|Year : 2019 | Volume
| Issue : 1 | Page : 58-60
Comparison between the Quincke's 22-gauge spinal needle and the 22-gauge hypodermic BD needle for the administration of caudal blocks in paediatric regional anaesthesia – A prospective randomised study
Vrushali C Ponde, Vinit V Bedekar, Ankit P Desai, Rishiraj Borhazowal
Department of Anaesthesiology, Children's Anaesthesia Services and Surya Children Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||10-Jan-2019|
Dr. Vinit V Bedekar
Yogi Nagar, Bldg. No. B-41/201, Yogi Saraswati CHS, Eksar Road, Borivali West, Mumbai - 400 091, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ponde VC, Bedekar VV, Desai AP, Borhazowal R. Comparison between the Quincke's 22-gauge spinal needle and the 22-gauge hypodermic BD needle for the administration of caudal blocks in paediatric regional anaesthesia – A prospective randomised study. Indian J Anaesth 2019;63:58-60
|How to cite this URL:|
Ponde VC, Bedekar VV, Desai AP, Borhazowal R. Comparison between the Quincke's 22-gauge spinal needle and the 22-gauge hypodermic BD needle for the administration of caudal blocks in paediatric regional anaesthesia – A prospective randomised study. Indian J Anaesth [serial online] 2019 [cited 2019 Mar 26];63:58-60. Available from: http://www.ijaweb.org/text.asp?2019/63/1/58/249774
| Introduction|| |
High efficacy and low rate of complications of the caudal epidural block make it one of the most preferred techniques in paediatric patients. A distinctive pop is the hallmark endpoint. Any equipment that improves the perception of the “pop” should increase its ease and efficacy. Intuitively, a blunt needle tip should enhance the perception and a sharper needle tip should reduce it. Second, ultrasonography (USG) adds an objective confirmation of the needle placement in the caudal epidural space. Styletted needles are widely considered to be more easily seen in comparison to hollow non styletted needles under USG scan.
The purpose of this study was to compare the Quincke tip styletted 22-gauge needles and 22-gauge non styletted hypodermic needles.
The primary outcome was to compare needles for a perception of “pop” and visibility of needle under USG. The secondary objective was to evaluate the incidence of complications such as a subarachnoid puncture yielding cerebrospinal fluid (CSF) and/or a vascular puncture producing a blood tap.
| Methods|| |
This was a prospective parallel randomised trial. Institutional Ethical Committee approval was obtained (IEC No. SC 10032017). This was a pilot study done from July 2017 to October 2017. This trial is registered under the Central Trial Registry of India (CTRI) – CTRI/2017/06/008910. After preoperative evaluation and written informed consent from the guardian, the subjects were enrolled into the study. A total of 40 patients, age 1 day to 5 years of either gender, belonging to American Society of Anaesthesiologists (ASA) I and II were recruited. Patients age 1 day to 5 years of either gender posted for elective inguinal hernia, circumcision and orchidopexy surgeries were included. Exclusion criteria included refusal for consent, infection at the insertion site and coagulopathy. Patients were randomly allocated to one of the following two groups using computer-generated randomisation sequence table. The enrolment of participants was done by a separate anaesthesia team in the preoperative area.
On the day of the surgery, standard nil per mouth guidelines was followed along with standard monitoring. Patients above 6 months were premedicated with 0.75 mg/kg of oral midazolam. Anaesthesia was induced with sevoflurane 2–8 volumes percent in an air–oxygen mixture. Intravenous (IV) access was secured and anaesthesia was maintained with sevoflurane 2 volumes percent in air–oxygen mixture by face mask. For the block procedure, all the patients were placed in the lateral position. The caudal area was painted with 5% betadine followed by 2.5% chlorhexidine solution and draped. The caudal block was administered with a 22-gauge, 25-mm hypodermic [Becton Dickinson (BD) Precision Glide™] needle in patients in Group B, and for patients in Group Q the caudal block was performed with a styletted 22-gauge, 38-mm Quincke tip needle. (VYGON UK Ltd) The following points were recorded:
Ease of appreciation of the “pop” as the needle pierced the sacrococcygeal membrane. This was perceived as “pop” not felt at all, “pop” felt, but not very distinctive and a distinct “pop” felt. This was recorded as per the perception of the anaesthesiologist;
The needle placement was confirmed by USG visualisation of the needle tip.
