Epidural Catheter For Postoperative Analgesia Research Articles

Continuous Epidural Catheter for Postoperative Analgesia in Children: A Case Report

The management of postoperative pain in children and infants has now become a significant concern. Continuous epidural anesthesia is a proven method for controlling acute pain after surgery. We present the case of thoracic epidural analgesia used for the repair of an extensive burn involving the back and trunk, assisted by a skin graft, in a 6-year-old girl. Department of Pediatric Intensive Care Unit, Children's Hospital of Rabat. In pediatric surgery, postoperative pain awareness is crucial for medical and paramedical teams. Continuous epidural anesthesia, utilizing suitable equipment, is feasible for young children. Its advantages during long procedures are manifold: it eliminates the need for central analgesics, ensuring stable cardiovascular function and a calm awakening post-surgery. Moreover, it provides high-quality analgesia in the postoperative phase, decreasing morbidity and easing care for children. With safe analgesics and advances in locoregional anesthesia, managing postoperative pain in pediatrics has markedly improved.

Post-Operative Thoracic Epidural Analgesia and Incidence of Major Complications according to Specific Safety Standardized Documentation: A Large Retrospective Dual Center Experience.

(1) Background: Thoracic epidural analgesia is considered the gold standard in post-operative pain management following thoracic surgery. This study was designed to explore the safety of thoracic epidural analgesia and to quantify the incidence of its post-operative complications and side effects in patients undergoing thoracotomy for major surgery, such as resection of lung malignancies and lung transplantation. (2) Methods: This is a retrospective, dual-center observational study including patients that underwent major thoracic surgery including lung transplantation and received concurrent placement of thoracic epidural catheters for post-operative analgesia. An electronic system of referral and documentation of complications was used, and information was retrieved from our electronic critical care charting system. (3) Results: In total, 1145 patients were included in the study. None of the patients suffered any major complication, including hematoma, abscess, or permanent nerve damage. (4) Conclusions: the present study showed that in experienced centers, post-operative epidural analgesia in patients with thoracotomy is a safe technique, manifesting minimal, none-serious complications.

Intercostal nerve cryoablation versus thoracic epidural catheters for postoperative analgesia following pectus excavatum repair: Preliminary outcomes in twenty-six cryoablation patients

BackgroundMultimodal pain management strategies are used for analgesia following pectus excavatum repair. However, the optimal regimen has not been identified. We describe our early experience with intercostal cryoablation for pain management in children undergoing the Nuss procedure and compare early cryoablation outcomes to our prior outcomes using thoracic epidural analgesia. MethodsA multi-institutional, retrospective review of fifty-two patients undergoing Nuss bar placement with either intercostal cryoablation (n=26) or thoracic epidural analgesia (n=26) from March 2013 to January 2016 was conducted. The primary outcome was hospital length of stay. Secondary outcomes included telemetry unit monitoring time, total intravenous narcotic use, duration of intravenous narcotic use, and postoperative complications. ResultsPatients who underwent intercostal cryoablation had a significant reduction in the mean hospital length of stay, time in a monitored telemetry bed, total use of intravenous narcotics, and the duration of intravenous narcotic administration when compared to thoracic epidural patients. Cryoablation patients had a slightly higher rate of postoperative complications. ConclusionIntercostal cryoablation is a promising technique for postoperative pain management in children undergoing repair of pectus excavatum. This therapy results in reduced time to hospital discharge, decreased intravenous narcotic utilization, and has eliminated epidurals from our practice. Level of evidenceRetrospective study – level III.

Frequency of colonization and isolated bacteria from the tip of epidural catheter implanted for postoperative analgesia

Background and objectiveThe increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization. MethodsFrom November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis. ResultsOf 68 cultured catheters, six tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45h (18–118) (p=0.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis. ConclusionPostoperative epidural catheter analgesia, under these study conditions, was found to be low risk for bacterial colonization in patients at surgical wards.

Frecuencia de colonización y bacterias aisladas de punta de catéter epidural implantado para analgesia postoperatoria

ObjectivesThe increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization. MethodsFrom November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis. ResultsOf 68 cultured catheters, 6 tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45h (18-118) (P=.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis. ConclusionPostoperative epidural catheter analgesia, under this study conditions, was found to be low risk for bacterial colonization in patients at surgical wards.

