Caudal Catheter Research Articles

Epidural insertion height for ureteric reimplant surgery; does location matter?

Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain. To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques. Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'-single-shot caudal; (iii) 'epidural'-epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 μg·ml(-1) ; (iv) 'caudal catheter'-caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain. Over the study period, the caudal catheter technique (mean interventions/patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload. Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required.

Effect of Donor Nephrectomy Technique on Recipient Lymphatic Drainage

AimWe sought to evaluate the postoperative recipient lymphatic drainage depending on open donor nephrectomy (ODN) or laparoscopic (LDN) techniques. MethodBetween March 2012 and August 2014, 58 patients underwent renal transplantation from living-related donors. Thirty donors underwent ODN (group 1), and 28 LDN (group 2). Operations were performed by the same surgeons. Both cranial and caudal drainage catheters for lymphatic leakage were placed preoperatively and all the recipients received tacrolimus, mycophenolate mofetil, and steroid as immunosuppressive regimen. None of the patients had coagulation abnormalities. ResultsAll grafts were functioning during the early postoperative period and diuresis was ensured. No difference was observed on early postoperative period regarding to acute rejection (P = .329) or infection (P = .546). No difference was seen concerning mycophenolate mofetil and mycophenolate sodium regimens among the 2 groups (P = .227). In groups 1 and 2, the cranial drainage catheters were not taken out until postoperative days 5.5 ± 2.5 (range, 0–11) and 6.4 ± 3.8 (range, 0–14) and the caudal catheters stayed in place until days 8.8 ± 3.5 (range, 1–16) and 9.9 ± 5.9 (range, 3–22), respectively. No difference was found when comparing the cranial (P = .308) and caudal (P = .426) drainage periods. However, during clinical acute rejection episodes the cranial drainage period was longer in group 1 (P = .003). Three patients developed lymphoceles, 1 requiring drainage, in group 2. ConclusionsThere seems to be no difference in recipient lymphatic drainage by donor nephrectomy technique. A laparoscopic procedure may be advantageous owing to shorter lymphatic drainage during clinical acute rejection episodes.

Anaesthesia and analgesia for bladder exstrophy correction. Case reports

IntroductionNeonatal bladder exstrophy repairs imply correcting the genitourinary malformation, and closing and stabilizing the pelvic girdle with external fixation and traction. Successful results are achieved in terms of reduced urinary incontinence, adequate aesthetic appearance, improved quality of life, reduction of the risk associated with neonatal surgery and minimization of the number of procedures associated with multistage repairs. In such procedures, prolonged perioperative anaesthesia is key for the patient to tolerate the traction and external fixation, to help osteotomy healing, and to reduce tension in the surgical wound. Patients’ age and weight have an effect on the risk of toxicity from local anaesthetics and respiratory depression from opioid analgesics. The prolonged use of caudal catheters in the management of these cases is associated with infection at the insertion site. Case presentationThe article presents the cases of three infants between 7 months and 1 year of age taken to bladder exstrophy repair and pelvic osteotomy with tunnelled caudal catheter and continuous local anaesthetic infusion as perioperative anaesthetic management technique. The use of these techniques was aimed at reducing the risk of infection at the insertion site and the risks associated with prolonged pain management in infants. ConclusionThe cases suggest that tunnelled caudal catheter placement and continuous local anaesthetic infusion are safe techniques in the management of prolonged anaesthesia in infants, decreasing the risk of insertion site infection.

