Spinal anesthesia in children: A review

Characterization of infant spinal anesthesia using surface electromyography: An observational study

BACKGROUND

As the risks of general anesthesia in infants become clearer, pediatric anesthesiologists are seeking alternatives. Though infant spinal anesthesia is one such alternative, its use is limited by its perceived short duration. Prior studies investigating infant spinal anesthesia are open to interpretation and may not have accurately characterized block onset or density. Surface electromyography is a passive, noninvasive modality that can measure the effects of neural blockade.

AIMS

To quantitatively describe the onset, density, and duration of infant spinal anesthesia using surface electromyography.

METHODS

In this observational study, 13 infants undergoing lower abdominal surgery received spinal anesthesia (0.5% bupivacaine with clonidine). Surface electromyography collected continuous data at T2, right T8, left T8, and L2. Data were processed in MATLAB. Onset, density, and duration were defined as the mean derivative within the first 30 s after block administration, the maximum difference in signal compared with preblock baseline, and the time elapsed between block administration and the return of a persistent signal to 50% above the maximum difference, respectively.

RESULTS

Mean patient age and weight were 7.5 ± 2.6 months and 8.0 ± 2.2 kg, respectively. All patients were male. There was a statistically significant difference in the average rate of spinal anesthesia onset (mean percent decrease per second [95% confidence interval]) between myotomes (F (3, 35) = 7.42, p < .001): T2 = 15.93 (9.23, 22.62), right T8 = 20.98 (14.52, 27.44), left T8 = 17.92 (11.46, 24.38), L2 = 32.92 (26.46, 39.38). There was a statistically significant difference in mean surface electromyography signal (mean decibels, 95% confidence interval) across both pre- and postspinal anesthesia Timepoints between myotomes (F (3, 36) = 32.63, p < .0001): T2 = 45.05 (38.92, 51.18), Right T8 = 41.26 (35.12, 47.39), Left T8 = 43.07 (36.93, 49.20), L2 = 22.79 (16.65, 28.92). Within each myotome, there was statistically significant, near complete attenuation of sEMG signal due to spinal anesthesia: T2 mean (pre-post) difference: mean decibels (95% confidence interval) = 39.53 (28.87, 50.20), p < .0001, right T8 = 51.97 (41.30, 62.64), p < .0001, left T8 = 46.09 (35.42, 56.76), p < .0001, L2 = 44.75 (34.08, 55.42), p < .0001. There was no statistically significant difference in mean (pre-post) differences between myotomes. The mean duration of spinal anesthesia lasted greater than 90 min and there was no statistical difference between myotomes. There were also no statistically significant associations between age and weight and onset or duration.

CONCLUSIONS

Surface electromyography can be used to characterize neural blockade in children. Importantly, these results suggest that awake infant spinal anesthesia motor block lasts, conservatively, 90 min. This exploratory study has highlighted the potential for expanding awake infant spinal anesthesia to a broader range of procedures and the utility of surface electromyography in studying regional anesthesia techniques.

Regional Anesthesia for Neonates

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

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Current indications for spinal anesthesia-a narrative review

Spinal anesthesia is a commonly performed regional anesthesia technique by most anesthesiologists worldwide. This technique is learned early during training and is relatively easy to master. Despite being an old technique, spinal anesthesia has evolved and developed in various aspects. This review attempts to highlight the current indications of this technique. Understanding the finer aspects and knowledge gaps will help postgraduates and practicing anesthesiologists in designing patient-specific techniques and interventions.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Neuraxial block anesthetic technique in a patient with SCN8A encephalopathy: case report

Mutations in SCN8A gene lead to changes in sodium channels in the brain, which are correlated with severe epileptic syndrome. Due to the rarity, there are few studies that support anesthesia in that population. The present study aims to report alternatives to inhalation anesthesia at epileptic encephalopathy. CASE REPORT: Male, 4 years old, with SCN8A encephalopathy with surgical indication of orchidopexy. Neuroaxis block was performed and dexmedetomidine was used as a pre-anesthetic and sedation. The anestheticsurgical act was uneventful. CONCLUSION: The association of neuraxial block and dexmedetomidine proved to be a viable alternative for surgery in patients with SCN8A encephalopathy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Regional anesthesia for ambulatory pediatric penoscrotal procedures

