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

Awake caudal anesthesia in ex-premature infants undergoing lower abdominal surgery: A narrative review

BACKGROUND AND OBJECTIVES

The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic-based techniques in premature and ex-premature infants undergoing lower abdominal surgery.

METHODS

All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, abstracted data, and appraised quality.

RESULTS

Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of "awake" caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation. The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7-18.4), intermediate for awake caudal (6.6%, 5.26-9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48-7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%-24%), intermediate for awake caudal (7.62%, 0%-60%), and lowest for CSEA (5.53%, 0%-14.3%). High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals). Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high-quality randomized controlled trials, and the eight single-center retrospective data reviews lacked sufficient data to perform meta-analysis.

CONCLUSIONS

There is insufficient evidence to validate or refute the benefits of the use of "awake" caudal anesthesia in premature and ex-premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block.

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.

The effect of caudal epidural block on the surgical complications of hypospadias repair in children aged 6 to 35 months: A randomized controlled trial

BACKGROUND

Caudal epidural block (CEB) in hypospadias surgery has the benefit of reducing post-operative pain and possibly intra-operative bleeding. Some studies, however, have suggested that this technique may increase the rate of post-operative complications. Considering the uncertainty about the effect of CEB on surgical complications of hypospadias repair, the current study was performed.

OBJECTIVE

The aim of this randomized clinical trial was to compare the complication rates between patients who receive CEB after hypospadias surgery and those who did not.

STUDY DESIGN

This double-blind randomized controlled trial was conducted on boys aged 6-35 months, who underwent hypospadias repair surgery in a university hospital from March 2018 to March 2019. Sixty patients were randomly divided into two groups (group A: 31 and group B: 29). In group B, CEB was performed, using 0.5 mg/kg of 0.125% bupivacaine (Marcaine). Postoperative complications including fistula, meatal stenosis, dehiscence, and occurrence of bleeding were assessed during six months after surgery.

RESULTS

The patients were assessed for possible complications at 24 h, one week, one, three and six months after surgery. No remarkable differences were observed between the patients in the two groups in terms of the frequency of dehiscence, fistula, and meatal stenosis (P > 0.05). Moreover, the difference in complication rates between the patients with proximal and distal hypospadias did not reach statistical significance (P = 0.549).

DISCUSSION

Assessment of complications showed no significant difference between the two study groups in terms of dehiscence, fistula, and meatal stenosis (Clavien type III). In addition, complication rate was not significantly different according to severity of hypospadias between the two groups. Our study had limitations such as short follow up and small sample size, which resulted in insignificant difference in complication rate between proximal and distal hypospadias. These limitations request large studies with long term follow up.

CONCLUSION

The current study showed that the use of caudal block anesthesia in comparison with general anesthesia did not increase surgical complications, which approved CEB protocol as a safe method in hypospadias repair.

Systemic and regional cerebral perfusion in small infants undergoing minor lower abdominal surgery under awake caudal anaesthesia: An observational study

BACKGROUND

Infants undergoing general anaesthesia have an increased risk of severe respiratory and cardiovascular critical events. Awake caudal anaesthesia is an alternative for small infants undergoing minor lower abdominal surgery. While clinical experience has shown stable intra-operative haemodynamic conditions, there are no studies evaluating systemic and regional cerebral perfusion during such a procedure.

OBJECTIVES

The purpose of this study was to evaluate the effects of awake caudal anaesthesia on systemic and regional cerebral perfusion in small infants.

DESIGN

A prospective observational cohort study.

SETTING

Clinic of Anaesthesiology, University Children's Hospital, between November 2017 and June 2018.

PATIENTS

Twenty small infants (postmenstrual age 36 to 54 weeks, weight 1800 to 5700 g) scheduled for lower abdominal surgery under awake caudal anaesthesia were enrolled in this study.

INTERVENTION

Standard monitoring was expanded to include cardiac index using electrical velocimetry and regional cerebral oxygen saturation using near infrared spectroscopy. The caudal block was performed with 0.3% ropivacaine 1 ml kg Hypotension was defined as mean arterial blood pressure (BP) less than 35 mmHg and regional cerebral desaturation as regional cerebral oxygen saturation less than 80% of baseline.

MAIN OUTCOMES

Mean arterial BP, cardiac index and regional cerebral oxygen saturation parameters under awake caudal anaesthesia.

