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MINERVA ANESTESIOL 2006;72:453-9

Caudal anesthesia in pediatrics: an update

P. SILVANI 1, A. CAMPORESI 1, M. R. AGOSTINO 2, I. SALVO 1

Aim. Caudal anesthesia is one of the most usedpopular regional blocks in children. This technique is a useful adjunct during general anesthesia and for providing postoperative analgesia after infraumbilical operations. The quality and level of the caudal blockade is dependent on the dose, volume, and concentration of
the injected drug. Although it is a versatile
block, one of the major limitations of the single-injection technique is the relatively short
duration of postoperative analgesia. The most
frequently used method to further prolong
postoperative analgesia following caudal block
is to add different adjunct drugs to the local
anesthetics solution. Only few studies evaluated quality and duration of caudal block against
the volume of the local anaesthetic applied.
After reviewing recent scientific literature, the
authors compare the duration of postoperative analgesia in children scheduled for
hypospadia repair when 2two different volumes and concentrations of a fixed dose of
ropivacaine are used.
Methods. After informed parental consent, 30
children (ASA I, 1-5 years old) were enrolled in
a multicentre, perspective, not randomized,
observational study conducted in two 2 children hospitals. After premedication with midazolam, anesthesia was induced with thiopental
and maintained with sevoflurane in oxygen/air.
After induction, patients received a caudal
blockade either with ropivacaine 0.375% at 0.5

Experimental data will be partially presented as poster at

Euroanaesthesia 2006 Meeting, Madrid, June 3-6, 2006.

Address reprint requests to: Dr. P. Silvani, Department of

Anesthesia and Intensive Care, Children Hospital V. Buzzi,
Via Castelvetro 32, Milan, Italy. E-mail: paolo.silvani@tiscali.it

Vol. 72, N. 6

1Department

of Anesthesia and Intensive Care

V. Buzzi Children Hospital, Milan, Italy
2Anesthesia and Pediatric Intensive Care Unit,
Meyer Children Hospital, Florence, Italy

mL/kg (Low Volume High Concentration

Group, LVHC; n=15), or ropivacaine 0.1% at 1.8
mLl/kg (High Volume Low Concentration
Group, HVLC; n=15). Surgery was allowed to
begin 10ten minutes after performing the
block. MAC-hour was calculated. In the recovery room, pain was assessed using the
Childrens Hospital of Eastern Ontario Pain
Scale (CHEOPS). In addition, the motor block
was scored. After transferral to the ward, the
patients were observed for 24 hours for signs
of postoperative pain. The time period to first
supplemental analgesic demand, i.e., from
establishment of the block until the first registration of a CHEOPS score 9, was considered
the primary endpoint of the study. The time
periods were compared using analysis of variance adjusted for age, weight and duration of
surgical procedure as covariates.
Results. All patients were judged to have sufficient intraoperative analgesia, and none of
them received additional analgesics intraoperatively. Patients characteristics were similar, besides the age (3210 vs 249 months;
P<0.05) and weigh (15.133.92 vs 11.93 1.83;
P=0.08). Analgesics were needed after 520480
min in the LVHC and 952506 min in the HVLC
group (P<0.05). Motor block was less in the
HVLC group.
Conclusion. In children undergoing hypospa-

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The sacrum and sacral hiatus are extreme

