Paediatric caudal and epidural analgesia

Epidural blocks (caudal, lumbar or thoracic) are of common use in paediatric patients for special procedures such as open fundoplication as well as for postoperative analgesia. However, because neonates and infants have lower metabolic capacities and specific anatomy as compared to adults, the dose of local anaesthetics and the way of their administration need careful attention.

Recent pharmacokinetic studies have more precisely identified the differences in pharmacokinetics between age groups, and between local anaesthetic agents. In that respect, ropivacaine exhibits a unique pharmacokinetic profile. Among all adjuvant drugs proposed so far, S-ketamine is promising; however, complete safety in case of injection into the cerebrospinal fluid must be checked before routine use. Thoracic epidural anaesthesia is technically difficult, and carries a potential risk of spinal cord puncture. Numerous techniques have been proposed to avoid this risk. The advancement of a catheter into the epidural space after caudal insertion has long been proposed by German and Italian authors, but for anatomical reasons, this technique is only possible in young infants. Some improvement of the original technique using lumbar insertion at the L4-L5 interspace has recently been suggested; the possibility of catheter guidance by means of electric stimulation has also been proposed.

Pharmacokinetic studies allowing safer dosing, especially with ropivacaine have recently been published. New techniques of thoracic epidural with puncture at the lumbar level are also proposed. However, all these new techniques need to pass the test of time.