Epidural space "ballooning" during local anaesthetic injection in infants and children: An ultrasound observational study.

Abstract

Infants and children require a larger dose of a local anaesthetic (LA) to establish epidural analgesia than adults, but the reason for this remains unclear. We hypothesised that prominent ventro-dorsal expansion of the epidural space limits cranio-caudal spread of LA in infants. Accordingly, we studied the dimensions of the epidural space with real-time ultrasound (US) before and after epidural injection. Ninety-six infants and children aged 0-12 years who underwent abdominal surgery under combined epidural and general anaesthesia were examined in this prospective observational study. Using a micro-convex probe, US recordings of the posterior epidural space were performed while a LA (0.5 ml kg^-1 ) was infused at 0.54 ml s^-1 . The width in the ventro-dorsal dimension (VDD) of the posterior epidural space before and after injection was recorded; the change in VDD was defined as "ballooning". Correlations between "ballooning" and patient age, body mass index, and volume and rate of LA administration were analysed. "Ballooning" correlated positively but weakly with age (R²  = 0.25; p < .001) and the infused LA volume (R²  = 0.32; p < .001). The "magnitude of ballooning" ("ballooning" per ml of injected LA) correlated negatively but weakly with age (R²  = 0.27; p < .001). "Magnitude of ballooning" of the epidural space become inconspicuous with growing during epidural injection. This effect may slow the cranio-caudal spread of LA and explain partially why larger volumes of LA are required to effect a block in children.