variable anatomical structures. However, the
equilateral triangle located between the apex
of the sacral hiatus and superolateral sacral
crests will certainly be of use in determining
the location of the sacral hiatus during the
block.8 Ivani 9 proposed a variation of the
original technique, entering the needle at 60
angle and injecting the drug directly after the
perforation of the sacrococcygeal ligament,
reducing the risk of dural puncture, vascular
damage or intraosseous injection. As tissue
coring had been related to late development
of epidermoid tumors, the use of dedicated
metallic needles with an internal stylet or
venous catheters,10 is generally recommended. Nevertheless, Baris 11 did not find any
difference in tissue coring using hollow needle or caudal block needle. Several techniques have been considered in detecting
proper caudal needle placement: nerve stimulation,12 ultrasound imaging after injection of
saline test bolus,13 whoosh test or modified
swoosh test 10, 14 (Table I).
Needle displacement into vessels or sacral
bone may result in systemic toxicity related to
the local anesthetic, while intrathecal and
subdural epidural displacement is usually
associated to total spinal anesthesia. Although
aspiration and return of blood or liquor is
definite evidence for intravascular or intrathecal needle misplacement, a negative aspiration lacks sensitivity in preventing these complications.15 The most popular method of
identifying accidental systemic or intrathecal
injection is the test dose. However, its validity has been questioned in the literature and
several centers have abandoned its use.15 A
recent review 16 analysed the ability of the
classical epidural test dose and other strategies to detect intravascular, intrathecal, or
subdural epidural needle/catheter misplacement: while increase in systolic blood pressure 15 mmHg after the injection of 0.5
g/kg of epinephrine showed good sensitivity (81-100) and positive predictive value
(100), more studies are required to determine the best strategies to detect intrathecal
and subdural epidural needle misplacements.
For these reasons the current literature support only the use of an epinephrine test dose.

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dia repair, caudal block with a high volume,

low concentration regimen produces prolonged analgesia and less motor block, compared to a low volume, high concentration
regimen.
Key words: Anesthesia - Pediatrics - Analgesia Postoperative complications - Ropivacaine.

audal block is the regional technique that

is used with the greatest frequency in
pediatric patients. Its use was first described
in 1933,1 but it gained great popularity only in
the early 1960s.2 Caudal block is commonly
practiced by 96% of pediatric anesthetists of
UK,3 represented the 61.5% of all pediatric
regional techniques in France 4 and the 49.5%
of all regional blocks performed in our
Institution in 2004. Although such a diffusion,
several limitations of this technique must be
considered: at first, it is almost exclusively a
single shot technique, due to the high risk of
catheters contamination from fecal soiling.
Furthermore, high cephalic spread can be
obtained only by injection of large volume
of anesthetic mixtures. Finally, several complications of this block were reported.4 Small
blocks (penile block, ilioinguinaliliohypogastric nerve blocks) for infraumbilical procedures, single shot or continuous peripheral
block for orthopedics procedures and systemic analgesia may represent a valid alternative to this technique. A recent review 5 concluded that there is insufficient evidence to
make any firm conclusion regarding the efficacy of caudal analgesia when compared with
other methods of pain relief following circumcision, while caudal block was more
effective than ilioinguinaliliohypogastric block
in suppressing the stress response as reflected in epinephrine and norepinephrine blood
levels in orchidopexy patients.6
Techniques

The block is perhaps the most easily

learned and mastered of all regional anesthetic techniques and Schuepfer et al. have
shown that only 32 blocks are needed for an
anesthetic registrar to reach about the same
skill level as older and more experienced
colleagues.7

454

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SILVANI

TABLE I.Sensitivity, specificity and positive predictive value of methods described to detect proper caudal needle placement during caudal block.
Author

Nerve stimulation
US
Whoosh test
Swoosh test

Tsui 12
Roberts 13
Talwar 14
Orme RMLE 10
Talwar 14

Sensitivity

100
96.5
100
91
93

Specificity

Positive predictive value

100
100
100
100
50

100
100
100
100
96

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Methods

Local anesthetics and additives

Plan bupivacaine, levobupivacaine and

ropivacaine are widely utilized in caudal
block. As established by several Authors,2
metameric spread depends on volume of
injected mixture, while the desired density
of the block (less dense for postoperative
analgesia and more dense for intraoperative
anesthesia) depends on the concentration of
anesthetic. However, concentration must be
established in order to avoid anesthetics toxicity. Usually, a maximum volume is 1 ml/kg
is injected, while minimal concentrations
assuring adequate anesthesia and/or postoperative analgesia are summarized in Table
II. Anesthetics solutions with vasoconstrictors (epinephrine 1:200 000) have been used
for many years but, recently, lost their popularity.20 Actually, the most frequently used
method to prolong postoperative analgesia
following caudal block is to add different
adjunct drugs to the local anesthetic solution. These additives can be divided in non
opioids (clonidine, ketamine, S-ketamine,
midazolam, neostigmine) and opioids (morphine, fentanyl, buprenorphine, tramadol).
The use of caudal opioids significantly prolongs the duration of analgesia but carries
with a number of unpleasant side-effects
(nausea, vomiting, pruritus, urinary retention) as well as the risk of late respiratory
depression. For these reasons, the use of opioids seems to be superseded by non opioids. Neostigmine is associated to high incidence of side effects (postoperative nausea
and vomiting) 21 and the use of midazolam
remains controversial.20 Although Whee-ler 22
failed to demonstrate efficacy of caudal clonidine in prolonging postoperative analgesia,
several other studies demonstrated signifi-

