VOLUME
41, No. 2 - MARCH-APRIL,
1962
in pediatric surgery:
a preliminary report
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is one of the
C AUDAL ANESTHESIA
easiest methods for regional anes-
thesia in children. The sacral hiatus is
felt easily. Patients under the age of 7
have to be well sedated. We have used
intramuscular 5 per cent PentothaP so-
dium for children in whom intravenous
was impracticable, and intravenous Pen-
tothal sodium for the larger children.
Our aim was to determine the lowest
concentration of local anesthetic agent
suitable for each group to achieve satis-
factory caudal anesthesia, including suf-
ficient relaxation. We also tried to de-
termine the volume of anesthetic agent
needed to insure an adequate level of
anesthesia.
This report concerns our experience
on 124 consecutive caudal pediatric an-
esthesias for children between 2 days
and 14 years of age.
PREMEDICATION
All patients must be well premedi-
cated. They should be manageable for
injection of the anesthetic agent; they
should have complete or partial amnesia
t o all the psychologic stresses imposed
by a strange environment and painful
needle pricks. T h e y should be quiet,
without forceful restraint, preferably
sleeping, during the surgical procedure.
*Department of Anesthesia, Hospital Pedro Ernesto, Rio de Janeiro, Brazil.
218
PETER SPIEGEL
Rio de Janeiro, Brazil*
On the other hand, they should have
no excessive or prolonged cardiorespira-
tory depression; they should wake up
early; they should not vomit; and they
should be able to take food orally as soon
as the surgical procedure permits.
Children weighing over 15 kg. are pre-
medicated according to the schedule of
- and Beltonel Due to freauent er-
rors in dilution when using a routine
premedication schedule and to the opti-
mum result obtained with intramuscu-
lar 5 per cent Pentothal sodium, 20 to
25 mg. per kilogram of body weight,2
we prefer this rapid premedication for
our smaller children. I n 69 patients i n
good physical condition, none showed
any clinical evidence of cardiorespira-
tory depression or local reaction after
these doses of intramuscular Pentothal
sodium.
The addition of 1500 T.U. of hyalu-
ronidase did not decrease the time of
onset of sleep, decrease the motor re-
action to the blocking procedure, or de-
crease the time of sleep in 16 of our
patients, so we abandoned its use. Our
patients were sufficiently asleep in 5 to
8 minutes after the intramuscular Pen-
tothal sodium. They still had to be re-
strained lightly to proceed with the skin
wheal and during the caudal injection,
219 ANESTHESIA
and ANALGESIA
although they had no memory of this
second injection ( a t least the older chil-
dren).
Intramuscular Pentothal s o d i u m is
administered by the anesthesiologist in
the induction room of the surgical suite,
while the patient is restrained by a
nurse. Most children over age 7 are
cooperative enough to permit the induc-
tion of caudal anesthesia after the con-
ventional doses of Nembutale, morphine,
and atropine. For those who are not,
we give an additional 5 to 10 mg. per
kilogram of 2.5 per cent Pentothal so-
dium, intravenously. If no veins are
easily available, or if the patient weighs
less than 25 kg., the dose is given intra-
muscularly.
During surgery, if we must sedate the
child, we may inject Pentothal sodium
easily in a vein of the foot or ankle, as
these will be anesthetized also.
TECHNIQUE
While the landmarks of the child’s sa-
cral hiatus are the same as for the adult,
they are felt more easily, as they are
more superficial. I n the newborn and
infant the distance between the sacral
, . . Current Researches
hiatus and the dural sac is very small
and may be as little a s 1 cm. For this
reason we t r y t o perforate the sacrococ-
cygeal membrane with a small (1to 11/2
inch) 22 t o 24-gauge short-beveled nee-
dle, and do not advance i t any further.
All equipment is autoclaved, as are
the anesthetic solutions and a 10-cc. am-
pule of 0.9 per cent saline for mixing
with the 2 per cent lidocaine, to dilute
to proper concentration. After this mix-
ing, and after skin preparation, a wheal
is made carefully, with the patient re-
strained. The injection i s done with the
patient prone, the face turned t o the
assistant, hands and feet restrained by
the two hands of the assistant, the but-
tocks restrained by one hand of the an-
esthesiologist w h i l e making t h e s k i n
wheal with the other hand.
Once the needle is introduced through
the sacrococcygeal membrane, which is
identified by its resistance, we aspirate
carefully for blood or spinal fluid. If
the patient is moving too much, we in-
ject 1 cc. of anesthetic a g e n t before
aspirating. The injection of air into the
sacral c a n a l w i l l cause a crepitation
through the sacral foramina. This does
VOLUME
41, No. 2 - MARCH-APRIL,
1962 220

not mean that we are not in the sacral To o b t a i n a level of a n e s t h e s i a

