PR2-170
Pre-Procedure Ultrasound Mapping for the Anticipated Difficult Epidural Placement in an Obese Pediatric Patient: A Case Report
Schackman J, Sutton C
Baylor College of Medicine Texas Children's Hospital, Houston, Texas, United states of america
Introduction:
Epidural placement in the pediatric population is most commonly performed using a blind landmark-based technique. The procedure can be prolonged if the patient has variant anatomy such as scoliosis, kyphosis, lordosis, or obesity. Live, intraprocedural use of ultrasound guidance has been demonstrated to increase success rates and decrease onset time of neuraxial anesthesia in the pediatric population1. While pre-procedural ultrasound measurement has been described in infants and small children 1,2, to our knowledge it has not been described in the obese pediatric patient population. We present a case of use of pre-procedural ultrasound for a suspected difficult epidural in a pediatric patient weighing 141kg undergoing retroperitoneal lymph node dissection.
Case Report:
A 17 year old, 141 kg male (BMI 44kg/m2) with a history of testicular cancer presented for transabdominal retroperitoneal lymph node dissection with planned incision from xiphoid to pelvis.. After multidisciplinary discussion between the surgery, anesthesiology, and acute pain services, the decision was made to place an epidural for intra- and postoperative analgesia. Given the patient’s body habitus, pre-procedural ultrasound mapping of the spine was planned.
After optimal positioning in the seated position, the spinous processes were unable to be palpated by three different providers. An ultrasound exam lasting approximately 5 minutes was used to visualize the spinous processes, anterior complex, posterior complex, ligamentum flavum, dura, and epidural space using techniques described in literature3. The optimal window, trajectory, and depth were determined. Using full sterile technique and the ultrasound map, the epidural space was identified at 8.5 cm as measured with ultrasound after a single needle pass. From administration of local anesthetic for the skin to the time of catheter placement, the procedure duration was less than 4 minutes. On postoperative day 1, the patient rated his pain 0/10 with a bilateral sensory block from T6-T11.
Discussion:
When faced with suspected difficult epidural placement, the use of ultrasound technology to better evaluate vertebral spaces can be used for more accurate needle placement1,2,3,4. As the childhood obesity rate increases, the pediatric anesthesiologist may be increasingly faced with challenging epidurals without palpable landmarks. Potential benefits of the use of ultrasound for pre-procedural mapping include creating a better experience for both the patient and the provider, decreasing number of epidural attempts, and decreasing valuable operating room time.
References
1. Rubin, Kasia, et al. “Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children?†Pediatric Anesthesia, 2009.
2. Kil, H, et al. “Prepuncture Ultrasound-Measured Distance: An Accurate Reflection of Epidural Depth in Infants and Small Children.†Regional Anesthesia and Pain Medicine, 2007.
3. Chin, Ki Jinn, et al. “Ultrasonography of the Adult Thoracic and Lumbar Spine for Central Neuraxial Blockade.†Anesthesiology, 2011.
4. Borges, Bruno C.r., et al. “Sonoanatomy of the Lumbar Spine of Pregnant Women at Term.†Regional Anesthesia and Pain Medicine, 2009.
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