Evaluation of a new flexometallic catheter for thoracic epidural analgesia via the caudal route in infants and neonates

Introduction: Thoracic epidural anesthesia via the caudal route in infants and children has been shown to be a reliable alternative to direct thoracic epidural placement1'2. The caudal route avoids difficulties and hazards of trochar insertion in the lumbar and thoracic spine. The placement of a thoracic epidural catheter via the caudal route will also allow the use of small volumes of local anesthetic agent. A new catheter, the Arrow FlexiTip Plus (Arrow International, PA), has been shown to reduce intravascular placements and catheter-induced paresthesia3'". The body of the catheter has a stainless steel coil wire designed to prevent kinking and make it more radio-opaque. It also has a removable stylet to provide a degree of stiffness to allow it to pass up the epidural space. AIM: The aim of this pilot study was to evaluate the ease and safety of insertion of the FlexiTip Plus catheter inserted via the caudal route in pédiatrie patients in whom epidural analgesia was desired for pain relief. METHODS: IRB approval was obtained for publication of the data. Seventeen patients, 24 months or younger, who were scheduled to have laparotomies under general anesthesia were considered for epidural analgesia via the caudal route. After induction of anesthesia the patients were turned to the lateral decubitus position. Following sterile preparation and skin nick, the length of the 20g FlexiTip Plus catheter was measured from the skin overlying the sacrococcygeal ligament to the highest dermatome to be blocked. A Crawford needle was then inserted through the sacrococcygeal ligament or an 18g, 1.25 inch cannula was used if the Crawford could not be passed. Saline 1-3ml was injected through the needle to dilate the epidural space. The catheter was inserted up to the measured length and a lateral X-ray was taken to confirm its position. Placement of the catheter within two vertebrae of the desired level was considered successful. The ease of palpation of the sacral hiatus, insertion of the Crawford, and threading of the catheter were recorded as easy, difficult or not possible. The presence of cerebral spinal fluid (CSF) or blood in the catheter was noted. The lack of adequate analgesia during and after surgery as detected by tachycardia or hypertension, restlessness or unconsolable crying postoperatively was noted. RESULTS: Laparotomy was performed for Nissen's procedure (n=10), pyeloplasty (n=3), nephrectomy (n=1), ureteral reconstruction (n=1), splenectomy (n=1) and removal of teratoma (n=1). The mean age (range) was 6 months (0.5-18) and weight 7.9 kg (2.5-20.5). In five patients the sacrococcygeal ligament was difficult to palpate and the Crawford needle could not be passed in eight patients. The cannula passed successfully in these. The catheter was passed easily in 14 patients (82%) and with difficulty in three patients. The catheter was easily seen on X-ray in all patients. Fourteen patients (82%) had successful placement of the catheter. The catheter coiled in two patients although the tip was placed within four vertebral bodies. The catheter coiled several times in the sacral space in one patient and was removed at the end of the procedure and reinserted (the reinsertion was not counted in the results). One patient with a history of epilepsy had a seizure after injection of a second dose of bupivicaine 0.25% in the recovery room although there was no apparent blood on aspiration after insertion of the catheter and no signs of subarachnoid injection of the test dose. Apart from this one episode there were no other incidents of intravenous or intrathecal injections. The desired level of analgesia was achieved in all patients. DISCUSSION: The FlexiTip Plus catheter inserted via the caudal route is a safe and reliable alternative to the thoracic epidural route in small children. It is easy to visualize with an X-ray so fluoroscopy may be used to for the insertion. Further investigation comparing the FlexiTip with other catheters is warranted.

Duke Scholars

Author Allison Kinder Ross Anesthesiology, Pediatrics

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