Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia

Urgent surgical exploration for neonatal torsion under spinal anesthesia

INTRODUCTION/BACKGROUND

The repeated or lengthy use of general anesthesia (GA) in children under three years old is cautioned against due to potential neurodevelopment effects. Spinal anesthesia (SA) has emerged as a safe and effective alternative for routine pediatric urologic procedures. In this study, we describe the use of SA in the urgent surgical treatment of neonatal testicular torsion.

OBJECTIVE

We aim to evaluate the safety and efficacy of SA for urgent scrotal exploration in neonates.

STUDY DESIGN

We retrospectively collected data on neonates younger than 30 days old undergoing SA for the indication of testicular torsion from May 2018 to June 2022. We recorded patient demographics, adjuvant medications use, and time points for start/stop of spinal injection, procedure, and operating room utilization.

RESULTS

Six neonates, with an average age of 1.9 days of life and average weight of 3.4 kg, underwent scrotal exploration for testicular torsion using SA. Four patients (67%) required orchiectomy of the nonviable torsed testicle, and all patients underwent orchiopexy of the unaffected testicle. Mean total operative time was 45.3 (SD 11.7) minutes, including Gomco circumcision in five patients. One patient received preoperative intranasal dexmedetomidine for sedation. Mean time for SA administration was 6.3 (SD 5.5) minutes, with a mean total time in the operating room of 77.3 (SD 9.8) minutes. There were no perioperative or postoperative complications.

DISCUSSION

We describe a single institution experience of surgical management of neonatal torsion under SA. In this case series, SA was safely utilized for all neonates involved without the need for conversion to GA or intravenous (IV) sedation.

CONCLUSION

The use of SA is safe and efficacious for urgent scrotal exploration for testicular torsion in neonates, even those under 48 h of age. More widespread utilization requires collaboration between pediatric urologists and experienced pediatric anesthesiologists trained in SA.

Second infant spinal anesthetic: Incidence, dose modification, and adverse events after initial failure

INTRODUCTION

Infant spinal anesthesia is an important technique in premature and ex-premature infants undergoing lower abdominal surgery. Previous studies of infant spinal anesthesia report high failure rates, but fail to adequately identify contributing factors. The aim of this study is to retrospectively review spinal anesthetics from a quaternary anesthetic centre to determine overall spinal failure rate, incidence of second spinal attempts and adverse events associated with a second spinal anesthetic.

METHODS

A retrospective review of infant spinal anesthetics performed between May 2016 and June 2023.

RESULTS

Five hundred and fifty-one infants (mean postmenstrual age 42.9 weeks and weight 3873 g) were included. The overall success rate on first attempt was 86.5% with a further 5.1% requiring a successful second spinal anesthetic after initial failure. Spinal anesthetic failure requiring conversion to general anesthesia occurred in 9.4% of cases The causes of failed spinal anesthetic were inability to access the subdural space (dry tap 4.2%), inadequate motor blockade (2.9%), and repeated bloody taps (2.2%). Spinal anesthetic failure was significantly increased in cases where the anesthetist was routinely performing less than 5 spinal anesthetics per year [OR 2.21 (95% CI 1.28, 3.83, p = .004)] but only weakly associated with years of pediatric anesthetic experience. Failure rates were 21.4% with styletted spinal needles and 9.2% for non styletted [OR 2.68 (95% CI 1.23-5.86, p = .012)]. The incidence of perioperative apnoea was 6.7% with the highest rate in infants in which failed spinal anesthesia required conversion to general anesthesia (25%). There were 28 cases where initial spinal anesthetic failed to produce adequate anesthesia and a repeat spinal anesthetic was performed. Repeat spinal anesthesia was successful in 92.8% of cases with awake caudal anesthesia successful in 7.2% of cases. In three cases high spinal blockade occurred, one after a single spinal and two after a repeat spinal. Both repeat spinal high block cases required intubation and brief resuscitation.

CONCLUSION

Infant spinal anesthesia is associated with high success rates if experienced anesthetists are present or performing the block. Repeat spinal anesthesia may be associated with an increased incidence of high spinal block. Greater awareness of the slow onset of high block should promote techniques aimed at minimizing cephalad spread of local anesthetic including slight head up positioning during surgery.

Ultrasound-guided spinal anesthesia in infants: a narrative review

BACKGROUND/IMPORTANCE

Infant spinal anesthesia has many potential benefits. However, the delivery of infant spinal anesthesia is technically challenging. The landmark-based technique has not changed for over a century. Advancements in ultrasound technology may provide an opportunity to improve infant spinal procedures.

OBJECTIVE

Our primary objective is to conduct a comprehensive review of the current literature on ultrasonography for spinal anesthesia in infants. Given the narrow scope of this topic, our secondary objective is to review the current literature on ultrasonography for lumbar puncture in infants.

EVIDENCE REVIEW

We reviewed all papers related to the use of ultrasound for infant spinal anesthesia. Two large databases were searched with key terms. Eligibility criteria were full-text articles in English. For our secondary objective, we searched one large database for key terms relating to ultrasonography and infant lumbar puncture. Eligibility criteria were the same.

FINDINGS

Our primary search retrieved six articles. These consisted of four review articles, one case report, and one retrospective observational study. Our secondary search retrieved fourteen articles. These consisted of five randomized control trials, four prospective studies, three retrospective studies, and two review papers.

CONCLUSIONS

Ultrasound yields high-quality images of the infant spine. Most literature regarding ultrasound for infant spinal procedures arises from emergency medicine or interventional radiology specialties. The literature on ultrasound for infant spinal anesthesia is extremely limited, but shows promise. Future studies are needed in order to determine whether ultrasound can improve the success rate for delivery of infant spinal anesthesia.

Comparison of Postoperative Outcome in Children Undergoing Inguinal Hernia Repair Using Regional With General Versus General Anesthesia Alone: A Single Center Study

BACKGROUND

Inguinal hernia repair is one of the most common general surgical procedures. It has been performed under local, regional, or general anesthesia. We hypothesized that using regional plus general anesthesia rather than general anesthesia alone would improve outcomes in neonates and pediatric patients undergoing hernia repair.

METHODS

This is a retrospective cohort study, including all pediatric patients who underwent inguinal hernia repair from 2015-2021. We divided patients into two groups. The first group was labeled "general anesthesia" (GA), while the second group was labeled "combined general and regional anesthesia" (GA+RA). We compared both groups in terms of demographic data, intraoperative outcome variables, and postoperative outcome variables.

RESULTS

 212 children fulfilled the study criteria, with 57 in the GA group and 155 in the GA+RA group. Demographic and preoperative data were comparable between both groups except for age, which was 60.3±49.4 months in the GA group versus 26.7±33.13 months in the GA+RA group (p<.0001). Outcome variables demonstrated statistically significant improvement in postoperative pain occurrence, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation in the GA+RA group in comparison to the GA group with P values of 0.031, 0.02, 0.005, and 0.02, respectively.

