📚 Invasive Techniques - Caudal Anesthesia

MT(RT) 502 | Dr. Ayesha Iqbal

🔵 SLIDE 1 - Title Slide

🔵 SLIDE 2 - Lecture Title

• Neuraxial = Neuro (nerve) + Axial (axis/spine) - spine ke aas paas ki jagah se related
• Anesthesia = Dawa jo feeling/sensation khatam kar deti hai

🔵 SLIDE 3 - Learning Objectives

1. Know the indications (when to use), contraindications (when NOT to use), and complications (side effects/problems) of caudal anesthesia
2. Learn the method of insertion (how it is done)

1. Caudal anesthesia kab di jati hai, kab nahi di jati, aur iske kya masail ho sakte hain
2. Ye technique kaise ki jati hai

🔵 SLIDE 4 - Caudal Anesthesia (Definition)

• Regional anesthesia = Sirf ek hisse ko numb karna (poori body nahi)
• Local anesthetic = Dawa jo ek jagah inject karke nerve signals rok deti hai (e.g., Bupivacaine, Ropivacaine)
• Caudal = Latin mein "tail" - matlab sacrum/tailbone ke paas wali jagah
• Epidural space = Spinal cord ke covering (dura) ke bahar wali jagah
• Sacral hiatus = Sacrum ki haddi mein ek natural opening (gap)
• Numb = Mehsoos karna band ho jaana

• Caudal = Epidural ka ek type hai
• Spinal anesthesia se farq: Epidural mein needle dura ke bahar rukti hai, Spinal mein dura ke andar jati hai
• Caudal especially children mein zyada use hoti hai

🔵 SLIDE 5 - Caudal Epidural Space (Anatomy Part 1)

• Caudal space is the sacral portion of the epidural space
• Needle/catheter penetrates the sacrococcygeal ligament covering the sacral hiatus - this hiatus is created by the unfused S4 and S5 laminae
• Hiatus can be felt as a groove or notch above the coccyx and between two bony prominences - the sacral cornua
• Anatomy is more easily identified in infants and children

• Caudal space, epidural space ka sacral (sacrum haddi ka) hissa hai
• Needle "sacrococcygeal ligament" ko paar karti hai - yeh ligament sacral hiatus ko dhakay hue hai
• Sacral hiatus S4 aur S5 vertebrae ke naa judne (unfused) ki wajah se banta hai
• Yeh hiatus coccyx ke upar ek groove ya notch ki tarah feel hota hai - dono taraf "sacral cornua" hoti hain
• Bachon mein yeh anatomy zyada asani se pehchani ja sakti hai

• Sacrococcygeal ligament = Sacrum aur coccyx ko jodne wala ligament - yeh hi needle se pehle aata hai
• Laminae = Vertebra ke pichle hisse ke flat bone parts
• Unfused = Jude nahi hue - S4 aur S5 ke laminae akay nahi hote, isliye gap banta hai
• Sacral cornua = Sacrum ke do chhote bone projections jo sacral hiatus ke dono taraf hote hain
• Coccyx = Tailbone - riidh ki haddi ka sabse aakhri hissa
• Groove/Notch = Ek dab ya khaanch

🔵 SLIDE 6 - Caudal Epidural Space (Anatomy Part 2)

• The posterior superior iliac spines (PSIS) and the sacral hiatus form an equilateral triangle (landmark for locating the hiatus)
• Calcification of the sacrococcygeal ligament can make caudal block difficult or impossible in older adults
• Sacral canal contains: dural sac, nerves, blood vessels, adipose tissue, and connective tissue
• Within the sacral canal, the dural sac extends to S1 in adults and S3 in infants
• Because the dural sac goes lower in infants (S3), unintended intrathecal injection is more common in infants

• Posterior superior iliac spines (PSIS) aur sacral hiatus milke ek "equilateral triangle" banate hain - yeh triangle hiatus dhoondne ka landmark hai
• Bade buzurg logon mein sacrococcygeal ligament calcify (sakht/calcium se bhar) ho jata hai, isliye caudal anesthesia mushkil ya na-mumkin ho sakti hai
• Sacral canal ke andar: dural sac, nerves, blood vessels, fat tissue aur connective tissue hote hain
• Dural sac adults mein S1 tak aur bachon mein S3 tak hota hai
• Kyunki bachon mein dural sac neeche (S3) tak hai, isliye unhe intrathecal injection ki galti zyada ho sakti hai

• PSIS (Posterior Superior Iliac Spine) = Hip bone ka peechay upar wala ubhar - haath se feel hota hai
• Equilateral triangle = Woh triangle jisme tino sides barabar hon - yahan PSIS (dono sides) aur sacral hiatus (neecha) milke ek aisa triangle banate hain
• Calcification = Calcium jama ho jaana - tissue sakht ho jata hai
• Dural sac = Spinal cord ki taanf (dura mater) ka bag - cerebrospinal fluid aur spinal nerves is mein hain
• Adipose tissue = Fat tissue (charbi)
• Intrathecal injection = Dural sac ke ANDAR injection (yeh galat jagah hai caudal mein, kyunki hum epidural space mein jaana chahte hain)

