Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia

Awake Combined Spinal Caudal Anesthesia for Longer-Duration Urologic Surgery in Infants: A Case Series

Awake combined spinal caudal anesthesia has been used as an anesthetic technique for longer-duration infraumbilical surgeries in infants. Literature on the safety and feasibility of this technique is limited. We share our experience with 27 infants undergoing longer-duration urologic surgery using awake combined spinal and caudal anesthesia without the use of systemic sedatives or inhalational agents. We describe our technique, safety considerations, and details surrounding the optimal timing of caudal catheter activation for prolongation of surgical anesthesia.

A Single Center's Experience With Spinal Anesthesia for Pediatric Patients Undergoing Surgical Procedures

PURPOSE

To perform a single institution review of spinal instead of general anesthesia for pediatric patients undergoing surgical procedures. Spinal success rate, intraoperative complications, and postoperative outcomes including unplanned hospital admission and emergency department visits within seven days are reported.

METHODS

Retrospective chart review of pediatric patients who underwent spinal anesthesia for surgical procedures from 2016 until 2022. Data collected included patient demographics, procedure and anesthetic characteristics, intraoperative complications, unplanned admissions, and emergency department returns.

RESULTS

The study cohort included 1221 patients. Ninety-two percent of the patients tolerated their surgical procedure without requiring conversion to general anesthesia, and 78% of patients that had spinals placed successfully did not receive any sedation following lumbar puncture. The most common intraoperative event was systolic blood pressure below 60 mm Hg (14%), but no cases required administration of vasoactive agents, and no serious intraoperative adverse events were observed. Post-Anesthesia Care Unit Phase I was bypassed in 72% of cases with a median postoperative length of stay of 84 min. Forty-six patients returned to the emergency department following hospital discharge, but no returns were due to anesthetic concerns.

CONCLUSIONS

Spinal anesthesia is a viable and versatile option for a diversity of pediatric surgical procedures. We noted a low incidence of intraoperative and postoperative complications. There remain numerous potential advantages of spinal anesthesia over general anesthesia in young pediatric patients particularly in the ambulatory setting.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective cohort treatment study.

Mepivacaine dosing for spinal anesthesia in pediatric orthopedic surgery: a retrospective chart review

BACKGROUND

Mepivacaine is an intermediate-acting local anesthetic used for spinal anesthesia in adults. Currently, there are no published dosing guidelines for spinal mepivacaine in patients under age 18.

AIMS

The purpose of this study is to describe the clinically used doses of mepivacaine by weight and age for orthopedic surgery in pediatrics.

METHODS

We performed a retrospective chart review of patients aged 0-18 who received mepivacaine for spinal anesthesia from 2016 to 2022. We performed a secondary analysis for patients aged 0-18 who received spinal anesthesia with bupivacaine or chloroprocaine.

RESULTS

The data extraction yielded 3627 single-shot mepivacaine spinals. Patient age ranged from 5 to 18 years. Median dosage in milligrams/kilograms (mg/kg) of mepivacaine was calculated for each age group. Our analysis revealed that dosage in mg/kg decreased by patient age and began to plateau at age 15. Bupivacaine was the most common single-shot spinal agent in patients under age 10. After age 10, mepivacaine was more common. Chloroprocaine began to be used in patients older than 8 years.

CONCLUSIONS

We describe mepivacaine dosage as a function of age and weight in patients younger than 18 years. As age and weight increased, a lower dose of mepivacaine per kg was administered for spinal anesthesia.

Regional Anesthesia for Neonates

Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.

Spinal versus general anesthesia: Comparing outcomes in pediatric patients undergoing urologic procedures

INTRODUCTION

Available literature comparing spinal anesthesia (SA) to general anesthesia (GA) in the pediatric population describes multiple benefits in appropriately selected patients including cost reduction, lower incidence of complications, and shorter operative times. In patients undergoing urologic procedures, data are sparse.

OBJECTIVE

Our goal was to expand on the paucity of existing urologic literature as SA appears to be uniquely suited for a substantial number of its common pediatric procedures.

METHODS

Within a single institution, patients who had a urologic procedure performed under SA between May 2019 and July 2021 and were less than 18 months old were compared with a matched cohort of patients who had GA. The SA and GA groups were compared by two-sample t-tests, chi-square test for independence, and Fisher's exact test.

