Continuous Caudal Analgesia Research Articles

Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical Center.

Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.

Ultrasound guided continuous caudal epidural analgesia in neonates undergoing thoracotomy

ABSTRACT Background and Aims: Adequate postoperative analgesia guarantees adequate ventilation and minimizes respiratory complications after thoracotomy. This study compares postoperative outcomes of continuous caudal epidural blockade to systemic intravenous analgesia in neonates undergoing thoracotomy for trachea-esophageal fistula (TOF) repair. Methods: A randomized, single-center, prospective, controlled study was conducted at El-Shatby University Hospital, from August 2016 to September 2020 where 40 neonates, weighing 2.5–4 kg belonging to the ASA physical Grade II to IV, posted for a TOF repair via thoracotomy. After general anesthesia, in group A, the epidural catheter was inserted through standard caudal epidural technique. Initial bolus of 0.25% bupivacaine (0.2 ml/kg) and postoperatively continuous infusion of 0.125% bupivacaine (0.1 ml/kg/h) was given. In group B, they received fentanyl (2 μg/kg) and paracetamol (10 mg/kg) IV Intraoperatively and postoperatively paracetamol (10 mg/kg/6 h) intravenously. Results: In group A, good quality of analgesia for 48 h postoperative with a lesser doses of rescue opioids (1 µg/kg fentanyl) required to maintain adequate analgesia, which shortened the length of hospital stay compared to group B. Conclusion: Very efficient postoperative analgesia can be achieved via continuous caudally inserted epidural blockade compared to intravenous fentanyl in neonatal post-thoracotomy pain.

Re: Continuous Caudal Epidural Analgesia and Early Feeding in Delayed Bladder Exstrophy Repair: A Nine-Year Experience.

Re: Continuous Caudal Epidural Analgesia and Early Feeding in Delayed Bladder Exstrophy Repair: A Nine-Year Experience.

Continuous caudal analgesia as a safe and effective method for pediatric post - chordectomy analgesia

Continuous caudal analgesia as a safe and effective method for pediatric post - chordectomy analgesia

Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience

Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shiftsand require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects. We present nine years of caudal epidural anaesthesia in delayed bladder exstrophy repair and describe its facilitation of early extubation and early feeding (within 12h) without surgical complication. We retrospectively evaluated consecutive infants with classic bladder exstrophy undergoing delayed primary closure with anterior pelvic osteotomies between November 2007 and January 2016. Outcomes and complications were evaluated in terms of postoperative comfort (using the FLACC score-Face, Legs, Activity, Cry, Consolability), epidural failure rate, re-intubation rateand gastrointestinal complications. Forty-four infants had average age of 5.8 months (range 1.6-17.1 months) and weight of 7.0kg (range 3.5-11.8kg), and their duration of surgery was 9.5h (range 6.9-14.3h). Forty-two of 44 (95.5%) patients received caudal epidural catheters. At 24h, 15 of 42 (35.7%) caudal epidurals required supplementation with intravenous opioids. Fewer patients with optimally functioning epidurals required postoperative ventilation (1/27 [3.7%] compared with 3/15 [20.0%]). None of the patients with caudal epidural catheters required re-intubation. Pain scores were lower in infants with isolated caudal epidurals catheters than those with caudal epidurals supplemented by intravenous opioids(day 1 [18 vs 53; P=0.008]; day 2 [8 vs 15; P>0.05] and overall [32 vs 65; P=0.014]). Infants with intravenous opioids experienced higher complications: pruritus (25% [95% confidence interval {CI}: 5%-57%] vs 0% [95% CI: 0%-13%]; P=0.026)and nausea and vomiting (25% [95% CI: 5%-57%] vs 8% [95% CI: 1%-25%]; P=0.30) requiring treatment. Nineteen of 44 (43.1%) infants were fed early (within 12h of surgery). Infants who were fed early had lower pain scores than infants feeding late(day 1 [17.5 vs 31; P>0.05]; day 2 [5.5 vs 15; P=0.045]; overall [26 vs 55.5; P=0.015]) without increase in complications (nausea and vomiting [6.3% vs 20.0%; P=0.06]; ileus [0.0% vs 0.0%]; aspiration [0.0% vs 0.0%]and re-intubation aspiration [0.0% vs 0.0%]). Caudal epidural analgesia facilitates postoperative extubation in infants undergoing delayed exstrophy repair. Early feeding (within the first 12h) in delayed bladder exstrophy repair is likely to improve patient comfort and consolability without increasing the incidence of gastrointestinal complications. Intravenous opioid may be associated with increased postoperative complications that may influence peri-operative outcomes.

