C. Lewis, F. Harrison, O’ Clancy

Royal Manchester Children's Hospital, UK


We decided to audit the use of epidurals at our tertiary paediatric trust due to a safety incident, as well as concerns raised by nursing staff regarding safe and appropriate staffing levels on wards accepting patients with epidurals.


To review our current practice with regard to the insertion and management of epidurals in paediatric patients


A search was conducted on our electronic database to identify patients who received an epidural as part of their anaesthetic care for procedures within Royal Manchester Childrens Hospital between July and December 2023. Caudal epidural catheters were excluded.


A total of 14 patients were identified between the ages of 10-17 (median age 14). The epidurals were inserted for a variety of procedures including 9 orthopaedic, 3 general paediatric surgery and 2 urology, all of which were elective procedures. 5 out of 14 were thoracic epidurals, 9 were lumbar, all of which were uncomplicated insertions under general anaesthesia with no complications immediately identified. The majority, 12 out of 14, were inserted and used throughout the surgical procedure, with only two being inserted post procedure. Plain Levobupivacaine (0.25%) was used in all cases; loading boluses varied in quantity and timing at the discretion of the anaesthetist. Post operatively levobupivacaine 0.1-0.125% was used plain or with either 2 microgram/ml fentanyl or 1microgram/ml clonidine according to the anaesthetists preference and was started at an infusion of 0.4mg/kg/h. One headache was identified post procedure that was reviewed for possible dural puncture, however the headache resolved without an epidural blood patch. There were two cases of accidental disconnection which resulted in premature removal of the epidural. Significant motor block was reported in 6 cases and there were 6 cases of inadequate or unilateral block requiring opiod analgesia, sometimes as a result of pausing the infusion to assess the reversibility of the motor block. Hypotension was seen in 6 cases, one of which may have contributed to a new acute kidney injury seen on day 3 post operatively of a complex patient. The hourly monitoring of epidurals including Bromage scores was poorly documented.


Although the technical insertion of epidurals appears to be uncomplicated, the incidence of unwanted side effects including motor block and hypotension is high and impacting negatively on the patients post operative experience. We aim to review current guidelines with regard to loading doses and infusion protocols, as well as continuously audit future epidurals. A new software update introduced in December 2023 allowing all pain and epidural observations in one flowsheet will aid monitoring and documentation.

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