Neuroaxial Anesthesia in Infants and Children

Neuroaxial Anesthesia in Infants and Children

  • Caudal anesthesia provides predictable and effective anesthesia/analgesia during and after surgery below the umbilicus. After identifying the landmarks (the sacral cornu) while the patient is in the lateral position, a 22 g short bevel needle or angiocath is directed at a 45-degree angle into the sacral hiatus until a loss of resistance is felt. The needle is then flattened to a 10-20 degree angle and advanced slightly. Following a negative aspiration for blood/cerebrospinal fluid, 1cc/kg of 0.25% bupivicaine is generally administered. For neonates and older outpatients (e.g., children who walk), a more dilute concentration of bupivicaine is often recommended. Morphine or fentanyl can be added to a caudal to enhance/prolong the block, but this requires post op monitoring for 12-24 hours because of risk of post op hypoventilation. Clonidine can also be added to a caudal to enhance duration of the block.
  • Epidural anesthesia can be employed to provide intra- and postoperative analgesia at any age. In practice, because the staff in our intensive care nursery is unfamiliar and uncomfortable with epidurals, we rarely utilize this technique in newborns.
  • For neonates, an epidural catheter can be placed in the caudal space and threaded to the desired dermatome. A small amount of radiopaque contrast can be used to verify proper depth. Unfortunately, contaminating the caudal site with stool is a risk and necessitates removal.
  • In infants >3 months, a lumbar epidural can be threaded to an appropriate thoracic level, again guided by radioopaque contrast. Compared to caudal catheters, lumbar epidurals can be more easily stabilized and maintained sterile.
  • Thoracic epidurals can be placed in toddlers and older children usually via a midline, lateral approach. For infants >10 kg, the epidural depth in millimeters is generally equal to the weight in kilograms; for example a 20 kg child will have loss of resistance at 20 mm.
  • In infants >6 months, the appropriate initial bolus of 0.5ml/kg of 0.25% bupivicaine, is followed by an infusion of 0.1% bupivicaine (0.3 ml/kg/hr; maximum rate, 0.4mg/kg/hr). In infants <6 months, 2, 3 chlorprocaine or 1% lidocaine should be considered to avoid toxicity associated with limited ability to metabolize bupivacaine.
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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.