BACKGROUND/PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-Shot Spinal Anesthesia in an Infant Requiring Magnetic Resonance Imaging and Open Lower-Extremity Surgery: A Case Report

Spinal anesthesia (SA) is a safe and effective anesthetic technique for lower abdominal and lower extremity surgery in neonates and infants and is associated with an apparent state of sedation. We report the use of single-shot SA in a 6-week-old infant for a combined magnetic resonance imaging and open surgical biopsy of a deep soft tissue lower extremity mass. By leveraging the unique qualities of SA (sedation and surgical blockade), we avoided the need for general anesthesia. To our knowledge, this is the first reported use of single-shot SA for an infant undergoing two procedures in the same day.

Urgent surgery for COVID-19-positive pediatric patient

Background

We present a case of COVID-19–positive pediatric patient for urgent urological surgery by spinal anesthesia to avoid aerosolizing procedure.

Case presentation

A 12-year-old, COVID-19–positive boy presented for urgent wound incision and drainage at the circumcision site. Our anesthetic plan consisted of spinal anesthesia with sedation. He was transported from the COVID-19 isolation floor to the negative pressure operating room. He was placed in lateral decubitus position and oxygen was delivered through facemask. Under sedation, spinal anesthesia was achieved at first attempt. The patient maintained spontaneous ventilation without airway intervention. Patient was recovered in the operation room then transported back to the floor.

Conclusion

Spinal anesthesia is a safe alternative to general endotracheal anesthesia for many pediatric urology procedures. Effective team communication and preparation are keys when caring COVID-19–positive patient in perioperative setting to avoid minimize the risk to healthcare providers.

Spinal Anesthesia is Superior to General Anesthesia for Percutaneous Achilles Tenotomy in Infants

BACKGROUND

Concern about the effects of inhaled, halogenated anesthetics on neurodevelopment of infants has renewed interest in regional anesthesia as an alternative to general anesthesia (GA). Infants undergoing percutaneous Achilles tenotomy (PAT) are well suited for spinal anesthesia (SP).

METHODS

Thirty infants (mean age: 2.3 mo) undergoing PAT with SP were compared with 15 infants (mean age: 2.0 mo) undergoing PAT with GA. Data collected included perioperative times, heart rate and blood pressure, and the administration of opioids.

RESULTS

Ten of 15 GA (67%) patients received perioperative opioids as opposed to 1 of 30 SP patients (3.3%) (P<0.0001). The time from the start of anesthesia to the start of surgery was shorter in the SP group (8.5 vs. 14 min, P<0.0009). The time from the start of anesthesia to first oral intake was shorter in the SP group (12 vs. 31 min, P<0.0033). The time of first phase recovery (phase 1 post anesthesia care unit) was shorter in the SP group (15.5 vs. 34 min, P<0.0026). Surgery time was not significantly different between the groups (SP: 15.5 min, GA: 15 min, P=0.81).

CONCLUSION

Infants undergoing PAT with SP received less opioid, did not require an airway device, did not receive potent inhaled, halogenated hydrocarbon anesthetics, and exhibited faster and qualitatively better postoperative recovery.

LEVEL OF EVIDENCE

Level III-case control study.

Prediction of levobupivacaine concentrations in neonates and infants following neuraxial rescue blocks

AIM

Pharmacokinetic simulation was used to characterize levobupivacaine disposition after regional anesthetic rescue for failed spinal anesthesia in neonates and infants.

