CAUDAL EPIDURAL

09-02-2013

Wahyudi
 SINGLE-SHOT CAUDAL ANESTHESIA IS
APPROPRIATE FOR : ANAL , VULVA, VAGINA,
SCROTAL AND PENIS PROCEDURE

IN THE PAIN CLINIC , LABOR AND DELIVERY UNIT,

THE CAUDAL TECHNIQUE PROVIDES USEFUL
ACESS TO THE EPIDURAL SPACE IN PATIENTS
WITH LUMBAR SPINE PATHOLOGY
 CAUDAL ANESTHESIA/ANALGESIA IN CHIDREN IS
FREQUENTLY COMBINED WITH GENERAL
ANESTHESIA FOR LOWER EXTREMITY AND LOWER
ABDOMINAL PROCEDURE
THIS ALLOWS LOWER DOSES OF SYSTEMIC
AGENTS, THUS DECREASING THE INCIDENCE OF
SIDE EFFECT AND PROVIDES POST-OPERATIVE
ANALGESIA
EQUIPMENT AND PATIENT POSITIONING

EQUIPMENT FOR CAUDAL ANESTHESIA IS SIMILAR

TO THAT DESCRIBE FOR SPINAL AND EPIDURAL
ANESTHESIA
FOR SINGLE-SHOT PROCEDURE, A 22-GAUGE
SHORT-BEVELED NEEDLE IS PREFERABLE
THE SHORT-BEVELED NEEDLE GIVES A BETTER
FEEL AS THE LIGAMENT IS PENETRATED AND THE
ENTIRE BEVEL IS MORE LIKELY TO ENTER CAUDAL
CANAL WHEN THE CANAL IS VERY SHALLOW
 A STANDARD OF SHORT CRAWFORD TYPE
EPIDURAL NEEDLE IS OFTEN USED IF A CATHETER
TECHNIQUE IS PLANNED
IN CONTRAST TO A TOUCHY NEEDLE IN WHICH THE
BEVEL NEEDLE OPENS TO THE SIDE OF THE LONG
AXIS OF THE NEEDLE, THE BEVEL OF THE
CRAWFORD NEEDLE FACES FORWARD ALONG
THE LONG AXIS OF THE CANAL, THIS ALLOW
DIRECTION THE CATHETER ALONG THE AXIS
 POSITIONING FOR CAUDAL MAY BE PRONE OR
LATERAL IN ADULT
THE LATERAL DECUBITUS IS CHOSEN IN CHILDREN
BECAUSE IT IS EASIER TO MAINTAIN A PATENT
AIRWAY THAN IN THE PRONE POSITION AND
LANMARKS ARE MORE EASILY PALPABLE THAN IN
ADULT
CAUDAL ANESTHESIA IS USUALLY PERFORMED IN
AWAKE ADULTS BUT CHILDREN ARE USUALLY
ANESTHETIZED
 WHEN POSITIONING AN ADULT IN THE PRONE
POSITION, A PILLOW SHOULD INSERTED BENEATH
THE ILLIAC CREST TO MAKE CANULATION OF THE
CAUDAL CANAL
IN THE LEFT LATERAL POSITION, THE LOWER
THIGH AND LEG ARE MORE FLEXED AT THE HIP
AND KNEE
THE UPER THIGH AND LEG ARE MORE FLEXED
AND LAY OVER THE LOWER THIGH WITH THE KNEE
 TECHNIQUE