canal. Our best guide to identify this above Tlo in most patients, we h a v e
space has been the resistance offered by used the following empirical formula :
the sacrococcygeal membrane and the
lack of resistance to the injection, al- v =4 +-D-15 where V is the total
2
though the needle is quite small. Rapid volume of anesthetic agent to be injected
injection of the anesthetic agent, even if in cubic centimeters and D is the dis-
the needle is properly located, causes tance between c, and the hiatus.
pain, and movement of the patient.
COMPLICATIONS
The whole calculated dose is injected We can obtain a high level of anesthe-
at once, no test dose being given. sia if desired (T4to T,) . With the doses
Dosage of Local Anesthetic Agent- and volumes we used, we never had any
In order to use the smallest amount of clinical evidence of shock. The smaller
local anesthetic agent necessary to ob- the child, the smaller will be the fall of
tain an appropriate degree and level of blood pressure, even with high blocks.
anesthesia at different ages, we p r o - The smaller the child, the better he will
ceeded on a basis of trial and error. Our tolerate a fall of blood pressure due to
initial data were obtained from For- a high block. We observed a 9-month-
tuna.3 old baby with a level up to T5 whose
blood pressure dropped from 100/60
We have used successfully the follow- mm. of mercury to a palpatory systolic
ing minimum concentration of the fol- pressure of 40 mm. of mercury, without
lowing local anesthetic agents (table 1). any symptoms. On the other hand, we
Our most rewarding experience has saw a 14-year-old boy, weighing 37 kg.,
been with lidocaine alone or in combina- who had a caudal block performed with
tion with tetracaine (104 cases). Anes- 15 cc. of 1.5 per cent procaine and a
thesia is complete in 10 minutes at the level of TI, who had nausea and retch-
most. Tetracaine was used alone or in ing and whose blood pressure dropped
combination in 25 cases. With epineph- from 120/70 mm. of mercury to 70/30
rine 1:200,000 to 1:300,000, its action mm. of mercury.
lasts a t least 2% hours. Although many of our patients were
Volume of Local Anesthetic Agent- ambulatory and were not followed up,
The most useful parameter for deter- they a t least all left without complaints
mining the volume to be injected into of pain at the injection site. All had re-
the caudal canal we found to be the dis- covered completely from the anesthesia
tance between the seventh cervical spi- before being sent home. Several pa-
nous process and the sacral hiatus, meas- tients had some urinary retention re-
ured in the prone position on a flat oper- quiring catheterization.
ating table, the measuring tape touching We had no convulsions in this series.
the skin. Children seem to tolerate quite well high

Table 1
DOSAGE RELATED TO AGE
221 ANESTHESIA . . . Cu,went Researches
and ANALGESIA

doses of local anesthetic agents, at least Table 2

if premedicated with intramuscular or DISTRIBUTION BY AGE GROUPS
intravenous Pentothal sodium, although
in some cases we injected more than Age I Cases
the recommended maximum doses. No
First week of life I 2
patient with high l e v e l of anesthesia
presented respiratory problems. T h e First month to 1 vear I 20
concentration of t h e l o c a l anesthetic 1 to 2 vears I 12
agent used did not produce a complete
paralysis of the intercostal muscles. Any 2 to 3 years I l7
respiratory problems observed were due 3 to 4 s e a r s 1 10
to overdose of intravenous Pentothal 4 t o 5 gears I 10
sodium in poor-risk patients. Now we
avoid all depressant drugs in such pa- 5 t o 6 gears I 13
tients, especially those with water and 6 to 8 years I 18
electrolyte imbalance. 8 to 10 years I 11
We have used caudal anesthesia for
abdominal, perineal, anorectal, and uro-
10 to 14 years I 11
genital operations. It can be used, of
course, for surgery of the lower ex- Table 3
tremities. We used it for two pyloromy-
o t o m i e s (Fredet-Ramstedt operation) REASONS FOR FAILURES
and for a marsupialization of a pancre-
atic cyst. Faulty injection technique 4
CASE ANALYSIS Surgical procedure outlasting time
Caudal anesthesia is the regional an- of regional anesthesia 6
esthesia of choice for surgery of the ab- Unilateral distribution
domen, perineum and lower extremities of anesthesia 2
for children 2 years of age or younger.
Our youngest patient was 2 days old. Lack of experience with the volume
and concentrations of the
Table 2 shows the distribution of our different anesthetic agents a t
patients in the different age groups. different age groups 17 '!'
Failwes of Anesthesia - Caudal an- 29
esthesia was attempted in 124 patients
"Of these 17, 8 were due t o use of too diluted
by 10 different anesthesiologists, most anesthetic a g e n t ; of t h e 8, 2 produced good
of whom had never done a caudal in anesthesia but poor relaxation. In t h e other
children, and some not even with much 9, the anesthesia was below the level needed
experience in caudal anesthesia in adults. f o r the planned surgery.
These also found caudal anesthesia tech-
nically easier in children a s compared
cording to age, is presented. The volume
to adults. We had a total of 29 failures of anesthetic agent t o be injected is cal-
(23.2 per cent) as shown in table 3.
culated from a formula relating the total
SUMMARY volume t o the length of a segment of the
A preliminary report on 124 pediatric spinal column.
patients subjected to caudal anesthesia REFERENCES
is p r e s e n t e d . Premedication in the 1. Leigh, M. D. and Belton, M. K.: Pediatric
vounger patients consisted of intramus- Anesthesia. New York, The Macmillan Com-
cular Pentothal sodium. Standard pedi- pany, 1948.
atric premedication a n d l o r intravenous 2. Dhruva, A. J.: Intramuscular Use of Pen-
tothal@ Sodium as a n Aid t o Pediatric Anes-
Pentothal sodium was used for older thesia. Anesth. & Analg. 39:236 (May-June)
patients. A schedule of lidocaine, tetra- 1960.
caine, and procaine concentration, ac- 3. Fortuna, A . : Personal communication.