Female patient, 4 years of age and 16 kg of weight, with a lymph node diagnosis of rhabdosarcoma in the left thigh and ipsilateral inguinal lymph node metastasis, was electively scheduled for resection of local tumor recurrence in inguinal tissues.
The patient had received chemotherapy in the previous months, had no history of allergy to drugs and in the previous intervention of her tumor she had no anesthetic complications.
Her preoperative tests showed hemoglobin 10.9 g/dl, hematocrit 31.7%, platelet count 213,000/μl, TPT 24.5 seconds, PT 11.3 seconds and INR 1.06.
One unit of packed red blood cells was reserved for pre-anesthetic evaluation.
The possibility of offering a continuous regional technique for perioperative management was discussed with her mother in the preanesthetic evaluation, highlighting her role in postoperative analgesic control.
Informed consent was obtained.
The patient had a peripheral vein cannulated on admission to the operating room and conventional anesthetic induction was performed with fentanyl 2 μg/kg, lidocaine 1 mg/kg, propofol 2 mg/kg, dexamethasone 0.15 mg/kg orotracheal tube remifentanil twitch, sevoflurane maintenance
Then the patient was placed in left lateral decubitus and hip flexion.
In this position, we performed a previous scan of the caudal area using a SonoSite M-Turbo® equipment with a linear transducer L25x of 13-6 MHz, where the different structures included at this level were identified.
Subsequently, antisepsis was performed with 4% chlorhexidine in the lumbosacral and perineal area and covered with sterile drapes.
With aseptic technique again the structures were scanned and with the transducer in the longitudinal axis to the sacrum and proceeded to approach the caudal space in plane with a 20G needle SonKUN® catheter continuous catheter.
Once there and under direct ultrasonographic view, the catheter was passed through the needle, advancing to a distance of 8 cm, remaining 3 cm in the caudal space, the filter was removed and the equipment was infused.
Visualizing the tip of the catheter in the caudal space and with the color Doppler mode activated in the scalp, a bolus dose of 16 ml of anesthetic mixture was injected (0.5% bupivacaine plus 1:200,000 epidural space) confirming 8 ml of epidural
Finally, the external portion of the catheter was directed towards and covered with sterile dressings 3MTM TegadermTM.
1.
After the placement of the catheter, the patient was repositioned in supine position and surgery was performed where there is tumor conglomerate on inguinal vessels which were released. A negative biopsy was sent for an initial resection.
A vastus medialis and cruralis were completely resected in the affected area.
Eight brachytherapy catheters were left.
Blood loss was approximately 50 ml and was not transfused.
Surgery lasted 4 hours and 15 minutes and anesthetic requirements were minimal.
At the end of the surgery, 2 mg of intravenous morphine were applied, the patient was discharged without complications and was taken to recovery for monitoring where infusion of 3 ml/h of a mixture of fentanyl and 3 μg of caudal catheter was initiated.
The patient remained stable for 3 hours without requiring supplements and then remained in the pediatric general hospital ward.
Analgesic drugs additionally received during hospitalization were acetaminophen 240 mg every 6 hours orally and diclofenac 15 mg every 12 hours intravenously per hour, with hydromorphone rescues as needed.
Analgesic follow-up until discharge is detailed in Table I. No rescues with opioids were required.
The catheter was removed on the third postoperative day after 70 hours of placement without complications.
The same day the patient was discharged with adequate pain control, oral medication and instructions.
