The hemodynamic effects of newborn caudal anesthesia assessed by transthoracic echocardiography: a randomized, double-blind, controlled study

Cardiovascular Effects of Adding Epinephrine to Bupivacaine in Children Undergoing Caudal Block: A Double-blind Randomized Clinical Trial

Background: Caudal block is a common, safe, and effective anesthetic technique for lower abdominal, urological, and lower extremity surgeries in pediatrics. Objectives: This study aimed to evaluate the cardiovascular effects of adjuvant epinephrine in the caudal block on heart rate and blood pressure changes in children. Methods: This double-blind, randomized clinical trial was performed on 60 children who underwent elective infra-umbilical surgeries. They were under general anesthesia with midazolam, fentanyl, lidocaine, and propofol. The patients were ventilated through laryngeal mask airway (LMA), and anesthesia was maintained with sevoflurane in O2 and N2O mixture. The intervention group received a caudal block with 0.2% bupivacaine and 1/200000 epinephrine (1 mL/kg), while the control group received a caudal block without epinephrine. Heart rate, blood pressure, and ECG were monitored before the block and in the first, fifth, and 20th minutes after surgery. Results: The two groups showed no statistically significant differences in demographics and systolic and diastolic blood pressures. However, sinus arrhythmia was more prevalent in the study group in the first minute after the block (P < 0.001). No differences were observed in the incidence of arrhythmia in the fifth and 20th minutes after the block. Conclusions: It appears that epinephrine as an adjuvant to the caudal block does not have long-lasting effects after the block, except sinus tachycardia in the first minute. Considering that no changes in blood pressure and other hemodynamic parameters were observed, it seems that epinephrine can be used safely in the caudal block in pediatric patients.

The association between caudal block and urethroplasty complications of distal tubularized incised plate repair: experience from a South China National Children's Medical Center

Background

The effect of caudal block (CB) on the incidence of urethroplasty complications in hypospadias repair remains controversial. The evidence is conflicting, and some confounding bias issues need to be addressed. We sought to study a more homogenous group of distal hypospadias patients undergoing primary tubularized incised plate (TIP) repair by a senior pediatric urology surgeon in the past 2 years to examine the relationship between urethroplasty complications and the use of CB.

Methods

We reviewed our database to identify consecutive patients who had undergone hypospadias repairs by a senior director surgeon at our Center between January 2018 and November 2020. To be eligible to participate in the study, patients had to meet the following inclusion criteria: (I) have distal hypospadias; (II) have undergone a primary TIP repair; and (III) have attended follow-up appointments for a minimum period of 6 months. The primary outcome was the development of urethroplasty complications during the follow-up period. The principal variable of interest was whether or not CB was used perioperatively. The patients were categorized into a CB group (general anesthesia combined with CB) or a control group (general anesthesia only). Other potential risk factors were analyzed, including patient age at operation, patient weight, glans width, and the length of the urethral plate defect.

Results

Thirty (12.2%) of the distal patients developed postoperative surgical complications. The postoperative surgical complication rates were similar between the different anesthesia groups. Weight, the length of the urethral plate length, and glans width did not contribute to the risk. Age was the only independent risk factor for postoperative surgical complications, and the complication rates increased in older patients.

Conclusions

Our data from consecutive TIP repairs in distal hypospadias patients indicated no association between the use of CB anesthesia and the postoperative urethroplasty complication rate. Patients who were older in age when they underwent surgery had a higher risk of complications.

Regional anesthesia in neonates and infants outside the immediate perioperative period: A systematic review of studies with efficacy and safety considerations

This review examines the quality and quantity of literature regarding methods that measure efficacy in the context of reported safety of regional anesthesia techniques in preterm and term infants <1 year of age. Because the role of anesthesiologists continues to expand outside the operating room, we focused on all relevant settings with assessments that extend beyond 24 hours from the intraoperative period. All study designs were included from a search of MEDLINE, EMBASE, CINAHL, Scopus, and Cochrane databases from 1946 to the end of 2019. A total of 31 studies were included (n = 1038 participants), consisting of five randomized controlled trials and 26 observational studies. Twenty-three studies examined neuraxial procedures, seven studies examined peripheral procedures, and one study examined both. Efficacy measures included pain assessment tools, analgesic use, and factors pertaining to the recovery of patients. Safety was assessed in multiple systems (neurological, cardiovascular, respiratory, pathological) and with vital signs and/or measures of systemic toxicity. Evidence in this review establishes that neuraxial and peripheral anesthesia treatments may be applied to neonates and infants with a high degree of safety. However, large gaps in the consistency of methods used to assess pain in these studies underline the need for rigorous prospective efficacy studies of these techniques in this population. This systematic review was registered on PROSPERO (CRD42018114466).