RESULTS

There were a total of 184 SA and 202 GA patients. There was no significant difference in the demographics except that SA patients were younger and weighed less than GA patients. The patients in the SA group needed less opioids both during the surgery (0% vs 26.1% p N/A) and in the immediate postoperative period when compared with GA patients (0% vs 18.2% p N/A). The patients who had SA had fewer complications necessitating PICU admission, or cancellation of surgery (0% vs 6.8% p = 0.03). Total anesthesia and emergence time were lower for SA patients (41 vs 50.2 p = 0.001 & 3.4 vs 6.1 p = 0.001). Both surgery and total OR time were not different between the groups (37.6 vs 35.5 p = 0.35 and 56.3 vs 54.4 p = 0.49). Overall, raw material cost was also found to be lower per procedure in the SA group vs the GA group ($8.90 vs $38.8: 77% reduction). Adjusted total mean costs for the surgery were not different between groups. The reduction in opioid use postoperatively also suggests reduced cost in the management of postoperative pain in the SA group.

DISCUSSION

Total anesthesia time, opioid use, and serious complications were all significantly lower in the SA group. We did not find significant difference in total surgery cost between two groups. However, patients who had SA had better pain control and needed less rescue analgesics in the immediate postoperative period. No patients in either group were sent home with opioids.

CONCLUSION

Spinal anesthesia was found to be an equally effective and appropriate alternative to GA with many proposed benefits for common pediatric urologic procedures. With further research, SA may prove to be a safer alternative in patients at risk for complications related to GA general anesthesia while also offering a cost benefit.

Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients

Introduction

Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months.

Methods

An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart.

Results

Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001).

Conclusion

This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

Manual Palpation versus Ultrasound to Identify the Intervertebral Space for Spinal Anesthesia in Infants

Purpose

Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends.

Patients and Methods

After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded.

Results

The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography.

Conclusion

Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.

Spinal anesthesia in infants undergoing urologic surgery duration greater than 60 minutes

INTRODUCTION

Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60 min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60 min.

OBJECTIVE

To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60 min.

METHODS

We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60 min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected.

RESULTS

Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60 min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169 min (for the last <10 min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5-7) months, and median procedure length was 95 (IQR 75-120) minutes. Following initial preoperative intranasal dexmedetomidine ± fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60-120) minutes into surgery. Following closure, patients exited the OR after a median 10 (IQR 8-12) minutes and subsequently discharged after spending a median of 73 (IQR 61-96) minutes in recovery.

DISCUSSION

We describe pediatric urologic surgical cases lasting ≥60 min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60 min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia.

CONCLUSION

A single-injection bupivacaine-only spinal anesthesia approach for urologic surgery lasting over an hour and up to 3 h is safe and effective in infants. Selecting appropriate candidates for SA should be a joint decision between the surgeon and the anesthesiologist.

Ambulatory spinal anesthesia in infants ≤ six months of age: A retrospective review of outcomes and safety

PURPOSE

To review experience with outpatient spinal anesthesia (SA) from a single center in infants ≤6 months of age.

METHODS

Retrospective review of all SAs performed in the ambulatory setting in the outpatient surgery centers in infants ≤6 months of age from 2016 to 2020, focusing on success rate, adverse events, post-anesthesia care unit (PACU) times, and emergency department (ED) or urgent care (UC) returns within 7 days of the operation.

RESULTS

The study cohort included 175 SAs performed on 173 patients ≤6 months of age. One hundred and sixty-two patients (93%) were able to undergo their respective surgical procedures under SA without conversion to general anesthesia. One hundred and thirty-six patients (78%) did not require additional sedation or analgesic agents. The median time from entering the operating room until the start of surgical procedure was 17 min. One hundred and twenty-six patients (72%) were able to bypass Phase I of the PACU. One hundred and forty-seven patients (86%) were discharged in less than two hours postoperatively. Only one complication related to SA was noted. This was a patient who returned on postoperative day 2 with a possible CSF leak noted by ultrasound. After overnight hospital floor admission, he was discharged the next day after receiving intravenous fluids without further sequelae.

CONCLUSIONS

SA is a viable option for anesthetic care in infants ≤6 months of age presenting for outpatient surgery. Advantages included the ability to bypass PACU Phase I and facilitation of hospital discharge.