Vol. 72, N. 6

TABLE II.Minimal concentrations of anesthetics to

obtain adequate postoperative analgesia in caudal
block.
Author

Anesthetic

Concentration
(%)

Khalil 17
Ivani 18
Gunter 19

Ropivacaine
Levobupivacaine
Bupivacaine

0.175
0.2
0.125

cant extension of the duration of postoperative analgesia when clonidine is added to the
anesthetic mixture.20 Main side effects of
clonidine are hypotension, bradycardia and
sedation. Clonidine may be unsafe in
neonates and preterm infants, and until further studies have evaluated the association of
dose and side-effects, its use in this group
of patients, cannot be recommended in children <1 year old or in patients weighing <10
kg.20
The efficacy of caudal ketamine in children has been demonstrated in a great number of studies 20 and the optimal dose seems
to be 0.5 mg/kg.23 After its commercial availability, preservative- free S(+)-ketamine was
analysed as adjuvant in caudal block.24 Due
to favourable results, levo isomer formula
replaced racemic mixtures. Although the
apparent lack of significant side-effects, there
is still some debate about possible neurotoxicity with ketamine.25, 26
In conclusion, even though severe adverse
or toxic effects following use of non opiate
adjuvants have not been reported, further
randomized controlled trials need to be conducted before these new agents can be recommended as a safe for use in pediatric caudal anesthesia. Even so, cognisance should be
taken of the fact that these drugs are not
licensed for use in the epidural space.

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TABLE III.Complication of caudal block.4

Complication

Rate

Total spinal anesthesia

Convulsion
Arrhythmia
None
None
Arrhythmia
Apnea
None

2.5/1 000
1.25/1 000

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Dural puncture
Intravascular injection

Consequence

Difficult injection of anesthetic mixture

Rectal penetration
Drug overdose
Morphine apnea
Skin lesion

Complications

The survey by Giaufr 4 reported, for caudal block, a rate of complication of 0.7/1 000.
Complication are summarized in Table III.
As described above, while the injection of
0.5 g/kg of epinephrine represents a valid
test for intravascular/intraosseus misplacement, no test reached sufficient sensitivity,
specificity and positive predictive value for
intratechal misplacement.
Some abnomarmalities like low-lying coni,
tethered cords and neurenteric cysts, both
intra- and paraspinal can increase the incidence of intratechal misplacement of the needle during caudal block.27 These defects are
often under diagnosed. Symptoms may consist in lower extremity weakness and incontinence. Notably, 50-100% of all patients with
lumbosacral spinal dysraphism have cutaneous
abnormalities ranging from dimples, hypertrichosis, hemangiomas and lipomas to nevi,
port-wine stains and hyperpigmentation.27
As mentioned above, the volume of the
injected anesthetic mixture is established to
obtain adequate cephalic spread, according
to the requested metameric level of anesthesia. However, only few studies 28, 29 considered the role of volume in determining quality and duration of the block. For this reason we conducted a study to analyse the
effect of a fixed dose of ropivacaine, injected at different volumes, on duration of postoperative analgesia in hypospadia repair.
Materials and methods
After IRB approval and informed parental
consent, 30 children (aged 1-5 years) sched-

