CAUDAL

ANESTHESIA
TR
 INTRODUCTION
• Caudal anaesthesia has been used for many years and
is the easiest and safest approach to the epidural
space. When correctly performed there is little danger
of either the spinal cord or dura being damaged.
• It is used to provide peri and post operative analgesia
in adults and children. It may be the sole anaesthetic
for some procedures, or it may be combined with
general anaesthesia.
• The caudal space is the sacral portion of the epidural
space. Caudal anesthesia involves needle and/or
catheter penetrationof the sacrococcygeal ligament
covering the sacral hiatus that is created by the
unfused S4 and S5 laminate
 INDICATIONS
• Anaesthesia and analgesia below the umbilicus
• In children, caudal anesthesia is typically combined
with general anesthesia for intraoperative
supplementation and postoperative analgesia. It is
commonly used for procedures below the diaphragm,
including urogenital, rectal, inguinal, and lower
extremity surgery
• Obstetric analgesia :For the 2nd stage or instrumental
deliveries. Care should be taken as the foetal head lies
close to the site of injection and there is real risk of
injecting local anaesthetic into the foetus.
• Chronic pain problems relating to lower limbs and
lower abdominal pains.
 CONTRAINDICATIONS
• Infection near the site of the needle insertion.
• Coagulopathy or anti coagulation.
• Pilonidal cyst
• Congenital abnormalities of the lower spine or
meninges, because of the unclear or impalpable
anatomy.
 ANATOMY
• The caudal epidural
space is the lowest
portion of the epidural
system and is entered
through the sacral hiatus.
The sacrum is a triangular
bone that consists of the
five fused sacral
vertebrae (S1- S5). It
articulates with the fifth
lumber vertebra and the
coccyx.
• The sacral hiatus is a
defect in the lower part of
the posterior wall of the
sacrum formed by the
failure of the laminae of S5
and/or S4 to meet and
fuse in the midline. The
sacral canal is a
continuation of the lumbar
spinal canal which
terminates at the sacral
hiatus.
 ANATOMY
• The hiatus may be felt as a groove or notch above the
coccyx and between two bony prominences, the
sacral cornua. Its anatomy is more easily appreciated
in infants and children.
• The posterior superior iliac spines and the sacral hiatus
define an equilateral triangle.
• Calcification of the sacrococcygeal ligament may
make caudal anesthesia difficult or impossible in older
adults.
• Within the sacral canal, the dural sac extends to the
first sacral vertebra in adults and to about the third
sacral vertebra in infants, making inadvertent
intrathecal injection more common in infants
 CHOICE OF DRUGS &
DOSAGE
• 0.5–1.0 mL/kg of 0.125–0.25% bupivacaine (or
ropivacaine), with or without epinephrine, can be used
(Morgan, 2015)

Hadzic, 2017
Schulte-Steinberg dose scheme
• The age of the child is used according to the following
formula:
• 0.1 mL per segment to be blocked x age in years

Armitage dose scheme

• This schema is easy to use and has also proved itself with less
experienced anesthetists. The following dosage is
recommended:
• Lumbosacral block: 0.50 ml/kg b.w.
• Thoracolumbar block: 1 .OO ml/kg b.w.
• Mid-thoracic block: 1.25 ml/kg b. w.
Busoni and
Andreucetti
dose scheme

(Danilo, 2004)
 TECHNIQUE
• The patient is prepared as for general anaesthesia:
• He/she should be fasted
• All appropriate equipment for resuscitation must be
available.
• An intravenous cannula should always be inserted in an
upper limb, in case of accidental intravenous injection,
or profound sympathetic blockade from a high
epidural block.
• Pediatric caudal blocks are most commonly performed
aft er the induction of general anesthesia. Th e patient is
placed in the lateral or prone position with one or both
hips flexed, and the sacral hiatus is palpated.
• After sterile skin preparation, a needle or intravenous
catheter (18–23 gauge) is advanced at a 45° angle
cephalad until a pop is felt as the needle pierces the
sacrococcygeal ligament.
• The angle of the needle is then flattened and advanced.
• Aspiration for blood and CSF is performed, and, if
negative, injection can proceed
 COMPLICATIONS
 Intravascular or intraosseous injection. This may lead to
grand mal seizures and/or cardio-respiratory arrest.
 Dural puncture. Extreme care must be taken to avoid this as
a total spinal block will occur if the dose for a caudal block is
injected into the subarachnoid space. If this occurs then the
patient will become rapidly apnoeic and profoundly
hypotensive.
 Perforation of the rectum. Contamination of the needle is
extremely dangerous if it is then inserted into the epidural
space.
 Sepsis. This should be a very rare occurrence if strict aseptic
procedures are followed.
 Urinary retention.
 Haematoma
 REFERENCES
• Morgan, 2015
• Hadzic, 2017
• Danilo, 2004
THANK YOU