LEVEL OF EVIDENCE

IV. Retrospective cohort treatment study.

Pediatric spinal anesthesia at a tertiary care hospital: Eleven years after

BACKGROUND

Pediatric spinal anesthesia is an old technique whose use is not widespread, in spite of reducing the risk of cardiorespiratory events (hypoxemia, bradycardia, and hypotension) associated with general anesthesia, especially in neonates and infants. This retrospective cohort study aimed to assess the safety and effectiveness of the pediatric spinal anesthesia program at our tertiary care hospital over 11 years.

METHODS

Two hundred children, between 8 days and 13 years of age, who underwent lower body surgery under spinal anesthesia from May 2010 to July 2021 were included. Demographic and procedural data were collected, and success, failure, and complication rates calculated.

RESULTS

The success rate was 97.5% (n = 195). The incidence of complications was 2% (n = 4). They were 2 cases of intraoperative hypoxemia and 2 cases of postoperative postdural puncture headache , and they quickly resolved with no sequelae.

CONCLUSION

Pediatric spinal anesthesia is a safe and effective technique with good acceptance among anesthesiologists. Thus, the implementation of a pediatric spinal anesthesia program at a tertiary care hospital is feasible and affordable.

Regional anesthesia for ambulatory pediatric penoscrotal procedures

BACKGROUND/PURPOSE

Pediatric urology procedures are amongst the most commonly performed in children. The need for proactive treatment of pain is essential for optimal patient care. Current guidelines recommend the routine use of regional anesthesia in children as appropriate unless contraindicated. Given the commonality of urologic procedures in children, it is essential to understand the indications for and the utility of regional anesthesia.

METHODS

The current literature was searched using PubMed as the primary platform. Search words included 'dorsal penile nerve block,' 'pudendal nerve block,' 'ring block,' 'spinal anesthesia,' and 'caudal,' along with 'pediatric', 'circumcision,' 'hypospadias,' 'urology', and 'urological surgery' as part of the keywords of the search.

RESULTS

The articles resulting from the literature search were reviewed for content, clarity and study design by two co-authors, and agreement determined the incorporation into the review. Additionally, a detailed description of study design, regional anesthetic technique, local anesthetic(s) used, and outcomes of each study referenced was incorporated into the supplemental table.

CONCLUSION

Given the variance in block technique and local anesthetic choice amongst the current reported studies in the literature, it is difficult to truly compare and infer superiority of the regional anesthetic choices for ambulatory penoscrotal procedures. When choosing a regional anesthetic technique, careful consideration must be placed on block coverage, severity of expected pain and surgical duration of the procedure, type and dose of local anesthetic, as well as the patient's past medical history and anatomy. Moreover, the regional block chosen should result from a thorough preoperative discussion between the surgeon and the anesthesiologist.

Electroencephalographic assessment of infant spinal anesthesia: A pilot prospective observational study

INTRODUCTION

Spinal anesthesia is utilized as an alternative to general anesthesia in infants for some surgeries. After spinal anesthesia, infants often become less conscious without administration of sedative medications. The aim of this study was to assess electroencephalographic (EEG) correlates after spinal anesthesia in a cohort of infants.

PATIENTS AND METHODS

This pilot study included 12 infants who underwent spinal anesthesia. Unprocessed electroencephalography was recorded. The electroencephalogram was interpreted by four neurologists. Processed analyses compared electroencephalogram changes 30 min after spinal anesthesia to baseline.

RESULTS

Following spinal anesthesia, all 12 infants became sedated. Electroencephalography in all 12 demonstrated Stage 2 sleep with the appearance of sleep spindles (12-14 Hz) in the frontal and central leads in 8/12 (67%) of subjects. The median time to onset of sleep spindles was 24.7 interquartile range (21.2, 29.9) min. The duration of sleep spindles was 25.1 interquartile range (5.8, 99.8) min. Voltage attenuation and background slowing were the most common initial changes. Compared to baseline, the electroencephalogram 30 min after spinal anesthesia showed significantly increased absolute delta power (p = 0.02) and gamma power (p < 0.0001); decreases in beta (p = 0.0006) and higher beta (p < 0.0001) were also observed. The Fast Fourier Transform power ratio difference for delta/beta was increased (p = 0.03). Increased coherence was noted in the delta (p = 0.02) and theta (p = 0.04) bandwidths.