Anestesia y analgesia para corrección de extrofia vesical. Reporte de 3 casos

IntroductionNeonatal bladder exstrophy repairs imply correcting the genitourinary malformation, and closing and stabilizing the pelvic girdle with external fixation and traction. Successful results are achieved in terms of reduced urinary incontinence, adequate aesthetic appearance, improved quality of life, reduction of the risk associated with neonatal surgery and minimization of the number of procedures associated with multi-stage repairs. In such procedures, prolonged perioperative anaesthesia is key for the patient to tolerate the traction and external fixation, to help osteotomy healing, and to reduce tension in the surgical wound. Patients’ age and weight have an effect on the risk of toxicity from local anaesthetics and respiratory depression from opioid analgesics. The prolonged use of caudal catheters in the management of these cases is associated with infection at the insertion site. Case presentationThe article presents the cases of three infants between 7 months and 1 year of age taken to bladder exstrophy repair and pelvic osteotomy with tunnelled caudal catheter and continuous local anaesthetic infusion as perioperative anaesthetic management technique. The use of these techniques was aimed at reducing the risk of infection at the insertion site and the risks associated with prolonged pain management in infants. ConclusionThe cases suggest that tunnelled caudal catheter placement and continuous local anaesthetic infusion are safe techniques in the management of prolonged anaesthesia in infants, decreasing the risk of insertion site infection.

Continuous caudal epidural anaesthesia for vaginal hysterectomy in a patient of heart disease and severe spinal deformity; a case report

We present this case report where we have used fluoroscopic localization of caudal space and caudal epidural catheter placement to conduct caudal epidural anaesthesia in a case of vaginal hysterectomy and colporrhaphy with co-morbidity of severe spinal deformity, valvular heart disease and pulmonary hypertension.

Great saphenous vein patency and endovenous heat-induced thrombosis after endovenous thermal ablation with modified catheter tip positioning

Thrombus extension into a deep vein after superficial venous thermoablation remains a unique complication in the treatment of superficial reflux disease of the great saphenous vein (GSV). In this study, we evaluate if catheter tip positioning or vein diameter correlate with the length of proximal patent segment of GSV after ablation and more caudal catheter positioning decreases the incidence of proximal thrombus extension into the femoral vein. This was a prospective study conducted from January 2008 to November 2009 of 73 patients undergoing radiofrequency ablation (RFA). Preoperative, intraoperative, and postoperative duplex ultrasound scans were obtained using standard protocols to establish reflux and target vein diameter. Intraoperative measurements were performed from the catheter tip to the femoral vein margin. Duplex ultrasound studies were obtained between 5 and 7 days after the procedure, with 1-month follow-up. The relationship between catheter tip positioning and vein diameter with the length of the proximal patent GSV segment after ablation and the incidence of proximal thrombus extension were analyzed. RFA was performed in 73 patients. Intraoperatively, the mean catheter tip positioning distance was 2.75 cm (range, 2.4-3.0 cm) from the saphenofemoral junction (SFJ), with 93% of the catheters placed within 2.6 to 2.9 cm of the femoral vein. The GSV mean diameter at the SFJ was 0.90 cm (range, 0.37-1.88 cm). After RFA, all GSVs were occluded, with a mean residual patent proximal GSV length of 1.17 cm (range, 0.3-10 cm). Two patients demonstrated thrombus extension from the SFJ into the femoral vein for a 2.7% incidence of endovenous heat-induced thrombosis. In patients undergoing RFA for saphenous reflux, neither catheter tip positioning nor vein diameter correlates with the length of the proximal patent segment of GSV after ablation. In addition, catheter positioning does not decrease the incidence of proximal thrombus extension into the femoral vein.

Changes in total and surface N-methyl-D-aspartate receptor NR1, NR2A and NR2B subunits in spinal cord in a rat model of incisional pain-remifentanil-induced hyperalgesia