METHODS

Population pharmacokinetics of levobupivacaine were estimated after spinal blockade in a cohort of neonates and infants (n = 25, postnatal age 5-18 weeks, gestation 21-41 weeks, weight 2.4-6 kg). Total levobupivacaine concentrations were assayed 3-4 times in the first hour after spinal levobupivacaine 1 mg kg^-1 administration. Parameters were estimated using nonlinear mixed-effects models and supported by priors. Covariates included postnatal age and total body weight. Parameter estimates were used to simulate total levobupivacaine concentrations after a primary spinal levobupivacaine 1 mg kg^-1 with rescue caudal levobupivacaine 1.5-2.5 mg kg^-1 .

RESULTS

A one-compartment model with a mature clearance 21.5 L h^-1  70 kg^-1 (CV 47.3%) and central volume 189 L 70 kg^-1 (CV 37%) adequately described time-concentration profiles. Clearance maturation was described using a maturation half-time of 11.5 weeks postnatal age. The absorption half-time for spinal levobupivacaine was 2.6 min (CV 56.8%). The upper (97.5% prediction) for peak concentrations after rescue caudal levobupivacaine were 1.5 mg kg^-1 , 2 mg kg^-1 , and 2.5 mg kg^-1 was 2.05 mg L^-1 , 2.5 mg L^-1 , and 2.9 mg L^-1 respectively.

CONCLUSION

Total bupivacaine concentrations greater than 2.5 mg L^-1 are associated with neurotoxicity in adults. Predicted concentrations after either a repeat spinal or a caudal rescue dose of levobupivacaine 1.5 mg kg^-1 1 h after spinal levobupivacaine administration are below the neurotoxic concentration threshold.

Use of spinal anaesthesia in neonates and infants in Antananarivo, Madagascar: a retrospective descriptive study

Objective

The aim of this study was to present the first cases of spinal anesthesia, in newborns and infants, preterm/ex-prematures, in order to determine its feasibility and its potential harmlessness, in Antananarivo—Madagascar. Indeed, spinal anesthesia is a low cost technique and can limit respiratory complications, postoperative apnea a contrario with pediatric general anesthesia which can lead to perioperative risks.

Results

In a retrospective, descriptive, 7-year (2013 to 2019) period study, conducted in the University Hospital Joseph Ravoahangy Andrianavalona, 69 patients’ data files planned to have spinal anesthesia were recorded. These pediatric patients were predominantly male (sex ratio = 2.8) and 37 [28–52] days old. The smallest anesthetized child weighed 880 g; the youngest was 4 days old. Twenty-seven (27) of them were premature and 20.3% presented respiratory diseases. They were mostly scheduled for hernia repair (90%). Spinal anesthesia was performed, with a Gauge 25 Quincke spinal needle, after 2 [1–2] attempts with hyperbaric bupivacaine of 4 [3.5–4] mg. Failure rate was 5.8%. The heart rate was stable throughout perioperative period and no complications were observed.

Emergency Surgery in a Child with Cretinism with Anticipated Difficult Airway Under Low-Dose Subarachnoid Block

A child with cretinism poses multiple anaesthetic challenges due to the associated mental and physical disability, deranged metabolic and physiologic functions, difficult airway and propensity to perioperative cardiorespiratory complications. Spinal anaesthesia in children is associated with remarkable cardiorespiratory stability and provides complete surgical anaesthesia. Here, we report a case that describes the first successful anaesthetic management of a child who was an unevaluated case of cretinism under subarachnoid block.

A cadaveric study of the erector spinae plane block in a neonatal sample

Background

The aim of this article was to provide a detailed description of the neonatal anatomy related to the erector spinae plane block and to report the spread of the dye within the fascial planes and potential dermatomal coverage.

Methods

Using ultrasound guidance, the bony landmarks and anatomy of the erector spinae fascial plane space were identified. The erector spinae plane block was then replicated unilaterally in two fresh unembalmed neonatal cadavers. Using methylene blue dye, the block was performed at vertebral levels T5—using 0.5 mL in cadaver 1—and T8—using 0.2 mL in cadaver 2. The craniocaudal spread of dye was tracked within the space on the ultrasound screen and further confirmed on dissection.