DISCUSSION

Spinal anesthesia in infants is associated with increased electroencephalographic slow wave activity and decreased beta activity compared to the awake state, with appearance of sleep spindles suggestive of normal sleep. The etiology and significance of the observed voltage attenuation and background slowing remains unclear.

CONCLUSIONS

The EEG signature of infant spinal anesthesia is distinct from that seen with general anesthesia and is consistent with normal sleep. Further investigation is required to better understand the etiology of these findings. Our preliminary findings contribute to the understanding of the brain effects of spinal anesthesia in early development.

Analgesic Efficacy of Quadratus Lumborum Block in Infants Undergoing Pyeloplasty

Post-operative analgesic management is challenging in infants and opioids have been the standard of care. However, they are associated with adverse effects which may negatively impact infants. In this retrospective cohort study, we sought to explore the postoperative analgesic efficacy of quadratus lumborum (QL) block in the infant population undergoing dorsal lumbotomy pyeloplasty. Chart review of 34 infants (≤12 months) who underwent dorsal lumbotomy pyeloplasty between 2016–2020 was performed. Post-operative pain was assessed using externally validated pain scales (CRIES & FLACC) and monitored hemodynamics (pulse and blood pressure). Opioid doses were standardized by using morphine milligram equivalency (MME). The Prescription Database Monitoring Program (PDMP) was utilized to determine if discharge opioid prescriptions were filled. Of 34 patients, 13 received the QL block. Mean age at the time of surgery was 6.2 months ± 3.2 months. The QL group received 0.8 MME postoperatively, whereas the non-QL group received 0.9 MME (p = 0.82). The QL group (20%) filled their discharge opioid prescription less frequently compared to non-QL group (100%) (p = 0.002). There were no observed differences between pain scale or hemodynamic variables. Further studies are warranted to explore QL block’s efficacy for post-operative infant pain management.

Update on Local Anesthetic Toxicity, Prevention and Treatment During Regional Anesthesia in Infants and Children

Local anesthetic agents play a key role in the treatment and prevention of pain in children. Although generally safe and effective, as with any pharmacologic agent, adverse effects may occur with the administration of these medications. Systemic absorption or inadvertent systemic injection during bolus dosing or continuous infusion can result in local anesthetic systemic toxicity with life-threatening neurological and cardiac complications. The following article reviews the pharmacology of local anesthetic agents, outlines previous reports of systemic toxicity during regional anesthesia, and discusses prevention and treatment algorithms.

Fundamentals and innovations in regional anaesthesia for infants and children

Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.

Spinal anesthesia for muscle biopsy in an infant with a suspected neuromuscular disorder: a case report

Background

Neuromuscular disorders (NMDs) occur in different forms and are generally diagnosed using muscle biopsy. Among the available anesthetic management options for infants with a suspected NMD are general anesthesia (GA) and regional anesthesia (RA), including spinal anesthesia (SA). Anesthesia selection is often challenging from the point of potential airway risks and anesthetic drug-related complications.

Case presentation

A 6-month-old male infant repeatedly underwent endotracheal intubation and extubation after birth because of respiratory muscle weakness and copious secretions. He was suspected of having NMD and was scheduled for muscle biopsy. His generalized hypotonia and decreased respiratory function presented a potentially difficult airway and complicated the selection of an appropriate anesthetic method. We selected SA and dexmedetomidine, which are safe for infants.

Conclusion

We report the successful and effective anesthetic management of SA and dexmedetomidine in an infant with a suspected NMD.

Implementation of a spinal anesthesia and sedation protocol that reliably prolongs infant spinal anesthesia: Case series of 102 infants who received spinal anesthesia for urologic surgery

BACKGROUND

The use of spinal anesthesia in infants is seeing resurgence as an alternative to general anesthesia.

AIMS

Our primary aims are to describe our institution's experience introducing a spinal anesthesia and sedation protocol for infants undergoing urologic surgery, to describe methods of improving prolonged anesthesia, and to describe the failure rate of spinal anesthesia in these patients. Sedation was provided for some infants with intranasal dexmedetomidine ± fentanyl.

METHODS

This is a retrospective case series examining infants aged 1-<14 months who received spinal anesthesia for circumcision, orchiopexy, orchiectomy, hypospadias repair, or epispadias repair. The electronic medical record was reviewed and compared with unmatched historical controls who received general anesthesia.

