• Paediatric epidurals
    • General considerations
      • Less haemodynamic instability in children due to relatively vasodilated circulation and lower circulatory volume in legs and splanchnic circulation
      • Spinal cord and dural sac ends at lower level in paediatric patients
      • The sacrum does not fuse posteriorly until late teens so sacral epidurals are possible
      • Sacral hiatus is due to failure of fusion of the 5th sacral vertebrae and is larger and higher in neonates
      • It is easier to insert catheters from a low level on paeds as there is less fat and fibrous tissue
    • Relationships
      • Age
        • Termination of SC
          • Termination of SA space
      • Neonates/infants
        • L3
          • S3-4
      • Child/adult
        • L1
          • S1-2
    • Pharmacokinetic considerations
      • Larger Vd so reduces peak plasma concentrations after a single bolus
      • Risk of drug accumulation higher after continuous infusion
      • Liver and renal function immature up to 3/12 so reduce rate in infants after 24hrs
      • Large cardiac output so increased uptake from neuraxial spaces
      • Lower plasma proteins, particularly a1-acid glycoprotein so more free LA
      • More penetrable BBB
    • Additives
      • Clonidine 1-2μcg/kg
      • Ketamine 0.5-1mg/kg
      • Diamorphine 30μcg/kg
      • Morphine 50μcg/kg
      • Assd with apnoea and sedation however
      • Fentanyl does not prolong the duration of analgesia
    • Thoracic epidural
      • Mean distance from dura to spinal cord is only 4.3mm at T9/10
      • Can do midline approach as spines are nearly horizontal
      • Low threshold for abandoning procedure
      • Best left to experienced individuals
    • Lumbar epidural
      • Only do under GA
      • LORS is used
      • Depth is about 1mm/kg with minimal distance of 10mm in children aged 6 months - 10 yrs
      • Softer ligamentum flavum
      • Complications seen less frequently than in adult practice
        Link:Dural puncture
      • PDPH is managed in a similar way to adults
    • Caudal epidural
      • Safe, simple and suitable for day case
      • Reliably block T10-S5 in infants but only sacral dermatomes in children
      • Indications
        • Operation below the umbilicus (infants)
        • Herniotomy, hypospadias repair, orchidopexy
      • Technique
        • Full asepsis
        • Identify PSIS bilaterally
        • Use index finger to form equilateral triangle identifying the cornun and hiatus
        • A 20g cannula is commonly used due to better feel and less likelihood of vascular puncture
        • Dose
          • Age
            • Dose (sacral block)
              • Dose (lumbo-sacral)
          • 0-6 months
            • 1mg/kg
              • 1-2mg/kg
          • > 6 months
            • 1-1.25mg/kg
              • 2-2.5mg/kg
      • Complications
        • Rare
        • Failure in 2-10%
        • IV injection 1:10, 000
        • Haematoma or abscess 1:80, 000
        • Leg weakness and urinary retention common but self limiting
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/6/2/63.full.pdf?sid=c01ec311-8163-4791-b66f-67d08edb4f4c