Does Use of Ultrasound Reduce the Rate of Sham Caudal Block in Children
| Status: | Recruiting |
|---|---|
| Healthy: | No |
| Age Range: | Any - 7 |
| Updated: | 9/15/2017 |
| Start Date: | June 30, 2017 |
| End Date: | February 2018 |
| Contact: | Adam C Adler, MD, FAAP |
| Email: | axadler@texaschildrens.org |
| Phone: | 832-824-5800 |
Caudal blocks are one of the most commonly performed regional anesthetics in children and are
performed daily for a host of infra-umbilical surgical procedures. A caudal block is an
epidural injection, most commonly of local anesthetic into the epidural space as accessed via
the sacral hiatus. In children, the sacral hiatus is a normally occurring aperture in which
the epidural space may be accessed with extremely minimal risk; as neural tissue ends more
proximally. Due to this measure of safety, caudal blocks are preferred in children when
compared with standard lumbar epidurals. Caudal blocks are performed blindly using palpation
and tactile feedback to assess if the medication is being administered in the correct
location. As a result of blind injection, administration of local anesthetic totally or
partially outside of the correct site can often be unnoticed or identified after a
significant volume has already been injected. With the potential for toxicity of local
anesthetic, this may result in either the inability to give a complete dose or an
unintentional and often unnoticed sham block "incorrect site of injection".
performed daily for a host of infra-umbilical surgical procedures. A caudal block is an
epidural injection, most commonly of local anesthetic into the epidural space as accessed via
the sacral hiatus. In children, the sacral hiatus is a normally occurring aperture in which
the epidural space may be accessed with extremely minimal risk; as neural tissue ends more
proximally. Due to this measure of safety, caudal blocks are preferred in children when
compared with standard lumbar epidurals. Caudal blocks are performed blindly using palpation
and tactile feedback to assess if the medication is being administered in the correct
location. As a result of blind injection, administration of local anesthetic totally or
partially outside of the correct site can often be unnoticed or identified after a
significant volume has already been injected. With the potential for toxicity of local
anesthetic, this may result in either the inability to give a complete dose or an
unintentional and often unnoticed sham block "incorrect site of injection".
Caudal blocks are one of the most commonly performed regional anesthetics in children and are
performed daily for a host of infra-umbilical surgical procedures. A caudal block is an
epidural injection, most commonly of local anesthetic into the epidural space as accessed via
the sacral hiatus. In children, the sacral hiatus is a normally occurring aperture in which
the epidural space may be accessed with extremely minimal risk; as neural tissue ends more
proximally. Due to this measure of safety, caudal blocks are preferred in children when
compared with standard lumbar epidurals. Caudal blocks are performed blindly using palpation
and tactile feedback to assess if the medication is being administered in the correct
location. As a result of blind injection, administration of local anesthetic totally or
partially outside of the correct site can often be unnoticed or identified after a
significant volume has already been injected. With the potential for toxicity of local
anesthetic, this may result in either the inability to give a complete dose or an
unintentional and often unnoticed sham block "incorrect site of injection".
Use of ultrasound has been proposed for identification of caudal block placement and correct
medication spread. However, a recent review of the Pediatric Regional Anesthesia Network
database reveals that ultrasound is reportedly only used in less that 3% of blocks. The
benefit of ultrasound is safe and real-time confirmation of injection. Ultrasound allows the
provider to determine with minimal local anesthetic or even saline injection if the correct
space is accessed. Without ultrasound, failed blocks are either identified after significant
percentage of the total dose of local anesthetic is incorrectly administered or intra or post
operatively when the patient demonstrates a significant opioid requirement. This is
problematic given that one of the primary benefits of a caudal block in children is the
ability to avoid opioids.
Review of local practice here at Texas Children's Hospital for quality improvement purposes
revealed a failure rate of caudal blocks to be 18%. Failure was defined as a heart rate
increase with incision of >20% despite a caudal block and >1MAC of gas for the patient age.
These patients all required opioids both intra and post operatively in addition to surgical
levels of inhaled anesthetic agent.
performed daily for a host of infra-umbilical surgical procedures. A caudal block is an
epidural injection, most commonly of local anesthetic into the epidural space as accessed via
the sacral hiatus. In children, the sacral hiatus is a normally occurring aperture in which
the epidural space may be accessed with extremely minimal risk; as neural tissue ends more
proximally. Due to this measure of safety, caudal blocks are preferred in children when
compared with standard lumbar epidurals. Caudal blocks are performed blindly using palpation
and tactile feedback to assess if the medication is being administered in the correct
location. As a result of blind injection, administration of local anesthetic totally or
partially outside of the correct site can often be unnoticed or identified after a
significant volume has already been injected. With the potential for toxicity of local
anesthetic, this may result in either the inability to give a complete dose or an
unintentional and often unnoticed sham block "incorrect site of injection".
Use of ultrasound has been proposed for identification of caudal block placement and correct
medication spread. However, a recent review of the Pediatric Regional Anesthesia Network
database reveals that ultrasound is reportedly only used in less that 3% of blocks. The
benefit of ultrasound is safe and real-time confirmation of injection. Ultrasound allows the
provider to determine with minimal local anesthetic or even saline injection if the correct
space is accessed. Without ultrasound, failed blocks are either identified after significant
percentage of the total dose of local anesthetic is incorrectly administered or intra or post
operatively when the patient demonstrates a significant opioid requirement. This is
problematic given that one of the primary benefits of a caudal block in children is the
ability to avoid opioids.
Review of local practice here at Texas Children's Hospital for quality improvement purposes
revealed a failure rate of caudal blocks to be 18%. Failure was defined as a heart rate
increase with incision of >20% despite a caudal block and >1MAC of gas for the patient age.
These patients all required opioids both intra and post operatively in addition to surgical
levels of inhaled anesthetic agent.
Inclusion Criteria:
- Children ages 0-84 months
- Infra-umbilical procedure for which a caudal block is already planned
- American Society of Anesthesiology classifications of 1,2 or 3
Exclusion Criteria:
- Incarcerated hernias
- Emergency procedures
- Local Anesthetic allergy
- Sacral dimple
- Rash over sacrum
- Parents/legal guardians unable to consent for surgical procedure in English language
Foster Care/Child protective services as guardians
- Parental Refusal for caudal block or study participation
- American Society of Anesthesiology classifications other than 1,2 or 3
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