RESULTS

A total of 230 patients underwent a urologic procedure; 102 patients received spinal anesthesia and 128 received general anesthesia. Length of surgical time with spinal anesthesia ranged from 4 to 189 minutes. The hospital length of stay was shorter in the spinal anesthesia group (median [IQR] of 5.3 hours [4.3, 7.2]) compared to the general anesthesia group (17.1 hours [15.6, 17.5]).The median bupivacaine dose was 0.75 mg/kg [0.67, 0.85]. There was one case in which cerebral spinal fluid was unable to be obtained, and one case that required conversion to general anesthesia after surgery had started. There were no cases of apnea, bleeding, infection, or neurologic compromise.

CONCLUSIONS

We describe the successful implementation of an infant spinal anesthesia and sedation protocol and a technique that uniquely provides prolonged surgical anesthesia with a low failure rate. We also report shorter anesthesia time, surgical time, and recovery room length of stay in patients who received spinal anesthesia compared to general anesthesia.

Epidural and Spinal Anesthesia for Newborn Surgery

Neuraxial (spinal and epidural) anesthesia has become commonplace in the care of neonates undergoing surgical procedures. These techniques afford many benefits, and, when properly performed, are extremely safe. This article reviews the benefits, risks, and applications of neuraxial anesthesia in neonates.

Hypothermia Following Spinal Anesthesia in an Infant: Potential Impact of Intravenous Dexmedetomidine and Intrathecal Clonidine

The α₂-adrenergic agonists (dexmedetomidine and clonidine) have been used in several different clinical scenarios in infants and children including sedation during mechanical ventilation, procedural sedation, supplementation of postoperative analgesia, prevention of emergence delirium, control of post-anesthesia shivering, treatment of withdrawal and prolonging of duration of neuraxial anesthesia. Hemodynamic effects including bradycardia and hypotension remain the predominant adverse effects reported with the α₂-adrenergic agonists. We report hypothermia following intravenous sedation with dexmedetomidine and spinal anesthesia with a combination of bupivacaine and clonidine in a 2-month-old infant. The potential mechanisms involved are reviewed, the causal relationship between hypothermia and α₂-adrenergic agonists is explored and interventions to avoid its development are presented.

Inguinal hernia repair in preterm neonates: is there evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systematic review and meta-analysis

OBJECTIVES

Whether spinal anaesthesia (SA) reduces intraoperative and postoperative complications compared with general anaesthesia (GA) was investigated.

DESIGN

The meta-analysis was structured based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Databases (PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science) were searched, and four randomised controlled trials (RCTs) and two retrospective cohort studies were included. A random-effects model with pooled risk ratios and mean differences with 95% CIs were used. Statistical heterogeneity was evaluated using the I² statistic. Quality assessment of the studies was performed by assessing the risk of bias according to the Cochrane and GRADE methodology.

SETTING

Publications from January 1990 to November 2018 were included.

PARTICIPANTS AND INTERVENTIONS

Our study selection captured information from studies focusing on neonates born before the 37th gestational week who were scheduled for an inguinal hernia repair operation under either SA or GA.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measures were apnoea, postoperative ventilation and method failure rates according to predefined eligibility criteria. The duration of surgery, desaturation events <80%, hospital stay duration and postoperative bradycardia were secondary outcomes.

RESULTS

We found significantly fewer events for the outcomes 'any episode of apnoea' and 'mechanical ventilation postoperatively' in the SA group. Bradycardias were significantly less common in the SA group. In total, 7.5% of the SA group were converted to GA. The duration of surgery was significantly shorter in the SA group. No significant differences were found in the outcome measures 'postoperative oxygen supplementation', 'prolonged apnoea', 'postoperative oxygen desaturation <80%' and 'hospital stay'.

CONCLUSIONS

We consider SA a convenient alternative for hernia repair in preterm infants, providing more safety regarding postoperative apnoea. To the best of our knowledge, this is the first meta-analysis to include studies exclusively comparing SA versus GA. More high-quality RCTs are needed.

TRIAL REGISTRATION NUMBER

CRD42016048683.

