Pediatric Regional Anesthesia Caudal Anesthesia

Amr Abouleish, MD, MBA

University of Texas Medical Branch Galveston, Texas

Pediatric Regional Anesthesia

How do children differ from adults? Why do regional anesthesia and analgesia in children? Caudal Anesthesia and Analgesia
Test dose Single dose local anesthetic or morphine Continuous Caudal/Epidural Infusion

Spinal Anesthesia (if we have time)

How do children differ from adults?

Psychologically and Parents Physiology Pharmacology Anatomy

Physiology
Postoperative apnea in former premature infants Implications
Immature CNS and BBB Regional alone decreases risk

Pharmacology
General and Implications
Distribution
CSF Volume Total Body Water Protein Binding

Clearance
Liver Renal

Local Anesthetics Opioids

Approximate CSF Volume

16 14 12 10 8 6 4 2 0
Premature Full Term Child Adult

ml/kg

Cote, A Practice of Anesthesia for Infants and Children

 CSF Volume: Implications

Dosage of Drugs
tetracaine 1 mg/kg + epinephrine for spinal bupivacaine 0.5-1.0 ml/kg for caudal
200

minutes
150 100 50 0
Infants
Adults

Duration of action
e.g. Spinal Tetracaine with epinephrine

Cote, A Practice of Anesthesia for Infants and Children

Total Body Water

90% 80% 70%

ICF ECF

% of bodyweight

60% 50% 40% 30% 20% 10% 0%

<15 week fetus

Full Term

4-6 months

Adult
Clin Pharm, 14:189, 1988

Protein Binding and Clearance

Protein binding decreased at birth
Albumin and -glycoprotein levels decreased Adult levels at 1 year of age

Clearance
Liver: Phase I & Phase II decreased Renal: GFR 30% of adult Adult levels by 3-5 months of age

Clin Pharm, 14:189, 1988

General Pharmacology Implications

Increase CSF Volume Increase dose & decrease duration Increase Total Body Water Increase IV dose, decrease toxicity decrease Protein Binding Increase %drug available Increase toxicity decrease Clearance Increase t1/2 Increase toxicity

Local Anesthetics
BE CAREFUL with repeated dosing and infusions Neurologic symptoms > cardiac symptoms
May not be able to illicit early neurologic symptoms in small children First sign may be a grand mal seizure

Case Reports of Toxicity with Infusion

4 children, 1 neonate Children all presented with grand mal seizures Neonate presented with cardiac arrest
Anesth Analg, 75:164, 1992; Anesth Analg, 75:284, 1992; Anesth Analg, 75:287, 1992

Opioids
Morphine's t1/2 in neonates twice of adults
Approaches adult by 2-4 months

Implications: BE CAREFUL with opioids and infants Recommendation for opioids

For IV, <6 months of age consider apnea monitoring For CEI, <12 months of age no fentanyl

Anesthesiology 66:1389, 1987

Anatomy

Cote, A Practice of Anesthesia for Infants and Children

Why Regional Anesthesia and Analgesia in Children?

Regional Anesthesia only Combined Regional and General Anesthesia Contraindications

Regional Anesthesia Only!

Reduce risk of postoperative apnea in former premies
Regional anesthesia alone will reduce risk of postoperative apnea Still need to monitor overnight Techniques
Caudal: 0.25% Bupivacaine (1ml/kg) + Clonidine (1 mcg/kg) Spinal: Tetracaine, surgical anesthesia for 60-90 minutes

In other age groups, difficult to do regional alone

Anesthesiology 101:A1470, 2004

Combined Regional and General Anesthesia

Usually regional anesthesia for postoperative analgesia Types
Single dose caudal Continuous Epidural/Caudal Infusion Peripheral nerve blocks Field blocks Local infiltration

Combined Regional and General Anesthesia:

Indications
Malignant Hyperthermia Avoid need for opioids
Sedation or respiratory depression DSU patients

Better analgesia? for CEI

Pulmonary disease (cystic fibrosis, rib fractures) Bladder surgery Abdominal &/or thoracic surgery

Contraindications to Regional Anesthesia in Pediatrics

Parental refusal Need for intact sensory system for postoperative evaluation Sepsis Bleeding disorder Vertebral malformation or previous surgery Allergy

Pediatric Regional Anesthesia: Neuroaxial Techniques

Caudal anesthesia and analgesia
Single dose local anesthetic Morphine Clonidine Continuous infusion

Spinal anesthesia

Caudal Anesthesia Technique

Caudal Anesthesia

Caudal Anesthesia

Caudal Anesthesia

Needle or Angiocath

Caudal Anesthesia Where can it go?

