title: Determining the accuracy of caudal needle placement in children: a comparison of the swoosh test and ultrasonography.
abstract: BACKGROUND
  The aim of the present study was to compare two confirmatory tests - the 'swoosh' test (auscultation during caudal injection) and real time ultrasound imaging (both transverse 2D imaging and color flow Doppler imaging) in pediatric patients receiving a caudal epidural block.
  
  
  METHODS
  This was a retrospective observational study of caudal injections administered to 83 pediatric patients (0-11 years) presenting for elective surgery over a 4 month time period. While injecting small aliquots of local anesthetic, a standard stethoscope was placed over the lower lumbar spine to auscultate for the 'swoosh' test. An ultrasound machine (Sonosite Titan, Sonosite Inc., Bothell, WA, USA) was then utilized for real-time visualization of caudal injectate. Each test performed during the caudal injection (swoosh, turbulence on 2D imaging, or color flow on Doppler imaging) was recorded as positive, negative or equivocal.
  
  
  RESULTS
  Eighty out of 83 patients (96.4%) had a successful caudal block based on minimal or no perioperative narcotic use, minimal or no response to surgical stimulation, the presence of motor blockade and patient comfort in the PACU. Ultrasound was significantly superior to 'swoosh' for sensitivity (96.3% vs 57.5%), negative predictive (40% vs 5.6 value) % and likelihood ratio (2.89 vs 1.73). Specificity and positive predictive value were not different between 'swoosh' and ultrasound. Of the ultrasound tests, turbulence was more sensitive than color flow Doppler (95.0% vs 78.8%).
  
  
  CONCLUSIONS
  Ultrasonography is superior to the 'swoosh' test as an objective confirmatory technique during caudal block placement in children. We found the presence or absence of turbulence during injection within the caudal space to be the best single indicator of caudal success. We think ultrasonography should be used, if available, when teaching this technique.
authors.affiliation: Department of Anesthesiology, Baystate Medical Center, Springfield, MA, USA.
authors.forename: Karthik
authors.initials: K
authors.lastname: Raghunathan
authors.forename: Donald
authors.initials: D
authors.lastname: Schwartz
authors.forename: Neil Roy
authors.initials: NR
authors.lastname: Connelly
mesh_terms: D000763:Anesthesia, Caudal / Q000295:instrumentation*; D001314:Auscultation / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging* / Q000187:drug effects; D008297:Male; D009339:Needles; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018615:Ultrasonography, Doppler, Color / Q000379:methods