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

Purpose: To illustrate insertion of an epidural catheter via caudal route i n 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 thym ic hypoplasia, cleft palate, hypocalcemia due to hypoparathyroidism resulti ng from 22q11 deletion) was scheduled for fundoplication and gastrostomy tu be (G-tube) insertion. A combined light general anesthesia and continuous e pidural anesthesia technique was selected. Following induction of general a nesthesia and tracheal intubation with 1.5 mg midazolam, 10 mu g fentanyl a nd 10 mg succinylcholine, a 16G intravenous catheter was inserted into the caudal space, A 19G epidural catheter (Arrow Flextip Plus) epidural cathete r was then inserted up cranially. A low electrical current(1 - 10mA) was th en applied through the catheter. The level of motor movement was advanced f rom the lower limb muscles to the upper abdominal muscles as the catheter w as 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 radiogra phical imaging. The patient awakened without distress and the trachea was e xtubated the same evening. The infant was discharged to the ward next morni ng with good pain relief from a continuous epidural infusion of bupivacane 0.1% with 1 mu g.ml(-1) at 1.6 ml(-1). Conclusion: Epidural stimulation may help placement of the epidural cathete r at the appropriate dermatome For effective anesthesia and analgesia.