Comments a recent paper about the Caudal Epidural Block


A randomized comparison of caudal block by sacral hiatus injection under ultrasound guidance with traditional sacral canal injection in children

Li-Zhong Wang, Xiao-Xia Hu, Ying-Fa Zhang & Xiang-Yang Pediatric Anesthesia 23 (2013) 395–400



 This is a compelling article, very well designed and talking about a very contemporary subject, ultrasound guided caudal block.140 ASA I-II children undergoing inguinal hernia repair were randomized for a comparison between ultrasound guidance sacral hiatus caudal block and traditional sacral canal caudal block.The results, in my opinion, were as expected but nonetheless a valuable contribution to the matter. The success rate block was similiar between groups but strangely the duration of the block was slight shorter in the ultrasound group, even though not compromising the surgery performance. The incidence of bloody puncture was lower in the ultrasound group and no subcutaneous bulging was seen in that, leading to the conclusion that those complications can be avoided with ultrasound guidance.The success rate of the first puncture in the ultrasound group was 92,8% and in the traditional group 60%. Assuming the experience of the anesthetist, I find this percentage quite low, I feel it is still a quite easy and reliable block to do blindly, really commonly performed at the first attempt.I am a regional technique enthusiast and always looking for new ways of challenging myself. I began doing ultrasound guided caudal blocks 2 years ago and one of the questions I often asked myself was: is it worth it? Because this study does not show the duration of the technique if it is ultrasound guided but I can assure you it is a 5 fold increase. And don't forget of its learning curve. As for all other ultrasound guided blocks, you need to master the regional anatomy involved.So if time consuming is money and productivity loss, is it worth it?In my humble opinion it has its advantages if criterious selection is applied. I always do ultrasound guided caudal blocks if I want to thread a catheter through the epidural space in order to see where the tip is located (nearest to the involved methameric surgical incision points) or if I need to follow the local anesthetic spread until it reaches the desired block level (when I'm working near the local anesthetic maximum doses recommended in neonates, for example).My last justification for ultrasound guided performance is failure of the traditional technique and it has ocurred to me a few times.So in conclusion, I would like to congratulate the authors for this assertive and "give pause for thought" article.


Even though I can't considerer the ultrasound guided caudal block technique the gold standard technique, it is still an added value that can improve your success and diminish your complication rates.There is none so blind as those that cannot see.


Career Path

Frequented and concluded high school in 1994, at the European School of Luxembourg (Luxembourg) - final classification: 17.5/20

Graduated in Medicine in 2001, at the Faculty of Medicine of Coimbra's University (Portugal) - final classification: 13/20

Frequented and concluded the 4 year Anaesthesiology residency in Dec 2007, at the Centro Hospitalar de Lisboa Central, Dona Estefânia Hospital (Portugal) - final classification: 19/20

Fellowship (by examination) in Feb 2008 - final classification: 18,4/20



Pre-Hospital Emergency Medicine Course -2006 (included basic life support, advanced life support, medical emergencies and trauma support)

Fundamental Critical Care Support Course -2007


Responsible for the building of 2 "oxford boxes" for flexible fiberscope training

Responsible for a protocol implementation at the Dona Estefânia Hospital: "opioid uses in the pediatric setting"

Active element of Pre-Hospital Emergency Medicine between 2006 and 2008

Attended several mettings and congresses

Poster presentations:

"Double brachial plexus block: a case report" -2007- The XXXVI Annual Congress of the European Society of Regional Anesthesia (author)

"Esthesia" -2007- The XXXVI Annual Congress of the European Society of Regional Anesthesia (author)

"Management of medium chain Acyl-Coenzyme A Deshydrogenase deficiency in anesthesia: a case report" -2007- Association of Anaesthetists of Great Britain and Ireland Annual Congress (co-author)

Oral presentations: "ESTHESIA" -2007- 29th Congress of Scandinavian Society of Anaesthesiology and Intensive Care Medicine (author)

He coordinated the Portuguese Guidelines of Patients Medicated with Anticoagulation Drugs Proposed to Regional Anesthesia (Part I and II). Those guidelines were published in the Journal of the Portuguese Society of Anesthesia.


Paediatric anaesthetist at the Dona Estefânia Hospital, Feb 2008 – present. 


Transplant Coordination Advanced Course - by the Transplant Procurement Management group - Nov 2009 - Tomar (Portugal)

Post Graduate Specialization Course in Regional Anaesthesia - Faculdade de Ciências Médicas de Lisboa - Sep/Nov 2011 - Lisbon (Portugal)

VI Course of Advanced Simulation in Pediatrics - by the Santiago's Simulation Center group - Nov 2012 - Braga (Portugal) European Pediatric Life Support Course - European Resuscitation Council accredited - Oct 2012 - Lisbon (Portugal)


Element of the organ harvest team of Portugal southern region - Jun 2009 - Aug 2012

Dona Estefânia Hospital sub-coordinator of organ donation - Jun 2009 - present

Dona Estefânia Hospital coordinator of the Resuscitation Comission - Jan 2010 - present

Dona Estefânia Hospital coordinator of the Simulation Center and Clinical Practice group - Jan 2012 - present

Dona Estefânia Hospital co-responsible of equipment and protocol implementation in the intraoperative setting - Jan 2010 - present

Responsible for the assembly of the first difficult airway trolley at Dona Estefânia Hospital's operating theatre - 2011


Responsible for the site structure and co-editor of the "Clube de Anestesia Regional" journal (one of the two current existing portuguese anesthesiology societies) - May 2012 - present