RESULTS

Mean arterial BP, cardiac index and regional cerebral oxygen saturation remained above the predefined lower limits. No episodes of hypotension or regional cerebral desaturation were observed. Operation time was 35 ± 13 (range 20 to 71) min. The infants were discharged to the neonatal ward after the end of surgery, and milk was fed 22 ± 15 (range 6 to 55) min thereafter. Five preterm infants experienced self-limiting episodes of apnoea intra-operatively.

CONCLUSION

The current study shows that awake caudal anaesthesia does not impair systemic and regional cerebral perfusion in small infants.

TRIAL REGISTRATION

German registry of clinical studies (DRKS-ID: 800015742).

Association of anesthesia type with prolonged postoperative intubation in neonates undergoing inguinal hernia repair

PURPOSE

The purpose of this study is to determine factors associated with prolonged intubation after inguinal herniorrhaphy in neonates.

METHODS

Retrospective, single institution review of neonates undergoing inguinal herniorrhaphy between 2010 and 2018. Variables recorded included demographics, comorbidities, ventilation status at time of hernia repair, and anesthetic technique.

RESULTS

We identified 97 neonates (median corrected gestational age 39.9 weeks, IQR 6.6). The majority (87.6%) received general anesthesia (GA); the remainder received caudal anesthesia (CA). Among the GA subjects, 25.8% remained intubated for at least 6 h after surgery, whereas none of the CA patients required intubation postoperatively (p = 0.03). Two risk factors associated with prolonged postoperative intubation: a history of intubation before surgery (p = 0.04) and a diagnosis of bronchopulmonary dysplasia (p = 0.03).

CONCLUSIONS

Neonates undergoing inguinal herniorrhaphy under GA have a greater rate of prolonged postoperative intubation compared with those undergoing CA. A history of previous intubation and bronchopulmonary dysplasia were significant risk factors for prolonged postoperative intubation.

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.

Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit

Introduction

Caudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia.

Materials and methods

Data of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained.

Results

Data of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001).

Conclusion

Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

Dexmedetomidine sedation combined with caudal anesthesia for lower abdominal and extremity surgery in ex-preterm and full-term infants

BACKGROUND

Awake caudal anesthesia is a potentially attractive option, because the administration of general anesthesia is associated with a high rate of respiratory complications and hemodynamic disturbances and potential neurotoxic effects. To facilitate the caudal puncture and subsequent surgical intervention, additional sedatives are commonly administered.

AIM

We aimed to establish a new, safe, and effective anesthetic procedure for very young children with comorbidities.

METHODS

We retrospectively analyzed 23 children who underwent lower abdominal or lower extremity surgery with dexmedetomidine sedation and caudal anesthesia from January 2015 to August 2015. Dexmedetomidine was initiated with a total bolus infusion of 0.7-1.1 μg·kg^-1 followed by a continuous infusion of 1 μg·kg^-1 ·h^-1 . Bupivacaine (2.5 mg·kg^-1 ) was supplemented with 5-10 μg·kg^-1 epinephrine to strengthen and prolong motor block. According to maturity at birth, two groups were defined: ex-preterm and full-term infants.

RESULTS

There were 12 ex-preterm and 10 full-term infants available for analysis. The median postmenstrual age was 44 (38-52) weeks in ex-preterm and 46.5 (40-72) weeks in full-term infants. Without any additional intervention, surgery was successfully accomplished in 82% of all cases. While respiratory complications were not a problem, hemodynamic disturbances commonly occurred. Maximum decreases in heart rate (HR) of 30% were accompanied by maximum decreases in mean arterial pressure (MAP) of 38%. No infant had a heart rate below 100 bpm. MAP declined in one ex-preterm infant to a minimum value of 32 mmHg.

CONCLUSION

Caudal anesthesia combined with dexmedetomidine sedation is an effective anesthetic technique for lower abdominal and extremity surgery in ex-preterm and full-term infants with severe comorbidities.

Regional anaesthesia in neonates, infants and children: an educational review

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml  kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

Success rates and complications of awake caudal versus spinal block in preterm infants undergoing inguinal hernia repair: A prospective study

BACKGROUND

Inguinal hernia is a common disease in preterm infants necessitating surgical repair. Despite the increased risk of postoperative apnea in preterm infants, the procedure was conventionally performed under general anesthesia. Recently, regional anesthesia approaches, including spinal and caudal blocks have been proposed as safe and efficient alternative anesthesia methods in this group of patients. The current study evaluates awake caudal and spinal blocks in preterm infants undergoing inguinal hernia repair.

