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Thoracic epidural anesthesia via the modified Taylor approach in infants
1Department of Anesthesia, Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, USA. gunterjb@email.uc.edu
Insights
The midline modified Taylor approach provides a feasible method for advancing epidural catheters to the thoracic level in infants. This technique is safer than the caudal approach, reducing contamination risk.
Area of Science:
- Anesthesiology
- Pediatric Anesthesia
- Pain Management
Background:
- Thoracic epidural anesthesia is challenging in infants due to potential contamination risks with the caudal approach.
- Advancing catheters from the caudal to the thoracic level is an alternative but carries contamination risks.
Purpose of the Study:
- To examine the feasibility of the midline modified Taylor approach (L(5)-S(1)) for advancing epidural catheters to the thoracic level in infants.
- To assess the safety and efficacy of this approach in pediatric patients.
Main Methods:
- The L(5)-S(1) interspace was accessed in infants aged 3 months to 2 years using an 18-gauge needle and saline loss of resistance.
- A 20-gauge catheter was advanced to the desired thoracic level, with adjustments made for resistance.
- Radiographs confirmed catheter placement, and the catheter was secured and tested.
Main Results:
- The study included 16 infants (mean age 14.4 months).
- Catheter insertion to the planned thoracic level was successful in 15 out of 16 infants.
- Catheter placement was predominantly straight, with minimal discrepancy between desired and obtained levels, which decreased with experience.
Conclusions:
- The midline modified Taylor approach is a feasible and effective method for thoracic epidural catheter placement in infants.
- This technique offers an advantage over the caudal approach by being below the spinal cord terminus and reducing contamination risk.
Background And Objectives:
Advancement of catheters from the caudal to the thoracic level is an alternative to thoracic epidural anesthesia in infants and younger children; however, contamination of the insertion site may occur. This study examined the feasibility of the midline modified Taylor approach (L(5)-S(1)) for the advancement of epidural catheters to the thoracic level in infants.
Methods:
After Institutional Review Board (IRB) approval and parental consent, the L(5)-S(1) interspace of infants 3 months to 2 years old was entered with an 18-gauge Crawford needle using the saline loss of resistance technique. A 20-gauge catheter with stylet (Abbott; North Chicago, IL) was then advanced the distance from the L(5)-S(1) interspace to the desired thoracic level. If resistance was encountered, the catheter was withdrawn 1 to 2 cm, rotated along its long axis, and readvanced. The stylet was left in place, and a radiograph of the thoracolumbar spine was taken. The stylet was then removed, and the catheter was secured, tested, and dosed.
Results:
Sixteen infants (mean age, 14.4 +/- 5.7 months and mean weight, 9.3 +/- 1.4 kg) were studied. Fifteen of 16 catheters were inserted the full length planned. Fourteen of 16 catheters were straight (1 had a single bend, and 1 had multiple loops). Mean discrepancy between level desired and obtained was -1.7 +/- 1.7 segments (median, -1.75). Discrepancy did not correlate with either desired level or length inserted, but did decrease with experience.
Conclusions:
The midline modified Taylor approach allows access to the thoracic epidural space via catheter advancement, while being below the terminus of the spinal cord and less likely to suffer contamination than the caudal approach.