Thoracic epidural anesthesia via the modified Taylor approach in infants

Background and Objectives: Advancement of catheters from the caudal to the thoracic level is an alternative to thoracic epidural anesthesia in infants and younger children; however, contamination of the insertion site may occ ur. This study examined the feasibility of the midline modified Taylor appr oach (L-5-S-1) for the advancement of epidural catheters to the thoracic le vel in infants. Methods: After Institutional Review Board (IRB) approval and parental conse nt, the L-5-S-1 interspace of infants 3 months to 2 years old was entered w ith an 18-gauge Crawford needle using the saline loss of resistance techniq ue. A 20-gauge catheter with styler (Abbott; North Chicago, IL) war then ad vanced the distance from the L-5-S-1 interspace to the desired thoracic lev el. If resistance was encountered, the catheter was withdrawn 1 to 2 cm, ro tated along its long axis, and readvanced. The stylet was left in place, an d a radiograph of the thoracolumbar spine was taken. The stylet was then re moved, and the catheter was secured, tested, and dosed. Results: Sixteen infants (mean age, 14.4 +/- 5.7 months and mean weight, 9. 3 +/- 1.4 kg) were studied. Fifteen of 16 catheters were inserted the full length planned. Fourteen of 16 catheters were straight (1 had a single bend , and 1 had multiple loops). Mean discrepancy between level desired and obt ained was -1.7 +/- 1.7 segments (median, -1.75). Discrepancy did not correl ate with either desired level or length inserted, but did decrease with exp erience. Conclusions: The midline modified Taylor approach allows access to the thor acic epidural space via catheter advancement, while being below the terminu s of the spinal cord and less likely to suffer contamination than the cauda l approach.