CONCLUSION

Using regional and general anesthesia techniques rather than general anesthesia alone is associated with a decrease in postoperative pain, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation. Further studies are still warranted to validate our conclusions.

Impact of supplemental anesthesia in preterm infants undergoing inguinal hernia repair under spinal anesthesia : A retrospective analysis

BACKGROUND

In preterm infants, spinal anesthesia (SpA) is recognized as an alternative to general anesthesia for inguinal hernia repair (IHR); however, some patients require supplemental anesthesia during surgery. The purpose of this study was to investigate the frequency and impact of supplemental anesthesia on perioperative care and adverse respiratory and hemodynamic events.

METHODS

A retrospective study of preterm infants undergoing IHR at Heidelberg University Hospital within the first year of life between 2009 and 2018 was carried out.

RESULTS

In total, 230 patients (255 surgeries) were investigated. Among 189 procedures completed using SpA 24 patients received supplemental anesthesia. Reasons for supplemental anesthesia included loss of anesthetic effect, returning motor response, and respiratory complications. Compared to SpA alone, no differences were found concerning hemodynamic parameters; however, patients requiring supplemental anesthesia displayed higher rates of postoperative oxygen supplementation and unexpected admission to the intensive care unit. The rate of perioperative apnea was 2.7%. Apneic events exclusively occurred after supplemental anesthesia. Bilateral IHR and duration of surgery were associated with the need for supplemental anesthesia.

CONCLUSION

Whereas SpA might be favorable when compared to general anesthesia for IHR, the data indicate that particular caution is required in patients receiving supplemental anesthesia due to the possible risk for adverse respiratory events.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee

INTRODUCTION

 Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.

MATERIALS AND METHODS

 The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

 Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.

CONCLUSION

 Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Development: Epidemiology and management of postoperative apnoea in premature and term newborns

Postoperative apnoea (PA) is defined as a respiratory pause of more than 15seconds or as a respiratory pause associated with bradycardia < 120/min, desaturation (Sat02<90%), cyanosis or hypotonia. This is a relatively frequent phenomenon that affects 10% of infants under 60 weeks of post-conceptual age, born prematurely or not, and occurs during the first 12-48h postoperatively. The population exposed to PA is heterogeneous and it is necessary to standardise the management both during the intra- and postoperative period, and to adapt this management according to the risk factors for PA and the status as prematurely born infants or not, based on recent data from the literature.

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.

Anaesthetic concerns in preterm and term neonates

Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for "Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia", as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.

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.

Cerebrospinal fluid volume in neonates undergoing spinal anaesthesia: a descriptive magnetic resonance imaging study

BACKGROUND

Spinal anaesthesia (SA) reduces the risk of postoperative apnoea after general anaesthesia in neonates. In 30% of patients, however, the duration of anaesthesia provided does not allow completion of surgery. When compared with term infants, formerly preterm neonates experience a shorter duration of anaesthesia after SA. A difference in the cerebrospinal fluid (CSF) volume between those two populations could explain this difference, but this has never been investigated. The study was designed to evaluate the relationship between the spinal CSF volume and patient characteristics in neonates.

METHODS

Sixty-seven neonates, aged 30-60 weeks postconception, were included in this study. Their spinal CSF volumes were calculated using magnetic resonance imaging, and these volumes were plotted individually against sex, term at birth, birth weight, current gestational age, civil age, and weight. Correlations between CSF volume and these variables were investigated.

RESULTS

Fifty-four neonates completed the study. The CSF volume was found to be closely and linearly correlated with weight and postconceptional age. The relationship between spinal CSF volume and weight can be described as follows: CSF volume (ml)=1.94 weight (kg)+0.13. The CSF volume was not correlated with sex, weight, or term at birth, nor with civil age.

CONCLUSIONS

The amount of spinal CSF in neonates can be estimated as 2 ml kg(-1) in both term and formerly preterm neonates. A difference in the CSF volume between them does not provide an explanation for a shorter duration of SA in the latter. Our findings reinforce weight-adjusted dosage of SA in neonates.

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.

Brain tissue oxygen regulation in awake and anesthetized neonates

Inhaled general anesthetics are used commonly in adults and children, and a growing body of literature from animals and humans suggests that exposure to anesthesia at an early age can impact brain development. While the origin of these effects is not well understood, it is known that anesthesia can disrupt oxygen regulation in the brain, which is critically important for maintaining healthy brain function. Here we investigated how anesthesia affected brain tissue oxygen regulation in neonatal rabbits by comparing brain tissue oxygen and single unit activity in the awake and anesthetized states. We tested two common general anesthetics, isoflurane and sevoflurane, delivered in both air and 80% oxygen. Our findings show that general anesthetics can greatly increase brain tissue PO₂ in neonates, especially when combined with supplemental oxygen. Although isoflurane and sevoflurane belong to the same class of anesthetics, notable differences were observed in their effects upon neuronal activity and spontaneous respiration. Our findings point to the need to consider the potential effects of hyperoxia when supplemental oxygen is utilized, particularly in children and neonates.

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

BACKGROUND

Spinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA), we developed a SA program to provide an alternative option. We present our initial experience with this program.

OBJECTIVE

To implement a SA program at a large tertiary care pediatric center and assess the safety and efficacy of the technique as an alternative to GA for urologic surgery.

STUDY DESIGN/METHODS

We prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the SA, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA, and perioperative complications.

RESULTS

SA was attempted in 105 consecutive children (104 boys, 1 girl) with a mean age of 7.4 ± 4.3 months (range 19 days-24 months) and mean weight of 8.3 ± 1.7 kg (range 3.5-13.7). Placement of the SA was successful in 93/105 children (89%). Inability to achieve lumbar puncture (cerebrospinal fluid was not obtained) meant that SA was abandoned in seven (7%) patients and GA was administered. In five patients in whom SA was successful and surgery was begun, 5/93 (5%) required conversion to GA: two because of evisceration of intestine through large hernia defects related to coughing and abdominal irritation, two because of lack of motor blockade despite an adequate sensory block, and one because of an inability to place an intravenous catheter in the lower extremities (required per SA protocol). If necessary, an intravenous catheter can be placed in the upper extremity, but this must be weighed against the fact that the block has already been placed and is of limited duration. Overall, SA was successful (SA was placed and surgery was completed without conversion to GA) in 88/105 children (84%). No additional sedation and no systemic anesthetic agents were required in 75/88 children (85%). The average time required to place the SA was 3.8 ± 2.7 min (range 1-12). The average time for the surgical procedure was 38.3 ± 23.1 min (range 10-122). No patient required conversion to GA because of recession of block. There were no surgical complications.

