The Implementation and Optimization of Neonatal Epidural Analgesia in a Tertiary Care Hospital: A Technical Report

Abstract

Effective analgesic therapy in neonates continues to be fundamental for improving quality of life and decreasing the need for further medical intervention. When pain is not well controlled in the neonatal intensive care setting, we see an increased use of sedation pharmaceuticals, mechanical ventilation, and altered somatosensory development, among other complications. Currently, there is no standardized protocol addressing effective pain management while decreasing the need for further sedation. In this article, we seek to demonstrate how our institution standardized and implemented the utilization of epidural analgesia in neonates as the preferred method of pain management for open thoracic and abdominal surgeries.

Keywords: analgesia; caudal; epidural; neonatal; ropivacaine; ultrasound.

Figure 1. Example of a 20-gauge Crawford epidural needle.

A Crawford needle is used for the insertion of a spinal catheter into the subarachnoid space for procedures requiring spinal anesthesia or drug administration. Some needles feature a curved design and a sharp beveled tip, while others have a rounded rear heel and short bevel to resist shearing from the catheter tip during insertion. These catheters facilitate insertion through the skin, subcutaneous tissue, and spinal ligaments into the desired spinal level. It typically has markings to help gauge depth and is available in various sizes to accommodate different patient anatomies and procedural requirements.

Figure 2. Ultrasound visualization of epidural needle placement.

The different anatomic locations seen during ultrasound guidance insertion of the epidural catheter. The following landmarks were identified: (A) thoracic lamina, (B) epidural fluid, and (C) tip of the epidural catheter.

Figure 3. Tunneling of the epidural catheter.

A subcutaneous tunnel between the skin insertion site and the epidural space where the catheter is placed. This technique reduces the risk of infection by minimizing the direct contact between the skin and the catheter.

Figure 4. Tunnelled epidural catheter with skin glue placement.

Figure 5. Clean and sterile dressing placement over the epidural catheter.

Transparent film dressing is used to secure and protect the insertion site of the catheter. It provides a barrier against infectious organisms and contaminants while allowing visualization of the catheter insertion site.

Figure 6. Neonatal perioperative pain management guide.