Objective To investigate the changes in total and surface N-methyl-D-aspartate receptor (NMDAR) NR1,NR2A and NR2B subunits in spinal cord in a rat model of incisional pain(IP)-remifentanil-induced hyperalgesia.Methods Thirty-two male SD rate in which caudal vein catheter were successfully placed were randomly divided into 4 groups ( n =8 each):control group(group C),remifentanil group(group R),IP group (group I) and IP + remifentanil group (group R + I).In groups R and C remifentanil 1.2 μg· kg-1 · min-1 or the same volume of normal saline was infused intravenously for60 main.In groups R + I and I,a 1 cm longitudinal incision was made in the plantar surface of left hindpaw and remifentanil 1.2 μg· kg-1 ·min-1 or the same volume of normal saline was infused intravenously for 60 min.Paw withdrawal threshold (PWT) and paw withdrawal latency (PWL) were measured at 24 h before and 2,6,24,48 h after remifentanil or normal saline administration.The animals were sacrificed after last pain threshold measurement.The L4-6 segment of the spinal cord was isolated for determination of the expression of the total and surface NMDAR NR1,NR2A and NR2B subunits in spinal cord by Western blot.The ratio of surface NR2B/NR2A was calculated.Results Compared with group C,PWT was significantly decreased,PWL shortened,the expression of the total and surface NMDAR NR1,NR2A and NR2B subunits up-regulated and the ratio of surface NR2B/NR2A increased in groups 1,R and R + I( P ＜ 0.05).Compared with groups R and I,PWT was significantly decreased,PWL shortened,the expression of the total and surface NMDAR NR1,NR2A and NR2B subunits up-regulated and the ratio of surface NR2B/NR2A increased in group R + I( P ＜ 0.05).There was no significant difference in the total and surface NMDAR NR2A subunits among the four groups( P ＞ 0.05).Conclusion The up-regulation of total and surface NMDAR NR1 and NR2B subunits and the increased percentage of surface NR2B subunits in rats spinal cord may be involved in the development of incisional pain- remifentanil- induced hyperalgesia. Key words: Piperidines; Hyperalgesia; Receptors, N-methyl-D-aspartate; Spinal cord

Experience With 724 Epidurograms for Epidural Catheter Placement in Pediatric Anesthesia

Epidural analgesia via continuous catheters, placed either via the caudal approach or directly at the desired level, is a commonly used technique in children. It is particularly important that these catheters are placed correctly because most are placed under general anesthesia and require deep sedation or repeat general anesthesia for replacement if malfunctioning. Ideally, correct placement should be confirmed at the time of insertion. We combined the experience of 2 academic teaching hospitals that both perform routine epidurography for the placement of epidural catheters in children. The data from 2 quality assurance regional anesthesia databases were screened for unrecognized misplacements of epidural catheters. Of a total of 724 epidurograms, 45.8% were caudal catheters, 9.6% were lumbar catheters, and 32.3% were thoracic catheters. Epidurograms detected 12 (1.6%) unexpected misplacements: 4 were intrathecal, 3 were intravenous, and 3 were intraperitoneal. Our experiments suggest that confirmation of epidural catheter placement via epidurogram is highly efficacious. Epidurography is the only currently available technique that accomplishes all of the following: (a) confirms correct placement, (b) rules out incorrect anatomic space, and (c) predicts analgesic coverage.

The Effect of Sex on the Minimum Local Analgesic Concentration of Ropivacaine for Caudal Anesthesia in Anorectal Surgery

Caudal anesthesia is routinely used in our hospital for most of ambulatory anorectal surgery; patients need to recover as quickly as possible. The dose of local anesthetic may be different for male and female patients. We designed this study to investigate the effect of sex on the minimum local anesthetic concentration (MLAC) of ropivacaine for caudal anesthesia. In this double-blind, prospective study, we enrolled 70 ASA physical status I patients (35 male and 35 female) who were scheduled for anorectal surgery under caudal anesthesia, and allocated them to 2 study groups according to their gender. Each participant received a single injection of 20 mL ropivacaine through a caudal catheter. Using Dixon's up-and-down sequential allocation, the first participant received 0.2% and subsequent concentrations were determined by the analgesic response of the previous patients to the initial skin incision and laxity of the anal sphincter. The concentration change was 0.025%. The up-and-down sequences were analyzed using the Dixon and Massey method to quantify the caudal analgesic block effective concentrations in 50% of patients. The MLAC of ropivacaine for caudal analgesia was 0.296% (95% confidence interval, 0.286%-0.307%) in male patients and 0.389% (95% confidence interval, 0.372%-0.407%) in female patients (P < 0.01). We conclude that the ropivacaine MLAC for caudal anesthesia in female patients is 31% larger than in male patients.

