The caudal catheter in neonates: where are the restrictions?

Purpose of review In neonates, epidural catheters inserted at the sacral hiatus can easily be advanced to a lumbar or thoracic level. These ‘caudal catheters’ are popular because they allow the neonate to benefit from epidural analgesia without the concerns of spinal cord injury potentially associated with primary thoracic placement in an asleep neonate. This review looks at use and benefits, and risks and complications of caudal epidural catheters in neonates. Recent findings Restrictions of neonatal caudal catheters are related to risks associated with placement and advancement of the catheters, infectious risks of caudal catheters, and toxicity risks related to the higher free fraction and lower clearance of bupivacaine in neonates. Caudal catheters in neonates are popular, but evidence that they improve outcome is lacking. Summary Epidural anesthesia and analgesia for neonates should be performed and managed by pediatric anesthesiologists. Potential risks and complications must be appreciated and all steps to maximize safety of the technique must be taken. In particular, close postoperative observation and pain service management are indispensable. Future research should investigate the risks of caudal and segmentally placed catheters in neonates, study the role of epidural analgesia in outcome improvement for neonates, and guide us to safer use of local anesthetics suitable for neonates with their pharmacologic immaturity.

[1]  D. Harrison,et al.  Prevention and management of pain and stress in the neonate , 2015 .

[2]  J. D. Tobias,et al.  Caudal Epidural Block: A Review of Test Dosing and Recognition of Systemic Injection in Children , 2001, Anesthesia and analgesia.

[3]  R. Kearney,et al.  Thoracic Epidural Analgesia Via the Caudal Approach in Pediatric Patients Undergoing Fundoplication Using Nerve Stimulation Guidance , 2001, Anesthesia and analgesia.

[4]  W. Fujinaka,et al.  Decreased risk of catheter infection in infants and children using subcutaneous tunneling for continuous caudal anesthesia. , 2001, Acta medica Okayama.

[5]  N. Rifai,et al.  The Pharmacokinetics of Epidural Ropivacaine in Infants and Young Children , 2001, Anesthesia and analgesia.

[6]  L. Vas,et al.  A study of epidural pressures in infants , 2001, Paediatric anaesthesia.

[7]  R. Howard,et al.  Inflammatory Pain and Hypersensitivity Are Selectively Reversed by Epidural Bupivacaine and Are Developmentally Regulated , 2001, Anesthesiology.

[8]  R. Diwan,et al.  Continuous caudal epidural analgesia for congenital lobar emphysema: a report of three cases. , 2001, Anesthesia and analgesia.

[9]  K. Samii,et al.  Pharmacokinetics of Bupivacaine after Continuous Epidural Infusion in Infants with and without Biliary Atresia , 2001, Anesthesiology.

[10]  M. Yaster,et al.  Tunneled Epidural Catheters for Prolonged Analgesia in Pediatric Patients , 2001, Anesthesia and analgesia.

[11]  M. Pinaud,et al.  Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases , 2001, Paediatric anaesthesia.

[12]  M. Greenberg,et al.  Separation of omphalopagus conjoined twins using combined caudal epidural — general anesthesia , 2001, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[13]  D. P. Boggs,et al.  Caudal epidural blood patch for treating intractable vomiting in a child after placement of a permanent intrathecal catheter. , 2001, Anesthesia and analgesia.

[14]  P. Nordmann,et al.  Chlorhexidine versus Povidone Iodine in Preventing Colonization of Continuous Epidural Catheters in Children: A Randomized, Controlled Trial , 2001, Anesthesiology.

[15]  J. Bouchut,et al.  Clonidine in Preterm‐Infant Caudal Anesthesia May Be Responsible for Postoperative Apnea , 2001, Regional anesthesia and pain medicine.

[16]  R. Likar,et al.  Intraspinal haematoma following lumbar epidural anaesthesia in a neonate , 2001, Paediatric anaesthesia.

