Spinal anesthesia for diagnostic cardiac catheterization in high-risk infants

[Anesthetic management of neonates undergoing diagnostic and therapeutic cardiac catheterization: a systematic literature review]

BACKGROUND

Several interventional cardiology procedures are required in neonates with congenital heart disease. Interventional cardiology procedures have a higher risk of cardiac arrest compared to other interventions. At present, there is great heterogeneity in the perioperative management of congenital heart disease neonates undergoing diagnostic cardiac catheterization or therapeutic cardiac catheterization.

STUDY OBJECTIVES

Primary aim: Provide a systematic review of the most effective and/or safe anesthetic and perioperative management in neonates with congenital heart disease who undergo diagnostic cardiac catheterization or therapeutic cardiac catheterization. Secondary aim: Identify the medications, monitoring parameters and airway management used in the same population.

DESIGN

Systematic literature review.

SETTING

Catheterization laboratory.

METHODS

Literature was searched (December 2017) in electronic databases Medline, EMBASE, ScienceDirect, BIREME-Lilacs-Biblioteca Virtual de la Salud, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database.

MAIN RESULTS

From 130 records identified, four studies met inclusion criteria and quality assessment. None of the studies were relevant to the primary objective. Regarding the secondary objectives, one study compared the efficacy and adverse effects of racemic ketamine and its S(+) ketamine enantiomer, one study reported the efficacy of subarachnoid anesthesia for high-risk children undergoing diagnostic cardiac catheterization, one study identified the factors associated to high severity adverse events related to sedation, anesthesia and airway, and one study retrospectively analyzed cardiac catheterization procedures in neonates weighing less than 2.5 kg.

CONCLUSION

There are no evidence-based recommendations available for congenital heart disease neonates undergoing cardiac catheterization. More studies are required to evaluate the ideal anesthetic and perioperative management in this population.

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

BACKGROUND AND OBJECTIVE

Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia.

METHODS

Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages.

RESULTS

The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed.

CONCLUSION

Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

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.

Evidence for the need for anaesthesia in the neonate

Neonates are both capable of experiencing pain and memory formation, albeit implicit memory. During surgical procedures, insufficient ablation of the stress response and possible implicit memory formation of intra-operative events might result in adverse early and long-term outcomes. Neonates deserve the same respect as adult patients. It is thus the responsibility of the anaesthetist to provide sufficient anaesthesia for neonates undergoing surgery. A critical approach in weighing the risks and benefits of exposing a neonate to anaesthesia is prudent, and truly elective surgery should be delayed.