Técnicas locorregionales para analgesia perioperatoria en anestesia pediátrica: estudio en 116 pacientes

Pain control is essential to patient comfort and reduced stress response, morbidity, and mortality after pediatric anesthesia. We assessed analgesic quality and the incidence of complications of regional blocks in combination with general anesthesia. Prospective study of 116 patients under 3 years of age who underwent surgery in our hospital over a period of 2 years. The studied patients were classified in 3 groups according to whether they received general anesthesia only, a regional block by single injection, or a caudal nerve block via catheter. We recorded demographic and intraoperative variables, postoperative analgesic requirements, and the time the first postoperative analgesic dose was needed. Analgesia was significantly more effective in the patients who received either type of regional block. The patients who received general anesthesia alone needed supplemental analgesia earlier than the others (P < .001); patients with nerve blocks required fewer doses of rescue analgesics (P < .001). The incidence of complications was low and all were minor. No case of caudal catheter contamination occurred. Regional nerve blocks combined with general anesthesia in children are effective and safe. Advantages of providing nerve blocks include hemodynamic stability, prolonged postoperative analgesia, lower consumption of analgesics, and few complications.

A survey of pediatric caudal extradural anesthesia practice

Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice. To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia. An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008. There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric 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. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection. This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.

A Small Tolerance for Catheter Displacement in High–Dose Rate Prostate Brachytherapy is Necessary and Feasible

We examined catheter displacement in patients treated with fractionated high-dose rate (HDR) brachytherapy boost for prostate cancer and the impact this had on tumor control probability (TCP). These data were used to make conclusions on an acceptable amount of displacement. The last 20 patients treated with HDR brachytherapy boost for prostate cancer at our center in 2007 were replanned using simulated interstitial catheter displacements of 3, 6, 9, and 12 mm with originally planned dwell times. The computer-modeled dose-volume histograms for the clinical target volumes were exported and used to calculate the TCP of plans with displaced needles relative to the original plan. Actual catheter displacements were also measured before and after manual adjustment in all patients treated in 2007. In the 20 patients who were replanned for caudal catheter displacements of 3, 6, 9, and 12 mm, the median relative TCP was 0.998, 0.964, 0.797, and 0.265, respectively (p < 0.01 when all medians were compared). All patients replanned with a 3-mm displacement, compared with only 75% with a 6-mm displacement, had a relative TCP greater than 0.950. In the 91 patients treated in 2007, before adjustment, 82.3% of fractions had a displacement greater than 3 mm compared with 12.2% of fractions after adjustment. Catheter displacement in HDR brachytherapy significantly compromises the TCP. The tolerance for these movements should be small (< or =3 mm). Correcting these displacements to within acceptable limits is feasible.

A survey of paediatric caudal extradural anaesthesia practice

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.

Caudal Cannula as an alternative to Caudal Epidural Catheter for Prolonged Analgesia

Caudal Cannula as an alternative to Caudal Epidural Catheter for Prolonged Analgesia

Measurement of craniocaudal catheter displacement between fractions in computed tomography–based high dose rate brachytherapy of prostate cancer

