This video demonstrates an epidural catheter placement on a 2-year-old, 12kg male patient presenting for left hip osteotomy. His past medical history was remarkable for congenital heart defects, bilateral congenital hip dislocations, and a sacral dimple which is sometimes associated with neurologic spinal canal abnormalities. In this case, no neurologic anatomical abnormalities were demonstrated on the neonatal spine ultrasound. The patient was placed in a left lateral decubitus position. Using anatomical landmarks like Tuffier’s line or the intercristal line corresponding to L4-L5 level, the target level for needle placement was identified and marked. The patient’s skin was sterilized and draped under sterile conditions. An 18-gauge, 5 cm length Tuohy needle was used to encounter the epidural space. A general guideline for the depth to the epidural space from the skin is approximately 1mm/kg of body weight¹. Subsequently, a 20-gauge catheter was placed through the needle to a depth of 4.5 cm at the level of the skin. Negative aspiration of blood or CSF was confirmed. A test dose was calculated at 0.5 mcg/kg epinephrine or 0.1ml/kg of lidocaine 1.5% with epinephrine 1:200,000. In this case, a 1.2 mL test dose of lidocaine 1.5% with epinephrine 1:200,000 was given without any observed cardiovascular changes (e.g. ≥ 25% increase or decrease in T wave amplitude, HR increase ≥ 10 bpm, or SBP increase ≥ 15 mmHg)¹. Finally, the catheter was secured to the back of the patient. Parental consent was obtained for the publication of this video.
This video demonstrates the surface landmark technique for epidural catheter placement for postoperative pain control in a pediatric patient undergoing left hip osteotomy. Following induction of general anesthesia, an epidural catheter (20 Gauge closed-tip) was placed at the L4-L5 vertebral level through a Tuohy needle (18 Gauge 5-cm long). Negative catheter aspiration of blood or CSF was confirmed followed by a negative test dose. A bolus of local anesthetic followed by an infusion was administered via the epidural catheter for intra- and post-operative pain control. After completion of the surgery, the child was extubated and exhibited adequate postoperative pain control with the continuous epidural analgesia and multimodal pain management. In complex surgical procedures associated with significant postoperative pain, epidural analgesia is a useful technique to manage intraoperative and postoperative pain. Epidural catheter placement can be performed either using surface landmark or ultrasound-guided techniques. For patient safety, it is imperative to understand relevant differences between adults and children when determining and performing neuraxial blocks. Parental consent was obtained for the publication of this video.
Epidural analgesia is a technique used as part of multimodal pain management for invasive and painful surgical procedures. In addition to pain relief, epidural analgesia has been associated with decreased volatile anesthetic requirements, decreased catecholamine release, improved ventilation, earlier return of gut function, and decreased hospital and ICU length of stay¹. Neuraxial blocks have been traditionally performed using the surface landmark technique. In recent times, ultrasound guidance is also being used to guide epidural catheter placement. In the pediatric population, the performance of this procedure after induction of general anesthesia has been shown to be safe¹. Children’s cognitive immaturity often precludes compliance with immobility for the procedure, and also they are less capable of reporting paresthesia during placement. The benefits of epidural analgesia with catheter placement under general anesthesia outweigh the risks associated with needle placement in uncooperative patients¹.
We did not encounter any complications before, during, or after the epidural catheter placement. Subsequently, the catheter was removed uneventfully after transitioning to oral pain medications on postoperative day 2 after surgery.
The most common indications for epidural anesthesia in the pediatric population include procedures involving the lower limbs, pelvis, perineum, abdomen and thorax. Contraindications to neuraxial blockade include patient or guardian refusal, infection at the insertion site, spina bifida, increased intracranial pressure, local anesthetic allergy, and coagulopathy². In patients with sepsis, degenerative neurologic conditions, spine abnormalities or spine hardware, and hypovolemia, the increased risk for complications should be carefully weighed against the benefits. There are some anatomical differences in infants and children vs. adults: 1) the pediatric conus medullaris is located lower in the spinal column, L3 level compared with L1-2 in adults, 2) the pediatric ligamentum flavum is thinner and less dense leading to a diminished loss of resistance sensation when entering the epidural space with the potential for unintended dural puncture, and 3) the pediatric sacrum is flatter and narrower². A correct size of introducer needle and epidural catheter should be selected based on age for pediatric patients: A 5-cm 20 Gauge Tuohy needle with a 24 Gauge epidural catheter is appropriate for patients younger than 2 years. A 5- or 10-cm 18 Gauge Tuohy needle and a 20 Gauge epidural catheter are typically used in older children¹. Prescription and dosing of test solution and medication also varies by age and size (see below). Pharmacologic differences between pediatric and adult patients can significantly impact epidural management necessitating dosing adjustments for volume, concentration and toxic limits for efficacy and patient safety. These differences include: surface area to body mass ratio, immaturity of liver and kidney function, concentration of plasma-binding proteins, and underdeveloped blood-brain barrier¹. The two most common local anesthetics used for epidurals are bupivacaine and ropivacaine. Lidocaine is used for the test dose only. Bupivacaine or levobupivacaine 0.25% and ropivacaine 0.2% are typically used at 0.5 mL/kg for lumbar epidural initial loading (0.3 mL/kg thoracic epidural initial loading) and 0.25 mL/kg for subsequent “top-up” in order to obtain intraoperative analgesia. Continuous epidural anesthesia with either bupivacaine or levobupivacaine, or ropivacaine can be safely infused at rates of 0.2 mg/kg/h for children younger than 3 months, 0.3 mg/kg/h for children between 3 months and 1 year, and 0.4 mg/kg/h for children older than 1 year³. Some authors use more volume of diluted ropivacaine (0.1%), or bupivacaine or levobupivacaine (0.125%) on the continuous infusion to achieve the desired level while keeping the dosage under toxic limits. In this case, we used ropivacaine for bolus and infusion at the age appropriate doses mentioned before. For testing of catheter location, epinephrine is the only adjunct added by drug manufacturers to their marketed local anesthetic preparations. Typically, it has been used in a concentration of 5 mcg/mL (1 : 200,000), with the intent of identifying inadvertent intravascular injection (test dose). The test dose of epinephrine is typically limited to 0.5 mcg/kg (0.1 mL/kg of a 1 : 200,000 solution) to a maximum dose of 15 mcg (3mL). A positive test dose after intravenous injection of 0.5 mcg/kg of epinephrine is defined as an increase in HR of 10 to 20 bpm, a 25% change in T-wave amplitude, new ST segment changes on ECG, or an increase of 15 mmHg or 10% in systolic blood pressure¹. Epidural complications and side effects can be associated with the procedure itself or to the drug administered. Potential complications associated with the administration of the drug include local anesthetic systemic toxicity (LAST), allergy to local anesthetic, direct local anesthetic-induced nervous tissue injury, and errors from drug or mode of delivery. Transient complications include back pain, pneumocephalus, and postdural puncture headache. Life-threatening complications include subdural injection of local anesthetic, total or high spinal, infectious or aseptic meningitis, cardiac arrest, spinal epidural abscess, epidural hematoma formation, and permanent neurologic injuries⁴. Consistent protocols help prevent complications: ensuring correct dosing of medication, performing the epinephrine test dose, proper calculation of the desired depth of the catheter, location and availability of lipid emulsion (20%) solution for rescue in the event of suspected LAST. Daily patient evaluations should be done for assessment of the block and possible catheter-related complications.