Responsible for a project initiated in Dec 2011: MD ("Melhores Dez" - best ten) project consisting of choosing, each month, from the top ten best journals, the top ten articles of choice, to be shared amongst all the anesthesiologist's staff

Element of the organizing comittee of the "2nd journeys of organ harvest and transplantation" to be held by 24-25 Oct 2013, in Lisbon (Portugal)

Attended regularly national and international anaesthesiology's congresses


Responsible for the tutorship of a resident's full residency - Jan 2010 - present Regular teaching of residents that are doing their pediatric anaesthesia clinical rotation at Dona Estefânia Hospital

Regular instructor of basic and advanced adult and pediatric life support to Dona Estefânia Hospital's target staff (profissional health and professional non-health providers) - 2010 - present

Instructor: "WHO surgical safety check-list" - Nov/Dec 2012 - Dona Estefânia Hospital's Simulation Centre Instructor: "Post-graduate course of pediatric emergencies" - Jun 2013 - Dona Estefânia Hospital's Simulation Centre

Instructor: "Basic ultrassonography in anaesthesia and pain medicine course" - Jan 2013 - 11th Convenio da ASTOR, Lisbon (Portugal)

Instructor: "3rd Course of Sonoanatomy apllied to peripheral nerve blocks" - 12-14 Dec 2013 - Minho's University, Braga (Portugal)


"Role of the anaesthesiologist in the organ harvest" - 1st Journeys of Organ Harvest and Transplantation - May 2011 - Lisbon (Portugal)

"Basic and advanced life support", "Difficult airway algorithm" - 1st Post Graduate Course of Perioperative Nursing Care - Jun 2011 - Lisbon (Portugal)

"Sexuality and anaesthesiology" - Tertúlias de Anestesiologia - Oct 2011 - Viseu (Portugal) "Simulation in a pediatric hospital setting" - 1st Congress of the Portuguese Simulation Society - Nov 2012 - Braga (Portugal) "Ultrassonography and pain management: tips and tricks" - 11th ASTOR Convenium - Jan 2013 - Lisbon (Portugal) " Pediatric sedation by non-anaesthetists" - I Encontro Anestesiologia - 26th Oct 2013 - Leiria (Portugal)


Author of the book "Maximanestesia" (ISBN: 9789892023182) -2011, focusing on a compilation of anesthesia aphorisms dissected by the author

As co-author: "Anaesthesia for hand and forearm plastic and reconstructive surgery in the emergency room" - poster - ESRA Congress - Sep 2009 - Salzburg (Austria)

"Epidural anaesthesia morbility in pediatrics" - poster - Portuguese Anaesthesiology Society Congress - Mar 2012 - Oporto (Portugal)

"Pediatric regional anesthesia techniques" - oral presentation - 5th Meeting of Pediatric Anaesthesia - Jun 2012 - Oporto (Portugal)

"Regional techniques in pediatric anaesthesia: a two year retrospective comparison" - poster - ESPA Congress - Sep 2012 - Stresa (Italy)

"The airway approach of a Treacher Collins syndrome neonate: plan A to Z" - poster - ESPA Congress - Sep 2012 - Stresa (Italy)

"Regional anaesthesia techniques in pediatric orthopaedic surgery: 2012 retrospective study" - accepted for publication - Clube de Anestesia Regional journal - Nov 2013



Interview with the expert
Sharing experiences...

1- You work in a dedicated pediatric hospital center. Are there major differences between children and adult ultrasound guided regional anesthesia?


The differences are huge but perhaps the major one is the fact that the vast majority of the blocks in children are performed under general anesthesia. Its such a comfort knowing that the child is comfortable and wil not recall any of the stimuli induced by myself.

And children are so "echogenic"! Meaning that the little fat combined with the greater water content allows better visualization of the anatomic structures.

On the other hand everything is smaller and our precision has to be refined, as well as the volume and concentration of drug administration.

Lets not forget as well about the anatomical differences between children and adults. For instance, 50% of children have only 2 instead of 3 abdominal muscular layers on the territory where usually ilioinguinal iliohypogastric blocks are performed.


2- Is there a place for pediatric chronic pain treatment, such a differentiated field?


 No doubt about it! Even though the incidence might be lower than in adults, it still exists, namely in oncologic and post surgical settings. And I think every pediatric anesthesiologist working in Portugal is aware of that specific problem. But one thing is the perception of it, another thing is the expertise of dealing with it, particularly the lack of it, where humbly I must include myself on the latter. As far as I know, at this point, in Portugal, unfortunately, no one has really embraced the pediatric chronic pain field, and it remains very challenging to deal with.


3- You seem a passionate person about ultrasound regional anesthesia that eagerly shares his knowledge with every collegue that wants to know more about it. Which aspect of regional anesthesia seduced you more, especially with the ultrasound boom?


Considering just the fact that you can anesthesise that part of the body that is being submitted to a severe surgical agression is like a magical performance and I truly feel honoured to be a main character of that act. I have no doubt that the introduction of ultrasound was the most revolutionary anesthesia tool of the beginning of this century. The fact that know you can see what you used to just imagine before has truly enhanced our profissional abilities.The field that currently seduces me the most is pediatric neuraxial ultrasound guided blocks, because of the easiness and beauty of the anatomical structures seen. Particularly in that matter I've been doing ultrasound guided caudal epidural blocks as sole anesthetic technique for pyloric hypertrophic stenosis correction, with very good results so far, avoiding the vastly known potential complications of the general anesthesia for this particular surgery. 


Specialist Anaesthetist

Central Lisbon Complex Hospital