Frequência de colonização e bactérias isoladas de ponta de cateter de peridural implantado para analgesia pós‐operatória

Background and objectiveThe increased use of epidural analgesia with catheter leads to the need to demonstrate the safety of this method and know the incidence of catheter colonization, inserted postoperatively for epidural analgesia, and the bacteria responsible for this colonization. MethodsFrom November 2011 to April 2012, patients electively operated and maintained under epidural catheter for postoperative analgesia were evaluated. The catheter tip was collected for semiquantitative and qualitative microbiological analysis. ResultsOf 68 cultured catheters, six tips (8.8%) had positive cultures. No patient had superficial or deep infection. The mean duration of catheter use was 43.45hours (18‐118) (p=0.0894). The type of surgery (contaminated or uncontaminated), physical status of patients, and surgical time showed no relation with the colonization of catheters. Microorganisms isolated from the catheter tip were Staphylococcus aureus, Pseudomonas aeruginosa and Sphingomonas paucimobilis. ConclusionPostoperative epidural catheter analgesia, under this study conditions, was found to be low risk for bacterial colonization in patients at surgical wards.

A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair

Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.

Two Cases of Horner Syndrome After Administration of an Epidural Test Dose That did not Recur With Subsequent Epidural Activation

We describe 2 cases of Horner syndrome after epidural test dose injections in thoracic surgery patients. The Horner syndrome was transient and did not recur with full epidural activation and infusion. Two patients undergoing thoracic surgery procedures received preoperative midthoracic epidural catheters for postoperative analgesia. Following the 3-mL 1.5% lidocaine test dose, a unilateral Horner syndrome was observed. No other signs and symptoms of high epidural blockade were seen, and the Horner syndrome subsequently resolved. After epidurogram confirmation of proper catheter position and at the conclusion of surgery, the epidural was activated with an appropriate bolus and infusion dose without recurrence of the Horner syndrome. Two cases of Horner syndrome presenting after administration of an epidural test dose are reported. This uncommon initial finding could not be reproduced with subsequent epidural activation, perhaps suggesting that initial conditions within the epidural space had been altered. Successful utilization of neuraxial regional analgesia was achieved with careful postoperative monitoring of the patients.

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The pectus excavatum treatment has two different approaches: non-surgical techniques (modified dynamic thoracic compressor, exercises and the vacuum bell) or surgical techniques (silastic or solid silicone implant, open surgical repair like sternochondroplasty and minimally invasive repair). The introduction of Nuss procedure improved the pectus excavatum treatment, but its low acceptance was due to the high complication rate (e.g. cardiac perfuration). The thoracoscopy use for bar mediastinal passage reduced the complication rate. In comparison with sternochondroplasty, the Nuss procedure has smaller incision, less blood loss and less operative time. However, it has more reoperations, complications, longer hospital stay and more readmission rates, more time of thoracic epidural catheter for postoperative analgesia and more need for analgesic after being discharged. Although Nuss procedure has been used in children, patients under ten years must be only observed. The Nuss procedure is applicable to moderate or light symmetrical pectus excavatum, without costal protrusion, in young and adolescents patients. Furthermore, the sternochondroplasty is applicable to severe or asymmetric pectus excavatum, with or without inferior costal protrusion. Therefore, Nuss procedure and sternocondroplasty are not antagonistic procedures, and they must be used in accordance with a treatment organogram and the technique choice must be by functional and aesthetic outcome.

A Prospective Comparative Study of Two Indirect Methods for Confirming the Localization of an Epidural Catheter for Postoperative Analgesia

We prospectively evaluated, in randomized order, 2 indirect methods of confirming the localization of an epidural catheter for postoperative analgesia in 218 surgical patients: epidural stimulation test (EST) and epidural pressure waveform analysis (EPWA). The epidural space was localized by using a loss of resistance technique. All catheters were inserted 5 cm into the epidural space and primed with 5 mL of 0.9% normal saline. There were no differences between the methods: the positive predictive value and specificity were high (100% in both groups), but the sensitivity was moderate (80% for EST and 81% for EPWA) and the negative predictive value was low (16% for EST and 17% for EPWA). Combining both methods yielded better sensitivity (97%) and negative predictive value (57%) (P < 0.001). The sensitivity of EST was increased to 87% (P < 0.05) if sensory response was included as well as motor response for stimulation less than 10 mA. We suggest the inclusion of sensory response in the appropriate dermatome at a current <10 mA as a criterion for adequate epidural catheter localization for EST testing. EPWA sensitivity was significantly better with older patients: 94% for patients older than 80 yr compared with 63% for patients younger than 40, 73% for patients 40 to 60, and 85% for patients aged 60 to 80 yr (P = 0.03). We conclude that the two tests are comparable for confirming catheter placement.