🔵 SLIDE 7 - Indications (Kab Use Karein)

1. Primary anesthetic or adjunct to general anesthesia in pediatrics (children)
2. Subumbilical procedures - below the belly button: inguinal hernia repair, urological interventions, anal atresia repair, lower extremity procedures
3. Minor anorectal procedures in adults (primary method)
4. Postoperative analgesia in pediatric inguinal surgeries
5. Chronic lower back pain management
6. Previously used for labor analgesia during 2nd stage of labor

1. Bachon mein main ya helping anesthesia ke tor par
2. Naaf ke neeche ki operations: hernia repair, peshab ki nali ki surgery, anal atresia (guda ka band hona) ki surgery, paon ki surgery
3. Bade logon mein guda (anorectal) ki chhoti operations
4. Bachon ki hernia surgery ke baad dard control karne ke liye
5. Purani kamar dard ki treatment mein
6. Pehle: delivery ke waqt dard khatam karne ke liye (2nd stage of labor mein) - ab yeh zyada use nahi hoti

• Indications = Woh conditions/situations jab yeh technique use ki jaye
• Adjunct = Madad karne wali - yahan matlab general anesthesia ke saath milake use karna
• Subumbilical = Sub (neeche) + umbilical (naaf) = naaf se neeche
• Inguinal hernia = Kamar ke paas (groin area) mein anntriyan bahar nikalna
• Urological = Peshab se related (kidney, bladder, ureter)
• Anal atresia = Guda (anus) ka paidaishi band hona - naye paida hue bachon mein
• Anorectal = Anus aur rectum (badi aant ka aakhri hissa) se related
• Analgesia = Dard khatam karna
• Chronic = Lambay arsay se chala aa raha
• Labor = Dard-e-zah, prasav (delivery ka waqt)

🔵 SLIDE 8 - Contraindications (Kab Na Karein)

• Patient or guardian refusal
• Localized infection at the insertion site
• Severe coagulopathy (severe blood clotting problem)
• Increased intracranial pressure (ICP)
• Allergy to medications
• Spinal dysraphism (e.g., tethered cord syndrome)

• Spinal stenosis
• Hypovolemia (low blood volume)
• Less severe coagulopathies
• Systemic infection
• Pilonidal cysts
• Sacral anomalies (e.g., previous meningomyelocele)

• Mareez ya us ke wali ka inkaar
• Injection ki jagah infection
• Severe blood clotting ki bimari
• Dimag ke andar pressure zyada hona
• Dawa se allergy
• Spinal cord ka paidaishi masla (tethered cord)

• Spinal canal ka tang hona
• Khoon ki kami (hypovolemia)
• Halki blood clotting ki takleef
• Poore jism mein infection
• Coccyx ke paas cyst hona
• Sacrum ki haddi mein koi masla (jaise purana meningomyelocele)

• Contraindications = Woh conditions jab kuch NA karna chahiye
• Absolute contraindication = Bilkul forbidden - koi justification nahi
• Relative contraindication = Shayad na karo - risk vs benefit dekho
• Coagulopathy = Khoon jamne ki takleef (blood clotting disorder)
• Intracranial pressure = Khoplay (skull) ke andar pressure
• Spinal dysraphism = Spine ka paidaishi dhang se na banna
• Tethered cord syndrome = Spinal cord ka neeche se attached hona - kheenchti hai
• Spinal stenosis = Spinal canal ka tang ho jaana
• Hypovolemia = Jism mein khoon ya fluids ki kami
• Pilonidal cyst = Coccyx ke paas baalon ki wajah se banne wali cyst
• Meningomyelocele = Paidaishi bimari jisme spinal cord aur its coverings back se bahar nikal aate hain

🔵 SLIDE 9 - Complications (Mushkilaat)

1. Subdural, intravascular, or intraosseous injection (needle goes wrong place)
2. Infection
3. Hypotension (low blood pressure)
4. Injury to nerve roots
5. Antesacral injection with rectal perforation (needle goes in front of sacrum into rectum)
6. Hematoma formation (blood collection)
7. Local anesthetic toxicity (dawa ki zaharilat)
8. Delayed respiratory depression (saans dheeray hona, baad mein)
9. Urinary retention (peshab band ho jaana)
10. Sacral osteomyelitis (sacrum ki haddi mein infection)
11. Total spinal anesthesia (poori riidh ki haddi numb - dangerous!)

