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Caudal Anaesthesia Positions 1. Lateral position with hips and knees flexed (foetal position) 2. Prone position with the pelvis raised on a pillow and feet turned medially Drugs 15-20 ml (0.5% bupivacaine or 1.5% lignocaine or mixture) will fill the sacral canal of an adult, and provide a perinea! block. Increasing the volume further will push the fluid into the lumbar canal. Add fentanyl 50µg for quick onset, and better quality of block. Add morphine (preservative free) 2mg to provide post operative analgesia for 12-24h. Anatomy • The dural sac ends at S2 in adults and lower in children. • The sacral hiatus is identified with the non dominant hand by moving the finger down along the midline of the sacrum till a give is felt which is usually just above the natal cleft and bordered by the two sacral comua. It forms an equilateral triangle with the posterior superior ilac spines. The sacral hiatus is covered by the sacro-coccygeal membrane. Injection 1. Clean the area with antiseptic. Av...

 Epidural Anaesthesia (EDB) The epidural space is a potential space between the ligamentum flavum and the dura mater, occupied by areolar tissue, loose fat and the internal vertebral venous plexus. The ligamentum flavum and the epidural space are both widest (5mm) at L3/4. TECHNIQUE Needle Use 18G Tuohy needles (8, 9 or 11 cm length) as the curved Huber tip decreases the possibility of dural puncture and facilitates passage of the catheter. Note the 1 cm markings on the needle. Injection 1. Raise a wheal with 2% lignocaine ( 27G needle) at the selected point. 2. Infiltrate the expected path of the epidural needle via a moving needle to avoid intravenous injection. Wait 30 seconds for lignocaine to act. 3. Insert the epidural needle through the supra-spinous ligament. 4. Attach a syringe with 7ml of saline. Steady the back of the non-dominant hand against the back of the patient. Hold the hub of the needle firmly, and push the needle inwards steadily and continuously. (a) Needle in:...

 THE POST-ANESTHESIA CARE UNIT General Management All children should be transported to the post-anesthesia care unit (PACU) in the lateral decubitus position with the head extended to provide an unobstructed airway; all children—other than absolutely healthy children having minor surgery—should receive oxygen or be monitored with SpO 2 during transport to PACU. Evidence suggests that decreases in SpO 2 during transport are most likely due to airway obstruction; be alert to this possibility. However, administering oxygen while monitoring SpO 2 renders the oximeter an insensitive metric of hypopnea; respiration should be monitored by observing chest movements, mist in the facemask, or by feeling exhaled breathing. The anesthesiologist walks at the head of the bed facing forward to continuously observe and monitor the child. If the airway is in doubt, do not leave the OR. If the airway becomes precarious while on route to the PACU, apply digital pressure to the condyle of the mandibl...

 Breathing Systems "We shape our tools, and thereafter our tools shape us." Breathing systems connect the continuous flow machine to the intermittently breathing patient's airway. FEATURES OF AN IDEAL BREATIIING SYSTEM 1. Prevents significant fluctuations in pressure 2. Offers low resistance to breathing 3. Has a low dead space 4. Minimizes re-breathing of alveolar gas 5. Prevents breathing from the atmosphere 6. Is economical with regard to gas flows 7. Causes no significant pollution of the atmosphere Re-breathing of expired gases is always possible when simple systems without absorbers and uni-directional valves are used, and can be prevented by giving appropriate fresh gas flows (FGF). Re-breathing of expired gases changes the composition of inspired gas by : 1. adding significant carbon dioxide concentrations 2. diluting the oxygen and volatile agent in the fresh gas (FG) Re-breathing can be used to advantage 1. Dead space gas, which has not been involved in gas exch...