Continuous caudal epidural analgesia for perioperative pain control after bilateral mastectomy in a mare

An epidural catheter was used to provide perioperative analgesia as part of a multimodal balanced anaesthesia and analgesia in a mare undergoing a bilateral mastectomy. Despite development of severe hypoxaemia...

Labor epidural analgesia: Past, present and future

One of the most severe pains experienced by a woman is that of childbirth. Providing analgesia for labor has always been a challenge more so because of the myths and controversies surrounding labor. It is imperative to understand the pain transmission during various stages of labor in order to select a proper technique for providing labor analgesia. The adverse effects of labor pain are numerous and affect both the mother as well as the fetus. Currently lumbar epidural is considered to be the gold standard technique for labor analgesia. Local anaesthetics like bupivacaine and ropivacaine are commonly used and adjuvants like clonidine, fentanyl and neostigmine have been extensively studied. However, despite being so popular, epidural analgesia is not without complications, with hypotension being the most common. Other complications include accidental dural puncture, infection, intravascular placement, high block and epidural hematoma. Other neuraxial techniques include continuous caudal analgesia, and combined spinal epidural analgesia. The numerous studies investigating the various aspects of this method have also served to dispel various myths surrounding epidural analgesia like increased incidence of cesarean section and instrumental delivery, prolongation of labor and future back pain. The future of labor analgesia lies in the incorporation of ultrasound in identifying the epidural space helping in proper catheter placement. The keywords labor epidural in the PUBMED revealed a total of 5018 articles with 574 review articles and 969 clinical trials. The relevant articles along with their references were extensively studied.

Painless labour: how far have we travelled?

Almost every woman in their lifetime bears the pain of parturition since the birth of mankind. The belief that bearing the pain of parturition and delivering a healthy baby makes a woman 'complete' in all aspects is a myth. Given a chance, every woman experiencing the dynamicity of childbirth will want to get rid of the labour pain as soon as possible. History is full of myths and controversies regarding the relief of pain in labour. The concept of modern labour analgesia was born in the early nineteenth century when a woman was administered ether during childbirth by Dr. James Young Simpson. The concept of regional anaesthesia for painless delivery came into existence during mid-twentieth century when the first report for continuous caudal analgesia for childbirth was published by Edward and Hugson1. The true perspectives of painless labour came into existence with advancements over the last three decades as the birth of obstetric anaesthesia as a sub-speciality has cemented a permanent place in the field of obstetrics and anaesthesia.

Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients.

Nerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors' institution. The authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. In five patients (aged 5 months-1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day-1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. The results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.

Continuous caudal analgesia in labour for a patient with Harrington rods

We report the case of a 29-year-old patient who had Harrington rods inserted from T8 to L4 at the age of 14. She had been discouraged from having epidural anaesthesia in the antenatal clinic but, whilst in labour, requested analgesia in addition to Entonox and pethidine. Continuous caudal analgesia was commenced and provided good pain relief for labour and delivery.

Continuous caudal epidural and subarachnoid anesthesia in mares: A comparative study: R.T. Skarda, Dr Med Vet, and W.W. Muir, DVM, PhD. Am J Vet Res 44:12, 2290–2298 (1983)

