Intervertebral epidural anaesthesia in paediatric surgery: success rate and adverse effects in 650 consecutive procedures

Abstract

The success rate and occurrence of adverse effects are reported in a retrospective study of 650 (99 sacral, 468 lumbar, 76 thoracic and seven cervical) paediatric epidurals performed, mostly (91%) under light general anaesthesia, by several anaesthetists. Seventeen‐gauge Tuohy and 20‐gauge (Potts‐Cournand® and Tuohy) needles were used. Anaesthetic solutions used were 1% lignocaine, 0.5% bupivacaine and a mixture of equal volumes of 0.5% bupivacaine with either 1% lignocaine or 1% etidocaine, all containing 1:200 000 adrenaline. The epidural space was identified by loss‐of‐resistance technique (LORT) with normal saline, air or CO 2 . Up to five attempts were occasionally necessary. LORT using fluid resulted in more subarachnoidal penetrations than the LORT using air ( P < 0.05) which was easy and reliable but produced patchy anaesthesia (‘painful gaps') in 4.2% of patients. CO 2 ‐LORT was as easy and reliable as air‐LORT and did not result in painful gaps. Lateral and mid‐line insertion routes were equally suitable whatever the level of approach. Twenty‐gauge needles, especially Tuohy needles, resulted in significantly less dural punctures in young children. The spread of the local anaesthetic correlated with the volume injected and the height of the epidural approach. Epidural anaesthesia had little haemodynamic effects. Administration of epidural morphine improved the duration of postoperative pain relief but undesirable effects occurred in up to 50% of patients. Low doses of naloxone (2–5 μg?kg −1 .h −1 ) counteracted most adverse effects, avoiding urinary retention and delayed apnoea. Anaesthetists and residents without experience in paediatric anaesthesia had a good success rate in performing the techniques (under supervision of an experienced anaesthetist). At the same time, experience in regional anaesthesia would significantly boost the confidence of the anaesthetist in managing such cases. The authors recommend using CO 2 instead of air in the LORT.