Combined spinal/caudal catheter anesthesia: extending the boundaries of regional anesthesia for complex pediatric urological surgery

BACKGROUND

Spinal anesthesia (SA) is an established anesthetic technique for short outpatient pediatric urological cases. To avoid general anesthesia (GA) and expand regional anesthetics to longer and more complex pediatric surgeries, the authors began a program using a combined spinal/caudal catheter (SCC) technique.

STUDY DESIGN

The authors retrospectively reviewed the charts of all patients scheduled for surgery under SCC between December 2016 and April 2018 and recorded age, gender, diagnosis, procedure, conversion to GA/airway intervention, operative time, neuraxial and intravenous medications administered, complications, and outcomes. The SCC technique typically involved an initial intrathecal injection of 0.5% isobaric bupivacaine followed by placement of a caudal epidural catheter. At the discretion of the anesthesiologist, patients received 0.5 mg per kilogram of oral midazolam approximately 30 min prior to entering the operating room. One hour after the intrathecal injection, 3% chloroprocaine was administered via the caudal catheter to prolong the duration of surgical block. Intra-operative management included either continuous infusion or bolus dosing of dexmedetomidine, as needed, for patient comfort and to optimize surgical conditions. Prior to removal of caudal catheter in the post-anesthesia care unit, a supplemental bolus dose of local anesthesia was given through the catheter to provide prolonged post-operative analgesia.

RESULTS

Overall, 23 children underwent attempted SCC. SA was unsuccessful in three patients, and surgery was performed under GA. The remaining 20 children all had successful SCC placement. There were 11 girls and nine boys, with a mean age of 16.5 months (3.3-43.8). Surgeries performed under SCC included seven ureteral reimplantations, two ureterocele excisions/reimplantations, two megaureter repairs, four first-stage hypospadias repairs, one distal hypospadias repair, one second-stage hypospadias repair, two feminizing genitoplasties, and one open pyeloplasty. Average length of surgery was 109 min (range 63-172 min). Pre-operative midazolam was given in 13/20 (65%). All SCC patients were spontaneously breathing room air during the operation, and there were no airway interventions. Only one SCC patient received opioids intra-operatively. There were no intra-operative or perioperative complications.

DISCUSSION

This pilot study shows that the technique of SCC allows one to do more complex urologic surgery under regional anesthesia than what would be possible under pure SA alone. The main limitations of the study include the relatively small number of patients and the small median length of the operative procedures. As a proof of concept, however, this does show that complex genital surgery bladder level procedures such as ureteral reimplantation can be performed under regional anesthesia.

CONCLUSION

SCC allows for more complex surgeries to be performed exclusively under regional anesthesia, thus obviating the need for airway intervention, minimizing or eliminating the use of opioids, and thus avoiding known and potential risks associated with GA. The latter is of particular importance given current concerns regarding hypothetical neurocognitive effects of GA on children aged below 3 years.

Ultrasound-Guided, Continuous Brachial Plexus Blockade in a Neonate With Upper Extremity Limb Ischemia: A Case Report

Regional anesthetic blocks, especially in-dwelling catheters, are infrequently used in neonates and infants. The following report describes a neonate with a gangrenous right upper extremity requiring multiple painful debridements over several weeks. A brachial plexus catheter was placed using ultrasound guidance, and a continuous infusion of a local anesthetic was used to provide postoperative pain control. After the initial procedures, bolus doses of a local anesthetic agent provided surgical anesthesia for dressing changes, thus obviating the need for multiple general anesthetics. This case demonstrates the potential efficacy of regional techniques to both treat pain and limit anesthetic exposures in neonates.

Benefits of spinal anesthesia for urologic surgery in the youngest of patients

INTRODUCTION

Increasing concerns regarding potential negative effects of early use of inhalational and intravenous anesthetics on neurocognitive development have led to a growing interest in alternative forms of anesthesia in infants. The study institution's outcomes with spinal anesthesia (SA) for urologic surgery in infants aged less than 90 days are reported and their outcomes with a matched cohort of patients who underwent general anesthesia (GA) are compared.

METHODS

This is a retrospective single-center analysis. Patients aged less than 90 days who underwent SA for four urologic surgeries (inguinal hernia repair, scrotal exploration, posterior urethral valve ablation, and ureterocele puncture) were identified from the study institution's SA database. An age- and procedure-matched control cohort was identified from a list of patients who underwent the aforementioned four procedures under GA since 2013. Outcomes of interest included success rate of SA, complications from spinal placement, narcotic use, need for supplemental medications and oxygen, and length of hospital stay.