A new technique for producing continuous caudal epidural analgesia (CEA) and caudal subarachnoid analgesia (CSA) in adult horses (mares) without causing loss of pelvic limb function is described. A modified 17-gauge Huber-point directional needle was used to place a catheter with stylet into either the epidural or subarachnoid space at the lumbosacral intervertebral junction. The catheter was positioned at either the midsacral (S2-3) subarachnoid space or caudal portion of the sacral (S-3 to S-5) epidural space in 7 mares. The position of the catheter was confirmed radiographically. A 2% solution of mepivacaine HCl was used at an average dose of 0.061 +/- 0.013 mg/kg (1.3 +/- 0.3 ml) to produce CSA and 0.196 +/- 0.034 mg/kg (4.1 +/- 0.7 ml) to produce CEA. Onset of analgesia to superficial and deep muscular pinprick stimulation was faster with CSA than it was with CEA (8.2 +/- 2.4 minutes vs 21.4 +/- 3.8 minutes). Maximal caudal analgesia extended from spinal cord segments S-1 to coccyx during CSA and CEA. Periods of analgesia were shorter with CSA than with CEA (70.0 +/- 21.8 minutes vs 102.1 +/- 13.2 minutes). Perineal (S-4 to S-5) dermatome subcutaneous temperature was increased after epidural and subarachnoid injections of mepivacaine HCl solution. Heart rate, respiratory rate, systolic, diastolic, and mean arterial blood pressures, pulse pressure, rectal temperature, arterial blood gas tensions (PaCO2, PaO2), pHa, hematocrit, and total solid concentrations did not change significantly (P greater than 0.05) from base-line values after injection. The benefits and potential complications of CSA and CEA in horses are discussed.

Physiopathology and control of postoperative pain.

Potent systemic (narcotic) analgesics, when given in doses sufficient to produce ample pain relief, usually also produce mental and respiratory depression and, at times, circulatory impairment, that prolong postoperative morbidity. Complications due to morphine sulfate or meperidine hydrochloride can be minimized by titrating the patient's pain with small intravenous doses of narcotics (morphine sulfate, 2 to 3 mg, or meperidine hydrochloride, 15 to 25 mg) administered slowly at 15- to 20-minute intervals until the pain is relieved. On the third or fourth postoperative day, acetaminophen tablets usually suffice to provide relief of pain with little or no risk to patients. Continuous segmental epidural block or intercostal block, with or without splanchnic block, provide excellent pain relief that, in contrast to the narcotic, is complete. These are especially useful after operations on the chest or abdomen or the lower extremity. Regional analgesia is especially indicated in patients not adequately relieved from severe postoperative pain with narcotics, or when these drugs are contraindicated by advanced pulmonary, renal, or hepatic disease. Continuous caudal analgesia is also effective to completely releive severe postoperative pain in the lower limbs and perineum.

Clinical Evaluation of Etidocaine in Continuous Caudal Analgesia for Pelvic Floor Repair and Post-Operative Pain Relief

A randomized double-blind trial compared 1-0% etidocaine and 1-5% lignocaine (both with 1/200,000 adrenaline), for caudal anaesthesia for pelvic floor repair. Etidocaine was highly effective for the surgical procedure, with rapid onset of action, adequate muscle relaxation and longer duration of action. Its use for post-operative analgesia may be hindered by the concomitant immobilization of the legs. The problem of tachyphylaxis with etidocaine needs further investigation.

Continuous caudal analgesia and anesthesia for labor and vaginal delivery. A review of 4071 confinements.

Continuous caudal analgesia and anesthesia for labor and vaginal delivery. A review of 4071 confinements.

