Pediatric Neuraxial Anesthesia from Caudals, to Thoracic Epidurals, to Awake Spinals. Disclosure
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1 Pediatric Neuraxial Anesthesia from Caudals, to Thoracic Epidurals, to Awake Spinals Martin Müller, MD Assistant Professor Division of Pediatric Anesthesia Iowa Symposium XIII May 4, 2013 Disclosure No financial ties, compensation from or obligation to manufacturers of biomedical products or drugs 1
2 Overview Caudal single shot Thoracic epidural catheter Awake spinal block Introduction Most common block in children Easy to learn 1 Minimal equipment Favorable risk/benefit ratio Surgical stress response 2 1 Schuepfer G; et al.: Reg Anesth Pain Med 2000; 25: Erol A; et al.: Pediatr Int. 2007;49:
3 Indications Augmentation for GA and post operative analgesia Pediatric surgeries involving lower body Ureteral reimplantation, orchiopexy 1, complex hypospadias repair, inguinal herniorrhaphy, clubfoot repair, etc. 1 Rice LJ; et al: Canadian Journal of Anesthesia 1990; 37: Contraindications Refusal, no parental consent S1 S2 Skin infection Sepsis Immunodeficiency Coagulopathy/thrombocytopenia Post operative testing of motor/sensory function Anatomical sacral dimple indicative of myelodysplasia Ultrasound to confirm anatomy 1 1 Schwartz D; et al: Pediatric Anesthesia 2011; 21:
4 Anatomy Anatomy: Pediatric Sacrum narrow, flat direct route to dural sac Conus L3 Dural S3 Incomplete ossification Thin ligamentum flavum Compliance & size of epidural space Intervertebral foramina LA escape 4
5 Physiology Relative CSF volume 1 CSF turnover Hemodynamic stability in children < 6 years with neuraxial block 2 Small venous capacitance of lower extremities Lack of resting sympathetic peripheral vascular tone 1 Cutler RWP; et al.: Brain 1968;91: Dohi S; et al.: Anesthesiology 1979; 50: Dohi S; et al.: Anesthesiology 1979; 50:
6 Technique Monitoring: standard ASA monitors (ECG) Patient position: lateral decubitus, hips and knees flexed Operator: standing or sitting posteriorly vs. anteriorly bending over Good lighting Technique: Landmarks Equilateral triangle posterior superior iliac spines and sacral hiatus Hiatus rostral of gluteal crease Effect of gravity on skin 6
7 Technique: Needle Short bevel 22G straight needle ( intravascular injection) Short Bevel Regular Bevel 22G Jelco IV catheter Soft tip: perforation Kinking Technique: Pop and Drop Palpation of hiatus Needle insertion 45 ⁰ Characteristic give through sacrococcygeal ligament Drop angle 7
8 Technique: Verification Needle hub open to air Aspiration (clear fluid, blood) Test dose Lidocaine with 1: epinephrine Controversial Sensitivity questioned in children 1 1 Fisher QA; et al.: Can J Anesth. 1997;44: Technique: Injection Slow, incremental 10 cc syringe (comparable resistance) Subcutaneous palpation ECG monitoring (ST segment, T wave) Normal LA toxicity 8
9 Caudal Video 9
10 Bupivacaine 0.175% ideal for outpatient surgery (max. sensory block w/ minimal motor block) Max. dose: 2.5 mg/kg CNS toxicity: seizures Cardiac toxicity: therapy resistant arrhythmias, cardiac arrest 20% Intralipid, 1.5 ml/kg bolus, then infusion 0.25 ml/kg/h Ropivacaine Onset 7 14 min Duration 4 6 h Good sensory/weak motor block 0.2 % ideal for caudal More expensive Less CNS and cardiac toxicity 1 1 Scott DB; et al.: Anesth Analg 1989;69:
11 2,3 Chloroprocaine Denser block Ester hydrolysis Less risk of toxic accumulation in neonates Continuous infusion 1 Cheap Neurotoxic with subdural administration 1 Tobias JD; et al.: Can J Anesth 1996; 43: Adjuvants Clonidine Optimal dose 1 2 mcg/kg Sedation Bradycardia, hypotension, apnea in neonates Ketamine Preservative free ketamine not available in US Neostigmine PONV 30% Opioids Delayed respiratory depression 11
12 Caudal: Complications Intravascular/intraosseous injection Epidural hematoma Neural injury Subarachnoid injection Epidural abscess Urinary retention (opioids) Thoracic Epidural Catheter: Indication/Goals Abdominal/thoracic surgery Post operative analgesia Older children 12
13 Thoracic Epidural: Technique Under general anesthesia Lateral decubitus position Midline vs. paramedian approach LOR with NS (avoid air embolism) Ligamentum flavum not as prominent Depth of epidural space: ca. 1 cm/10 kg Thoracic Epidural Complications Drugs CNS/cardio toxicity Intravascular/subarachnoid injection Catheter placement Trauma to epidural structures (nerves, spinal cord, vessels) Catheter migration spinal block 1 Infection 1 Taenzer AH: Anesthesiology 2003; 98:
14 Awake Spinal Anesthesia Indications Preferable to avoid general anesthesia Muscular hypotonia (post op ventilation) Post op apnea?neurotoxicity Difficult AW (Pierre Robin) Inguinal hernia repair, muscle biopsy 14
15 PIV (timing variable) ASA monitors Sitting position Spinal: Technique Needs a good babysitter : restrain all 4 extremities, lumbar lordosis, avoid neck flexion (AW obstruction) pacifier Spinal: Technique 22g 1 ½ inch spinal needle TB syringe (slip tip) Sterile prep iodine/alcohol 15
16 Barbotage Supine positioning Soft restraints Spinal: Technique Immediate start of surgery L3-4 Spinal: Drugs Drug Concentration % Dose mg/kg Duration min Lidocaine Bupivacaine Tetracaine
17 Spinal: Complications 1 Desaturation High spinal Bradycardia (<100 bpm) Apnea Rarely: infection, bleeding, nerve damage, spinal cord injury CSF leak 1 Williams RK; et al.:anesth Analg. 2006; 102:
18 Common Problems Incomplete block (failed spinal) Rare (5 20%) Repeat SAB, do caudal block, i.v. supplementation, cancel surgery Agitation From heat, covers, physical restraints Solution: sweetened pacifier, padding, ventilation, i.v. sedation (benzodiazepines, propofol) Time running out: Common Problems Avoid delays during prep and intraop Have good communication with surgeon Addition of epinephrine Combination with caudal block: Total dose 2.5 mg/kg bupivacaine divided into SAB: 1 mg/kg (0.2 cc/kg of 0.5% bupivacaine) Caudal: 1.5 mg/kg (0.6 cc/kg of 0.25% bupivacaine) 18
19 Summary Caudal: most common block, easy to learn Intralipid needs to be immediately available Thoracic epidural: potential for serious complications, LOR with NS, asleep vs. awake Awake spinal: wonderful alternative to GA, potential to avoid suspected neurotoxic effects of GA, time limitations Questions? 19
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