Transesophageal echocardiography: a novel technique for guidance and placement of an epidural catheter in infants.

219 January 2013 E PIDURAL block has been used extensively in pediatric patients.1Epidural block reduces the need for opioid usage, improves hemodynamic stability,2 decreases the need for postoperative ventilator support,3and lowers perioperative stress levels.4 Although cephalad advancement of epidural catheters from the caudal space to the thoracic region is commonly used, blind catheter advancement can be technically challenging, yielding a frequent failure rate in infants due to catheter curling and arrest at lumbar levels.5 Moreover, the inability to verify catheter tip placement at the targeted thoracic levels could lead to an inappropriately high spinal level of catheter placement.6 To overcome these issues, a number of confirmatory techniques have been described, including radiological fluoroscopy, epidural electrocardiography,7 and epidural electrical stimulation for muscle contraction.8 In terms of problems, these methods may require unnecessary exposure to ionizing radiation and contrast9 or exhibit limitations in confirming exact catheter tip placement7,10. Due to the growing popularity of surface ultrasound in regional anesthesia, use of this technique in epidural catheter placement has also been successfully explored yet may be limited by patient age.11,12 In contrast, transesophageal echocardiography(TEE) may potentially overcome this age limitation by obtaining images through the intervertebral disc.We present a series of 12 cases using TEE to visualize the structures within the spinal column as well as caudally placed thoracic epidural catheters.The real-time images generated by TEE allow for three-dimensional visual confirmation of the intraepidural spread of anesthetic, making TEE advantageous to alternative confirmation methods. Our preliminary findings suggest that TEE can visualize thoracic epidural catheters and can evaluate injected anesthetic distribution in cardiac procedures.