Abstract
Purpose
Several methods have been described to locate the epidural space, but the loss-of-resistance (LOR) technique is the most commonly used. Expert opinion states that LOR to air is the best medium for neonates and infants. We conducted a Canadawide postal survey to determine the current state of practice for placement of epidural catheters in pediatric patients.
Methods
Two hundred and nine surveys were distributed to academic pediatric anesthesiologists across Canada. The survey was limited to six questions and was anonymous.
Results
The response rate was 62.2%. LOR was the method of choice for 124/130 anesthesiologists (95.4%). LOR to normal saline was the medium of choice for all age groups, although LOR to air and LOR to air/saline gained in popularity with increasing patient age. The majority of anesthesiologists do not change their LOR technique for different patient ages or level of epidural insertion. Most responders ranked 'training’ as the most important determinant of practice, whereas 'departmental guidelines’ were considered the least important. No complication attributable to the LOR technique used was reported.
Conclusion
LOR to normal saline is the preferred method for identification of the epidural space in children of all age groups. The suggestion by experts that LOR to air should be used in neonates and infants was not supported by the practice of pediatric anesthesiologists across Canada.
Résumé
Objectif
Parmi les méthodes décrites pour localiser l’espace péridural, la technique de la perte de résistance (PDR) est la plus courante. Un rapport d’expert souligne que la PDR à l’air est le meilleur moyen à utiliser chez les nouveau-nés et les jeunes enfants. Nous avons mené une enquête pancanadienne pour décrire l’utilisation actuelle de cathéters périduraux en pédiatrie.
Méthode
Deux cent neuf formulaires d’enquête ont été distribués aux anesthésiologistes de pédiatrie universitaire à travers le Canada. L’enquête, anonyme, ne comportait que six questions.
Résultats
Le taux de réponse a été de 62,2 %. La PDR était la méthode de choix de 124/130 anesthésiologistes (95,4 %). La PDR au soluté physiologique était préféré pour tous les groupes d’âge, même si la PDR à l’air et la PDR à l’air/au soluté physiologique devenaient plus populaires avec l’âge croissant des patients. La majorité des répondants ne changent pas leur technique de PDR en fonction de l’âge des patients ou du niveau d’insertion péridurale. La plupart ont classé «la formation» en tête des déterminants de la pratique, tandis que «les directives du département» étaient considérées comme les moins importantes. Il n’y a eu aucune complication liée à la technique de PDR.
Conclusion
La PDR au soluté physiologique est la méthode préférée pour identifier l’espace péridural chez les enfants de tous âges. L’opinion des experts voulant que la PDR à l’air doive être utilisée chez les nouveau-nés et les jeunes enfants n’est pas suivie par les anesthésiologistes pédiatriques canadiens.
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References
Dogliotti AM. A new method of block anesthesia. Segmental peridural spinal anesthesia. Am J Surg 1933;20:107–8.
Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth 1997; 22:3–15.
Shenouda PE, Cunningham BJ. Assessing the superiority of saline versus air for use in the epidural loss of resistance technique: a literature review. Reg Anesth Pain Med 2003; 28:48–53.
Beilin Y, Arnold I, Telfeyan C, Bernstein HH, Hossain S. Quality of analgesia when air versus saline is used for identification of the epidural space in the parturient. Reg Anesth Pain Med 2000; 25:596–9.
Busoni P, Messeri A. Loss of resistance technique to air for identifying the epidural space in infants and children. Use an appropriate technique! (Letter). Paediatr Anaesth 1995; 5:397.
Roelants F, Veyckemans F, Van Obbergh L, et al. Loss of resistance to saline with a bubble of air to identify the epidural space in infants and children: a prospective study. Anesth Analg 2000; 90:59–61.
Schwartz N, Eisenkraft JB. Probable venous air embolism during epidural placement in an infant. Anesth Analg 1993; 76:1136–8.
Flandin-Blety C, Barrier G. Accidents following extradural analgesia in children. The results of a retrospective study. Paediatr Anaesth 1995; 5:41–6.
Yamashita M, Tsuji M. Identification of the epidural space in children. The application of a micro-drip infusion set. Anaesthesia 1991; 46:872–4.
Bissonnette B, Dalens D. Pediatric Anesthesia. Principles and Practice. McGraw-Hill; 2002.
Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002; 324:1183.
Dalens B, Tanguy A, Haberer JP. Lumbar epidural anesthesia for operative and postoperative pain relief in infants and young children. Anesth Analg 1986; 65:1069–73.
Chalkiadis G. The rise and fall of continuous epidural infusions in children (Editorial). Paediatr Anaesth 2003; 13:91–3.
Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia “learning curve”. What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth 1996; 21:182–90.
Ruston FG. Epidural anaesthesia in infants and children. Can Anaesth Soc J 1954; 1:37–44.
Yaster M, Maxwell LG. Pediatric regional anesthesia. Anesthesiology 1989; 70:324–38.
Dalens B. Regional anesthesia in children. Anesth Analg 1989; 68:654–72.
Yentis SM. Time to abandon loss of resistance to air (Letter). Anaesthesia 1997; 52:184.
Russell R, Douglas J. Loss of resistance to saline is better than air for obstetric epidurals. Int J Obstet Anesth 2001; 10:302–6.
Dalens B, Chrysostome Y. Intervertebral epidural anaesthesia in paediatric surgery: success rate and adverse effects in 650 consecutive procedures. Paediatr Anaesth 1991; 1:107–17.
Stride PC, Cooper GM. Dural taps revisited. A 20-year survey from Birmingham Maternity Hospital. Anaesthesia 1993; 48:247–55.
Guinard JP, Borboen M. Probable venous air embolism during caudal anesthesia in a child. Anesth Analg 1993;76:1134–5.
Adornato DC, Gildenburg PL, Ferrario CM, Smart J, Frost EA. Pathophysiology of intravenous air embolism in dogs. Anesthesiology 1978; 49:120–7.
Sethna NF, Berde CB. Venous air embolism during identification of the epidural space in children. Anesth Analg 1993; 76:925–7.
Naulty JS, Ostheimer GW, Datta S, Knapp R, Weiss JB. Incidence of venous air embolism during epidural catheter insertion. Anesthesiology 1982; 57:410–2.
Jaffe RA, Siegel LC, Schnittger I, Propst JW, Brock-Utne JG. Epidural air injection assessed by transesophageal echocardiography. Reg Anesth 1995; 20:152–5.
Dalens B, Bazin JE, Haberer JP. Epidural bubbles as a cause of incomplete analgesia during epidural anesthesia. Anesth Analg 1987; 66:679–83.
Tobias JD, Lowe S, O’Dell N, Holcomb GW. Thoracic epidural anaesthesia in infants and children. Can J Anaesth 1993; 40:879–82.
Strafford MA, Wilder RT, Berde CB. The risk of infection from epidural analgesia in children: a review of 1620 cases. Anesth Analg 1995; 80:234–8.
Osaka Y, Yamashita M. Intervertebral epidural anesthesia in 2,050 infants and children using the drip and tube method. Reg Anesth Pain Med 2003; 28:103–7.
Williams DG, Howard RF. Epidural analgesia in children. A survey of current opinions and practices amongst UK paediatric anaesthetists. Paediatr Anaesth 2003; 13:769–76.
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Ames, W.A., Hayes, J.A., Pétroz, G.C. et al. Loss of resistance to normal saline is preferred to identify the epidural space: a survey of Canadian pediatric anesthesiologists. Can J Anesth 52, 607–612 (2005). https://doi.org/10.1007/BF03015770
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DOI: https://doi.org/10.1007/BF03015770