DISCUSSION/CONCLUSIONS

SA is a safe and efficacious technique for routine pediatric urological procedures. SA should be considered for cases such as neonatal torsion or patients with significant cardiac or pulmonary comorbidities when the risks of GA are often weighed against the risks of non-intervention.

Spinal anesthesia after intraoperative cardiac arrest during general anesthesia in an infant

Although generally safe and effective, severe perioperative complications, including cardiac arrest, may occur during general anesthesia in infants. With the emergence of evidence that specific anesthetic agents may affect future neurocognitive outcomes, there has been an increased focus on alternatives to general anesthesia, including spinal anesthesia. We present a case of cardiac arrest during general anesthesia in an infant who required urologic surgery. During the subsequent anesthetic care, spinal anesthesia was offered as an alternative to general anesthesia. The risks of severe perioperative complications during general anesthesia are reviewed, etiologic factors for such events are presented, and the use of spinal anesthesia as an alternative to general anesthesia is discussed.

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates

PURPOSE

The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants.

METHODS

A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter.

RESULTS

Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day.

CONCLUSION

Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

Predictors of Failure of Awake Regional Anesthesia for Neonatal Hernia Repair: Data from the General Anesthesia Compared to Spinal Anesthesia Study--Comparing Apnea and Neurodevelopmental Outcomes

BACKGROUND

Awake regional anesthesia (RA) is a viable alternative to general anesthesia (GA) for infants undergoing lower abdominal surgery. Benefits include lower incidence of postoperative apnea and avoidance of anesthetic agents that may increase neuroapoptosis and worsen neurocognitive outcomes. The General Anesthesia compared to Spinal anesthesia study compares neurodevelopmental outcomes after awake RA or GA in otherwise healthy infants. The aim of the study is to describe success and failure rates of RA and report factors associated with failure.

METHODS

This was a nested cohort study within a prospective, randomized, controlled, observer-blind, equivalence trial. Seven hundred twenty-two infants 60 weeks or less postmenstrual age scheduled for herniorrhaphy under anesthesia were randomly assigned to receive RA (spinal, caudal epidural, or combined spinal caudal anesthetic) or GA with sevoflurane. The data of 339 infants, where spinal or combined spinal caudal anesthetic was attempted, were analyzed. Possible predictors of failure were assessed including patient factors, technique, experience of site and anesthetist, and type of local anesthetic.

RESULTS

RA was sufficient for the completion of surgery in 83.2% of patients. Spinal anesthesia was successful in 86.9% of cases and combined spinal caudal anesthetic in 76.1%. Thirty-four patients required conversion to GA, and an additional 23 patients (6.8%) required brief sedation. Bloody tap on the first attempt at lumbar puncture was the only risk factor significantly associated with block failure (odds ratio = 2.46).

CONCLUSIONS

The failure rate of spinal anesthesia was low. Variability in application of combined spinal caudal anesthetic limited attempts to compare the success of this technique to spinal alone.

Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy

BACKGROUND

With improvements in neonatal intensive care, more preterm infants are surviving the neonatal period and presenting for surgery in early infancy. Inguinal hernia is the most common condition requiring early surgery, appearing in 38% of infants whose birth weight is between 751 grams and 1000 grams. Approximately 20% to 30% of otherwise healthy preterm infants having general anaesthesia for inguinal hernia surgery at a postmature age have at least one apnoeic episode within the postoperative period. Research studies have failed to adequately distinguish the effects of apnoeic episodes from other complications of extreme preterm gestation on the risk of brain injury, or to investigate the potential impact of postoperative apnoea upon longer term neurodevelopment. In addition to episodes of apnoea, there are concerns that anaesthetic and sedative agents may have a direct toxic effect on the developing brain of preterm infants even after reaching postmature age. It is proposed that regional anaesthesia may reduce the risk of postoperative apnoea, avoid the risk of anaesthetic-related neurotoxicity and improve neurodevelopmental outcomes in preterm infants requiring surgery for inguinal hernia at a postmature age.

OBJECTIVES

To determine if regional anaesthesia reduces postoperative apnoea, bradycardia, the use of assisted ventilation, and neurological impairment, in comparison to general anaesthesia, in preterm infants undergoing inguinal herniorrhaphy at a postmature age.

SEARCH METHODS

The following databases and resources were searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2015, Issue 2), MEDLINE (December 2002 to 25 February 2015), EMBASE (December 2002 to 25 February 2015), controlled-trials.com and clinicaltrials.gov, reference lists of published trials and abstracts published in Pediatric Research and Pediatric Anesthesia.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of regional (spinal, epidural, caudal) versus general anaesthesia, or combined regional and general anaesthesia, in former preterm infants undergoing inguinal herniorrhaphy in early infancy.

DATA COLLECTION AND ANALYSIS

At least two of three review authors (LJ, JF, AL) independently extracted data and performed analyses. Authors were contacted to obtain missing data. The methodological quality of each study was assessed according to the criteria of the Cochrane Neonatal Review Group. Data were analysed using Review Manager 5. Meta-analyses were performed with calculation of risk ratios (RR) and risk difference (RD), along with their 95% confidence intervals (CI) where appropriate.

