Kiddie-Caudals Caudal Epidural Analgesia in Everyday Pediatric Practice Sabine Kost-Byerly, MD, FAAP Associate Professor and Director, Pediatric Pain Management Department of Anesthesiology/Critical Care Medicine Johns Hopkins University, Baltimore, Maryland
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Kiddie-Caudals Caudal Epidural Analgesia in Everyday Pediatric Practice
Kiddie-Caudals Caudal Epidural Analgesia in Everyday Pediatric Practice . Sabine Kost-Byerly, MD , FAAP Associate Professor and Director, Pediatric Pain Management Department of Anesthesiology/Critical Care Medicine Johns Hopkins University, Baltimore , Maryland . Objectives. - PowerPoint PPT Presentation
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Kiddie-CaudalsCaudal Epidural Analgesia in Everyday Pediatric
Practice
Sabine Kost-Byerly, MD, FAAPAssociate Professor and Director, Pediatric Pain Management
Department of Anesthesiology/Critical Care Medicine
Johns Hopkins University, Baltimore, Maryland
Objectives
Upon completion of this lecture, the attendee will be able
to:
• Appreciate the technical aspects of caudal analgesia
• Select appropriate local anesthetic solutions for caudal
analgesia
• Recognize and manage complications of caudal epidural
analgesia
Disclosures
• I have no relevant financial relationships
with manufacturers of any commercial
products or providers of commercial
services discussed in these slides.
Caudal Epidural Analgesia
caudal
lumbar
thoracic Advantages:
Easy to performHigh success rateUsually no hemodynamic changes
Epidural Additives – improved and prolonged analgesia
The Common
Opioids• Inpatients only
– Fentanyl 2 mc/kg– Morphine 12-50 mcg/kg
• Pruritis, emesis, respiratory depression
Clonidine• Alpha -2-agonist• Single dose 1-2 mcg/kg
– Risk: bradycardia, apnea in young infants
– Increasing sedation with higher doses
The Rare
• Continued concerns of safety for neuroaxial use:– preservative, ph, neurotoxicity
• Ketamine 0.25 – 1 mg/kg• Neostigmine 2 mcg/kg
– Emesis common
• Midazolam 50 mcg/kg• Dexmedetomidine 1-
2mcg/kg– Analgesia similar to clonidine
• Tramadol 2 mg/kg
Caudal single Injection – Volume
• Correlation between cranial level and volume• Exact prediction of level not possible• Volumes < 1 ml/kg not likely to reach higher than L2 • Speed of injection does not matter Brenner L et al. Br J Anaeth
2011; 107:229-35; Tiffterer l et al. Br JAnaesth 2012;108;670-4
Thomas L< et al. Paediatr Anaesth 2010;11:1017-21
• Volume for injection:– 0.5 ml/kg for perineal surgery– 1.0 ml/kg for lower abdominal surgery– 1.25 ml/kg for upper abdominal surgery
Volume versus Concentration
• RCT• Bupivacaine with epi O.8 mL/kg 0.25% B vs 1 ml/kg 0.2
% B
• Lower GA requirement with higher volume• Maybe better postop analgesia with higher volume
• 10,098 epidurals– 8493 caudals– 7 with transient ECG changes – no treatment
Pediatric Anesthesia 2010;20:1061-1069
ASRA Recommendations – Prevention of LAST Neal JM et al. Reg Anesth Pain Med 2010;35:152-61
• Lowest effective dose of local anesthetic • Incremental injection of local anesthetics • Aspirate the needle or catheter before each injection • Use of an intravascular marker (epinephrine) is
recommended.
• Ultrasound guidance may reduce frequency of intravascular injection– Effectiveness remains to be determined
ASRA - recommended LAST -Management
• ABC’s• Seizures:
– Benzodiazepines, small dose propofol – avoid large dose propofol for risk of CV compromise– Succhinylcholine or other NDMB , small doses to minimize acidosis and hypoxemia
• Cardiac arrest – ACLS , but
• epinephrine - small initial doses (10mcg to 100 mcg boluses in the adult) preferred• Vasopressin not recommended • Calcium channel blockers and A-adrenergic receptor blockers – avoid• Amiodorone for ventricular arrhythmias, treatment with local anesthetics (lidocaine or procainamide) not
recommended
– Lipid emulsion therapy -Consider administering at the first signs of LAST, after airway management• 1.5 mL/kg 20% lipid emulsion bolus• 0.25 mL/kg per minute of infusion, continued for at least 10 mins after circulatory stability is attained• Consider rebolus if circulatory stability is not attained and increase infusion to 0.5 mL/kg per minute (up to 10
mL/kg lipid emulsion within 30 mins)– Propofol is not a substitute for lipid emulsion
– Cardiopulmonary bypass• failure to respond to lipid emulsion and vasopressor therapy• notify the closest facility capable of providing it when CV compromise is first identified during an episode of LAST.
Neal JM et al. Reg Anesth Pain Med 2010;35: 152-61
Lipid emulsion therapyConsider administering at the first signs of LAST, after airway management
1.5 mL/kg 20% lipid emulsion bolus0.25 mL/kg per minute of infusion, continued for at least 10 mins after circulatory stability is attained
Consider rebolus if circulatory stability is not attained and increase infusion to 0.5 mL/kg per minute (up to 10 mL/kg lipid emulsion within 30 mins)
Propofol is not a substitute for lipid emulsion
Intralipid for LA-induced Cardiotoxicity in infants
• 2-day-old 3.2 kg term infant– Caudal, 1 mL/kg 0.25% bupivacaine, with US guidance and confirmation– VT, cardiovascular collapse– 20% Intralipid 1 ml/kg – recovery Lin EP et al. Pediatric Anesthesia
2010; 20:955-7
• 40-day-old, 4.96 kg infant– Caudal, 0.9 mL/kg 0.25% bupivacaine– Tachycardia, T-wave inversion hypotension– Epinephrine 2 mcg/kg x2, 20mL 55 albumin – no change– 20% Intralipid 2 ml/kg – recovery Shah S et al. J Anesth 2009; 23:430-41
93% of caudal blocks placed without technical aids or imaging
3% with ultrasound guidance
Adverse Events and
Complications
Summary
Caudal anesthesia and analgesia is:• An easy technique to supplement general anesthesia• Requires few resources• Easy to learn• Provides several hours of postoperative analgesia• Is overall a very safe analgesic technique