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Spread of radioopaque dye in the epidural space in infants
Lakshmi Vas1, Vinay Kulkarni, Madhusudhan Mali
1Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel, Bombay, India. lakshmi1@hotmail.com
Insights
Increasing epidural dye volume in infants improves spread but not proportionally. A 1 ml/kg dose offers better quantitative and qualitative spread than 0.5 ml/kg for adequate anesthesia.
Area of Science:
- Pediatric Anesthesiology
- Epidural Pharmacology
- Radiographic Imaging
Background:
- Epidural anesthesia is crucial for pediatric thoracoabdominal surgery.
- Understanding dye spread in the epidural space is key to optimizing anesthetic delivery.
- Previous studies have not fully elucidated the dose-dependent spread of epidural injectates in infants.
Purpose of the Study:
- To assess the extent and pattern of dye spread in the infant epidural space.
- To determine if dye spread is directly proportional to injected volume.
- To compare the spread of two different epidural dye volumes (0.5 ml/kg and 1 ml/kg).
Main Methods:
- Prospective study of 10 infants (2-36 days old) undergoing major surgery.
- Injection of two volumes of radioopaque dye (0.5 ml/kg and 1 ml/kg) into the epidural space at a standardized rate.
- Radiographic imaging (X-rays) in the left lateral position to visualize dye spread after each injection.
Main Results:
- 10 distinct dye spread patterns were observed among the 10 infants.
- Uniform spread was rare; patchy anterior and posterior spread was more common.
- The 1 ml/kg volume showed statistically significant increases in the number of spread segments and extent of spread compared to 0.5 ml/kg.
- Doubling the volume did not consistently double the spread, indicating a non-proportional relationship.
Conclusions:
- Epidural dye spread in infants is variable, both quantitatively and qualitatively, between patients and volumes.
- A higher volume (1 ml/kg) provides significantly better spread than a lower volume (0.5 ml/kg).
- While 1 ml/kg offers improved spread and density, it is not directly proportional to the volume increase, suggesting optimized epidural anesthesia potential.
Background:
This prospective study aimed to assess the extent of spread of dye in the epidural space and whether it would vary in direct proportion to the volume when injecting two volumes of dye.
Methods:
Ten infants, aged 2-36 days (mean +/- SD, 13.30 +/- 13.68 days) and weighing 1.8-4.5 kg (mean +/- SD, 2.60 +/- 0.97 days), who were undergoing major thoracoabdominal surgery under epidural and general anaesthesia, were studied. At the end of surgery, two volumes of radioopaque dye (omnipaque) 0.5 ml.kg(-1) and 1 ml.kg(-1) were injected into the epidural space at a rate of 1 ml.2 min(-1). The spread was studied by taking X-rays after both injections in the left lateral position.
Results:
There were 10 different patterns of spread in the 10 cases. Uniformly circumferential and cylindrical spread was seen only in one infant. In the others, there were segregated patches of anterior and posterior spread with or without interspersed patches of circumferential spread. There was variation in the extent, location and the density of spread, filling defects and skipped segments with both volumes. Back leak of dye along the needle track was seen in three cases. Statistically, segments were 9.30 +/- 3.68 for 0.5 ml.kg(-1), for 1 ml.kg(-1) 11.50 +/- 3.03, 3.03, S, P=0.014; circumferential spread for 0.5 ml.kg(-1) 2.70 +/- 2.16, for 1 ml.kg(-1) 5.90 +/- 3.14 3.59, P=0.006; anterior spread for 0.5 ml.kg(-1) 3.60 +/- 1.58, for 1 ml kg(-1) 7.90 +/- 2.33 5.88, P=0.001; posterior spread for 0.5 ml.kg(-1) 8.20 +/- 3.71, for 1 ml.kg(-1) 9.80 +/- 3.68 3.54, P=0.006. Doubling of spread with doubling of the volume occurred in only one patient. There was a variable increase in extent or in the density of spread with reduction of skipped segments with the 1 ml.kg-1. The probable reasons for this variable spread and the mechanism of epidural anaesthesia in the presence of such spread are discussed.
Conclusions:
There is a difference in quantitative as well as qualitative spread in different patients and in the same patient with different volumes. There were statistically significant increases in the number of segments, circumferential, anterior and posterior locations in the 1.0 ml group. Both extent and density of spread improve with the higher volume but not in direct proportion to volume. 1 ml.kg(-1) has a better quantitative as well as qualitative spread than 0.5 ml and has a better chance of producing adequate anaesthesia.
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