[17]  O. Claris,et al.  Evaluation of caudal anaesthesia performed in conscious ex‐premature infants for inguinal herniotomies , 2001, Paediatric anaesthesia.

[18]  M. Stringer,et al.  Is epidural analgesia associated with an improved outcome following open Nissen fundoplication? , 2001, Paediatric anaesthesia.

[19]  K. Ilett,et al.  Caudal ropivacaine in infants: population pharmacokinetics and plasma concentrations , 2000, Anesthesiology.

[20]  A. Visram,et al.  A survey of the usage of caudal catheters amongst paediatric anaesthetists practising in the UK , 2000, Paediatric anaesthesia.

[21]  G. Lederhaas,et al.  An alternative for avoidance of general anaesthesia for infants when bilateral inguinal herniorrhaphy outlasts subarachnoid blockade , 2000, Paediatric anaesthesia.

[22]  G. Frawley,et al.  Plasma concentrations of bupivacaine after combined spinal epidural anaesthesia in infants and neonates , 2000, Paediatric anaesthesia.

[23]  A. Moriarty.  Infusions of local anaesthetic via caudal catheters in neonates and small infants for analgesia after major surgery , 2000, Paediatric anaesthesia.

[24]  T. Mancuso,et al.  Positive test dose in a neonate with a caudally placed epidural catheter , 2000, Paediatric anaesthesia.

[25]  I. Murat,et al.  Comparison of remifentanil versus regional anaesthesia in children anaesthetised with isoflurane/nitrous oxide , 2000, Anaesthesia.

[26]  H. Wulf,et al.  The pharmacokinetics of caudal ropivacaine 0.2% in children , 2000, Anaesthesia.

[27]  H. Ulusoy,et al.  Effects of Caudal Block on Cortisol and Prolactin Responses to Postoperative Pain in Children , 2000, European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie.

[28]  T. Berger,et al.  Caudal anesthesia with ropivacaine in an awake 1,090-g baby. , 2000, Anesthesiology.

[29]  A. Retik,et al.  Efficacy of Simulated Epinephrine-Containing Epidural Test Dose After Intravenous Atropine During Isoflurane Anesthesia in Children , 2000, Regional Anesthesia & Pain Medicine.

[30]  O. Zinder,et al.  Does the Addition of Fentanyl to Bupivacaine in Caudal Epidural Block Have an Effect on the Plasma Level of Catecholamines in Children? , 2000, Anesthesia and analgesia.

[31]  R. Howard,et al.  Paediatric lumbar epidurals: a comparison of 21‐G and 23‐G catheters in patients weighing less than 10 kg , 2000, Paediatric anaesthesia.

[32]  W. Büttner,et al.  Analysis of behavioural and physiological parameters for the assessment of postoperative analgesic demand in newborns, infants and young children: a comprehensive report on seven consecutive studies , 2000, Paediatric anaesthesia.

[33]  Bruno Staffelbach,et al.  Generating a Learning Curve for Pediatric Caudal Epidural Blocks: An Empirical Evaluation of Technical Skills in Novice and Experienced Anesthetists , 2000, Regional Anesthesia & Pain Medicine.

[34]  O. Dearlove,et al.  The caudal canal in children: a study using magnetic resonance imaging , 2000, Paediatric anaesthesia.

[35]  L. Vas,et al.  Tunnelling of caudal epidural catheters in infants , 2000, Paediatric anaesthesia.

[36]  J. Gunter.  Thoracic Epidural Anesthesia Via the Modified Taylor Approach in Infants , 2000, Regional Anesthesia & Pain Medicine.

[37]  A. Casta.  Attempted placement of a thoracic epidural catheter via the caudal route in a newborn. , 1999, Anesthesiology.

