocking. Caudal anesthesia as a supplementary mode of analgesia has been considered more appropriate for gynecological surgery, and many studies have shown that the application of ultrasound has increased the safety, ease, and consistency of a caudal block analgesia [9][10][11][12] . Thus we speculated that the epidural anaesthesia within T 11 -T 12 intervertebral space combined with caudal block anesthesia could achieve satisfactory anesthesia for cesarean section.…”

Current Neonatal Applications of Point-of-Care Ultrasound

“…In neonates, the incompletely ossified spinous processes, minimal fat aids in interrogation of the space by ultrasound compared to older kids and adults. The good resolution of image, lack of ionizing radiation and potential for real time guidance makes ultrasound a valuable tool for performing LP in neonates [48,56].…”