MAIN RESULTS

Seven small trials comparing spinal with general anaesthesia in the repair of inguinal hernia were identified. Two trial reports are listed as 'Studies awaiting classification' due to insufficient information on which to base an eligibility assessment. There was no statistically significant difference in the risk of postoperative apnoea/bradycardia (typical RR 0.72, 95% CI 0.48 to 1.06; 4 studies, 138 infants), postoperative oxygen desaturation (typical RR 0.82, 95% CI 0.61 to 1.11; 2 studies, 48 infants), the use of postoperative analgesics (RR 0.42, 95% CI 0.15 to 1.18; 1 study, 44 infants), or postoperative respiratory support (typical RR 0.09, 95% CI 0.01 to1.64; 3 studies, 98 infants) between infants receiving spinal or general anaesthesia. When infants who had received preoperative sedatives were excluded, the meta-analysis supported a reduction in the risk of postoperative apnoea in the spinal anaesthesia group (typical RR 0.53, 95% CI 0.34 to 0.82; 4 studies, 129 infants). Infants with no history of apnoea in the preoperative period and receiving spinal anaesthesia (including a subset of infants who had received sedatives) had a reduced risk of postoperative apnoea and this reached statistical significance (typical RR 0.34, 95% CI 0.14 to 0.81; 4 studies, 134 infants). Infants receiving spinal rather than general anaesthesia had a statistically significant increased risk of anaesthetic agent failure (typical RR 7.83, 95% CI 1.51 to 40.58; 3 studies, 92 infants). Infants randomised to receive spinal anaesthesia had an increased risk of anaesthetic placement failure of borderline statistical significance (typical RR 7.38, 95% CI 0.98 to 55.52; typical RD 0.15, 95% CI 0.03 to 0.27; 3 studies, 90 infants).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence to suggest that the administration of spinal in preference to general anaesthesia without pre- or intraoperative sedative administration may reduce the risk of postoperative apnoea by up to 47% in preterm infants undergoing inguinal herniorrhaphy at a postmature age. For every four infants treated with spinal anaesthesia, one infant may be prevented from having an episode of postoperative apnoea (NNTB=4). In those infants without preoperative apnoea, there is low-quality evidence that spinal rather than general anaesthesia may reduce the risk of preoperative apnoea by up to 66%. There was no difference in the effect of spinal compared with general anaesthesia on the overall incidence of postoperative apnoea, bradycardia, oxygen desaturation, need for postoperative analgesics or respiratory support. Limitations on these results included varying use of sedative agents, or different anaesthetic agents, or combinations of these factors, in addition to trial quality aspects such as allocation concealment and inadequate blinding of intervention and outcome assessment. The meta-analyses may have inadequate power to detect a difference between groups for some outcomes, with estimates of effect based on a total population of fewer than 140 infants.The effect of newer, rapidly acting, quickly metabolised general anaesthetic agents on safety with regard to the risk of postoperative apnoea and neurotoxic exposure has not so far been established in randomised trials. There is potential for harm from postoperative apnoea and direct brain toxicity from general anaesthetic agents superimposed upon pre-existing altered brain development in infants born at very to extreme preterm gestation. This highlights the clear need for the examination of neurodevelopmental outcomes in the context of large randomised controlled trials of general, compared with spinal, anaesthesia, in former preterm infants undergoing surgery for inguinal hernia.There is a particular need to examine the impact of the choice of spinal over general anaesthesia on respiratory and neurological outcomes in high-risk infant subgroups with severe respiratory disease and previous brain injury.

Spinal anesthesia in infants and children: A one year prospective audit

Context and Aims:

Spinal anesthesia though gaining popularity in children, the misconceptions regarding its safety and feasibility can be better known with greater use and experience. The objective of this study was to evaluate the success rate, complications and hemodynamic stability related to pediatric spinal anesthesia.

Materials and Methods:

In this 1-year prospective study, 102 pediatric patients aged 6 months to 14 years undergoing infraumbilical and lower extremity surgery were included. Spinal anesthesia was administered using hyperbaric bupivacaine 0.5% in a dose of 0.5 mg/kg (for child < 5 kg), 0.4 mg/kg (for 5-15 kg), 0.3 mg/kg (for >15 kg) in L4-L5 space under all aseptic precautions after sedation. Demographic data, vital parameters, supplemental sedation, number of attempts for lumbar puncture, sensory-motor block characteristics, and complications were noted.

Results:

Spinal anesthesia was successful in 98 (97.1%) patients. Remaining 4 (3.9%) were failures and were given general anesthesia. Lumbar puncture was successful in first attempt (60 [58.82%]) or 2^nd attempt (42 [41.18%]). There was no significant change in vital parameters. Mean peak sensory level was T 6.35 ± 1.20 (T4-T8). Mean sensory level at the end of surgery was T 8.11 ± 1.42 (T6-T10). Modified Bromage score was 3 in 98 (96.08%) patients. Sensory and motor block recovery was complete in all patients. Mean time to two segment regression was 43.97 ± 10.72 (30-70) min. Mean time to return Bromage score to 0 was 111.95 ± 20.54 (70-160). Mean duration of surgery was 52.5 ± 16.056 (25-95) min. Incidence of complications was minimal with hypotension occurring in 2 (2%) and shivering in 3 (2.9%) patients.

Conclusion:

Pediatric spinal anesthesia is a safe and effective anesthetic technique for lower abdominal and lower limb surgeries of shorter duration (<90 min) with high success rate. Owing to, its early motor recovery, it can be a preferred technique for day case surgeries in the pediatric population.

Spinal anesthesia for inguinal hernia repair in infants: a feasible and safe method even in emergency cases

BACKGROUND

Inguinal hernia repair is the most frequently performed surgical procedure in infants and children. Especially in premature infants, prevalence reaches up to 30% in coincidence with high rates of incarceration during the first year of life. These infants carry an increased risk of complications due to general anesthesia. Thus, spinal anesthesia is a topic of growing interest for this group of patients. We hypothesized that spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants even at high risk and cases of incarceration.

METHODS

Between 2003 and 2013, we operated 100 infants younger than 6 months with inguinal hernia. Clinical data were collected prospectively and retrospectively analyzed. Patients were divided into two groups depending on anesthesia procedure (spinal anesthesia, Group 1 vs. general anesthesia, Group 2).

RESULTS

Spinal anesthesia was performed in 69 infants, and 31 infants were operated in general anesthesia, respectively. In 7 of these 31 infants, general anesthesia was chosen because of lumbar puncture failure. Infants operated in spinal anesthesia were significantly smaller (54 ± 4 vs. 57 ± 4 cm; p = 0.001), had a lower body weight (4,047 ± 1,002 vs. 5,327 ± 1,376 g; p < 0.001) and higher rate of prematurity (26 vs. 4%; p = 0.017) compared to those operated in general anesthesia. No complications related to surgery or to anesthesia were found in both groups. The number of relevant preexisting diseases was higher in Group 1 (11 vs. 3%; p = 0.54). Seven of eight emergent incarcerated hernia repairs were performed in spinal anesthesia (p = 0.429).

CONCLUSIONS

Spinal anesthesia is a feasible and safe option for inguinal hernia repair in infants, especially in high-risk premature infants and in cases of hernia incarceration.

Caudal anesthesia with sedation for inguinal hernia repair in high risk neonates

BACKGROUND/PURPOSE

The use of caudal anesthesia with sedation (CAS) has theoretical benefits over general anesthesia (GA) in high risk neonates undergoing inguinal hernia repair. This benefit has not been established in clinical studies. We compare outcomes of these two approaches at a single institution.

METHODS

A retrospective review was performed of all neonates and preterm infants undergoing inguinal hernia over an 8year period.

RESULTS

Of 71 infants meeting inclusion criteria, 50 underwent repair with caudal block and systemic sedation, and 21 with general anesthesia. Minor incidents of respiratory depression requiring non invasive interventions were common in the first 24h post operatively (24% for CAS, 14% with GA), 4% of patients receiving CAS had a respiratory complication which prolonged their hospital stay beyond 24h post operation. Both required conversion to general anesthesia. Statistically significant differences between the two groups were lacking in terms of preoperative risk and post operative outcome.

CONCLUSIONS

CAS is a safe, effective anesthetic option for high risk neonates undergoing inguinal hernia repair. Patients requiring conversion to GA from CAS may be at increased risk for complications. Large, randomized trials are needed to determine any benefit over GA.

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

BACKGROUND

Various beneficial effects derived from neuraxial blocks have been reported. However, it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications.

