Download Guidelines for Caudal Anesthesia

Guidelines for Caudal Anesthesia- Single Shot
Edward Kaminski, MD and Emily Kather, CRNA
Post operative pain control. Used adjunctively in surgeries of the
perineum, anus, and rectum. It is also indicated in the cases
of inguinal and femoral herniorrhaphy; cystoscopy, urethral
surgery, and thoracic surgery.
1. Sacral deformities
Contraindications
2. Perianal deformities
3. Same day surgery in pt. over 6yrs, 30kg (Relative, not
absolute)
4. Bacteremia
5. Parent/ Patient refusal
22g Angiocath or 22g short (B) beveled needle
Equipment
Sterile gloves
Eye drape
Chloroprep
10ml syringe
Medications and Bupivicaine 0.25% with epinephrine 1:200,000
- For T6 Level draw up 1-1.5 ml/kg (use dilute solution 0.125% or
dosing
0.175%)
- For T10, 0.5-0.75mL/kg

Consider adjuncts such as preservative free
clonidine 1-2mcg/kg or morphine 50mcg/kg (inpatients
only due to delayed resp. depression), when appropriate

Consider dilute concentration of LA in patients who
are walking, if appropriate

Caudal is appropriate for many urologic procedures,
thoracotomy (vascular ring for example) procedures, and
hernia surgery

Dr. Lakshmanan (Urology) prefers clonidine to
narcotic as an additive
 Locate/ palpate landmarks: The sacral hiatus can be
Technique
located by first palpating the coccyx, and then sliding
the palpating finger in a cephalad direction (towards
the head) until a depression in the skin is felt.
 Clean the area with chloroprep
 A 22 gauge short beveled cannula or needle is then
inserted into the sacral depression and directed at
about 45° to skin. Insert until a “click” is felt as the
sacro-coccygeal ligament is pierced. The needle is
then carefully directed in a cephalad direction at an
angle approaching the long axis of the spinal canal.
 The needle should be aspirated looking for either CSF
Indications
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Complications
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Signs of Local
Toxicity in the
Anesthetized Pt.
Local Anesthetic
Toxicity
(LAST)Treatment
1.
2.
3.
4.
5.
1.
2.
3.
4.
or blood. A negative aspiration test does not exclude
intravascular or intrathecal placement.
Care should always be taken to look for signs of acute
toxicity during the injection. The injection should
never be more than 10 ml/30 seconds
A small amount of local anesthetic should be injected
as a test dose (2-4mls). It should not produce either a
lump in the subcutaneous tissues, or a feeling of
resistance to the injection, nor any systemic effects
such as arrhythmias or hypotension.
If the test dose does not produce any side effects then
the rest of the drug is injected, the needle removed
and the patient positioned for surgery.
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
apneic and profoundly hypotensive. Management
includes control of the airway and breathing, and
treatment of the blood pressure with intravenous
fluids and vasopressors such as ephedrine.
Perforation of the rectum. While simple needle
puncture is not important, contamination of the needle
is extremely dangerous if it is then inserted into the
epidural space.
Peaked T waves
Tachycardia/ Vent Ectopy/ Wide Complex Tachycardia
Bradycardia/ Asystole
VT/VF
Hypotension
Stop injection
Call for help
Maintain airway and circulation
Intralipid 20% 1.5mL/kg rapid bolus, may rpt X1 then if
needed 0.25mL/kg/min infusion (may inc. to 0.5)
5. Be cautious with epinephrine for resuscitation…vasopressin
preferred if required (see LAST guidelines)
Resources:
Caudal Anesthesia: http://www.nysora.com/techniques/neuraxial-andperineuraxial-techniques/landmark-based/3032-caudal-anesthesia.html
Useful video…
https://www.youtube.com/watch?v=8UwZkBAzrjc