Checking the anatomy with ultrasound before and during the procedure assures success. Because the sacrum is not fully ossified, it can still be penetrated by the ultrasound beams.
Loss of resistance is not significant when placing an epidural because the sacrococcygeal ligament is softer in the pediatric population.
The needle may be misplaced in the subcutaneous periosteal location or in the dural sac.
After induction with general anesthesia, the lateral decubitus position is the most optimum position for full exposure of the sacral hiatus. Flex both knees to the abdomen and identify the mid line above the gluteal crease, where the sacral hiatus can be palpated.
Draw a triangle with the base line between the two posterosuperior iliac spines (PSIS) and the apex at the sacral hiatus. The caudal tip will lie between the two sacral cornua of the fifth sacral vertebrae. The sacrococcygeal ligament, which resembles the ligamentum flavum, lies between the two sacral cornua ( Fig. 43.1 ).