Results

Craniocaudal spread was noted from vertebral levels T3 to T6 when the dye was introduced at vertebral level T5 and from vertebral levels T7 to T11 when the dye was introduced at vertebral level T8. Furthermore, the methylene blue spread was found anteriorly in the paravertebral and epidural spaces, staining both the dorsal and ventral rami of the spinal nerves T2 to T12. Small amounts of dye were also found in the intercostal spaces.

Conclusion

In two neonatal fresh cadavers, the dye was found to spread to multiple levels and key anatomic locations.

Incidence and Factors Contributing to Low Back Pain in the Nonobstetrical Patients Operated Under Spinal Anesthesia: A Prospective 1-Year Follow-Up Study

PURPOSE

To determine the incidence and factors contributing to postspinal anesthesia (SPA) low back pain (LBP) in patients undergoing nonobstetrical surgeries.

DESIGN

A prospective 1-year follow-up study.

METHODS

Patients having nonobstetrical surgery using SPA were included. The patients were followed up through phone calls and interviews every postoperative day for the first week, weekly for a month, and then monthly for a year after SPA. Patients' duration of LBP, duration of surgery, and need for LBP treatment were recorded.

FINDINGS

Of 410 patients, 5.8% (24 patients) experienced LBP. The incidence of LBP did not have a significant correlation with the recorded variables (P > .05). There was a negative significant correlation between duration of LBP and duration of surgery (r = -0.5096; P = .001). Of the 24 patients experiencing LBP, 16.7% (four patients) experienced it for less than 1 day, 66.7% (16 patients) 1 to 7 days, 16.7% (four patients) more than 7 days, and only one patient (4.2%) for up to 17 days. Special LBP treatment was not needed in any of the patients.

CONCLUSIONS

The incidence of LBP was very low, and those patients undergoing nonobstetrical surgery and receiving SPA did not experience persistent LBP.

Spinal Anesthesia for Pediatric Laparoscopic Hernia Repair: A Case Report

Spinal anesthesia is practical and safe in infants and toddlers and prevents perioperative complications including cardiorespiratory instability and apnea. Other perioperative advantages include reduced time from surgery completion to operating room exit and first feed. This article presents the case of an ex-premature infant who underwent laparoscopic inguinal hernia repair under spinal anesthesia. The infant remained calm and stable throughout the uneventful procedure and postoperative period. Spinal anesthesia may be feasible for laparoscopic herniotomy when pneumoperitoneum pressure and operative time are restricted to 8 mm Hg and 60 minutes, respectively, with sensory level at T10 or higher.

Spinal anaesthesia in neonates and infants: what about the cerebral oxygen saturation?

Background

Spinal Anaesthesia (SA) has been firmly established as an efficient and safe technique, with minimal cardio-respiratory disturbance when administered in the neonatal period. Our objective was to assess the haemodynamic consequences of SA in infants, particularly its impact on cerebral perfusion using near-infrared spectroscopy (NIRS)-based cerebral oximetry (rSco2).

Methods

All infants up to 60 weeks' postmenstrual age, whether formerly preterm or not, and undergoing spinal anaesthesia, were enrolled. Haemodynamic data records, rSco2 and mean arterial blood pressure (MAP), were prospectively collected before SA (T0) and every five min for 30 min (T30) after the puncture. Compared with baseline measures, any changes of > 10% in rSco2 and of > 20% in MAP were considered clinically significant. Relative variations of data between T0 and T30 were analysed.

Results

Data of 103 infants were analysed. The mean relative changes in rSco2 were -2.25% (97.5% CI [-3.97; -0.5]) at T15, and 0.11% (97.5% CI [-1.67; 1.90]) at T30. No significant variation of rSco2 was recorded. The mean changes in MAP were respectively -13.94% (97.5% CI [-17.74; -10.14]) at T15 and -20.27% (97.5% CI [-24,25; -16.29]) at T30. MAP decrease was statistically and clinically significant 30 min after SA. No correlation between changes in MAP and rSco2 was found. The subgroup analysis did not reveal any effect of added intrathecal clonidine or preterm birth history on these results.