Caudal in a

http://www.cvm.okstate.edu/~users/aerrane/mandsagr/www/vms5422/lect22.htm

Single Dose:

Local Anesthetic Volume

Traditional
0.05 ml/seg/kg 0.5 ml/kg T10 1.0 ml/kg T6

For longer duration or lower concentration

1.5 ml/kg T2

Anesthesiology 47:527, 1977 Anesthesiology 75:57, 1991

Single Dose:

Concentration of Local Anesthetic

Balance analgesia with risk of motor block 0.25% Bupivacaine (max 1 mg/kg)
Excellent analgesia Risk of some motor block Shorter duration cases Recommend: patients < 18 months of age

0.175% Bupivacaine (max 1.5 mg/kg)

Less motor block with good analgesia Higher levels Longer duration Mix 10 ml = 7 ml 0.25% + 3 ml NS

Single Dose:

Caudal Morphine
30 40 mcg/kg
Provides analgesia for 12-24 hours No respiratory depression in over 500 children Nausea incidence similar to general anesthesia

Less labor intensive Does not require special pain service Side Effects
Nausea Itching Propofol therapy single dose

Do not need to go to PICU

Anesthesiology 81:A1348, 1994 J Clin Anesth 7:640, 1995

Local with Clonidine

Clonidine in adults as oral sedative or adjunct to spinal or epidural Enhances and increases the effect of single shot bupivacaine caudal Risk: sedation with > 1mcg/kg At UTMB, we use for caudal alone for premies and hernia repair

Anesthesiology 101:A1470, 2004

Awake Caudals in Neonates

Anesthesiology 101:A1470, 2004

Anesthesiology 101:A1470, 2004

Anesthesiology 101:A1470, 2004

Anesthesiology 101:A1470, 2004

Caudal/Epidural Anesthesia and Analgesia:

Continuous Infusion
Technique and Dose
Caudal
16g angiocath with 19g epidural catheter Thread up to thoracic level Guard with clear steridrape

Epidural-lumbar
Use LOR to saline and continuous pressure method If thread up to thoracic level, need epidurogram

Initial Dose: 0.05 ml/seg/kg

Anesthesiology 69:265, 1988 Anesthesiology 79:400, 1993

Caudal/Epidural Anesthesia and Analgesia:

Continuous Infusion Rates and Types

Rates
<1 yoa: 0.1 to 0.2 ml/kg/hr >1 yoa: 0.1-0.4 ml/kg/hr *less than 0.5 mcg/kg/hr fentanyl to start

Types
<1 yoa: 0.1% bupivacaine >1 yoa: 0.1% bupivacaine + 3 mcg/ml fentanyl

Anesth Analg, 75:164, 1992

Continuous Caudal/Epidural Infusion:

Side Effects and Treatment

Itching Nausea
avoid sedating drugs

Diphenhydramine Metoclopramide Straight Cath prn Turn Down Infusion

Naloxone* 0.5-2 mcg/kg Naloxone Naloxone

Urinary Retention Sedation Respiratory Depression

Naloxone 10 mcg/kg *If infusion has fentanyl, then turn down infusion & may use naloxone
Cote, A Practice of Anesthesia for Infants and Children

Pediatric Regional Anesthesia: Goals to Understand

Identify differences between adults and infants When indicated and contraindicated Techniques Side Effects and Complications

Spinal Anesthesia
RARELY done Technique
IV access 1.5" 22g beveled needle

Dose
Tetracaine 1 mg/kg and "whiff" (0.02 ml) epinephrine

Approximate Distance: Skin to Subarachnoid Space

50 40 30 20 10 0

MILLIMETERS

Premie Newborn 5 months 1 yr

3 yr

5 yr

10 yr

18 yr

Cote, A Practice of Anesthesia for Infants and Children

Spinal Anesthesia

Positioning

Cote, A Practice of Anesthesia for Infants and Children

Spinal Anesthesia

CSF Returns

Cote, A Practice of Anesthesia for Infants and Children

Spinal Anesthesia

Injection

Cote, A Practice of Anesthesia for Infants and Children

Spinal Anesthesia
Complications
No hypotension seen in children under 6 years of age If blood encountered, difficult to identify CSF

Limitations
Procedure Duration 45 minutes Surgeon

Pearls
Sugar Nipple Do not flex head Bovie Pad

Spinal Anesthesia

Bovie Pad Placement

Cote, A Practice of Anesthesia for Infants and Children