Effects of awake caudal anesthesia on mean arterial blood pressure in very low birthweight infants

Background

Intraoperative blood pressure is a relevant variable for postoperative outcome in infants undergoing surgical procedures. It is therefore important to know whether the type of anesthesia has an impact on intraoperative blood pressure management in very low birth weight infants. Here, we retrospectively analyzed intraoperative blood pressure in very low birthweight infants receiving either awake caudal anesthesia without sedation, or caudal block in combination with general anesthesia, both for open inguinal hernia repair.

Methods

Ethical approval was provided by the University of Tuebingen Ethical Committee on 05/29/2018 with the project number 403/2018BO2. Patient records of infants admitted by the neonatologist (median age at birth 31.1 ± 3.5 weeks, median weight at birth 1240 ± 521 g) which were scheduled for inguinal hernia repair were retrospectively evaluated for the course of mean arterial blood pressure and perioperative interventions to stabilize blood pressure. A total of 42 patients were included, 16 patients (11 boys, 5 girls) received awake caudal anesthesia, 26 patients (22 boys, 4 girls) a combination of general anesthesia and caudal block.

Results

Approximately 3% of the measured mean arterial blood pressure values in the caudal anesthesia group were below a critical margin of 35 mmHg, in contrast to 47% in the combined anesthesia group (p < 0.001). Patients in the latter group showed a significantly larger drop of mean arterial blood pressure below 35 mmHg (4.7 ± 2.7 mmHg vs. 1.9 ± 1.6 mmHg; p < 0.005) and a significantly longer time of mean arterial blood pressure below 35 mmHg (25.6 ± 26.0 min vs. 0.9 ± 2.3 min; p < 0.001), although they received more volume and vasopressor boluses for stabilization (27 ± 14.8 ml vs. 10 ± 4.1 ml; p < 0.01 and 0.15 ± 0.06 ml vs. 0 ml of cafedrine/theoadrenaline; p < 0.001).

Conclusions

The study indicates that the use of caudal block as stand alone procedure for inguinal hernia repair in very low birthweight infants might be advantageous in preventing critical blood pressure drops compared to a combination of caudal block with general anesthesia.

The Use of Epinephrine in Caudal Anesthesia Increases Stroke Volume and Cardiac Output in Children

BACKGROUND AND OBJECTIVES

Caudal anesthesia is a common and effective regional anesthesia technique in pediatric patients. The addition of epinephrine to local anesthetics in caudal anesthesia is a frequent practice; however, changes in hemodynamic and cardiac parameters produced by epinephrine in caudal anesthesia are not well studied. Using data collected with the ICON noninvasive cardiac output monitor, we examined the hemodynamic changes associated with the administration of epinephrine containing local anesthetics during caudal anesthesia in children.

METHODS

We performed a retrospective analysis of 40 patients who received caudal anesthesia among 402 patients from whom we prospectively collected continuous noninvasive cardiac output data using the ICON monitor, which estimates cardiac output by measuring changes in thoracic bioimpedance during the cardiac cycle. Twenty-three children received epinephrine with local anesthetic (ELA), and 17 children received only local anesthetic (OLA) in their caudal blocks. We compared heart rate (HR), stroke volume (SV), cardiac output (CO), and cardiac index (CI) changes from baseline before caudal injection to 1-minute intervals over 15 minutes after caudal injection for both ELA and OLA groups (Table, Supplemental Digital Content 1, http://links.lww.com/AAP/A179). We also performed subgroup analysis of the same parameters comparing both ELA and OLA groups in infants younger than 6 months and in children 6 months or older.

RESULTS

Stroke volume, CO, and CI are significantly increased after caudal injection in the ELA group compared with baseline values at caudal injection time. Conversely, there were no statistically significant changes in SV, CO, and CI in the OLA group. There were no significant HR or blood pressure changes observed in either the ELA or OLA group within 15 minutes compared with baseline caudal injection time. In infants younger than 6 months, no significant differences were found in HR, SV, and CI in children in the ELA group compared with the OLA group. In children 6 months or older, SV and CI increased significantly in the ELA group compared with the OLA group.

CONCLUSIONS

Epinephrine added to local anesthetic injected for caudal anesthesia produces significant increases in SV, CO, and CI in children. Stroke volume and CI changes from epinephrine added to local anesthetic for caudal anesthesia seem to take place only in children 6 months or older.

Caudal blocks

Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).

[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.