[38]  R. Seal,et al.  Thoracic epidural analgesia via the caudal approach using nerve stimulation in an infant with CATCH22 , 1999, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[39]  B. Frey,et al.  Toxic methaemoglobin concentrations in premature infants after application of a prilocaine-containing cream and peridural prilocaine , 1999, European Journal of Pediatrics.

[40]  J. Finkel.  The epidural dorsomedian septum as a possible cause for unilateral anaesthesia in an infant , 1999, Paediatric anaesthesia.

[41]  L. Vas,et al.  Some vagaries of neonatal lumbar epidural anaesthesia , 1999, Paediatric anaesthesia.

[42]  E. Krane,et al.  Outcomes after single injection caudal epidural versus continuous infusion epidural via caudal approach for postoperative analgesia in infants and children undergoing patent ductus arteriosus ligation , 1999, Paediatric anaesthesia.

[43]  O. Zinder,et al.  Effect of caudal block on the plasma adrenaline and noradrenaline concentrations in paediatric patients undergoing ilioinguinal herniorrhaphy. , 1999, European journal of anaesthesiology.

[44]  R. Likar,et al.  Can a dose of 2μg??kg−1> caudal clonidine cause respiratory depression in neonates? , 1999, Paediatric anaesthesia.

[45]  A. Bösenberg.  Epidural analgesia for major neonatal surgery , 1998, Paediatric anaesthesia.

[46]  A. Bosenberg.  Epidural analgesia for major neonatal surgery. , 1998 .

[47]  E. Hellstrand,et al.  [Early signs of toxicity and "subtoxic" conditions in infant monitoring. Bupivacaine plasma levels following caudal anesthesia]. , 1998, Der Anaesthesist.

[48]  M. Yaster,et al.  Bacterial Colonization and Infection Rate of Continuous Epidural Catheters in Children , 1998, Anesthesia and analgesia.

[49]  R. Likar,et al.  Toxizität und „subtoxische” Frühzeichen im Wachzustand bei Säuglingen Bupivacainplasmaspiegel nach Kaudalanästhesien , 1998, Der Anaesthesist.

[50]  P. Bromage,et al.  Paraplegia Following Intracord Injection During Attempted Epidural Anesthesia Under General Anesthesia , 1997, Regional Anesthesia & Pain Medicine.

[51]  M. Yaster,et al.  Detection of intravascular injection of regional anaesthetics in children , 1997, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[52]  J. Peutrell.  Combined spinal and epidural anesthesia for major abdominal surgery in infants. , 1997, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[53]  J. Brock,et al.  Continuous caudal anaesthesia with chloroprocaine as an adjunct to general anaesthesia in neonates , 1997, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[54]  G. Olsson,et al.  Plasma Concentrations of Bupivacaine in Neonates After Continuous Epidural Infusion , 1997, Anesthesia and analgesia.

[55]  Gideon Koren,et al.  Effect of neonatal circumcision on pain response during subsequent routine vaccination , 1997, The Lancet.

[56]  L. Warnick,et al.  Systemic and local effects associated with long-term epidural catheterization and morphine-detomidine administration in horses. , 1997, Veterinary surgery : VS.

[57]  R. Giebler,et al.  Incidence of Neurologic Complications Related to Thoracic Epidural Catheterization , 1997, Anesthesiology.

[58]  N. Farber,et al.  Culture of Bacteria From Lumbar and Caudal Epidural Catheters Used for Postoperative Analgesia in Children , 1996, Regional Anesthesia & Pain Medicine.

[59]  B. Dalens,et al.  Epidemiology and Morbidity of Regional Anesthesia in Children: A One-Year Prospective Survey of the French-Language Society of Pediatric Anesthesiologists , 1996, Anesthesia and analgesia.

[60]  L. Broadman.  Use of Spinal or Continuous Caudal Anesthesia for Inguinal Hernia Repair in Premature Infants: Are There Advantages? , 1996, Regional Anesthesia & Pain Medicine.

[61]  T. Beushausen,et al.  Periduralkatheter zur postoperativen Daueranalgesie bei Kindern , 1996 .