456

0.6/1 000
0.6/1 000
0.6/1 000
0.6/1 000
0.6/1 000

uled for complex hypospadia repair were

included in this multicentre, perspective,
observational study. The children were otherwise healthy (ASA status I) and presented
no contraindications to caudal anesthesia.
After standard fasting times and premedication (midazolam 0.3 mg/kg per os, administered 45 minutes prior to surgery), anesthesia was induced with thiopental (5 mg/kg)
and then maintained with sevoflurane in oxygen/air (FiO2 0.5). The airway was managed
either with laryngeal mask or with orotracheal intubation according to the anaesthesiologists preference.
Following induction of anesthesia, patients
received a caudal block either with ropivacaine 0.375% at the dosage of 0.5 mL/kg (Low
Volume High Concentration Group, LVHC)
or ropivacaine 0.1% at the dosage of 1.8
mL/kg, at maximum dosage of 25 mL (High
Volume Low Concentration Group, HVLC).
Caudal block was performed in the lateral
decubitus position using an Epican 20 G caudal needle (B. Braun, Melsungen, Germany)
and the local anesthetic solution was injected in approximately 60 seconds. Surgery was
allowed to begin ten minutes after performing the block.
Inspiratory and end-tidal concentrations
of sevoflurane and ET-CO2 were measured
(Drger Primus, Luebeck, Germany). Peripheral oxygen saturation, heart rate, noninvasive blood pressure were also monitored
and recorded throughout surgery. All measurements were recorded at 5-minutes intervals. Minimum alveolar anesthetic concentration (MAC)-h (the average value for MAC
over the course of an hour) was calculated for
each of the groups. End-tidal sevoflurane

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TABLE IV.Demographic data and surgical duration

expressed as Mean and Standard Deviation.
LVHC
(meanSD)

Age (months)
Weight (kilos)
Surgical time

HVLC
(meanSD)

32.4710.23) 23.678,74
15.133.92)4 11.931,83
91.0723.13) 497.6729.87

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was maintained at 4% for the first 10 minutes after performing the block and then
reduced according to clinical parameters
(arterial blood pressure or heart rate within
20% of baseline or absence of responses such
as movement, tearing, or sweating). After
emergence from anesthesia, patients were
observed in the recovery room. Pain was
assessed using the Childrens Hospital of
Eastern Ontario Pain Scale (CHEOPS) 30 and
postoperative sevoflurane agitation was
assessed with a four-point scale (1=calm,
2=not calm but easily calmed, 3=moderately
agitated or restless, 4=combative, excited or
disoriented).31 Rescue fentanyl 1 g/kg was
administered for pain scores 9 and agitation scores grade 3 or 4 were treated with
midazolam 0.1 mg/kg. Motor blockade was
assessed with a modified Bromage score
(0=no motor block, 1=able to move legs,
2=unable to move legs).
Patients were then transferred to the ward
and observed for 24 hours for incidence of
postoperative pain. The time to first supplemental analgesic demand was defined as the
time from administration of block to the first
registration of a CHEOPS score 9 and was
considered the primary endpoint of the study.
Secondary endpoints were values of MAChour and incidence and degree of motor
blockade.
Results

Thirty patients were enrolled in the study.

All patients were judged to have successful
intraoperative analgesia and none of them
received additional intraoperative analgesia.
Patients demographic data are shown in
Table IV. Patients groups resulted to be statistically different regarding age and weight;
in particular, children of higher age and
weight were more represented among those
assigned to the LVHC Group. This can be
explained considering the anesthesiologists
attitude towards performing a low volume,
high concentration block in children whose
weight would imply surmounting of the maximum volume allowed if a high volume, low
concentration mixture was used. Time of res-

Vol. 72, N. 6

Significance

P=0.017
P=0.084
NS

TABLE V.Rescue analgesia time and MAC-hour in the

different groups.