A WIDE SKIN AREA SHOULD BE PREPARED SO THAT

ALL THE LANMARKS ARE VISIBLE AND CAN BE
PALPATED
A FOLDED GAUZE PAD SHOULD BE PLACED IN THE
GLUTEAL FOLD BEFORE THE ANTISEPTIC
SOLUTION IS APPLIED, SO THE SOLUTION DOES
NOT INTO THE SENSITIVE PERINEAL AREA AND
CAUSE DISCOMFORT OR IRRITATION
CAUDAL ANESTHESIA REQUIRES IDENTIFICATION
OF THE SACRAL HIATUS
 THE SACROCOCCYGEAL LIGAMENT ( EXTENSION
OF LIGAMENTUM FLAVUM ) OVERLYING THE
SACRAL HIATUS BETWEEN SACRAL CORNU
THE SACRAL HIATUS LIES AT THE APEX OF AN
EQUILATERAL TRIANGLE WHOSE BASE IS A LINE
CONNECTING THE POSTERIOR SUPERIOR ILIAC
CRESTS
 ALTERANTIVELY, THE SACRAL HIATUS CAN BE
LOCATED BY PALPATING THE TIP OF THE COCCYX,
AND THE PALPATING FINGER IS THEN MOVED
CEPHALAD APPROXYMATELY 4 -5 CM UNTIL THE
TIP OVERLIES THE SACRAL HIATUS
THE PALPATING FINGERS SHOULD REMAIN IN THE
SACRAL HIATUS OR ON THE CORNU IT HAS BEEN
IDENTIFIED
 A SKIN WHEAL IS RAISED BY INJECTING LOCAL
ANESTHETIC, THE CAUDAL NEEDLE IS
INTRODUCED THROUGH THE SKIN WHEAL AT AN
ANGLE OF 90 120 DEGREES TO THE SKIN
A DISTNCT POP IS RECEIVED AS THE NEEDLE
PENETRATES THE SACROCOCCYGEAL LIGEMENT
AND ENTER THE CAUDAL CANAL
 IF BONE IS CONTACTED, THE NEEDLE IS SLIGHTLY
WITHDRAWN AND REDIRECTED SO THAT THE
ANGLE OF INSERTION RELATIVE TO THE SKIN
SURFACE IS DECREASED
IF BONE IS NOT CONTACTED, THE NEEDLE IS
DIRECTED BY DEPRESSING THE HUB AND SHAFT
SO THEY ARE ALIGNED WITH THE AXIS OF THE
CAUDAL CANAL
 AFTER REDIRECTION THE NEEDLE IS ADVANCED 1
2 CM INTO THE SACRAL CANAL, FUTHER
ADVANCE SHOULD NOT BE ATTEMPTED AS THIS
INCREASES THE RISK DURAL PUNCTURE AND
INTRAVASCULAR CANULATION
THE INJECTION SHOULD BE FEEL SIMILAR TO
INJECTION INTO LUMBAR EPIDURAL SPACE
 AFTER ENSURING CORRECT NEEDLE POSITION
AND BEFORE INJECTING THE DOSE OF CAUDAL
ANESTHETIC, ASPIRATION SHOULD BE
PERFORMED AND TEST DOSE ADMINISTERED, THE
REMAINING DOSE SHOULD BE INJECTED SLOWLY
TWENTY MILLILITERS OF LOCAL ANESTHETIC IS
NECESSERY TO REALIABLY BLOCK ALL THE
SACRAL NERVE VIA THE CAUDAL APPROACH
 IF CONTINOUS TECHNIQUE IS PLANNED, AN
EPIDURAL CATHETER IS ADVANCED THROUGH THE
CAUDAL NEEDLE INTO THE CAUDAL CANAL
THE DEPTH OF INSERTION DEPENDING ON THE
ANTICIPATED SITE OF SURGERY AND THE DESIRE
EXTENT OF ANESTHESIA
 TYPICALY THE CATHETER IS SECURED 2 CM OR
MORE IN THE CAUDAL CANAL
IN CHILDREN ADVANCEMENT OF THE CATHETER
TO THE THORACIC SPINE HAS BEEN DESCRIBED
 TROUBLESHOOTING

THE IDENTIFICATION OF THE SACRAL HIATUS IS

OFTEN CONFUSING PARTICULARY IN OBESE
INDIVIDUALS
THERE IS MARKED ANATOMI VARIATION OF THE
DORSUM OF THE SACRUM AND SACRAL HIATUS
THE SACRAL HIATUS MAY BE ABSENT IN A SMALL
NUMBER OF PEOPLE AND THE APEX MAY EXTENT
CEPHALAD TO THE LOWER HALF OF S-4
 THE RESULT IS LIMITED UNILATERAL BLOCKADE
THE NEEDLE TIP MAY BE POSITIONED DORSAL TO
THE SACRUM IN THE SUPERFICIAL TISSUE OR MAY
BE VENTRAL TO THE SACRUM IN THE RECTUM
TERIMA KASIH