MATERIALS AND METHODS

In a randomized clinical trial, 66 neonates and infants (weight <5 kg) undergoing inguinal hernia repair were recruited in Tabriz Teaching Children Hospital during a 12-month period. They were randomly divided into two equal groups; receiving either caudal block by 1 ml/kg of 0.25% bupivacaine plus 20 μg adrenaline (group C) or spinal block by 1 mg/kg of 0.5% bupivacaine plus 20 μg adrenaline (group S). Vital signs and pain scores were documented during operation and thereafter up to 24 h after operation.

RESULTS

Decrease in heart rate and systolic blood pressure was significantly higher in group C throughout the study period (P < 0.05). The mean recovery time was significantly higher in group S (27.3 ± 5.5 min vs. 21.8 ± 9.3 min; P = 0.03). Postoperative need for analgesia was significantly more frequent in group S (75.8% vs. 36.4%; P = 0.001). Failure in anesthesia was significantly higher in group S (24.4% vs. 6.1%; P = 0.04).

CONCLUSION

More appropriate success rate, duration of recovery and postoperative need of analgesics could contribute to caudal block being a superior anesthesia technique compared to spinal anesthesia in awaked preterm infants undergoing inguinal hernia repair.

Regional anesthesia in pediatrics: marching forward

PURPOSE OF REVIEW

This review highlights new data and current trends of well tolerated and effective paediatric regional anesthesia. Historically, the practice of paediatric regional anesthesia was based largely on information from adult studies, but recent literature contains information on paediatric specific risks and benefits of old and new techniques as well as the impact of new ideas and technologies.

RECENT FINDINGS

Excellent pain relief with regional anesthesia is well demonstrated in children. Several databases of paediatric regional anesthesia (over 46,000 regional anesthetics) demonstrate overall safety and lack of major complications. Detailed analysis demonstrates additional safety and decreased failure rates of peripheral compared with neuraxial nerve blocks. Ultrasound technology confers additional safety and efficacy benefits.Increasingly, data support the safety and efficacy of novel peripheral nerve blocks, transversus abdominis plane and ultrasound-guided paravertebral, and the use of perineural catheters for both inpatients and outpatients. Regional anesthesia as a sole agent for surgical anesthesia and the use of regional anesthesia for pain in nonsurgical pain patients remains underutilized.

SUMMARY

Paediatric specific data for regional anesthesia are available to help guide optimal pain management. The paediatric regional anesthesia literature lags behind literature available for adult populations and increased studies are needed for additional information for informed decision-making.

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.

Postoperative pain management in children and infants: an update

Many factors contribute to suboptimal pain management in children. Current evidence suggests that severe pain in children has significant long-lasting effects, even more so than in adults. In particular, recent evidence suggests a lack of optimal postoperative pain management in children, especially following ambulatory surgery. This review provides simple guidelines for the management of postoperative pain in children. It discusses the long-term effects of severe pain and how to evaluate pain in both healthy and neurologically impaired children, including neonates. Currently available treatment options are discussed with reference to the efficacy and side effects of opioid and non-opioid and regional analgesic techniques. The impact of preoperative anxiety on postoperative pain, and the efficacy of some nonpharmacological techniques such as hypnosis or distraction, are also discussed. Finally, basic organizational strategies are described, aiming to promote safer and more efficient postoperative pain management in children.

Where is the apex of the sacral hiatus for caudal epidural block in the pediatric population? A radio-anatomic study

PURPOSE

Caudal epidural block (CEB), administered through the sacral hiatus, is a regional anesthetic technique commonly used in children. To facilitate and optimize pediatric CEB, morphometric data that may be important for the sacral hiatus have been obtained using multidetector computed tomography (MDCT).

METHODS

This study is the first radio-anatomic study designed to address this topic in children. Images of 79 children (39 girls and 40 boys between 1 and 9 years old) were divided into three groups according to age [group I (ages 1-3), group II (ages 4-6), and group III (ages 7-9)] and were retrospectively examined. Data were gathered via 3D volume-rendered images. Measurements included the height and width of the sacral hiatus, S2-S4 (sacral vertebra) distance, the distances between the poles of the unfused spinous process of each sacral vertebra, and the dimensions of an imaginary triangle formed between the right and left posterior superior iliac spines (PSIS) and the apex of the sacral hiatus.