Rescue analgesia
time
MAC-hour

LVHC
(meanSD)

HVLC
(meanSD)

Significance

520.67480

952,00506

P=0.024

0.770.27

0,860,36

NS

cue analgesia were compared between the

two groups with an analysis of variance
adjusting for age, weight and duration of surgical procedure as covariates. The difference
in rescue time was found to be significantly
different between groups. MAC-hour did not
differ significantly among groups (Table V).
We observed a motor block score of 2 in 7
patients of the LVHC group immediately following emergence; the remaining ones had
a score of 1. In HVLC group no patient experienced a motor block score of 2 and 6
patients had a score of 1.
Three children in the LVHC group required
midazolam in the recovery room because of
an agitation scale score 3 or 4.
Discussion

The required volume of caudal epidural

analgesic has been evaluated by several
Authors.2, 32 The volume per kilogram dosage
produces a tight linear correlation with number of dermatomes anaesthetized without
some potential for falsely negative results.
Few works considered the volume of the
anesthetic mixture as a determinant of quality and duration of the block.28, 29 Description
of neuraxial blockade by Bromage suggests
that blockade should regress from the site of
lowest anaesthetic concentration distal from
the injection caudally toward the higher con-

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3.
4.

anesthesia for infants and children. 3rd Edition.

Philadelphia: W. B. Saunders Company; 2001,p.647.
Sanders JC. Paediatric regional anaesthesia, a survey of
practice in the United Kingdom. Br J Anaesth 2002;89:
707-10.
Giaufre E, Dalens B, Gombert A. Epidemiology and
Morbidity of Regional Anesthesia in Children: A OneYear Prospective Survey of the French-Language Society
of Pediatric Anesthesiologists. Anesth Analg 1996;83:
904-12.
Cyna AM, Jha S, Parsons JE. Caudal epidural block
versus other methods of postoperative pain relief for circumcision in boys. The Cochrane Database of
Systematic Reviews 2003, Issue 2.
Somri M, Gaitini LA, Vaida SJ, Yanovski B, Sabo E,
Levy N et al. Effect of ilioinguinal nerve block on the
catecholamine plasma levels in orchidopexy: comparison with caudal epidural block. Paediatr Anaesth
2002;12:791-7.
Schuepfer G, Konrad C, Schmeck J, Poortmans G,
Staffelbach B, Johr M. Generating a learning curve for
pediatric caudal epidural blocks: an empirical evaluation of technical skills in novice and experienced anesthetists. Reg Anesth Pain Med 2000;25:385-8.
Senoglu N, Senoglu M, Oksuz H, Gumusalan Y, Yuksel
KZ, Zencirci B et al. Landmarks of the sacral hiatus
for caudal epidural block: an anatomical study. Br J
Anaesth 2005;95:692-5.
Ivani G. Caudal block: the no turn technique. Pediatr
Anesth 2005;15:80-4.
Orme RMLE, Berg SJ. The swoosh test-an evaluation of a modified whoosh test in children. Br J
Anaesth 2003;90:62-5.
Baris S, Guldogus F, Baris YS, Karakaya D, Kelsaka E.
Is tissue coring a real problem after caudal injection in
children. Pediatr Anesth 2004;14:755-8.
Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation
of caudal needle placement using nerve stimulation.
Anesthesiology 1999;91:374-8.
Roberts SA, Guruswamy V, Galvez I. Caudal injectate
can be reliably imaged using portable ultrasound a
preliminary study. Pediatr Anesth 2005;15:948-52.
Talwar V, Tyagi R, Mullick P, Gogia AR. Comparison of
whoosh and modified swoosh test for identification
of the caudal epidural space in children. Pediatr Anesth
2006;16:134-9.
Tobias JD. Caudal epidural block: a review of test dosing and recognition of systemic injection in children.
Anesth Analg 2001;93:1156-61.
Guay J. The epidural test dose: a review. Anesth Analg
2006;102:921-9.
Khalil S, Lingadevaru H, Bolos M, Rabb M, Matuszczak
M, Maposa D et al. Caudal Regional Anesthesia,
Ropivacaine Concentration, Postoperative Analgesia,
and Infants. Anesth Analg 2006;102:395-9.
Ivani G, De Negri P, Lonnqvist PA, Eksborg S, Mossetti
V, Grossetti R et al. A Comparison of Three Different
Concentrations of Levobupivacaine for Caudal Block in
Children. Anesth Analg 2003;97:368-71.
Gunter JB, Dunn CM, Bennie JB, Pentecost DL, Bower
RJ, Ternberg JL. Optimum concentration of bupivacaine for combined caudal-general anesthesia in children. Anesthesiology 1991;75:57-61.
de Beer DAH, Thonas ML. Caudal additives in children
- solutions or problems ? Br J Anaesth 2003;90:487-98.
Abdulatif M, El-Sanabary M. Caudal neostigmine, bupivacaine, and their combination for postoperative pain
management after hypospadias surgery in children.
Anesth Analg 2002;95:1215-8.
Wheeler M, Patel A. The addition of clonidine 2 gkg-