The objective of the present work was to measure the craniocaudal displacement of catheters occurring between consecutive fractions of transrectal ultrasound (TRUS)‐guided high dose rate (HDR) prostate brachytherapy. Ten consecutive patients were treated with 2 fractions of 9.5‐Gy TRUS‐guided HDR brachytherapy, with dental putty being used for the fixation of catheters. For each patient, a computed tomography (CT) scan with 3‐mm slice thickness was acquired before each of the 2 fractions. Two different references were used to measure the catheter displacement between fractions: the ischial bone as a bony marker (BM) and the center of two gold markers (COGM) implanted in the prostate. Catheter displacement was calculated by multiplying the thickness of the CT slice by the difference in number of CT slices between the reference slice and the slice containing the tip of a catheter. The average magnitude of caudal catheter displacement was 2.7 mm (range: −6.0 mm to 13.5 mm) for the BM method and 5.4 mm (range: −3.75 mm to 18.0 mm) for the COGM method. The measurement data obtained from the BM and COGM methods verified that prostate movement and catheter displacement both occurred independently between fractions. The most anterior and medial two catheters (catheter positions 8 and 12) had the greatest tendency to be displaced in the caudal direction because they were located at the most distant position from the fulcrum, making them susceptible to rotation of the dental putty in the lateral plane because of the movement of the patients’ legs between fractions. In conclusion, the combination of the BM and COGM methods can demonstrate prostate and catheter movement relative to the BM between fractions. Our technique found a pattern of catheter displacement. Based on that finding, further improvement of our results may be possible by modification of our current technique.PACS number: 87.53.Jw

Accuracy of image-guided radiotherapy of prostate cancer based on the BeamCath ® urethral catheter technique

Background and purpose To examine the accuracy of the BeamCath ® urethral catheter technique for prostate localization during radiotherapy. Materials and methods Sixty-four patients were CT scanned twice with the BeamCath ® catheter, and once without the catheter. The catheter contains radiopaque fiducial markers for prostate visualization on setup images. It is held in place by a balloon inflated with air in the bladder. The repeated CT scans were co-registered and the relative shifts of the BeamCath ® isocenter fiducial, the prostate center-of-mass, and external skin markers were evaluated. The displacement of the BeamCath ® isocenter fiducial relative to its position at the planning CT scan was also determined on setup films for 53 consecutive patients (222 setup films). Results The standard deviation (SD) of the prostate movement relative to the BeamCath ® isocenter fiducial was 0.9 mm in the left–right (LR), 2.8 mm in the cranial-caudal (CC), and 1.6 mm in the anteroposterior (AP) directions, respectively. When the balloon radius differed more than 1 mm between the CT scans (14 of 64 cases) the SD in the CC direction increased to 4.5 mm. The SD of the prostate movement relative to the pelvic bone was 0.6 mm (LR), 2.4 mm (CC), and 2.8 mm (AP), while the prostate movement relative to external skin markers was considerably larger. Removal of the catheter resulted in a mean cranial prostate movement of 1.5 mm relative to the pelvic bone. Caudal catheter displacements of 7–30 mm were observed in 5% of the setup films. In these cases, recatherization was necessary to obtain reliable prostate localization. Conclusions The BeamCath ® catheter technique markedly improved prostate localization in all directions when compared with skin markers. In the AP direction, the BeamCath ® technique was also superior to the use of bony structures. However, in the CC direction the catheter position was very vulnerable to changes in the balloon volume.

Tunnelled caudal catheter for perioperative analgesia in a woman with acute on chronic pelvic pain

Summary Objective This report outlines the use of an uncommon technique in current adult anaesthesia for the relief of pain pre and post-operatively, and the prevention of long-term sequelae of unrelieved pain. The tunnelling technique of the caudal catheter is briefly described. Case report A young woman with chronic back pain who had a more recent acute vaginal pain secondary to a vaginal wall cyst was admitted to hospital for 1 week prior to her scheduled surgery because of incapacitating vaginal pain. This case report describes the insertion of a caudal epidural catheter pre-operatively to control severe pain and its continuation both intra and post-operatively. The block was initiated with lignocaine and pethidine and maintained with an infusion of levobupivacaine and pethidine with the advantage of patient-administered boluses whenever required. The catheter was tunnelled to the right gluteal region and successful pain relief was achieved. This strategy accomplished better analgesia coupled with reducing the medication the patient had been taking for her pain syndromes. Conclusions Caudal analgesia was utilized in the hope of a better anatomical and pharmacological control of acute severe pain. This consequently reflected on a superior management of mental state in hospital. The catheter was left in situ until the day before discharge from hospital. No complications arose and conventional analgesics and mood stabilising drug doses were significantly reduced whilst the patient was hospitalised.