5:49 69. Transincisionally placed epidural catheters for postoperative analgesia in instrumented lumbar spinal fusion surgery

BACKGROUND CONTEXT: The use of epidural catheters for postoperative analgesia in spine surgery has been previously reported. The technique described herein varies from previously described intraoperative epidural catheterization techniques with epidural catheter placement through a nonoperated interspace rather than though an open laminectomy defect thereby giving the same control of catheter insertion as percutaneously placed catheters. Furthermore leakage of the infusion solution into the wound via the laminectomy defect is minimized and analgesic efficacy is maximized.

Clinical signs of infection during continuous postoperative epidural analgesia in children: the value of catheter tip culture

Infection arising from the use of epidural catheters for postoperative analgesia is a major source of anxiety. The routine culture of epidural catheter tips were studied in 100 consecutive children aged 1 day to 15 years. Epidural catheters were inserted aseptically in accordance with an agreed protocol. The catheter site was inspected regularly and the tip sent for microbiological culture following removal. Local signs of inflammation at the epidural site were seen in 16% of children, and bacteria were isolated from catheter tip culture in 32%. Positive catheter tip culture was found in 43% of children with local signs of inflammation and of the remaining children with no local signs, organisms were isolated from the catheter tip in 30%. Culture of skin swabs and catheter tips in two patients with purulent discharge at the epidural site yielded the same organism. No correlation between the number of attempts at catheter insertion and either local signs of inflammation or positive catheter tip cultures were found. Minor local signs of inflammation and infection are common in pediatric patients during continuous epidural infusion. Epidural catheter tips are also frequently culture positive in patients with and without local signs and who may not go on to develop further signs or symptoms of infection. Routine culture of catheter tips is unnecessary as it is not a good predictor of epidural space infection.

The Incidence and Severity of Venous Air Embolism Determined by Transesophaseal Echocardiography in Hepatic Resection Using a Cavitron Ultrasonic Surgical Aspirator Dong

Background: A new technique resecting the hepatic parenchyma without inflow occlusion using a Cavitron Ultrasonic Surgical Aspirator (CUSA) reduces intraoperative blood loss and perioperative morbidity. This study was designed to identify the incidence and severity of venous air embolism (VAE) using transesophaseal echocardiography (TEE) in hepatic resection using CUSA. Methods: Forty patients undergoing hepatic resection using CUSA of ASA class 1 and 2 were selected. After insertion of an epidural catheter for postoperative analgesia, all patients were anesthetized with sevoflurane in 50% air/. After the induction of anesthesia, A TEE probe was inserted into the esophagus. Blood pressure, heart rate, central venous pressure, end tidal , and arterial carbon dioxide tension were recorded after induction, and during and after hepatic resection. During hepatic resection, an anesthesiologist evaluated the degree of VAE by transesophageal echocardiography in the 4-chamber view. Results: The mean time of using CUSA was 65.3 24.4 minutes. Of 40 patients, 9 had VAE grade I, 14 grade II, 14 grade III, and 3 grade IV. However, no significant difference was observed in hemodynamics or PaCO2 after induction, or during or after hepatic resection. The mean amount of blood loss was 887.0 ml 598.8 ml and the mean transfused amount was 123.1 351.3 ml. Conclusions: All patients showed air embolism during hepatic resection with CUSA. Serious complications associated with air embolism would occur in patients with an undiagnosed intracardiac right to left shunt. Therefore, meticulous monitoring by transesophageal echocardiography might be recommended in hepatic resection with CUSA.