Bupivacaine in labour

Bupivacaine in labour

Double pregnancy in a uterus duplex unicollis

Mrs. B. P., a 22-year-old, white, female, para l-O-0-1, was seen during her second pregnancy at 8 weeks’ gestation on Aug. 16, 1965. Her last menstrual period was June 17, 1965. On examination the uterus measured 8 cm. above the symphysis and no abnormality was detected. Past history revealed one previous uneventful term delivery on Feb. 12, 1962, of a 6 pound, 13 ounce male infant. No uterine abnormality was detected with this pregnancy. One month later asymmetrical enlargement of the uterus was noted without fetal heart tones being detectable and twins or a left ovarian cyst were suspected. In succeeding months the uterine horns enlarged rapidly and fetal heart tones were detected separately in each horn. The prenatal course was uneventful except for threatened premature labor in the twenty-fifth week. In the thirty-fifth week on Feb. 18, 1966, the membranes ruptured prematurely. Poor quality labor ensued. After 15 hours, intravenous Pitocin augmentation was started. After 2 hours of Pitocin stimulation under continuous caudal analgesia, the head descended to the perineum and the cervix was completely dilated. Brow anterior position was ascertained and with forceps it was flexed, rotated to LOA position and a healthy 5 pound, 14 ounce female infant was delivered from the left horn over a left mediolateral episiotomy. The placenta was delivered easily and without excess blood loss. Pitocin stimulation was continued for 30 minutes during which time examination through the widely dilated external cervical OS revealed the vertex of the baby in the right horn PO be floating high with membranes intact and its separate internal OS to be only 3 to 4 cm. dilated. Only poor contractions every 2 to 3 minutes were noted. Intravenous Pitocin was stopped, contractions ceased and the internal OS closed to 2 cm. The episiotomy was repaired and the patient was returned to her bed and subsequently dismissed after an uneventful postpartum course. Two weeks later the involuting left horn of the uterus had prolapsed and the edematous cervix was visible at the introitus. One month after delivery of the first infant, vaginal examination revealed that the prolapsed left horn of the uterus occupied the posterior pelvis and was not displaceable upward. The external OS of the cervix was still very redundant and open. The internal OS of the right horn was 1 to 2 cm, dilated. The presenting part had not entered the pelvis because of the obstructing prolapsed left horn of the uterus. The estimated date of confinement was March 23, 1966. Induction with sparteine sulfate on March 19 failed. After Pitocin the membranes ruptured and moderately good contractions every 3 minutes failed to advance the head. Cesarean section was performed with delivery of an 8 pound, 2 ounce male infant scoring 10 on the Apgar scale. The region below the internal OS was examined and the communication between the two horns was located just above the external OS of the cervix. A decidual cast measuring approximately 6 x 4 x 3 cm. was removed with sponge forceps from the involuting left horn through its 2 cm. dilated internal OS. The tube and ovary attached to each horn were grossly normal. The postpartum course was uneventful.

Continuous caudal analgesia and anesthesia in obstetrics: A critical evaluation of 510 consecutive cases

1. Five hundred and ten patients in whom caudal analgesia was attempted were studied.2. Eighty per cent of patients in labor were found to be suitable for caudal analgesia with 97.5 per cent complete success.3. An increased incidence in the use of oxytocic agents and operative obstetrics was found.4. The advantages of caudal analgesia with elective induction of labor are stressed.5. Three babies were lost, of whom 2 had congenital abnormalities incompatible with life. This gives a corrected neonatal mortality rate of 0.2 per cent.

Postpartum hypertension after use of vasoconstrictor and oxytocic drugs. Etiology, incidence, complications, and treatment.

In a study of 8,000 deliveries performed under continuous caudal block analgesia, the records of 741 women indicated that the combined effect of a vasoconstrictor and an oxytocic drug, given three to six hours apart, led to severe hypertension in 34 (4.6% of 741) patients. These findings suggest that the patient's need for prophylactic administration of vasoconstrictor drugs in conjunction with caudal block analgesia in obstetrics should be evaluated before giving them. Treatment with chlorpromazine hydrochloride, to prevent the severe and disabling complications of postpartum hypertension, is essential.

Continuous Caudal Analgesia

Continuous Caudal Analgesia

The short umbilical cord

1.1. During the 12 month period from July 1, 1948, to June 30, 1949, there were 1,525 deliveries at the Brooklyn Womens Hospital. Of these, 269 presented the complication of the short umbilical cord, an incidence of 17.6 per cent.2.2. There was no significant increase in the duration of the first or second stage of labor.3.3. There was no difference in the types of deliveries in the study group as compared to the control group, i.e., no added operative interference was required.4.4. The type of anesthesia used played no part in the outcome of the cases. A suggestion regarding the use of continuous caudal and low spinal analgesia is made.5.5. The incidence of fetal distress and the need for resuscitation of the newborn are increased in the “short cord” group of cases.6.6. Shortening of the umbilical cord does not seem to be a major contributing cause of stillbirth.