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Introduction: Neonatal bladder exstrophy repairs imply correcting the genitourinary malformation, and closing and stabilizing the pelvic girdle with external fixation and traction. Successful results are achieved in terms of reduced urinary incontinence, adequate aesthetic appearance, improved quality of life, reduction of the risk associated with neonatal surgery and minimization of the number of procedures associated with multistage repairs. In such procedures, prolonged perioperative anaesthesia is key for the patient to tolerate the traction and external fixation, to help osteotomy healing, and to reduce tension in the surgical wound. Patients' age and weight have an effect on the risk of toxicity from local anaesthetics and respiratory depression from opioid analgesics. The prolonged use of caudal catheters in the management of these cases is associated with infection at the insertion site. Case presentation: The article presents the cases of three infants between 7 months and 1 year of age taken to bladder exstrophy repair and pelvic osteotomy with tunnelled caudal catheter and continuous local anaesthetic infusion as perioperative anaesthetic management technique. The use of these techniques was aimed at reducing the risk of infection at the insertion site and the risks associated with prolonged pain management in infants. Conclusion: The cases suggest that tunnelled caudal catheter placement and continuous local anaesthetic infusion are safe techniques in the management of prolonged anaesthesia in infants, decreasing the risk of insertion site infection.
Introducción: La corrección de la extrofia vesical en el lactante menor implica la reparación de la malformación genitourinaria y el cierre y estabilización del anillo pélvico utilizando un tutor externo y tracción. Se obtienen resultados exitosos en la continencia urinaria del paciente, adecuado aspecto estético y buena calidad de vida reduciendo el riesgo que implica la cirugía neonatal y minimizando el número de procedimientos. La analgesia postoperatoria prolongada es fundamental para tolerar el tutor y/o la tracción, permitir la cicatrización de las osteotomías y reducir la tensión sobre la herida quirúrgica. La edad y el peso de estos pacientes aumentan el riesgo de toxicidad por anestésico local y de depresión respiratoria con el uso de opioides, al igual que el uso prolongado de catéteres caudales se asocia a infección del sitio de inserción. Presentación de caso: Se describen tres casos de lactantes de 7 meses a 1 ano de edad llevados a corrección de extrofia vesical y osteotomía pélvica mas fijación con tutor externo donde el manejo analgésico postoperatorio se realizó mediante la infusión de anestésico local por catéter caudal tunelizado para prolongar el tiempo de analgesia y reducir el riesgo de infección. Conclusión: Se señala el uso de la tunelización de los catéteres caudales y la infusión continua de anestésico local como técnica segura para el manejo analgésico prologado en el paciente lactante con reducción del riesgo de infección del sitio de inserción.
Subject(s)
HumansABSTRACT
Introduction: The sacrum is a large triangular bone, formed by the fusion of five sacral vertebrae. The opening at the caudal end of sacral canal is known as sacral hiatus. It is formed due to the failure of fusion of laminae of the fifth (occasionally fourth) sacral vertebra. Sacrum is one of the bones which exhibit variations and the variation of sacral hiatus is of great clinical significance because it may also leads tomechanical low back pain. Previousworks on themorphometrical study on the sacral hiatus is limited, especially in Nepal, Parsa population. The present study was undertaken to help in filling this gap at least to a certain extent and also made an attempt to find out the variations of sacrum. Materials: One hundred dry human sacra were collected from the Department of Anatomy of National medical college & Teaching Hospital, Nepal. Methods& Observations: Themorphometrical studieswere done, and the parameters (Shape, length, Transverse width & Antero-posterior width of sacral hiatus and level of apex & base of sacral hiatus) were measured with the help of divider, the observations were recorded, tabulated & analyzed. Result: The study showed a significant co-relation between anatomical variations of sacral hiatus with the previous studies.
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Introduction: The purpose of the study was to compare the analgesic quality and duration of Ropivacaine 0.2% with the addition of Fentanyl (1 mcg/kg) with that of Ropivacaine 0.2% and the addition of Ketamine (0.5 mg/kg) and also compare the post complications. Materials and Methods: Ninety children, age one to ten years, undergoing sub-umbilical surgery, were prospectively randomized to one of three groups: caudal analgesia with 0.75 ml/kg of 0.2% Ropivacaine in normal saline (Group R) or caudal analgesia with 0.75 ml/kg of 0.2% Ropivacaine with Ketamine 0.5 mg/kg (Group RK) or caudal analgesia with 0.75 ml/kg of 0.2% Ropivacaine with Fentanyl 1 mcg/kg (Group RF). Post-operative pain was assessed for 24 hours using the FLACC scale. Results: The mean duration of analgesia was significantly longer in Group RK (629.06 ± 286.32 min) than other two groups P < 0.05. The pain score assessed using FLACC scale was compared between the three groups, and children in Group RK had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group RK. Ketamine in a dose of 0.5 mg/kg added to 0.2% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of Ropivacaine, without any side effects in compare to Ropivacaine alone or Fentanyl. Conclusion: We conclude that Ketamine in a dose of 0.5 mg/kg, added to 0.2% Ropivacaine for caudal analgesia and administered as a 0.75 ml/kg mixture in children, for sub-umbilical surgery, significantly prolongs the duration of post-operative analgesia without any side effects.
ABSTRACT
BACKGROUND: An anesthetic state can reduce adverse airway reaction during laryngeal mask airway (LMA) removal in children. However, the anesthetic state has risks of upper airway obstruction or delayed emergence; so possibly less anesthetic depth is advisable. Caudal analgesia reduces the requirement of anesthetic agents for sedation or anesthesia; it is expected to reduce the sevoflurane requirement for LMA removal. Therefore, we determined the EC(50) of sevoflurane for LMA removal with caudal analgesia and compared that to the EC(50) without caudal analgesia. METHODS: Forty-three unpremedicated children aged 1 to 6 yr were enrolled. They were allocated to receive or not to receive caudal block according to their parents' consent. General anesthesia were induced and maintained with sevoflurane and oxygen in air. EC(50) of sevoflurane for a smooth LMA removal with and without caudal analgesia were estimated by the Dixon up-and-down method. The LMA was removed when predetermined end-tidal sevoflurane concentration was achieved, and the sevoflurane concentration of a subsequent patient was determined by the success or failure of the previous patient with 0.2% as the step size; success was defined by the absence of an adverse airway reaction during and after LMA removal. EC(50) of sevoflurane with caudal block, and that without caudal block, were compared by a rank-sum test. RESULTS: The EC(50) of sevoflurane to achieve successful LMA removal in children with caudal block was 1.47%; 1.81% without caudal block. The EC(50) were significantly different between the two groups (P < 0.001). CONCLUSIONS: Caudal analgesia significantly reduced the sevoflurane concentration for a smooth LMA removal in anesthetized children.
Subject(s)
Aged , Child , Humans , Airway Obstruction , Analgesia , Anesthesia, General , Anesthetics , Laryngeal Masks , Methyl Ethers , OxygenABSTRACT
Caudal analgesia is a widely accepted technique for providing pain relief. However, both permanent and transient neurologic complications, including paraplegia, have been reported. We report on a patient who developed paraplegia following a caudal block for an epidural mass. The cause of the paraplegia was unknown, but possibly spinal angioma may have taken part in the onset and progression of the paralysis. A mechanism is proposed by which the caudal injection may have caused a change in blood flow through the spinal angioma resulting in cord ischemia.