OBJECTIVES

Our primary objective was to summarize Cochrane systematic reviews that assess the effects of neuraxial blockade on perioperative rates of death, chest infection and myocardial infarction by integrating the evidence from all such reviews that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various populations. Our secondary objective was to summarize the evidence on adverse effects (an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility) of neuraxial blockade. Within the reviews, studies were selected using the same criteria.

METHODS

A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have (1) included all Cochrane systematic reviews that examined participants of any age undergoing any type of surgical (open or endoscopic) procedure, (2) compared neuraxial blockade versus general anaesthesia alone for surgical anaesthesia or neuraxial blockade plus general anaesthesia versus general anaesthesia alone for surgical anaesthesia and (3) included death, chest infection, myocardial infarction and/or serious adverse events as outcomes. Neuraxial blockade could consist of epidural, caudal, spinal or combined spinal-epidural techniques administered as a bolus or by continuous infusion. Studies included in these reviews were selected on the basis of the same criteria. Reviews and studies were selected independently by two review authors, who independently performed data extraction when data differed from one of the selected reviews. Data were analysed by using Review Manager Version 5.1 and Comprehensive Meta Analysis Version 2.2.044.

MAIN RESULTS

Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from four to six of a maximal possible score of seven. Compared with general anaesthesia, neuraxial blockade reduced the zero to 30-day mortality (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53 to 0.94; I(2) = 0%) based on 20 studies that included 3006 participants. Neuraxial blockade also decreased the risk of pneumonia (RR 0.45, 95% CI 0.26 to 0.79; I(2) = 0%) based on five studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the two techniques (RR 1.17, 95% CI 0.57 to 2.37; I(2) = 0%) based on six studies with 849 participants. Compared with general anaesthesia alone, the addition of a neuraxial block to general anaesthesia did not affect the zero to 30-day mortality (RR 1.07, 95% CI 0.76 to 1.51; I(2) = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial blockade-general anaesthesia and general anaesthesia alone (RR 0.69, 95% CI 0.44 to 1.09; I(2) = 0%) based on eight studies that included 1580 participants. The addition of a neuraxial block to general anaesthesia reduced the risk of pneumonia (RR 0.69, 95% CI 0.49 to 0.98; I(2) = 9%) after adjustment for publication bias and based on nine studies that included 2433 participants. The quality of the evidence was judged as moderate for all six comparisons.No serious adverse events (seizure or cardiac arrest related to local anaesthetic toxicity, prolonged central or peripheral neurological injury lasting longer than one month or infection secondary to neuraxial blockade) were reported. The quality of the reporting score of complications related to neuraxial blocks was nine (four to 12 (median range)) of a possible maximum score of 14.

AUTHORS' CONCLUSIONS

Compared with general anaesthesia, a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk (level of evidence, moderate). Further research is required.

Spinal anesthesia in children: A review

Even after a vast safety record, the role of spinal anesthesia (SA) as a primary anesthetic technique in children remains contentious and is mainly limited to specialized pediatric centers. It is usually practiced on moribund former preterm infants (<60 weeks post-conception) to reduce the incidence of post-operative apnea when compared to general anesthesia (GA). However, there is ample literature to suggest its safety and efficacy for suitable procedures in older children as well. SA in children has many advantages as in adults with an added advantage of minimal cardio-respiratory disturbance. Recently, several reports from animal studies have raised serious concerns regarding the harmful effects of GA on young developing brain. This may further increase the utility of SA in children as it provides all components of balanced anesthesia technique. Also, SA can be an economical option for countries with finite resources. Limited duration of surgical anesthesia in children is one of the major deterrents for its widespread use in them. To overcome this, several additives like epinephrine, clonidine, fentanyl, morphine, neostigmine etc. have been used and found to be effective even in neonates. But, the developing spinal cord may also be vulnerable to drug-related toxicity, though this has not been systematically evaluated in children. So, adjuvants and drugs with widest therapeutic index should be preferred in children. Despite its widespread use, incidence of side-effects is low and permanent neurological sequalae have not been reported with SA. Literature yields encouraging results regarding its safety and efficacy. Technical skills and constant vigilance of experienced anesthesia providers is indispensable to achieve good results with this technique.

Hemodynamic changes during spinal anesthesia in premature infants with congenital heart disease undergoing inguinal hernia correction

INTRODUCTION

There are conflicting reports on the effects of spinal anesthesia (SA) on hemodynamics. Data on the hemodynamic effects of SA in infants with congenital heart disease (CHD) are limited.

METHODS

We reviewed our experience with 44 unsupplemented SA with 1 mg·kg(-1) of either hyperbaric tetracaine or bupivacaine in premature and former premature infants with noncyanotic CHD. Hemodynamics and oxyhemoglobin saturation (SpO(2)) were assessed. Neither preoperative fluid boluses nor atropine was administered to any of the infants.

RESULTS

There was no significant change in systolic, diastolic, or mean blood pressures from pre-SA induction compared with end of surgery. Heart rate showed a small but systematic decline (mean change of 10 beats per minute, P < 0.01) but was within the normative range values for age. There was a small, but clinically insignificant increase in SpO(2) across the time course. Intraoperatively, two infants developed transient apneic spells. No infant developed postoperative apnea, oxygen desaturation, or bradycardia.

CONCLUSIONS

The data suggest that SA with 1 mg·kg(-1) of either hyperbaric tetracaine or bupivacaine can be used safely as the sole anesthetic for inguinal hernia repair in infants with noncyanotic CHD even when fluid restricted and apparently causes minimal respiratory complications in these infants.

Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data

Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.

Delayed onset seizures after inguinal herniotomy in a premature infant: a case report

We report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

[Caudal block and light sevoflurane mask anesthesia in high-risk infants: an audit of 98 cases]

OBJECTIVE

In order to reduce the risk of postoperative apnoea, awake spinal anaesthesia or awake caudal anaesthesia are recommended for hernia surgery in newborn babies and former premature infants aged less than 60 weeks of amenorrhoea. However, additional sedation is sometimes necessary. Our working hypothesis was that a general anaesthesia with a face mask (sevoflurane) with no opiates nor neuromuscular blocking agents, maintaining the infant's spontaneous breathing and combined with a caudal anaesthesia, could provide a safe and effective alternative.

STUDY DESIGN

The epidemiological and technical data about the patient and the anaesthesia, as well as any per- and postoperative complications, were collected prospectively and analysed retrospectively.

PATIENTS AND METHODS

Ninety-eight infants undergoing hernia surgery were included during the period from 2003 to 2008.

RESULTS

Caudal anaesthesia proved successful at first attempt in 69% of the infants (term or premature). Three attempts were needed in 8% of the infants born at term and 2% of the infants born prematurely. One failure was recorded. Seven patients presented one episode of peroperative apnoea; they were easily taken care of by means of brief face mask ventilation. The follow-up of these seven infants did not reveal any reappearance of postoperative apnoea/bradypnoea.

