A survey of paediatric caudal extradural anaesthesia practice

Abstract

Introduction: Caudal extradural anaesthesia (CEA) is a common technique with wide application in paediatric anaesthesia [1]. An ‘on line’ World Wide Web survey of paediatric anaesthetists was undertaken to delineate any differences in the practice of this procedure. Methods: A web based questionnaire was devised to survey the practice of caudal extradural anaesthesia in children by anaesthetists who were members of the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). The questionnaire was designed to collect information on the experience of the anaesthetist, techniques employed, drugs used and the use of the caudal extradural catheter technique for continuous extradural anaesthesia and analgesia. Results: E-mails were sent to 600 anaesthetists and there were 366 useable on-line replies. The majority of respondents had greater than 5 years of paediatric anaesthetic experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. Those with less than 15 years experience tended to employ a cannula while anaesthetists with greater than 15 years experience favoured a needle technique. Most anaesthetists (91.5%) did not believe that there was a clinically significant risk of implantation of dermoid tissue into the caudal extradural space. The majority of anaesthetists used a combination of clinical methods to confirm correct placement of a needle or cannula and injection of local anaesthetic into the caudal extradural space. Only 27 respondents indicated that they used ultrasound. The local anaesthetic agents used were bupivacaine (43.4%), levobupivacaine (41.7%), ropivacaine (13.4%) and lignocaine (1.5%). A total of 104 anaesthetists used more than one type of local anaesthetic. Drug additives used included clonidine (42.3%), ketamine (37.5%) and opioids (18.1%). The caudal catheter technique was used by 43.6% of anaesthetists. For a single shot caudal injection most anaesthetists (74%) used gloves only with fewer adopting the ‘no touch’ technique (15.2%) or use of glove, gown and mask (10.8%). Anaesthetists with greater than 10 years experience tended to use a ‘no touch’ technique. Discussion: Caudal extradural anaesthesia is an extremely common technique among those surveyed. Most anaesthetists use a cannula to access the caudal space which is in variance with the description of the technique in the peer review literature. However, the needle technique still tends to be used by anaesthetists with more than 15 years of experience. The majority of anaesthetists concur with the lack of evidence that there is a risk of implantation of dermoid tissue into the caudal extradural space. The anaesthetists surveyed tended to use a combination of simple clinical methods to identify correct placement of local anaesthetic in the caudal space. Ultrasound is rarely used. This may change when ultrasound become more readily available. Despite the greater safety margin of levobupivacaine, bupivacaine is used slightly more frequently. This may be due to cost. Ketamine and clonidine are the most commonly used additives. The caudal extradural catheter technique is used by a large proportion of anaesthetists despite there being few commercially available sets of equipment [2]. While most anaesthetists wear gloves for asepsis some still employ a more traditional no-touch technique. Conclusion: To our knowledge this is the first electronic large scale survey of anaesthetists who perform caudal extradural anaesthesia in children. The findings of this survey provides a snap shot of current practice and act as a useful reference for the development of enhanced techniques and new equipment to improve safety and efficacy in the future.