Thoracic epidural analgesia via the caudal approach using nerve stimulation in an infant with CATCH22

Abstract

Purpose: To illustrate insertion of an epidural catheter via caudal route in a small infant under electrical stimulation guidance. Clinical features: A six month old boy, weighting 4.25 kg, with a diagnosis of CATCH22 (Cardiac abnormality/abnormal faces, T cell deficit due to thymic hypoplasia, cleft palate, hypocalcemia due to hypoparathyroidism resulting from 22q11 deletion) was scheduled for fundoplication and gastrostomy tube (G-tube) insertion. A combined light general anesthesia and continuous epidural anesthesia technique was selected. Following induction of general anesthesia and tracheal intubation with 1.5 mg midazolam, 10 μg fentanyl and 10 mg succinylcholine, a 16G intravenous catheter was inserted into the caudal space. A 19G epidural catheter (Arrow Flextip Plus) epidural catheter was then inserted up cranially. A low electrical current (1-10mA) was then applied through the catheter. The level of motor movement was advanced from the lower limb muscles to the upper abdominal muscles as the catheter was threaded cranially. After 19 cm of epidural catheter had been inserted, intercostal muscle movement (T9-10 level) was observed at 4.2mA. The tip of the catheter was later confirmed to be at the T9-10 interspace by radiographical imaging. The patient awakened without distress and the trachea was extubated the same evening. The infant was discharged to the ward next morning with good pain relief from a continuous epidural infusion of bupivacane 0.1% with 1 μg · ml-1 at 1.6 ml-1. Conclusion: Epidural stimulation may help placement of the epidural catheter at the appropriate dermatome for effective anesthesia and analgesia.