Caudal block in children Soroka University Medical Center, Soroka University Medical Center, Israel, Beer-Sheva 2004, Dr. S. Plamadeala, Chisinau Under supervision of : Dr. Ana Katz and Dr. V. Kotlovker

What is caudal anaesthesia? Caudal anaesthesia (block) is an extradural anaesthesia, produced by injection of local anaesthetic into the caudal canal. This produces block of the sacral and lumbar nerve roots et it is useful as a supplement to general anaesthesia and for provision of postoperative analgesia.

Anatomy The sacrum is a triangular bone that articulates with the fifth lumbar vertebra, the coccyx and the ilia. The dorsal roof consists of the fused laminae of the five sacral vertebrae and is convex dorsally. In the midline is a median crest which represents the sacral spinous processes. Lateral to this is the intermediate sacral crest with a row of four tubercles which represent the articular processes.

INDICATIONS 1. Emergency or one day-case surgery 2. Subumbilical surgery (abdominal, pelvic, orthopaedic). 3. Intra and postoperative analgesia is provide 4. In association with a light general anaesthesia (inguinal and scrotal hernia, the hydrocel cure, testicular ectopy, the anorectal surgery, the genito-urinary surgery, the retroperitoneal tumors surgery as well as the surgery of the basin, hips or lower limbs)

Contraindications absolute 1. Coagulopathy or anti coagulation 2. The administration of aspirin in the 7 days preceding the caudal anaesthesia, diminished the platelets aggregability. 3. The local or systemic infections problems. 4. The major sacrum malformations, pilonidal kyst. 5. Meningitis. 6. Myelomeningoceale 7. Hypovolaemia 8. Hydrocephalus shunted or not 9. Real allergy to local anaesthetics. 10. Parental refuse

Relative contraindication The relative contraindication for caudal anaesthesia results after evaluating the risk-benefice statement for the patient : 1. the existence of an evolutive neuropathy 2. in the spina bifida presence 3. neural blockade dismatched to the surgical 4. procedure needs 5. serious psychiatric disease 6. three unachieved attempts should lead to abandon this technique

Choice of local anaesthetic 0.5 ml/kg, 0.25% bupivacaine (sacro-lumbar block) 1.0 ml/kg, 0.25% bupivacaine (upper abdominal block) 1.2 ml/kg,0.25% bupivacaine (mid-thoracic block) Doses described by Armitage Therefore the maximum acceptable volume seems to be situated between 20 and 25 ml.

Complications 1. Subcutaneous puncture (rapid diagnosis if the palpating index keeps it's positioning during the injection (1 ml injected in the subcutaneous tissue is very easy recognized) 2. Vascular puncture (the puncture of a epidural vein, recognized on aspiration test, has no gravity. The needle is withdrawn than reintroduced) 3. Subperiosteal puncture (it will be recognized during the puncture or while injecting the test dose (important injecting resistance or tachycardia during the test dose) 4. Intravascular injection (convulsions, arrhythmias even ventricular fibrillation, respiratory arrest could be observed. The immediate resuscitation is to be performed).

Complications 5. Dural tap (If the needle is too long or too deep inserted in the sacral canal or if there is an anatomical anomaly such as a sacral hiatus at S1 or S2 level, all these could lead to a dural tap. In the presence of cerebral spinal fluid at aspiration test the needle has to be withdrawn) 6. Rectal puncture (Almost rare, appears often if obstinacy in difficulties and wrong anatomical guide marks) 7. Nerves injury 8. Cauda equina syndrome is exceptionally reported since the technique and the equipment are codified. 9. Allergic reactions on local anaesthetic agents

Experience DiagnosisWeight (kg) Age (months) N Fimosis4.221 Inguinal Hernia Undescending Testis6.454 Inguinal Hernia645 Rectovaginal Fistula11186 Rectovaginal Fistula Circumcision6.248

Experience 1.The procedure has been effectuated in association with a light general anaesthesia. 2. In all the cases it was introduced Bupivacain 0.25% 1.0 ml/kg. 3. Analgesia was accompanied by very little changes in blood pressure. 4. There were no complications.

Conclusion Caudal block is an easy and safe technique which can be used provide anaesthesia and postoperatve analgesia for a wide range of surgical procedures. When performed carefully complications are rare.