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Local anesthetics and adjuncts used for caudal block in children

Local anesthetics and adjuncts used for caudal block in children
Technique Local anesthetics <3 months age 3 to 6 months age >12 months of age Maximum dose
Caudal block, single injection Ropivacaine 0.2% 2 mg/kg 2.5 mg/kg 2.5 to 3 mg/kg 3 mg/kg
Bupivacaine 0.25% 2 mg/kg 2.5 mg/kg 2.5 mg/kg 2.5 mg/kg
Levobupivacaine 0.25% 2 mg/kg 2.5 mg/kg 2.5 mg/kg 2.5 mg/kg
2-Chloroprocaine 1.5 to 3% 30 mg/kg 30 mg/kg 30 mg/kg 30 mg/kg
Awake caudal anesthesia* Ropivacaine 0.375% 3.75 mg/kg N/A N/A  
Bupivacaine 0.25% 3.75 mg/kg N/A N/A  
Levobupivacaine 0.25% 3.75 mg/kg N/A N/A  
2-Chloroprocaine 1.5 to 3% 30 mg/kg, followed by infusion of 1.5% at 6.75 to 45 mg/kg/hour N/A N/A  
Caudal epidural infusion Ropivacaine 0.1 to 0.2% 0.2 mg/kg/hour 0.3 mg/kg/hour 0.4 mg/kg/hour  
Bupivacaine 0.1 to 0.125% 0.2 mg/kg/hour 0.2 to 0.3 mg/kg/hour 0.2 to 0.4 mg/kg/hour  
Levobupivacaine 0.1 to 0.125% 0.2 mg/kg/hour 0.2 to 0.3 mg/kg/hour 0.2 to 0.4 mg/kg/hour  
2-Chloroprocaine 1.5 to 3% 3.5 mg/kg/hour 6.75 mg/kg/hour 15 mg/kg/hour  
Adjuncts
Agent Dose Comments
Opioids
Morphine
  • Bolus 10 to 30 mcg/kg
  • Infusion 1 mcg/kg/hour
 Pruritus is common; delayed respiratory depression possible
Fentanyl
  • Bolus 0.2 mcg/kg
  • Infusion 1 mcg/kg/hour of 0.2 to 2 mcg/mL solution
 Not shown to increase duration of block
Sufentanil
  • Bolus 0.5 to 1 mcg/kg
  • Infusion 0.1 to 0.3 mcg/kg/hour
 Not shown to increase duration of block
Hydromorphone
  • Bolus 10 mcg/kg
  • Infusion 1 mcg/kg/hour of 5 mcg/mL or 10 mcg/mL solution
  
Others
Clonidine
  • Bolus 1 to 2 mcg/kg
  • Infusion 0.1 mcg/kg/hour of 0.04 mcg/mL solution

Sedation, bradycardia, and hypotension possible at higher doses

Apnea may occur in infants <3 months of age
Epinephrine
  • Test dose 5 mcg/kg
  • Adjunct 5 mcg/mL local anesthetic solution
 Biphasic reduction in absorption of local anesthetic from the epidural space

This table shows the drugs that are commonly used for caudal block in children. Doses are based on those that have appeared in the literature. The total dose of local anesthetic, including other routes of administration, should remain within the maximum allowable doses to minimize the risk of local anesthetic toxicity.

Other adjuncts have been used for caudal block, but efficacy and lack of neurotoxicity have not been proven and their use has not received regulatory approval for children in the United States. These include ketamine, S-Ketamine, dexmedetomidine, dexamethasone, midazolam, neostigmine, and buprenorphine. For further information refer to UpToDate content on caudal block.

* Awake caudal anesthesia is only rarely used, and only in young infants.
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