This is the only generally accepted access to the epidural space for children under the age of 2–3 years old and with a body weight of up to 10 kg.
INDICATIONS
1. Intra- and postoperative analgesia in operations on areas innervated by sacral roots (circumcisio, perianal, surgical correction of clubfoot.
2. And after all other operations on the lower limbs, caudal analgesia provides reliable anesthesia, and with a catheter – more and prolonged immobilization.
3. Common operations in the groin area (for hernias, cryptorchidism, dropsy of the testicle).
POSES
Pose on the abdomen (prone) is rarely used, since it is difficult to follow the airways of a deeply sedated child.
“Burp pose” (as after feeding a baby), when the baby is lying on his tummy on your mate’s shoulder girdle, is convenient for bare-legged babies (which is very rare).
Lateral posture with bent (like an embryo) legs is most convenient for simultaneously maintaining general anesthesia. If you are right, it is better to lay the child on your left side, with your head left. Then you will make an injection with your right hand (Fig. 120), and the sacral horns with the upper edge of hiatus sacralis will resemble the letter C.
TECHNOLOGY OF CAUDAL PUNCH
The point of injection is 1-2 mm cranial (above) the line connecting the ends of the sacral horns in infants (up to year I), and in older children it is 1-2 mm more caudal than (below) this line.
A thin needle ( G22 — G23) or “butterfly”, up to 2.5 cm long, with an attached syringe and a full dose of anesthetic collected in advance, injects, with a ventral (to the tummy) directional slice (so as not to pierce the front wall of the sacral canal) , in the median plane, forward and cranial (Fig. 120), at an angle of 30 ° -45 ° to the skin.
At a depth of 0.2-0.4 cm (from newborns to) 1-1.5 cm (in adolescents), your hand will feel a very weak dip (as when piercing a vein in adults).
Turning the needle (changing the angle of insertion) is not necessary, and in infants it is dangerous. Only in older children can the syringe be carefully turned in the direction of the interglacial fold so that it (and the needle) is directed parallel to the spine, and then the needle can be moved forward more.
more than 2 mm (not a centimeter, but a millimeter!), so that the entire needle section was in the caudal epidural space.
Fixing the needle with the left hand resting on the back of the child must be very reliable so that manipulations with the syringe piston will not be moved.
INTRODUCTION OF LOCAL ANESTHETICS
Aspiration for obtaining CSF or blood is even more important than for adults, since children are not given a test dose.
The test dose is not needed, because it does not show anything to the child under anesthesia.
Introduction of local anesthetic fraction of ‘A total dose was repeated with GOVERNMENTAL aspiration before each administration. At the same time, the one who follows the anesthesia keeps track of the pulse, and the one who injects the local anesthetic has skin over the needle. If “blowing” (subcutaneous injection), the needle should be advanced 1-2 mm deeper and continue the injection.
Caudal catheterization
Catheterization of the cannula on the needle. It is very convenient to perform a single vein catheterization cannula (Venflon from BD or Vasoftx from B | Braun) of G22 or G20 caliber . Even if the catheterization is needed primarily for postoperative analgesia, it is better to perform it before the operation in order to administer the first dose even before the start of the operation, to ensure the so-called preventive analgesia [Eng. pre-emptive analgesia; ukr Videredal analgesic \. A needle, with a cannula on it, is put on a syringe with a collected dose of a local anesthetic, a caudal puncture is performed, and then either the entire dose is injected and after that the cannula is advanced [DKRasch, 1994 \ or push the cannula, remove the needle and, by attaching the syringe to the cannula, inject the dialed dose . The first method more reliably ensures that the entire dose enters the epidural space, and the second method reduces the risk of getting into the blood vessels or into the subarachnoid space during injection.
Catheterization with a thin epilural catheter. It is performed either (1) after caudal puncture with catheterization with a short cannula, through which a thin epidural catheter can be carried out to the desired depth (in young children, it safely passes even to TB level ), or (2) after caudal puncture with a straight Crofor thin needle through which the catheter is passed.
COMPLICATIONS
When caudal anesthesia in children, all the same complications are possible as in adults. But children need to be especially careful for the following reasons.
The puncture of the dura mater and unexpected high spinal anesthesia are especially probable due to the proximity of the dura mater to the tip of the needle and the sharpness of this tip.
Intoxication with a local anesthetic, either due to an overdose or due to intravasal administration, is also more likely in young children. Arrhythmias and even cardiac arrest are described.
Puncture of the anterior plate of the sacrum (which is mistaken for the sacro-coccygeal membrane) and penetration into the internal organs of the pelvis. If during aspiration you received urine or feces — it is better to refuse from caudal anesthesia and prescribe an antibiotic intravenously in two days .