The visualisation of the needle on USG was recorded as visualised very well and not visualised well but drug spread seen;
Complications such as blood tap and CSF tap were noted.
A 20% increase in pulse rate after the surgical incision was termed as block failure. IV fentanyl 2 μg/kg was reserved as rescue analgesia. Postoperatively, additional analgesia was provided when necessary by diclofenac suppository 2 mg/kg 8 hourly.
For circumcision, 0.5 mL/kg of 0.25% bupivacaine was given. For a hernia and orchidopexy, 1 mL/kg of a combination of 0.25% bupivacaine and 2% lignocaine with adrenaline (1:200,000) was given. Data were analyzed using SPSS/PC+ (V.15.0) statistical package. Data were given as mean and standard deviation for quantitative data or number (%) for categorical data.
| Results|| |
An effective caudal block could be accomplished in all cases. [Table 1] and [Table 2] show the demographics, perception of “pop” and visualisation of needle tip on USG, respectively.
|Table 2: Feel of “pop” during the needle trajectory and visualisation of needle tip on USG|
Click here to view
There was no CSF tap in any patient. A blood tap was noted in 5% of patients in Group B and none in Group Q.
| Discussion|| |
Our study refutes our hypothesis. It was deduced that both needles gave a similar “pop” feel of piercing the sacrococcygeal ligament. The subsequent USG visualisation of both the needles in the caudal space was comparable. The incidence of complications of CSF and blood tap was similar. Due to its easy availability and cost-effectiveness, the BD needle seems to be as good as the styletted needle of similar gauge for a caudal epidural block for the outcomes we studied. We have been routinely using a 22-gauge hypodermic hollow needle for a caudal epidural block. We believe that the blood or CSF aspiration would be more obvious with a 22-gauge needle than the fine 24-gauge needle. It is likely that the veins may get collapsed around the needle tip for aspiration if the gauge is too small.
Specialised block needles with short “blunt” bevels enhance awareness and subjective perception of the needle penetrating the sacrococcygeal membrane. They may also decrease the incidence of vascular penetration when compared with standard long beveled hypodermic needles. This possibly could have made the needle tip trajectory into the tissue more perceivable. The results of our study do not support this. The chance of advancement of dermal or subdermal tissues into the caudal epidural space remains a possibility with the conventionally used non- styletted hypodermic needles. The Quincke's needle was introduced as a styletted needle to minimise epithelisation., Second, the possibility that the needle while piercing the skin might lead to the formation of a dermoid cyst in the epidural canal causing significant neurological sequelae must always be borne in mind. The styletted needles provide a theoretical advantage towards this issue bypassing any potential occurrence of neurological sequalae., Our study does not at the present time deal with these outcomes. A small skin prick with 18-gauge needle could be done through which hypodermal needle can be advanced. This might prevent dermal tissue advancement.
The cost of both the needles differs substantially, which seems to be an added advantage for the hypodermic needles. Also, the hypodermic needles are readily available. The limitations of our study were a small sample size and lack of follow-up of the patients for the prospect of any neurological complication in the long term
| Conclusion|| |
The caudal epidural block administered with the 22-gauge BD hypodermic needle is comparable to the use of a 22-gauge styletted spinal needle (Quincke) in terms of “pop” perception, visualisation under USG and short-term incidence of complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rohr M. Practical pediatric regional anesthesia. Curr Opin Anaesthesiol 2013; 26:327-32.
Chin KJ, Perlas A, Chan VW, Brull R. Needle visualization in ultrasound-guided regional anesthesia: Challenges and solutions. Reg Anesth Pain Med 2008; 33:532-44.
Rowney DA, Doyle E. Epidural and subarachnoid blockade in children. Anaesthesia 1998; 53:980-1001.
Gulddoguf F, Baris Y, Baris S, Karakaya D, Kelsaka E. Comparing tissue coring potentials of hollow needles without style and caudal needles with stylet: An experimental study. Eur J Anaesthesiol 2008; 25:498-501.
Goldschneider K, Brandom B. The incidence of tissue coring during the performance of caudal injection in children. Reg Anesth Pain Med 1999; 24:553-6.
[Table 1], [Table 2]