CONCLUSION

The technique proposed is an effective alternative to the awake locoregional anaesthesia techniques: it provides excellent conditions for surgery and presents similar perioperative morbidity and risk of postoperative apnoea.

Retrospective review of ilioinguinal-iliohypogastric nerve block with general anesthesia for herniotomy in ex-premature neonates

OBJECTIVES AND AIMS

We examine the efficacy and complications of general anesthesia with ilioinguinal-iliohypogastric nerve block performed on ex-premature neonates undergoing inguinal herniotomy.

BACKGROUND

  The ex-premature neonate has many co-morbidities and is at risk of postoperative apnea and bradycardia. Anesthesia techniques aimed to provide good surgical conditions include general anesthesia and central neuroaxial techniques. There are still significant complications after these techniques and none is superior.

METHODS/MATERIALS

A retrospective search of our department's computer database was conducted on ex-premature neonates, post-menstrual age of 48 weeks and under, who received general anesthesia and ilioinguinal-iliohypogastric nerve block for bilateral inguinal herniotomy from 1997 to 2009.

RESULTS

Eighty-two neonates were selected. All medical notes were traced and information including the demographics, co-morbidities and perioperative data were obtained. The mean gestational age was 30.3 weeks (sd ± 3.2) and the mean post-conception age was 40.0 weeks (sd ± 3.1). Mean birth weight was 1284 g (sd ± 518) and mean weight at the time of surgery was 2795 g (sd ± 958). Thirty-two (39.0%) neonates had apnea of prematurity, which required caffeine treatment. Thirty-five (42.7%) neonates required intubation for ventilatory support preoperatively. There was a good success rate of the ilioinguinal-iliohypogastric nerve block in 73 (89.0%) patients. They were deemed successful clinically by the attending anesthesiologist. No perioperative rescue opioid was required. Four neonates had postoperative apnea requiring intervention.

CONCLUSION

Ilioinguinal-iliohypogastric nerve block has a success rate similar to other techniques and when combined with general anesthesia, provides a viable alternative technique of anesthesia in these high-risk patients.

Comparison of awake spinal with awake caudal anesthesia in preterm and ex-preterm infants for herniotomy

BACKGROUND

Spinal anesthesia (SA) is widely used for awake regional anesthesia in ex-preterm infants scheduled for herniotomy. Awake caudal anesthesia (CA) is suggested as an alternative approach for these patients and type of surgery. The aim of this study was to compare efficacy and complications of the two different techniques.

METHODS

Two historical populations of 575 ex-preterm infants undergoing herniotomy under awake SA (n = 339; 1998-2001) and under awake CA (n = 236; 2001-2009) were investigated. Data are compared using t-test and chi-square tests (P < 0.05).

RESULTS

The SA group consisted of 339 patients, they were born after 32.0 (3.3) weeks of gestation on average with a mean birth weight of 1691 g (725). The CA group consisted of 236 patients born after 32.1 weeks (3.7) with a mean birth weight of 1617 g (726). At the time of operation, the total age was 41.37 (3.6) and 41.28 (4.0), respectively, for SA and CA patients, and the corresponding weights were 3326 (1083) g and 3267 (931) g for SA and CA patients, respectively. For SA, significantly more puncture attempts were needed (1.83 vs 1.44, P < 0.001). Surgery was performed under pure regional anesthesia in 85% (SA) and 90.1% (CA) (ns). A change to general anesthesia was necessary in 7.7% (SA) and 3.9% (CA) (ns). Overall, intra- and postoperative complications were not statistically different.

CONCLUSIONS

Caudal anesthesia was shown to be technically less difficult than SA and to have a higher success rate. Its application as awake regional anesthesia technique in these patients seems more appropriate than SA.

Optimal timing for repair of an inguinal hernia in premature infants

PURPOSE

The aim of this study was to determine the optimal timing for inguinal herniotomy in premature infants treated in the neonatal intensive care unit.

METHODS

A two-institutional-center retrospective study was performed including 41 prematures at gestational age 28-35 weeks who underwent herniotomy within 1 week of diagnosis [short-waiting group (SWG), median 5 days, n = 25] or more than 1 week after diagnosis [long-waiting group (LWG), median 30.55 days, n = 16]. Gestational age, birthweight, post-conceptional age at diagnosis, age at diagnosis, post-conceptional age at surgery, age at surgery, weight at surgery, timing of surgery, operative time, and occurrence of incarceration, postoperative apnea, hernia recurrence, testicular atrophy, and hospital stay were compared between the two groups. Statistical analysis was performed using one-way ANOVA.

RESULTS

Twelve preoperative episodes of incarceration occurred: three in the SWG and nine in the LWG (P < 0.05). Six infants had apnea postoperatively: four in the SWG and two in the LWG (P > 0.05). Follow-up revealed five hernia recurrences, one in the SWG and four in the LWG (P < 0.05); four testicular atrophies were found, one in the SWG and three in the LWG (P > 0.05).

CONCLUSION

Early elective herniotomy should be considered in prematures in order to avoid perioperative morbidity and to reduce the risk of incarceration and subsequent testicular ischemia, and hernia recurrence.

Impact of spinal anesthesia for open pyloromyotomy on operating room time

PURPOSE

When pyloromyotomy for hypertrophic pyloric stenosis (HPS) is performed under general anesthesia, metabolic abnormalities and fluid deficits coupled with residual anesthetics may increase the risk of postoperative apnea, thereby, prolonging operating room time and delaying extubation. Spinal anesthesia has been found to reduce the rate of postoperative apnea in high-risk infants. The aim of the study was to evaluate the effect of spinal vs general anesthesia on operating room time in infants undergoing open pyloromyotomy.

METHODS

Data for 60 infants who underwent pyloromyotomy under spinal (n = 24) or general (n = 36) anesthesia at a tertiary pediatric medical center were derived from the computerized database. Primary outcome measures were total operating room time, procedure duration, anesthesia release time, wake-up time, and anesthesia control time (anesthesia release plus wake-up). Nonparametric Mann-Whitney test was used for statistical analysis, and Levene's test was used to assess the equality of variances in samples; P <or= .05 was considered significant.

RESULTS

Mean total operating room time was 50.9 (12.1) minutes in the spinal anesthesia group and 69.5 (26.8) minutes in the general anesthesia group (P = .001). Corresponding values for mean wake-up time were 3.6 (2.9) and 17.2 (25.3) minutes (P < .001), and for mean anesthesia control time, 13.2 (6.7) and 28.5 (24.6) minutes (P < .001). There were no between-group differences in procedure duration or anesthesia release time. On Levene's test, between-group differences were significant for total operating time and wake-up time (P = .01 for both).

