THORACIC EPIDURAL-ANESTHESIA VIA THE LUMBAR APPROACH IN INFANTS AND CHILDREN

Background: In upper abdominal or chest surgery, the segmental approac h to thoracic epidural space has the advantage of reducing the total d ose of local anesthetic needed. This approach, however, is associated with greater risk of neurologic damage or dural puncture. The aim of t his study was to assess the success and the degree of difficulty In ad vancing a 19-G catheter from the lumbar epidural space to the thoracic level In patients aged 0-96 months. Methods: In 39 patients undergoin g abdominal surgery, the cutaneous distance between the L4-L5 and T10- T11 Interspaces was measured, and an appropriate length of 19-G cathet er was inserted into the epidural space through an 18-G Tuohy needle w ith bevel directed cephalad. The intent was to advance the full length of catheter measured to reach the objective. The tips were observed r adiologically, and all those positioned cephalad to the T12 level were considered well placed. The degree of difficulty in advancing the cat heter was classified as easy, difficult, or impossible. Complications reported were vascular and/or spinal puncture and difficulty removing the catheter. Results: The catheter tip reached T10-T12 in 7 patients, 12 in 1, L3 in 8, and L4-L5 in 23. Forty-eight percent of the cathete rs described as easily advanced remained at the L4-L5 level, and only 22% reached the desired level. Difficult Insertions occurred in eight patients, In whom the objective was never reached. One ease of intrava scular insertion was reported. All catheters were removed without diff iculty. Conclusions: The 19-G catheter is inappropriate for use in rea ching the thoracic epidural space by the lumbar approach. Easy entranc e of a catheter is not a reliable sign of having reached the desired l evel.