Clinical Procedure
 
Aliases:
Caudal anaesthesia
Caudal anaesthetic

Topic aliases are alternate phrasings for a particular topic.


If you are unable to inject whilst inserting a caudal despite being in the correct position consider that the needle may be blocked.

This is particularly the case if you've struck bone on first pass.

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If you get a bloody tap but are sure you are at the right level/angle, consider trying again (with a new needle) at the same level/angle but with a more lateral (left or right) entry point.

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In conditions such as vacterl association and spina bifida consider the implications of altered vertebral and epidural anatomy in the lumbosacral region before proceeding with an caudal and whether a ilio inguinal-nerve-block with infiltration along the incision site may be more appropriate.

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Model showing positioning of needle relative to sacral cornua and sacral hiatus.

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Model showing sacral hiatus in relation to the sacral cornua.

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Adrenaline test dose to detect intravascular injection for caudal:
Actual dose = 0.5 mcg/kg
0.1 ml 1:1000 Adrenaline (100 mcg)
Place in 20 ml 0.2% Rop or 0.25% Levobupivacaine to make a 5 mcg/ml dilution
Take the standard dose of 1 ml/ kg for caudal
Inject 1 ml - wait for 30 sec looking for inc HR > 10 bpm

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Armitage in 1979 proposed a caudal dosing guideline based on the required block height.
- 0.5ml/kg 0.25% bupivicaine for sacrolumbar surgery
- 1ml/kg for a thoraco-lumbar block, and
- 1.25 ml/kg for a mid thoracic block.
He recommended the use of 0.25% bupivacaine for the block up to a maximum of 20 ml.
Armitage EN. Caudal block in children.
Anaesthesia 1979; 34: 396.

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Caudal clonidine prolongs analgesia following caudal anesthesia academic.oup.com/bja/arti...

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Apr 20, 2017
2mcg/kg caudal clonidine, but consider avoiding in infants because of its sedative effect. refl.in/ex
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Good outline of technique www.pitt.edu/~regional/Ca...

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NYSORA website on Caudal anesthesia in adults and children.
www.nysora.com/regional_a...

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Oxford CCEAP article doi.org/10.1093/bjaceaccp...

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Sacral plate is not completely ossified at birth; continues to ossify until 8 yo
Failure of fusion of S5 \- S4 creates the sacral hiatus
Sacral cornua are the unfused transverse processes of S5
Epidural fat is less dense in younger children allowing predictable spread of LA & advancement of caudal catheter

0.25% Levobupivacaine (or 0.2 % Ropivacaine)
0.5 ml/kg -> Sacral
1 ml/kg -> T10 (most commonly used dose)
1.25 ml/kg -> T4 (0.19 % L-Bup)
Or 1 ml/kg 0.2% Rop

Left lateral position if Right handed
23 G hypodermic needle
Midway between sacral Cornu
Advance until pop is felt & then a further 1 mm
Leave needle open to air
Give test dose of 1 ml of solution
Easy injection expected
Observe ECG
Always perform with ECG on
Observe for peaking T-wave > 25% baseline

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Left lateral position with legs drawn up.
Sterile technique with mask and sterile gloves.
Prep with chlorhexidine alcohol solution.
23g syringe needle through the sacrocoxygeal membrane.
Armitage rule using 0.25% bupivicaine.
Ensure clear view of area above the injection to observe for evidence of subcutaneous injection.

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