Skin Disinfection before Epidural Catheterization: Comparative Study of Povidone-Iodine versus Chlorhexidine Ethanol

Background: Chlorhexidine is better than povidone-iodine for skin preparation before intravascular device insertion or blood culture collection, but it is not known whether chlorhexidine is superior in reducing the colonization of continuous epidural catheters. Methods: Patients requiring an epidural catheter for postoperative analgesia were randomly assigned to receive skin preparation with 0.5% chlorhexidine ethanol (CE group) or 10% povidone-iodine (PI group) before catheter insertion. Using surgical aseptic techniques, catheters were inserted into either the lumbar or the thoracic epidural space. Gloves used at catheter insertion, swabs of insertion site skin and the catheter tip at catheter removal were qualitatively cultured. Results: Of 70 randomly assigned patients, 62 were evaluable. The clinical characteristics of the patients and the risk factors for infection were similar in the two groups. Catheters were kept in place for 49 ± 7 h (mean ± SD). Seven cultures from gloves yielded microorganisms. In 1 case, the leak test of gloves was positive. Fifteen cultures of catheter insertion sites yielded microorganisms: 7/28 (25%) in the PI group and 8/34 (24%) in the CE group. Six cultures of catheter tips yielded microorganisms: 3/28 (11%) in the PI group and 3/34 (9%) in the CE group. As for the incidence of isolation of bacteria, no difference was seen between the two groups. In none of these 62 cases was any inflammatory reaction seen in the skin locally at catheter removal. Conclusions: The effect of 0.5% chlorhexidine ethanol is not different from that of 10% povidone-iodine in reducing catheter colonization associated with short-term epidural catheter placement.

The role of laparoscopic biopsies in lumbar spondylodiscitis.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

The Role of Laparoscopic Biopsies in Lumbar Spondylodiscitis

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

Perioperative stroke associated with postoperative epidural analgesia

A patient with an epidural catheter for postoperative analgesia developed a stroke in association with a hypotensive episode resulting from a bolus of local anesthetic. After undergoing resection for femoral chondrosacroma under epidural anesthesia, the patient received a continuous infusion of epidural morphine for postoperative analgesia. Lidocaine 1% (10 mL in divided doses) was administered through the catheter for breakthrough pain. The patient experienced a hypotensive episode and was noted to have a motor and cortical sensory deficit of the left arm and leg 8 hours after the hypotensive episode. Clinical presentation and subsequent workup were consistent with a watershed infarction. The patient recovered full neurologic function before discharge. Postoperative hypotension from epidural analgesia may be associated with stroke; however, a cause-and-effect relationship usually cannot be established with certainty.

Subcutaneous Tunnelling of Epidural Catheters for Postoperative Analgesia to Prevent Accidental Dislodgement: A Randomized Controlled Trial

The use of subcutaneous tunnelling to prevent movement of epidural catheters was examined in a prospective controlled trial. There were 113 patients in the standard group and 100 in the tunnelled group. The groups were similar with respect to age, sex and weight. There were 176 thoracic catheters, and 37 lumbar catheters. Mean duration of catheterization in the tunnelled group was 3.5 +/- 1.3 days and in the standard group, 3.1 +/- 1.5 days. In total, 60 catheters moved significantly from their initial position: 17 (28%) moved inwards and 43 (72%) moved outwards. 159 catheters were still functioning at the time of their removal, 76 standard and 83 tunnelled. This represents 67 and 83% of the two groups respectively. Subcutaneous tunnelling was shown to prevent clinically significant inwards (P = 0.043) and outwards (P = 0.0005) movement of epidural catheters and is more likely to result in a functional epidural blockade at the time of catheter removal (P = 0.0084).