RESULTS

The most frequently fused spinous process was at S2 level. The mean S2-S4 distance was 1.36 cm for group I, 1.78 cm for group II, and 2.17 cm for group III. There was not the imaginary equilateral triangle used in the method of finding the sacral hiatus for CEB, and the apex of this triangle did not occur at the standard level (S4) in most of the children. It was observed that the apex deriving from the most distal fused spinous process was at the level of S2 in one of two children.

CONCLUSION

Dural puncture is inevitable for CEB applied at the S2 level. Consequently, CEB should be applied below this level (range, 1.36-2.17 cm) from the midpoint of the interspinous distance between the PSIS (at the same level with S2) in children aged 1-9 years.

[Pediatric caudal anesthesia : importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. These are discussed in detail in this review. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

[Pediatric caudal anesthesia: importance and aspects of safety concerns]

Caudal block is a safe procedure commonly used for pediatric perioperative analgesia. Complications are extremely rare but nevertheless local and systemic contraindications must be excluded. Optimal safety and quality result when strict attention is paid to technical details. A local anesthetic (LA) containing epinephrine allows early detection of inadvertent intravascular LA administration; therefore an epinephrine/LA mixture is recommended at least for the test dose. In terms of safety the choice of LA itself is probably of secondary importance. Clonidine as an adjuvant has an excellent risk/benefit profile with minimal side effects. Inadvertent systemic LA intoxication is a rare but potentially fatal complication of regional anesthesia and measures for prevention and early detection are essential. Should circulatory arrest occur, immediate resuscitation following standard guidelines is to be initiated including the use of epinephrine as the first line drug. Intravenous administration of lipid solutions may be beneficial as a secondary adjunct to stabilize hemodynamics but is not an alternative to epinephrine.

Spinal blocks

Every anesthetist should have the expertise to perform lumbar puncture that is the prerequisite to induce spinal anesthesia. Spinal anesthesia is easy and effective technique: small amount of local anesthetic injected in the lumbar cerebrospinal fluid provides highly effective anesthesia, analgesia, and sympathetic and motor block in the lower part of the body. The main limitation of spinal anesthesia is a variable and relatively short duration of the block with a single-injection of local anesthetic. With appropriate use of adjuvant or combining spinal anesthesia with epidural anesthesia, the analgesic action can be controlled in case of early recovery of initial block or in patients with prolonged procedures. Contraindications are rare. Bleeding disorders and any major dysfunction in coagulation system are rare in children, but spinal anesthesia should not be used in children with local infection or increased intracranial pressure. Children with spinal anesthesia may develop the same adverse effects as has been reported in adults, but in contrast to adults, cardiovascular deterioration is uncommon in children even with high blocks. Most children having surgery with spinal anesthesia need sedation, and in these cases, close monitoring of sufficient respiratory function and protective airway reflexes is necessary. Postdural puncture headache and transient neurological symptoms have been reported also in pediatric patients, and thus, guardians should be provided instructions for follow-up and contact information if symptoms appear or persist after discharge. Epidural blood patch is effective treatment for prolonged, severe headache, and nonopioid analgesic is often sufficient for transient neurological symptoms.

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.

The caudal space in fetuses: an anatomical study

PURPOSE

The caudal epidural space is a popular site for analgesia in pediatrics. High variation in blind needle placement is common during caudal epidurals, increasing the risk of intravascular and intrathecal spread. Knowledge of safe distances and angles for accessing the caudal epidural space in premature infants can improve the safety of caudal epidural blocks.

METHODS

Thirty-nine fetuses with crown-heel length between 33 and 50 cm, corresponding to gestational age of 7-9 months, were included. The dorsal surface of the sacrum from the fourth lumbar vertebra to the tip of the coccyx was dissected, following which measurements were taken on dorsal surface and midsagittal sections. The angle of depression of the needle was measured using a goniometer following the two-step method of needle insertion.

RESULTS

Right and left sacral cornua were palpable in 23 of 39 fetuses (58.97%). Termination of dural sac was at S2 in most of the fetuses (53.84%), whereas the apex of the sacral hiatus was at S3 in most (58.97%). The distance from the apex of the hiatus to the termination of dura ranged from 3 to 13 mm; the anteroposterior distance of the canal at the apex of the hiatus ranged from 1.72 to 4.38 mm. All sacral parameters correlated with crown-heel length except inter-cornual distance, depth of canal at hiatus, and height of sacral hiatus.

CONCLUSION

Distances and angles for accessing the caudal epidural space in fetuses do not provide all parameters for safe performance of caudal epidural blocks in premature and low birth weight infants because the apex of the sacral hiatus and the termination of the dura show wide variation in location.

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.