CONCLUSIONS

The use of spinal anesthesia for open pyloromyotomy in infants with HPS shortens the operating room time by reducing the wake-up time.

The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit?

BACKGROUND

Postoperative apneas are reported in up to 49% of premature infants undergoing anesthesia for inguinal hernia repair. Our current practice is to monitor all of these babies in the intensive care unit (ICU) overnight after surgery. In addition to the considerable expense to the health care system, these cases are cancelled if no ICU bed is available.

METHODS

A retrospective chart review of all premature infants undergoing inguinal hernia repairs over the past 5 years was undertaken. All postoperative apneas were identified. Potential risk factors were evaluated.

RESULTS

Five (4.7%) of 126 premature infants had apneas after inguinal hernia repair. All of these babies had a previous history of apneas. They also had lower weights both at birth (1.08 vs 1.73 kg) and at the time of surgery (3.37 vs 4.4 kg) as well as lower gestational ages (29 vs 32.3 weeks). They were much more likely to have a complicated past medical history. Markers for this included intraventricular hemorrhage, patent ductus arteriosus, bronchopulmonary dysplasia, and requirement for mechanical ventilation and supplemental oxygen after birth. The use of sevoflurane was the only anesthetic factor which had significance.

CONCLUSION

Postoperative apnea in premature infants after inguinal hernia repair using current anesthetic techniques is much less common than previously reported. Infants with prior history of apneas are at highest risk. Other risk factors appear to include gestational age, birth weight, weight at time of surgery, and a complicated neonatal course. Selective use of postoperative ICU monitoring for high-risk patients could result in significant resource and cost savings to the health care system.

Spinal anesthesia in neonates and infants - a single-center experience of 505 cases

BACKGROUND

Our aim was to assess the safety and efficacy of spinal anesthesia (SA) in newborns and infants undergoing surgery appropriate for this technique.

METHODS

The files of 505 patients who underwent surgery under spinal anesthesia since 1998 at a major tertiary hospital in Israel were analyzed retrospectively. SA was performed with bupivacaine 5 mgxml(-1) by attending pediatric anesthesiologists or an anesthesia resident. Demographic data, prematurity history, comorbidities, technical data, cardiovascular stability, complications and supplementary drugs were documented. The surgeon assessed the quality of anesthesia at the end of surgery.

RESULTS

Appropriate SA was achieved in 95.3% of cases; in 69.9% at the first attempt. The mean number of attempts per patient was 1.41 and mean dose of bupivacaine was 0.66 +/- 0.16 mgxkg(-1). Intravenous sedation, usually with midazolam (dose 0.1-0.2 mgxkg(-1)) was required in 28.1% of children because of crying/restlessness. Intraoperative conversion to general anesthesia was necessary in five patients (1.04%). The main side effect was bradycardia (<100 bxmin(-1)) without desaturation which occurred in nine patients (1.8%). In three patients (0.62%), high spinal block occurred without bradycardia and hypotension. None of the patients had postoperative meningitis.

CONCLUSIONS

SA is safe and effective in newborns and infants undergoing low abdominal, perineal and orthopedic surgery. In order to save time, our advice is to attempt SA after the surgeon is scrubbed, and minimize surgical teaching activity. The need to deal with a small and sometimes sick patient independent of the type of anesthesia requires the presence of an experienced pediatric anesthesiologist.

Anästhesiologische Aspekte in der Neu- und Frühgeborenenchirurgie

The physiology of the preterm and term neonate is characterized by a high metabolic rate, limited pulmonary, cardiac and thermoregulatory reserve and decreased renal function. Multisystem immaturity creates important developmental differences in drug administration and response when compared to older children. Specific monitoring techniques are required because the neonate is not physically accessible to the anesthetist during the operation. This contribution reviews the specific pathophysiological characteristics of the newborn with relevance to anesthesia and also provides robust guidelines for the anesthetic management of the most frequent non-cardiac procedures which need surgery during the neonatal period. Consideration will also be given to the anesthetic management of very low birth-weight infants with anesthetic key issues such as avoiding hyperoxia, keeping hemodynamic parameters as stable as possible and preventing hypothermia.

The former preterm infant and risk of post-operative apnoea: recommendations for management

The preterm infant presenting for anaesthesia during the first 6 months of life is a major anaesthetic challenge. One of the most serious post-operative complications is apnoea with or without bradycardia. For this review, we conducted a search of the current literature in order to formulate a set of evidence-based clinical guidelines to help clinicians in the management of the former preterm infant to avoid post-operative apnoea. Only a small number of patients have been enrolled into prospective, randomized, controlled studies. Based on the current literature, regional anaesthesia is strongly recommended, preferably neuraxial block, but general anaesthesia is also used and in this setting, opioids and muscle relaxants should be avoided. Infants with a post-conceptual age of less than 46 weeks should be admitted for continuous monitoring for at least 12 h post-operatively. In infants with a post-conceptual age (PCA) between 46 and 60 weeks, a careful assessment of the child is mandatory and 12 h of respiratory monitoring is recommended if the patient's history reveals episodes of apnoea at home, chronic lung disease (CLD), neurological disease or anaemia. The otherwise healthy infant could be scheduled for theatre as the first patient on the list and subsequently monitored in the post-anaesthetic care unit for 6 h. The risk of apnoea in former preterm infants can be further reduced by the administration of intravenous caffeine (10 mg/kg). All of these patients should be referred to a tertiary centre for anaesthesia and surgery.

Prospective comparison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy

BACKGROUND

Formerly premature infants having inguinal herniotomy have been at a high risk of postoperative apnoea, newer less soluble anaesthetic agents may reduce this risk.

METHODS

Thirty infants, under 37 weeks gestation and under 47 weeks post-conceptional age, undergoing inguinal herniotomy had an inhalational induction with sevoflurane and were randomly allocated to sevoflurane (group S) or desflurane (group D) for maintenance. All infants received i.v. atracurium 0.5 mg kg(-1), rectal acetaminophen 20 mg kg(-1) and caudal bupivacaine 0.25% 1 ml kg(-1). Infants were monitored for apnoeas (using nasal thermistry and impedance), haemoglobin oxygen desaturations and bradycardias for 12 h before and after operation with an Alice 4 polysomnograph. Emergence timings were recorded.

RESULTS

There was no difference between pre- and postoperative incidence of apnoeas in either group, and no group difference between desflurane and sevoflurane in terms of pre- and postoperative ventilatory events or in the number of apnoeas in the postoperative period (nine patients in group D and five patients in group S had apnoeas). Median times to first movement, tracheal extubation, eye opening and first cry were all faster with group D (group D: 3.0, 10.0, 9.0 and 11.0 min and group S: 7.0, 15.1, 13.5 and 16.1 min, respectively). No infant had problems with airway irritation on emergence and no infant required airway intervention for apnoea.

