Thoracic epidural anesthesia via the modified Taylor approach in infants

BACKGROUND AND OBJECTIVES: Advancement of catheters from the caudal to the thoracic level is an alternative to thoracic epidural anesthesia in infants and younger children; however, contamination of the insertion site may occur. This study examined the feasibility of the midline modified Taylor approach (L(5)-S(1)) for the advancement of epidural catheters to the thoracic level in infants. METHODS: After Institutional Review Board (IRB) approval and parental consent, the L(5)-S(1) interspace of infants 3 months to 2 years old was entered with an 18-gauge Crawford needle using the saline loss of resistance technique. A 20-gauge catheter with stylet (Abbott; North Chicago, IL) was then advanced the distance from the L(5)-S(1) interspace to the desired thoracic level. If resistance was encountered, the catheter was withdrawn 1 to 2 cm, rotated along its long axis, and readvanced. The stylet was left in place, and a radiograph of the thoracolumbar spine was taken. The stylet was then removed, and the catheter was secured, tested, and dosed. RESULTS: Sixteen infants (mean age, 14.4 +/- 5.7 months and mean weight, 9.3 +/- 1.4 kg) were studied. Fifteen of 16 catheters were inserted the full length planned. Fourteen of 16 catheters were straight (1 had a single bend, and 1 had multiple loops). Mean discrepancy between level desired and obtained was -1.7 +/- 1.7 segments (median, -1.75). Discrepancy did not correlate with either desired level or length inserted, but did decrease with experience. CONCLUSIONS: The midline modified Taylor approach allows access to the thoracic epidural space via catheter advancement, while being below the terminus of the spinal cord and less likely to suffer contamination than the caudal approach.     

Thoracic epidural catheter placement via the caudal approach in infants by using electrocardiographic guidance

We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects. IMPLICATIONS: Epidural electrocardiography may be used to guide the positioning of the thoracic epidural catheter tip via the caudal approach to the appropriate dermatome for optimum analgesia.     

Thoracic epidural analgesia via the caudal approach in pediatric patients undergoing fundoplication using nerve stimulation guidance.

IMPLICATIONS: Epidural catheter placement using electrical stimulation guidance is an alternative approach for positioning the catheter into the thoracic region via the caudal space. This easily performed clinical assessment provides optimization of catheter tip positioning for achieving effective pain control.     

Thoracic epidural analgesia via the caudal approach using nerve stimulation in an infant with CATCH22

PURPOSE: To illustrate insertion of an epidural catheter via caudal route in a small infant under electrical stimulation guidance. CLINICAL FEATURES: A six month old boy, weighting 4.25 kg, with a diagnosis of CATCH22 (Cardiac abnormality/abnormal faces, T cell deficit due to thymic hypoplasia, cleft palate, hypocalcemia due to hypoparathyroidism resulting from 22q11 deletion) was scheduled for fundoplication and gastrostomy tube (G-tube) insertion. A combined light general anesthesia and continuous epidural anesthesia technique was selected. Following induction of general anesthesia and tracheal intubation with 1.5 mg midazolam, 10 microg fentanyl and 10 mg succinylcholine, a 16G intravenous catheter was inserted into the caudal space. A 19G epidural catheter (Arrow Flextip Plus) epidural catheter was then inserted up cranially. A low electrical current (1-10mA) was then applied through the catheter. The level of motor movement was advanced from the lower limb muscles to the upper abdominal muscles as the catheter was threaded cranially. After 19 cm of epidural catheter had been inserted, intercostal muscle movement (T9-10 level) was observed at 4.2mA. The tip of the catheter was later confirmed to be at the T9-10 interspace by radiographical imaging. The patient awakened without distress and the trachea was extubated the same evening. The infant was discharged to the ward next morning with good pain relief from a continuous epidural infusion of bupivacane 0.1% with 1 microg x ml(-1) at 1.6 ml(-1). CONCLUSION: Epidural stimulation may help placement of the epidural catheter at the appropriate dermatome for effective anesthesia and analgesia.     

Thoracic epidural catheter insertion using the caudal approach assisted with an electrical nerve stimulator in young children

OBJECTIVES: We evaluated whether thoracic epidural catheter placement using the caudal approach and assisted with an electrical stimulator could be performed in young children. METHODS: Ten young children (1-4 years) who underwent abdominal surgeries were studied. Under general anesthesia without muscle relaxants, caudal catheter placement was performed using an 18-gauge Crawford-type needle and a 20-gauge radiopaque epidural catheter with a stainless-steel stylet. A metal adapter and a 3-way stopcock were attached to the catheter to connect to an electrical stimulator and to inject physiological saline. Electrical stimulation was performed intermittently while advancing the catheter until it reached the target length. The catheter position was confirmed on postoperative roentgenogram. RESULTS: The mean age of the subjects was 32.2 +/- 10.1 months (13-48 months), and the height was 85.3 +/- 6.1 cm (72-93 cm). In 9 of 10 patients, an epidural catheter could be placed at the first insertion. In 1 patient, the catheter could be placed successfully at the second insertion. The electrical current required for muscle contraction at the target length was 5.8 +/- 1.5 mA. CONCLUSION: Electrical stimulation reliably indicated the location of the catheter tip. This technique for thoracic epidural catheter insertion was easy to perform and could be used in young children.     