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centration.33 In this perspective, a high volume anesthetic mixture should be effective in

providing long-lasting analgesia in surgical
procedures whose metameric innervation is
very low. We chose to consider hypospadia
repair because it fit with these characteristics and because it is a surgical procedure
whose postoperative analgesia is often difficult to achieve.
In spite to a recent paper by Khalil,17 that
failed to demonstrate the efficacy of 0.1%
ropivacaine in providing sufficient postoperative analgesia and duration, our results
show that the use of a high volume, low concentration anesthetic mixture leads to an adequate and longer lasting analgesia, thus confirming the hypothesis of the cranio-caudal
regression of the block.
We were expecting a significative difference for the MAC-hour between the two
groups, with a lower value in the LVHC group
because of an anesthetic-sparing effect of the
higher concentration of local anesthetic. Our
results showed, however, no appreciable difference between groups. This can be
explained considering the indirect central
effects of epidural anesthesia, independently of the metameric level reached. As pointed out by Hodgson, epidural anesthesia acts
in this regard producing a spinal deafferentation that lowers general anesthetics requirements.34

5.

6.

7.

8.

9.

10.
11.
12.

13.
14.

15.

Conclusions

In conclusion, the administration of a high

volume, low concentration anesthetic mixture in the caudal space seems to produce a
better postoperative analgesia and less motor
block for hypospadia repair surgery.

Acknowledgments.Dr. Massimo Romiti, Anesthesia

and Pediatric Intensive Care Unit, Children Hospital Meyer,
Florence, Italy.

16.

17.

18.

19.

20.

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1 does not enhance the postoperative analgesia of a caudal block using 0.125% bupivacaine and epinephrine 1:
200 000 in children: a prospective, double-blind, randomized study. Pediatr Anesth 2005;15:476-83.
Semple D, Findlow D, Aldridge LM, Doyle E. The optimal dose of ketamine for caudal epidural blockade in
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De Negri P, Ivani G, Visconti C, de Vivo P. How to
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Ahuja BR. Analgesic effects of intrathecal ketamine in
rats. Br J Anaesth 1983;55:991-5.
Stotz M, Oehen HP, Gerber H. Histological findings
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Cohen IT. Caudal block complication in a patient with
trisomy 13 Pediatric Anesthesia 2006;16:213-5.
Schrock CR, Barry J. The dose of caudal epidural analgesia and duration of postoperative analgesia. Pediatr
Anaesth 2003;3:403-8.

29. Verghese ST, Hannallah RS, Rice LJ, Belman AB, Patel
KM. Caudal anesthesia in children: effects of volume vs
concentration of bupivacaine on blocking spermatic
cord traction response during orchidopexy. Anesth
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30. McGrath PJ, Johnson G, Goodman JT. CHEOPS: a
behavioral scale for rating postoperative pain in children. In: Fields HL, Dubner R, Cervero F eds. Advances
in Pain Research and Therapy. New York: Raven Press;
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31. Aono J, Ueda W, Mamiya K, Takimoto E, Manabe M.
Greater incidence of delirium during recovery from
sevoflurane anesthesia in preschool boys. Anesthesiology 1997;87:1298-300.
32. Busoni P, Andreuccetti T. the spread of caudal analgesia in children: a mathematical model. Anesth Intensive
Care 1986;14:140-4.
33. Bromage PR. Aging and epidural dose requirement.
Br J Anaesth 1969;41:1016-22.
34. Hodgson PS, Liu SS, Gras TW. Does Epidural Anesthesia
Have General Anesthetic Effects? Anesthesiology
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