CONCLUSIONS

Infants wake faster from general anaesthesia when maintained with desflurane as compared with sevoflurane, but no difference in postoperative respiratory events was demonstrated between the groups.

Patient selection in ambulatory surgery

PURPOSE OF REVIEW

To evaluate the evidence regarding decisions made in the perioperative management of patients undergoing ambulatory surgery for the following: the elderly, hyper-reactive airways disease, coronary artery disease, diabetes, obesity, obstructive sleep apnea, the ex-premature infant and the child with an upper respiratory infection.

RECENT FINDINGS

Major morbidity and mortality following ambulatory surgery is exceedingly low. Minor adverse cardiac events during the intraoperative period are associated with hypertension and the elderly. Minor adverse respiratory events during the intraoperative period are associated with obesity. Respiratory events during the postoperative period are associated with obesity, smoking and asthma. Prolonged stays following ambulatory surgery are predominantly caused by surgical factors or minor symptoms such as pain or nausea. Surgical factors are also the main causes of unplanned admissions. Age greater than 85, significant co-morbidity and multiple admissions to hospital in the 6 months preceding ambulatory surgery, however, are associated with higher readmission rates.

SUMMARY

Evidence indicates that ambulatory anesthesia is currently very safe. Ambulatory surgery, however, is being offered to a population with increasing co-morbidity. As the population undergoing ambulatory surgery changes over time, the evidence regarding patient outcomes will need re-examination.

Spinal anesthesia in infants with ventriculoperitoneal shunt: report of five cases and review of literature

We describe five cases of children with ventriculoperitoneal shunt who underwent abdominal and perineal procedures under spinal anesthesia. Four of them had been born prematurely, and all had suffered from severe neonatal complications. All of our patients suffered from severe respiratory impairment, that had required mechanical ventilation, and three of them suffered additionally from apnea of prematurity. Four patients had ventriculoperitoneal shunt inserted because of obstructive hydrocephalus and one because of congenital central nervous system anomalies. Two underwent subsequently shunt revision. The benefits of spinal anesthesia in this high-risk population are described. The risks of spinal anesthesia in the presence of a ventricular shunt device, especially infection and dural leakage, are discussed, and the literature about this topic briefly reviewed.

The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry

Studies with modest numbers of patients have suggested that spinal anesthesia in infants is associated with a very infrequent incidence of complications, such as hypoxemia, bradycardia, and postoperative apnea. Although spinal anesthesia would seem to be a logical alternative to general anesthesia for many surgical procedures, it remains an underutilized technique. Since 1978, clinical data concerning all infants undergoing spinal anesthesia at the University of Vermont have been prospectively recorded. In all, 1554 patients have been studied. Anesthesia was performed by anesthesia trainees and attending anesthesiologists. The success rate for LP was 97.4%. An adequate level of spinal anesthesia was achieved in 95.4% of cases. The average time required to induce spinal anesthesia was 10 min. Oxygen hemoglobin desaturation to <90% was observed in 10 patients. Bradycardia (heart rate <100 bpm) occurred in 24 patients (1.6%). This study confirms the infrequent incidence of complications associated with spinal anesthesia in infants. Spinal anesthesia can be performed safely, efficiently, and with the expectation of a high degree of success. Spinal anesthesia should be strongly considered as an alternative to general anesthesia for lower abdominal and lower extremity surgery in infants.

Clonidine added to bupivacaine in neonatal spinal anesthesia: a prospective comparison in 124 preterm and term infants

BACKGROUND

Spinal anesthesia (SA) remains the 'gold standard' in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects.

METHODS

We conducted a prospective observational study of 124 infants undergoing herniorrhaphy under SA with bupivacaine and clonidine. Two cohorts, term (n = 57) and former preterm (n = 67) infants, were evaluated and compared with regard to episodes of apnea, desaturation, and bradycardia within 24 h of SA.

RESULTS

In both groups, postoperative desaturation episodes were unchanged after SA, compared with the 12 preoperative hours, despite significantly increased apnea (P < 0.003 and <0.011 respectively). Transient bradycardias occurred in former preterm infants (P < 0.014): they spontaneously resolved in all cases. Mean arterial pressure did not vary during the study. Upper sensory level of SA, sedation on entering the postanesthesia care unit (PACU) and duration of stay in the PACU were similar in both groups.

CONCLUSIONS

The clinical significance of short apneas, recovering spontaneously without desaturation, remains debatable. It is concluded that addition of clonidine to neonatal SA results in acceptable side effects. Side effects must be compared with the potential advantages before future recommendations.

Caudal anesthesia for vascular access procedures in two extremely small premature neonates

With advances in neonatology, there is an increasing need for central vascular access in extremely small (<1,000 g) premature infants. Although the use of peripherally inserted central venous lines have become common practice, surgeons still frequently perform central venous line placements via cut-down in difficult access patients. The advantages of general anesthesia for vascular access procedures are obvious for optimal pain control and ideal operative exposure; however, extremely premature infants are at significant risk for prolonged endotracheal intubation with postoperative apneas. We report two cases where regional caudal anesthesia with bupivacaine and clonidine without intubation was successfully utilized at bedside during central venous line placements in premature infants weighing <600 g. The operative field was ideal with adequate motor and sensory block with caudal anesthesia and both infants received only oxygen by nasal cannula.

Effect of different anesthesia techniques on red blood cell endogenous recovery in hip arthroplasty

STUDY OBJECTIVE

To compare the magnitude of postoperative red blood cell (RBC) recovery with 3 different anesthetic techniques, general anesthesia (GA), epidural anesthesia (EA) alone, and the combination of these 2 techniques (CA), in patients undergoing total hip arthroplasty.

DESIGN

Randomized, controlled study.

SETTING

Seven university or hospital departments of anesthesia.

PATIENTS

Two hundred ten patients with American Society of Anesthesiologists physical status I to III were randomly selected to receive EA, GA, or CA.

INTERVENTION

Patients undergoing total hip replacement were randomly assigned to 3 statistically comparable groups based on the type of anesthesia received: GA, EA, and CA groups.

MEASUREMENTS AND MAIN RESULTS

Intra- and postoperative blood loss was evaluated as either compensated or noncompensated blood loss by using Nadler's formula. The intra- and postoperative bleeding, referred to as compensated blood loss, was similar among groups. The circulating RBC mass, noncompensated blood loss, dropped on the first postoperative day to a similar extent among the groups. The endogenous recovery of the RBC is carried out on the fifth day after surgery in patients who underwent EA, whereas no RBC recovery was observed in those who had received GA alone or GA combined with EA.

CONCLUSIONS

Patients who had received EA had a faster recovery of the circulating erythrocyte mass than those who had had GA or CA. The presence of nitrous oxide in the anesthetic gas mixture might inhibit erythropoiesis by altering vitamin B(12) functions.