RESULTS

Forty patients were identified; 20 in the SA and 20 in the GA group. Mean patient age was 54 (standard deviation, 35) days. There were no significant differences between the groups in age, gender, weight, history of prematurity, or presence of comorbidities. Eighty percent of SA patients had successful SA; reasons for conversion to GA included failure of spinal needle placement (75%) and agitation during operative procedure (25%). Ninety-six percent of patients who received GA (primarily or converted) had an endotracheal tube (ETT) placed. No patient in the SA group had a complication from spinal needle placement. Patients in the SA group were less likely to receive narcotics during the operative procedure (P = 0.001) and also had a lower mean morphine equivalent dose/kilogram (P = 0.002). Patients in the SA group were also less likely to receive any supplemental medications during the operative procedure (P = 0.001), particularly intravenous corticosteroids (P < 0.001). There were no significant differences in the length of hospital stay.

CONCLUSIONS

The use of SA has clear advantages for this medically vulnerable population. For the majority of patients, it obviates the need for ETT placement and airway management and avoids the potential negative effects of GA on neurocognitive development. It also decreases the use of narcotics and other supplemental medications. In scenarios in which the benefit of surgery must be weighed against the risk of GA, such as neonatal torsion, SA may allow a paradigm shift in the timing of surgery.

Anesthesia in the Pediatric Patient

Improvements in anesthetic drugs and monitoring techniques over the past several decades have significantly reduced the anesthetic risks for pediatric patients. Neonates and infants are at increased risk for cardiovascular and pulmonary complications, and recent reports have led to concern that these young patients may be at risk for long-term detrimental neurodevelopmental effects as well. Although studies are currently under way to answer the question of anesthetic neurotoxicity in children, surgeons and anesthesiologists must work with parents to determine the best course of action for these vulnerable patients.

General anesthesia combined with epidural anesthesia on the postoperative cognitive functions in pregnant women with dystocia

Effects of general anesthesia combined with epidural anesthesia on the postoperative cognitive functions in pregnant women with dystocia were investigated. Postoperative cognitive functions of 84 dystocia pregnant women treated with cesarean section were retrospectively analyzed. Patients who received general anesthesia were included in group A (n=42), and those who received general anesthesia combined with epidural anesthesia were included in group B (n=42). Mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS) at different time-points after anesthesia in the two groups of patients were observed and compared. Recovery of anesthesia such as the recovery time of spontaneous breathing, recovery time of orientation and time of eye opening were observed and compared between two groups of patients. Mini mental state examination (MMSE) scores were obtained and compared between the the groups of patients at different time-points after operation. Three vital signs (MAP, HR and BIS) were not significantly different between group A and B at the same time-point (P>0.05) and the maintenance of anesthesia was satisfactory. Compared with group A, postoperative recovery time of spontaneous breathing, recovery time of orientation and the time of eye opening in group B were all significantly shorter (P<0.05). In addition, MMSE scores of patients in group B, 2 and 12 h after operation were 24.33±1.61 and 26.41±1.83 points, respectively, which were significantly improved compared with those of patients in group A (20.45±1.58 and 22.39±1.72 points, respectively) (P<0.05). In conclusion, recovery of postoperative cognitive functions in pregnant women with dystocia who received general anesthesia combined with epidural anesthesia was shorter to that of those who only received general anesthesia.

Spinal anesthesia instead of general anesthesia for infants undergoing tendon Achilles lengthening

Spinal anesthesia (SA) has been used relatively sparingly in the pediatric population, as it is typically reserved for patients in whom the perceived risk of general anesthesia is high due to comorbid conditions. Recently, concern has been expressed regarding the potential long-term neurocognitive effects of general anesthesia during the early stages of life. In view of this, our center has developed a program in which SA may be used as the sole agent for applicable surgical procedures. While this approach in children is commonly used for urologic or abdominal surgical procedures, there have been a limited number of reports of its use for orthopedic procedures in this population. We present the use of SA for 6 infants undergoing tendon Achilles lengthening, review the use of SA in orthopedic surgery, describe our protocols and dosing regimens, and discuss the potential adverse effects related to this technique.