1. Needle galat jagah jaye - dura ke neeche (subdural), ragon mein (intravascular), ya haddi mein (intraosseous)
2. Jagah par infection
3. Blood pressure girna
4. Nerves ko nuqsan
5. Needle sacrum se aagay nikal kar rectum (badi aant) ko toad de
6. Khoon ka jamav (hematoma)
7. Local anesthetic se zaharilat (LAST - Local Anesthetic Systemic Toxicity)
8. Baad mein saans ki raftar girna (opioids ki wajah se)
9. Peshab na aana
10. Sacrum ki haddi mein infection
11. Total spinal - poori spine block ho jaaye - bohat khatarnak!

• Subdural = Dura mater ke neeche
• Intravascular = Blood vessel ke andar (injection yahan chali jaaye to bohat khatarnak)
• Intraosseous = Haddi ke andar
• Hypotension = Low blood pressure
• Hematoma = Ek jagah khoon jama hona
• Local anesthetic toxicity = Anesthetic dawa ka jism mein zahar banna - heart aur brain affect hote hain
• Respiratory depression = Saans ki raftar bahut kam ho jaana
• Urinary retention = Bladder bhar jaye par peshab na aa sake
• Osteomyelitis = Haddi mein bacterial infection
• Total spinal anesthesia = Dawa itni upar chali jaaye ke poori spine block ho jaye - saans band ho sakta hai!

🔵 SLIDE 10 - Equipment (Saaz o Samaan)

1. Appropriately sized syringe
2. Needle (22 to 25 gauge, short-beveled Tuohy or Crawford needle) or catheter
3. Medication: 0.125% to 0.25% bupivacaine OR 0.1% to 0.375% ropivacaine, opioids, epinephrine, corticosteroids
4. Skin cleaning solution: alcohol, chlorhexidine, or iodine solution
5. PPE: sterile gloves, masks, and head covering
6. Ultrasound / Fluoroscopy (imaging guidance)

1. Syringe (dawa bhrne wala)
2. Needle - 22 se 25 gauge, short-beveled Tuohy ya Crawford needle, ya catheter
3. Dawa: Bupivacaine ya Ropivacaine (numbness ke liye) + opioids + epinephrine + corticosteroids
4. Skin saaf karne ki cheez: alcohol, chlorhexidine ya iodine
5. Sterile PPE: dastane (gloves), mask, head cover
6. Ultrasound ya Fluoroscopy - needle sahi jagah dekhne ke liye

• Gauge = Needle ki motaai naapne ka unit - number zyada = needle patli (22G > 25G motaai)
• Short-beveled = Needle ki nok thodi kaati hui - epidural mein zyada feel milti hai
• Tuohy needle = Specially designed epidural needle - nok curved hoti hai
• Crawford needle = Straight tip epidural needle
• Bupivacaine = Local anesthetic dawa - kaafi der tak kaam karti hai
• Ropivacaine = Bupivacaine se milti julti dawa - thodi kam toxic
• Epinephrine = Adrenaline - test dose mein dil ki raftar badh jaaye to pata chalta hai injection ragon mein gayi
• Corticosteroids = Sujan khatam karne wali dawa (e.g., chronic back pain mein)
• Fluoroscopy = X-ray ki ek type jo real-time mein needle ka rasta dikhati hai
• PPE = Personal Protective Equipment

🔵 SLIDE 11 - Technique (Tareeqa, Part 1)

• Review patient's medical history
• Conduct physical examination
• Obtain informed consent
• Position patient in either lateral decubitus (side-lying) or prone (face-down) position
• Sacral hiatus is identified by locating the sacral cornua on each side, just superior to the gluteal cleft

• Mareez ki medical history dekho
• Physical examination karo
• Mareez se ijazat (informed consent) lo
• Mareez ko lateral decubitus (karwat wali) ya prone (pait ke bal) position mein lao
• Sacral cornua dhoondhain jo gluteal cleft (gand ka darmiyan wali rekha) ke upar hote hain - is se sacral hiatus mila jaata hai

• Informed consent = Mareez ko poori baat bata ke uski ijazat lena - yeh legal zaroorat hai
• Lateral decubitus = Pehlu ke bal letna (side-lying)
• Prone position = Pait ke bal letna (face down)
• Sacral cornua = Sacrum ki haddi ke dono taraf ke chhote ubhar - yeh sacral hiatus dhoondhne ka landmark hai
• Gluteal cleft = Do gand cheeks ke darmiyan wali line/crack

🔵 SLIDE 12 - Technique (Part 2)

• Aseptic technique is used
• Needle is inserted at a 45° angle through the sacral hiatus
• Angle is then flattened (reduced) and advanced
• A "pop" or "give" is felt when needle passes through the sacrococcygeal ligament and enters the epidural space
• Aspiration for blood and CSF is done - if negative, proceed