Intra- und postoperative Analgesie mit Kaudalkatheter bei einem Kind mit Schwartz-Jampel-Syndrom

The Schwartz-Jampel syndrome, also known as myotonia chondrodystrophica, is a rare autosomal recessive disorder characterized by bone dysplasia, growth retardation and generalized myotonia. Laryngoscopy and intubation may be difficult because of micrognathia and limited mouth opening due to myotonia of the masseter muscles. As regional anaesthesia reduces myotonic contractions and avoids administration of opioids causing respiratory depression, it appears to be the ideal method for postoperative analgesia. We report on a 5-year-old girl who underwent osteotomy of both hips and received intraoperative and postoperative analgesia via a caudal catheter. Excellent analgesia without myoclonic episodes could be achieved by continuous infusion of ropivacaine.

Caudal analgesia and anesthesia techniques in children

Caudal epidural blockade remains the cornerstone of pediatric regional anesthesia. In this article we provide a comprehensive review of the recent developments in caudal anesthesia in infants and children. Research has focused on prolonging the duration of single-shot caudal blocks and accurately positioning continuous caudal catheters. New local anesthetics with similar potencies but less toxicity have been introduced. Opioids prolong the duration of analgesia of local anesthetic, but have also been associated with unacceptable side effects, particularly in pediatric outpatients. Various non-opioid adjuncts with more favorable side-effect profiles may increase the duration of analgesia. New ultrasound and nerve-stimulation techniques have been developed to accurately guide epidural catheters to a specific spinal level. The addition of ketamine or clonidine to a caudal local anesthetic prolong the duration of the block. However, a preservative-free preparation of ketamine that is suitable for neuraxial use is not widely available. Ultrasound imaging and electrical stimulation are promising options to accurately position a caudal needle. However, because ultrasound imaging is more difficult in older children, nerve stimulation is a more-suitable technique to accurately guide caudal catheters in this patient population. Although complications associated with caudal block are rare, the risks and benefits must be carefully considered on an individual basis.

SU‐FF‐T‐37: Measurement of Cranio‐Caudal Catheter Displacement Between Fractions in CT‐Based HDR Brachytherapy of Prostate Cancer

Purpose: To measure the cranio‐caudal displacement of catheters occurring between consecutive fractions of transrectal ultrasound (TRUS) guided high dose rate (HDR) prostate brachytherapy. Method and Materials: Ten consecutive patients were treated with 2 fractions of 9.5 Gy TRUS guided HDR brachytherapy using dental putty for the fixation of catheters. For each patient, a CT scan with 3 mm slice thickness was acquired before each of the two fractions. Two different references were employed to measure the catheter displacement between fractions: the ischial bone as a bony marker (BM) and the center of two gold markers (COGM) implanted in the prostate. The catheter displacement was calculated by multiplying the thickness of CT slice with the difference in number of CT slices between the reference slice and the slice containing the tip of a catheter. Results: The average (range) magnitude of caudal catheter displacement was 4.1 mm: 2.7 mm (−6.0 to 13.5 mm) for BM method and 5.4 mm (−3.75 to 18.0 mm) for COGM method, respectively. The measurement results obtained from BM and COGM methods verified that both prostate movement and catheter displacement independently occurred between fractions. The most anterior and medial two catheters (catheter position 8 and 12) had the greatest tendency to be displaced in the caudal direction because they were located at the most distant position from the fulcrum, susceptible to the rotation of the dental putty in lateral plane due to patient movement between fractions. Conclusion: The catheter displacement using dental putty for the fixation of catheters is smaller than the conventional technique using pre‐fabricated template. The use of both BM and COGM methods for catheter displacement measurement can demonstrate the prostate movement relative to the catheter displacement between fractions.