Thoracic epidural anesthesia and epidural hematoma

This report involves a 74-year-old-male who developed a thoracic epidural hematoma with paraparesis on the second postoperative day in conjunction with thoracic epidural anesthesia established before surgery for acute abdominal aortic dissection. The finding indicates that laminectomy can be performed successfully as late as three days after diagnosis of the hematoma, with a complete restitution of neurological function. High-dose steroid treatment may have been a contributing factor for the positive outcome.     

Thoracic epidural anesthesia for coronary bypass via left anterior thoracotomy in the conscious patient.

Cardiac surgery is perceived to be maximally invasive and fraught with complications. Secondary to this, cardiothoracic surgeons have been refining traditional techniques to minimize their invasive nature. Epidural anesthesia has been utilized safely and effectively for numerous surgical procedures to reduce the associated morbidity. In hopes of achieving a similar result, we utilized thoracic epidural anesthesia for a coronary artery bypass via a left anterior thoracotomy, in an awake, spontaneously breathing patient. To the best of our knowledge, this is the first reported case utilizing this approach. Herein we report the results and technique utilized.     

Thoracic epidural anesthesia in the perioperative period

Thoracic epidural anesthesia and analgesia is a valuable tool in the perioperative period. Successful thoracic epidural catheter placement requires a thorough knowledge of anatomy and its role in the performance of thoracic epidural block. The paramedian approach in the mid-thoracic region (T5-8) makes use of definitive bony landmarks to facilitate successful thoracic epidural space identification. In properly trained hands using carefully defined endpoints, potential risks and complications of thoracic epidural placement are minimized.The physiologic response produced by thoracic epidural drug administration differs from lumbar epidural administration. This must be taken into consideration when dosing the catheter with opioids or local anesthetics. When used appropriately, thoracic epidural drug administration provides high quality anesthesia and postoperative analgesia, and has favorable effects on postoperative outcome. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children

Thirty infants scheduled for a variety of gastrointestinal, genitourinary and thoracic surgical procedures were selected for insertion of lumbar or thoracic epidural catheters via the caudal approach using either an Intracath or a Burron continuous brachial plexus kit. The catheters were inserted with ease by residents in training and no catheter-related complications were encountered. Lidocaine 0.5 per cent with 1:200,000 epinephrine was then injected to assure proper placement of the catheter before narcotics were administered. Postoperative analgesia was adequate in all patients using preservative-free morphine 0.05 mg.kg-1. The mean dosing interval was 15 hr and no episodes of nausea, vomiting, hypotension or histamine release were noted. Urinary retention occurred in two infants and one infant became apnoeic three hours after epidural morphine administration but responded to naloxone and pulmonary ventilation with bag and mask. In conclusion, epidural catheters placed via the caudal approach are a safe and effective means of providing postoperative pain control in infants using preservative-free morphine. However, the use of epidural narcotics in infants less than two years of age is restricted to those who will receive intensive care unit monitoring postoperatively so that if apnoea occurs, rapid intervention can be taken by skilled nursing personnel.     

Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus arteriosus ligation

Adequate postoperative analgesia enhances deep breathing and minimizes respiratory complications after thoracotomy. This study compares postoperative outcomes after single injection caudal epidural vs continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing thoracotomy for patent ductus arteriosus (PDA) ligation. A retrospective chart review was performed for 27 children who had undergone PDA ligation. The children were divided into three groups. We compared patient demographics, surgical duration, anaesthesia duration, length of ICU stay, incidence of emesis requiring treatment, time required to establish regular oral intake, requirement for supplemental intravenous opioids during the first postoperative day, and length of hospital stay. For paediatric patients undergoing PDA ligation, postoperative analgesia with continuous infusion epidural via caudal approach produced shorter ICU stay, less occurrence of postoperative emesis, earlier oral intake, elimination of intravenous opioid supplementation, and shorter hospital stay compared with single injection caudal epidural techniques.     

Thoracic caudal epidural catheter localization using ultrasound guidance

Caudal epidural catheters provide exceptional analgesia while avoiding or minimizing opioids. Historically, the catheter tip location (dermatomal level) was estimated or verified via epidurogram. According to the Pediatric Regional Anesthesia Database, the majority of caudal‐to‐thoracic epidural catheters are placed without imaging guidance or verification of the position of the catheter tip. Ponde et al demonstrated that catheter insertion depth was longer when using ultrasound guidance than when estimated by external measurement. We report a simple yet novel ultrasound approach for catheter localization.     

Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients

BACKGROUND: Nerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors' institution. METHODS: The authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. RESULTS: In five patients (aged 5 months-1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day-1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. CONCLUSIONS: The results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.