• Aseptic technique use karo (koi germs nahi aane chahiye)
• Pehle needle 45 degree angle par daalo
• Phir needle ka angle kam karo (flat karo) aur aagay le jao
• Jab needle sacrococcygeal ligament paar karti hai aur epidural space mein daakhil hoti hai to ek "pop" ya "give" feel hoti hai
• Aspiration karo - agar khoon ya CSF nahi aata to theek hai, aagay barhao

• Aseptic technique = Koi bacteria/germs na aaney dena - gloves, sterile instruments
• 45° angle = 45 darje ka zaaweya
• Flattened = Angle kam karna - needle zyada horizontal ho jaati hai epidural space mein jaane ke baad
• "Pop" or "Give" = Ek aahista si feeling jab needle ligament ko paar karti hai - yeh confirmation hai ke sahi jagah pahunchi
• Aspiration = Syringe piston ko peeche kheenchna - dekhte hain kuch aata hai ya nahi
• CSF (Cerebrospinal Fluid) = Dimag aur riidh ki haddi ke aas paas wala saaf paani jaisa liquid

🔵 SLIDE 13 - Technique (Part 3)

• "Whoosh test": air or saline injected - stethoscope on the back hears a "whoosh" sound confirming correct placement - has higher specificity
• Test dose: Small amount of local anesthetic with epinephrine injected first
  • If injection goes IV (into blood vessel): Tachycardia (fast heart rate) or T-wave changes on ECG are seen
• Repeated injections can be done by re-inserting needle or by using a catheter left in place

• "Whoosh test": thodi si hawa ya normal saline inject karo - peeth par stethoscope rakh ke "whoosh" ki awaaz aaye to needle sahi jagah hai - yeh test zyada specific hai
• "Test dose": Epinephrine wali thodi si dawa pehle do:
  • Agar injection ragon mein gayi: dil ki raftar tez ho jaati hai (tachycardia) ya ECG par T-waves bari ho jaati hain
• Baar baar injection chahiye to needle dobara daalain ya catheter andar chhod dain

• Whoosh test = Injection wali jagah confirm karne ka test - hawa ya saline dete hain aur stethoscope se awaaz suntay hain
• Specificity = Test kitna sahi "sahi" ko pakadta hai - galat positive nahi deta
• Test dose = Pehle chhoti dose jo check kare ke injection sahi jagah hai
• Tachycardia = Dil ki raftar zyada tez hona (>100 bpm)
• T-wave = ECG par dil ki activity ka ek hissa - agar badi ho jaaye to intravascular injection ka sign
• Catheter = Patli plastic tube jo jagah par chord di jaye baar baar dawa dene ke liye

🔵 SLIDE 14 - Technique (Part 4 - Adults)

• Caudal anesthesia provides dense sacral sensory blockade with limited cephalad spread
• This means numbness stays in the lower area (sacral/anal region) without going too high up the spine
• Injection can be given with the patient in prone jackknife position (face down, hips raised, knees bent) - same position used for anorectal surgery

• Caudal anesthesia sacral area (guda ke paas) ko achi tarah numb karta hai lekin dawa zyada upar nahi jaati (limited cephalad spread)
• Injection "prone jackknife" position mein di ja sakti hai - yeh wahi position hai jo surgery ke waqt bhi use hoti hai (pait ke bal, kamar upar, ghutne jhuke)
• Fayda: Position badlni nahi padti!

• Anorectal procedures = Guda (anus) aur rectum ki surgeries
• Dense sensory blockade = Bahut achi aur poori numbness
• Cephalad spread = Dawa upar ki taraf phailna (cephalad = head ki taraf)
• Limited cephalad spread = Dawa zyada upar nahi jaati - sirf sacral area numb hota hai
• Prone jackknife position = Pait ke bal, kamar upar uthi, ghutne ghuma ke - guda ki surgery ke liye ideal position

🔵 SLIDE 15 - References

1. Chapter 6, LANGE Clinical Anesthesiology 4th Edition, pp. 309-322
2. National Center for Biotechnology Information (NCBI)
3. BrainKart - Caudal Anesthesia

🌟 MEGA EXAM TIPS SUMMARY

⭐ Must-Know MCQs:

⭐ Short Answer Points:

• Absolute (SCISA-S): Sacral dysraphism, Coagulopathy (severe), Infection (local), Site allergy, Allergy to meds, (patient refusal), Spinal dysraphism
• Relative: Spinal stenosis, Hypovolemia, mild coagulopathy, Systemic infection, Pilonidal cyst, Sacral anomalies

💡 Pro Tip: Caudal anesthesia ki sabse zyada use pediatric patients mein hoti hai kyunki unki anatomy (sacral hiatus) zyada clear hoti hai aur dural sac S3 tak neeche hoti hai - isliye care chahiye!