Ultrasound-Guided Versus Conventional Method for Caudal Block
Condition: Ultrasound Therapy; Complications
Study type: Interventional

Summary: 
      Caudal epidural block has been widely used, especially in pediatric surgery, to supply
      intraoperative and postoperative analgesia by affecting the region between T10 and S5
      dermatomes in surgeries below the umbilical level.

      In conventional single-shot caudal block, the needle is inserted through the skin with a
      60-80 degrees angle, until the sacrococcygeal ligament is passed through. Then the angle of
      the needle is decreased to 20-30 degrees and inserted further for an additional 2-3 mm,
      entering into the sacral canal.There is a risk of dural or vascular puncture when the needle
      is passing through sacral canal. Other complications are the soft tissue bulging,
      intraosseous injections and systemic toxicity.

      Many anatomical variations have been reported for sacral hiatus and sacral cornua. Therefore,
      the success rate of the classic caudal epidural anesthesia method in pediatric patients has
      been reported to be about 75%.

      With the usage of ultrasonography in regional anesthesia, many advantages have been reported.
      In particular ultrasonography under longitudinal image is helpful for visualization of the
      sacral hiatus, sacrococcygeal ligament, duramater, epidural space and the distribution of the
      local anesthetic agent Therefore, this significantly increases the block success and
      visualization of where local anesthetic is injected.

      The primary aim of this study was compare the success rate of ultrasound guided sacral hiatus
      injection and conventional sacral canal injection. Secondary objectives are; block performing
      time, number of needle puncture, success at first puncture and complication rate. However age
      and weight encountered wtih these complications are registered.
    

Detailed description: 
      The caudal block was performed in Group C by via conventional methods. The sacral cornus and
      the sacral hiatus were palpated. After sterilization of the region, a 22- gauge caudal needle
      was inserted into the skin with at a 60-80 degree angle and until the sacrococcygeal ligament
      was passed punctured, as determined with by a "popping sensation." feeling (puncture of the
      sacrococcygeal ligament). Then, the angle of the needle was then reduced to 20-30 degrees and
      inserted further for an additional 2-3mm, entering into the sacral canal. After
      verifingverifying the absence of any blood or cerebrospinal fluid in the aspiration, a test
      dose of 0.1 ml/kg of local anesthetic (LA) with adrenalin at a ratio of 1: 200000 was
      injected under hemodynamic and ECG monitoring. Following a negative test dose, the rest of
      the LA was slowly injected slowly over 1 min. In the case of the needle touching the bony
      tissue, blood aspiration, or bulging into of the subcutaneous tissue, the angle of the needle
      was changed and the intervention was repeated.

      The caudal block was performed by via ultrasound guided ultrasound guidance in Group U. After
      sterilization of the region and using ultrasound guidanceUSG with a sterile plastic cover and
      gel, the sacral hiatus was visualized via an out-of-plane technique at the level of the
      sacral cornus at the out of plane via the lineerlinear transducer of an M-Turbo ultrasound
      machine (TM; Fujifilm SonoSite Inc., (Washington, WA, United StatesUSA) ultrasound machine at
      13 MHz, and the, depth and gain was adjusted to for optimal visual quality. The ultrasound
      ultrasound transducer was first placed transversely at the midlain midline to obtain the
      transvers view of the two cornua, the sacrococcygeal ligament, the sacral bone, and the
      sacral hiatus. At this level, the ultrasound ultrasound transducer was rotated 90 degrees to
      obtain the longitudinal view of the sacrococcygeal ligamantligament and sacral hiatus, and
      was then placed between the two cornua. A 22- gauge caudal needle was advanced toward the
      upper third of the sacrococcygeal ligament. The needle advancement was terminated right after
      penetrating the sacrococcygeal ligament. At this level, after confirming the absence of any
      blood or cerebrospinal fluid in the aspiration and a negative test dose, the rest of the LA
      was injected over 1 min under while observing the ultrasound ultrasound longitudinal image
    

Intervention name(s): Bupivacaine; Adrenalin; Ultrasound
Intervention type(s): Drug; Drug; Device
Intervention description(s): caudal block was performed by conventional and ultrasound method with %0,25 bupivacaine + 1/200000 adrenalin; caudal block was performed by conventional and ultrasound method with %0,25 bupivacaine + 1/200000 adrenalin; caudal block was performed by ultrasound method
Other intervention name(s): Bustesin,Vem Drug, Ankara, Turkey; Adrenalin 0.5 mg, Osel Drug, Istanbul, Turkey; Sonosite M Turbo, USA
Intervention MeSH terms: Epinephrine; Racepinephrine; Bupivacaine; Epinephryl borate
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: sacral canal; sacral hiatus; ultrasound