Professional Documents
Culture Documents
Bloqueo Causal Ennpediatria
Bloqueo Causal Ennpediatria
62]
Department of Anesthesiology, Intensive Care, Caudal block is one of the most popular and effective techniques of regional anesthesia in
and Pain Management, Faculty of Medicine, pediatric surgery. Good anatomic knowledge and accurate adherence to guidelines pertaining
Ain-Shams University, Cairo, Egypt
to the technique and to drug administration is necessary to perform this block safely. The
Correspondence to Abdelaziz Abdallah usual approach is well-known and has been extensively described, but failure is seen in
Abdelaziz, MD, 28 Taqseem Elawqeef, some cases. Another approach is the ‘no turn’ technique, which is a new method developed
Elquppa, Helliopolois, Cairo 11234, Egypt
Tel: 002-02-24513702; fax: 002-01118003283;
in the Ain-Shams University, Pediatric Surgical Unit by the author. It has a high success rate
e-mails: drabdelaziz@hotmail.com and and can be easily learned and implemented even by junior staff.
draaabdo_75@yahoo.com
Anatomical considerations
Significant anatomic differences between adults and
children should be considered when performing the
caudal block. The sacrum of children is more narrow
and flat compared with that of adults. At birth, the
sacrum, which is formed of five sacral vertebrae, is
not completely ossified and continues to fuse until 8
years of age. The incomplete fusion of the posterior
arches of the fifth and sometimes the fourth sacral
vertebrae forms the sacral hiatus, which is covered by
a ligamentous membrane called the sacrococcygeal
membrane (Fig. 1). The caudal epidural space can be
Anatomy of the sacrum.
accessed easily in infants and children through the
1687-7934 © 2016 Department of Anesthesiology, Intensive Care and Pain Management,
Faculty of Medicine, Ain-Shams University, Cairo, Egypt DOI: 10.4103/1687-7934.178898
[Downloaded free from http://www.asja.eg.net on Monday, April 20, 2020, IP: 189.203.45.62]
In the common technique, the needle is inserted at The needle is then raised 15°–30° and advanced slowly
a 90° angle to the cutaneous plane and, after passing until loss of resistance is felt. Thereafter, the needle
the sacrococcygeal membrane, is lowered 30° and then is advanced not more than 0.5 cm. An aspiration
advanced several millimeters into the sacral canal. test is performed to avoid inadvertent intrathecal
or intravascular injection of local anesthetics. The
In the no turn technique [8] the needle is inserted at local anesthetic is injected slowly and the sacral area
a 60° angle to the sacral plane instead of 90°, in the is inspected for inadvertent subcutaneous injection
midline at the apex of the sacral hiatus, after crossing (Fig. 5).
the sacrococcygeal ligament. The needle does not have
to be advanced because the bevel (facing anteriorly) is Continuous caudal block can be achieved by placing
at the beginning of the sacral canal and already within the connection line (arterial line) to the cannula for
the epidural space. intraoperative analgesia; a poster dose can be given
before removing the cannula postoperatively (Fig. 6).
In our new and easy technique, the sacral hiatus is first
identified and the left index finger is placed over it (if This technique guarantees that no subcutaneous
the doctor is right handed) (Fig. 3). The needle is then injection will be required, because the left index finger
inserted caudally 1–1.5 cm from the hiatus (Fig. 4), is placed over the hiatus, and for subcutaneous injection
introduced into the subcutaneous tissue, and advanced the needle should pass completely under the index
subcutaneously until the needle tip is felt by the left finger, which will be easily felt because the skin and
index finger. subcutaneous tissues in pediatric patients are very thin.
Figure 2 Figure 3
Anatomical landmark of the sacral hiatus. Identification of the sacral hiatus by the left index finger.
Figure 4 Figure 5
Needle insertion 0.5–1 cm from the sacral hiatus. Local anesthetic injection.
[Downloaded free from http://www.asja.eg.net on Monday, April 20, 2020, IP: 189.203.45.62]
Figure 6
Acknowledgements
Conflicts of interest
None declared.
References
1 Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success rate
and adverse effects in 750 consecutive patients. Anesth Analg 1989; 68:83–89.
2 Gunther J. Caudal anesthesia in children. A survey. Anesthesiology 1991;
75:A936.
3 Broadman L, Ivani G. Caudal block. Tech Reg Anesth Pain Manage 1999;
3:150–156.
4 Ivani G. Paediatric regional anaesthesia. A practical approach. Florence,
Italy: SEE Editrice; 2001.
5 Adewale L, Dearlove O, Wilson B, Hindle K, Robinson DN. The caudal
canal in children: a study using magnetic resonance. Paediatr Anaesth
2000; 10:137–141.
Continuous caudal block.
6 Bosenberg AT, Wiersma R, Hadley GP. Oesophageal atresia:
caudothoracic epidural anesthesia reduces the need for postoperative
ventilatory support. Pediatr Surg Int 1992; 7:289–291.
We can use traditional 22 G needles, spinal needles, 7 Gunter JB, Eng C. Thoracic epidural anesthesia via the caudal approach
in children. Anesthesiology 1992; 76:935–938.
Tuohy needles, 22 G intravenous cannulae, or 22 G 8 Ivani G, De Negri P. Techniques in Regional Anesthesia and Pain
arterial cannulae. Management, 2002;6:136–140.