Enoxaparin and Epidural Analgesia

Department of Anesthesia, University of California, San Francisco, 521 Parnassus Avenue, San Francisco, California 94143–0648.To the Editor:--Enoxaparin sodium (Lovenox), a low molecular weight heparin (LMWH) manufactured by Rhone-Poulenc Rorer Pharmaceuticals, has a new warning included in its recently changed package insert. This change can have significant implications for anesthesiologists. It states “Lovenox injection, like other anticoagulants, should be used with extreme caution in conditions with increased risk of hemorrhage, such as [1]… in patients with indwelling intrathecal or epidural catheters, …” Because of this warning, some orthopedic surgeons at our institution have decided against the use of an epidural catheter for postoperative pain management in patients receiving Lovenox for deep venous thrombosis (DVT) prophylaxis after total hip and knee replacement surgery.Lovenox was released for use in Europe in 1987 and in the United States in 1993. Bergqvist et al. [1]reported that of more than one million patients receiving LMWH, there was one case of a spinal hematoma. In other controlled studies of at least 10,000 patients who received epidural/spinal anesthesia or analgesia during LMWH prophylaxis, this combination of treatments did not produce any catheter-related complication. [1,2]A similar safety record was observed in three other studies of 1,792 patients. [2–4]In contrast, during post-market clinical use in the United States since 1993, Rhone-Poulenc Rorer Pharmaceuticals reports that there have been seven cases of epidural hematoma formation after epidural anesthesia/analgesia in association with Lovenox use. All but two cases were associated with an epidural catheter that was inserted or removed, either before the patient was started on Lovenox. Because of this new development, the drug manufacturer recently changed the package insert to reflect the perceived increased risk of epidural hematoma formation in patients with an epidural catheter during Lovenox prophylaxis.Epidural hematoma formation in patients receiving anticoagulation therapy is a known but rare complication irrespective of central neuraxial blockade. Is the risk of spontaneous or catheter-related spinal hematoma greater with Lovenox than with other effective forms of anticoagulant DVT prophylaxis? Is it safe to leave an indwelling epidural catheter for postoperative analgesia or to remove it during Lovenox therapy? Although we are now aware of the seven cases of epidural hematoma reported by Rhone-Poulenc Rorer in the past 2 yr, we cannot estimate the incidence of epidural hematoma formation in patients receiving Lovenox and have an epidural catheter, because the number of patients receiving intraoperative and/or postoperative epidural anesthesia and/or analgesia is unknown. The perceived “high” incidence of epidural hematoma formation in patients receiving Lovenox may be explained by the increased use of epidural analgesia after total joint replacement surgery. Therefore, it may appear that specifically having a catheter in place increases the risk of epidural hematoma formation.We must identify whether the risk of epidural hematoma formation is related to the timing of epidural catheter insertion or catheter removal, or related to the duration of catheter indwelling; whether there is a relation between the administered dose of Lovenox and epidural hematoma formation. Information regarding the circumstances under which epidural hematoma occurred in the reported cases is lacking or incomplete. A cause-effect relation cannot be established at this time. A prospective determination of the incidence of epidural hematoma formation in patients with epidural catheters removed at the end of surgery and in patients whose catheter is left in place for postoperative analgesia is needed. There is no evidence in the literature that removal of an epidural catheter portends greater risk of epidural hematoma formation than does epidural catheter insertion.Finally, further studies are needed to delineate the role and effectiveness of epidural anesthesia and analgesia in improving outcome. Postoperative epidural analgesia is an excellent method for providing postoperative pain control, particularly in patients undergoing total hip and knee joint replacement. It would be unfortunate to abandon this form of postoperative pain management without further eludication of the risk:benefit profile for Lovenox and epidural anesthesia and analgesia.Sandra R. Weitz, MD; Vincent Chan, MD; Department of Anesthesia, University of California, San Francisco, 521 Parnassus Avenue, San Francisco, California 94143–0648.(Accepted for publication April 29, 1996.)

Peridural catheter for postoperative long-term analgesia in children

Continuous epidural anaesthesia is a well established procedure for postoperative analgesia as well as sympathicolysis in adult patients. It is, however, much less frequently reported in infants and children. From October 1991 to November 1994 65 infants, children and adolescents aged 4 weeks to 19 years, body weight 3.9 kg to 79 kg, received 77 epidural catheters for postoperative analgesia. 54 catheters were inserted via the caudal approach either with (n = 19) or without (n = 35) subcutaneous tunnelling. 23 catheters were placed via a low midline lumbar epidural puncture either through interspace L5/S1 or L4/L5. The local anaesthetic of choice in this study was bupivacaine 0.125% without adrenaline infused continuously via a constant-flow infusion pump. 20 patients received additional boluses of morphine and in 3 patients clonidine was added. The catheters were left in place for an average of 84.5 h. After removal the catheter-tip was submitted for bacteriological examination. The results of 64 specimens were available. For satisfactory analgesia an average of 0.18 mg x kg-1 x h-1 bupivacaine 0.125% had to be administered via the lumbar route, while the mean dose for caudal catheters was 0.3 mg x kg-1 x h-1. Intestinal peristalsis re-occurred within 33 h after surgery. The first stool was passed within 48 h. Of the 64 catheters which were microbiologically examined, 15 exhibited bacterial colonisation with a statistically significant difference between those subcutaneously tunnelled and those inserted directly (p < 0.05). There were, however, no signs of local or systemic infection. The results of continuous epidural anaesthesia and sympathicolysis in infants and children are encouraging. This technique is readily employable and complications seem to be rare. Satisfactory analgesia and sympathicolysis were achieved. Based on the results of our bacteriological studies we recommend that caudal catheters are tunnelled subcutaneously in cranio-lateral direction.