[62]  N. Farber,et al.  Epidural Analgesia Improves Outcome Following Pediatric Fundoplication: A Retrospective Analysis , 1996, Regional Anesthesia & Pain Medicine.

[63]  F. Vidal,et al.  Thoracic Epidural Anesthesia Via the Lumbar Approach in Infants and Children , 1996, Anesthesiology.

[64]  M. Takasaki,et al.  Dural Puncture with a 26-Gauge Spinal Needle Affects Spread of Epidural Anesthesia , 1996, Anesthesia and analgesia.

[65]  J. Badgwell,et al.  Complications of epidural and spinal anesthesia in children , 1995 .

[66]  V. Comfort,et al.  Caudal epidural blood patch for the treatment of a paediatric subarachnoid-cutaneous fistula , 1995, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[67]  G. Barrier,et al.  Accidents following extradural analgesia in children. The results of a retrospective study , 1995, Paediatric anaesthesia.

[68]  I. Murat,et al.  Blood glucose and insulin levels during epidural anaesthesia in children receiving dextrose‐free solutions , 1994 .

[69]  J. Martínez-Mora,et al.  [Utility of epidural catheterization by the caudal route in pediatric anesthesia]. , 1994, Revista espanola de anestesiologia y reanimacion.

[70]  C. E. Wood,et al.  Complications of continuous epidural infusions for postoperative analgesia in children , 1994, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[71]  J. Martínez-Mora,et al.  [Thoracic epidural anesthesia by the caudal route in pediatric anesthesia: age is a limiting factor]. , 1994, Revista espanola de anestesiologia y reanimacion.

[72]  J. Tobias,et al.  Continuous regional anaesthesia in infants , 1993, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[73]  J. Tobias,et al.  Thoracic epidural anaesthesia in infants and children , 1993, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[74]  C. Berde,et al.  Continuous caudal anesthesia for inguinal hernia repair in former preterm infants. , 1993, Journal of clinical anesthesia.

[75]  D. G. Hughes,et al.  Epidural anaesthesia through caudal catheters for inguinal herniotomies in awake ex‐premature babies , 1993, Anaesthesia.

[76]  C. Berde.  Convulsions associated with pediatric regional anesthesia. , 1992, Anesthesia and analgesia.

[77]  K. Anand,et al.  Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. , 1992, The New England journal of medicine.

[78]  C. Eng,et al.  Thoracic epidural anesthesia via the caudal approach in children. , 1991, Anesthesiology.

[79]  J. Geurts,et al.  Epidurography in premature infants , 1990, Anaesthesia.

[80]  T. G. Pollard,et al.  Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children , 1990, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[81]  Boscoe M. Paes,et al.  Development of the human coagulation system in the healthy premature infant. , 1988, Blood.

[82]  A. Bösenberg,et al.  Thoracic epidural anesthesia via caudal route in infants. , 1988, Anesthesiology.

[83]  E. R. Savolaine,et al.  Anatomy of the human lumbar epidural space: new insights using CT-epidurography. , 1988, Anesthesiology.

[84]  K. Anand,et al.  Pain and its effects in the human neonate and fetus. , 1987, The New England journal of medicine.

[85]  P. Powers,et al.  Development of the human coagulation system in the full-term infant. , 1987, Blood.

[86]  A. Gasbarrini,et al.  Caudal blockade as alternative therapeutic approach in neonatal arterial thrombosis , 2001, European Journal of Pediatrics.

[87]  J. Abajian,et al.  Combined spinal and epidural anaesthesia for major abdominal surgery in infants , 1997, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[88]  K. Boos,et al.  [Peridural catheter for postoperative long-term analgesia in children]. , 1996, Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie : AINS.

[89]  G. Hirshberg,et al.  Caudal epidural anesthesia in conscious premature and high-risk infants. , 1991, Journal of pediatric surgery.