Conclusions

In neonate and infants, SA did not cause clinically significant variation in cerebral oxygen saturation. Despite a significant decrease in MAP, cerebral auto-regulation seems to remain effective in neonates and not altered by spinal anaesthesia.

Lumbosacral and thoracolumbosacral cerebrospinal fluid volume changes in neonates, infants, children, and adolescents: A retrospective magnetic resonance imaging study

BACKGROUND

The volume of cerebrospinal fluid can affect the pharmacokinetics and pharmacodynamics of local anesthetics for spinal anesthesia and other intrathecal medications.

AIMS

The objective of this study was to estimate the lumbosacral cerebrospinal fluid volume and thoracolumbosacral cerebrospinal fluid volume using magnetic resonance images in pediatric patients from neonates and infants to adolescents.

METHODS

Spinal magnetic resonance images of 500 pediatric patients (age <18 years) were reviewed. The lumbosacral cerebrospinal fluid volumes of 418 patients and thoracolumbosacral cerebrospinal fluid volumes of 248 patients were measured. The relationship between cerebrospinal fluid volumes and age, height, and weight were evaluated. The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes per weight were calculated to elucidate developmental changes.

RESULTS

The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes showed linear correlations with height (r²  = 0.730 and r²  = 0.661, respectively), whereas they showed curvilinear correlations with age (r²  = 0.752 and r²  = 0.717, respectively) and weight (r²  = 0.734 and r²  = 0.734, respectively). The mean lumbosacral cerebrospinal fluid volume per weight (mL/kg) was 0.85 (standard deviation [SD]: 0.19, 95% confidence interval [CI]: 0.81-0.90) in neonates and infants, 0.86 (SD: 0.22, 95% CI: 0.83-0.89) in toddlers and preschoolers, 0.71 (SD: 0.26, 95% CI: 0.66-0.76) in schoolers, and 0.54 (SD: 0.20, 95% CI: 0.49-0.60) in adolescents. The mean thoracolumbosacral cerebrospinal fluid volume per weight (mL/kg) was 1.95 (SD: 0.37, 95% CI: 1.86-2.04) in neonates and infants, 1.82 (SD: 0.41, 95% CI: 1.75-1.88) in toddlers and preschoolers, 1.38 (SD: 0.40, 95% CI: 1.23-1.52) in schoolers, and 0.99 (SD: 0.34, 95% CI: 0.45-1.53) in adolescents.

CONCLUSION

The lumbosacral and thoracolumbosacral cerebrospinal fluid volumes in pediatric patients were much smaller than previously presented values, showing linear correlations with height, and demonstrate curvilinear correlations with age and weight.

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.

Age-based Local Anesthetic Dosing in Pediatric Spinal Anesthesia: Evaluation of a New Formula - A Pilot Study in Indian Patients

Background:

Spinal anesthesia is a safe alternative to general anesthesia and often the anesthetic technique of choice in many lower abdominal and lower limb surgeries in children. As the vertebral column and spinal cord grows variedly with age and not weight, we planned to administer an age-based dosing schedule of hyperbaric bupivacaine in the intra-thecal space in select infra umbilical surgeries in children. The aim was to find out the efficacy and complications associated with this dosage.

Methodology:

Twenty-five pediatric patients between 2 and 12 years, posted for elective infra umbilical surgeries were given a sedation as a combination of effective doses of pentazocine, midazolam, and atropine. In all those patients, spinal anesthesia was administered at a dose of age/5 of hyperbaric bupivacaine. The number of attempts, the onset of blockade, the mean sensory level, and the duration of anesthesia were noted. Any other complications were also noted.

Results:

The mean and standard deviation of age is 7.68 ± 2.49 years. Intra-thecal anesthesia was administered successfully in the first attempt in 88% of cases whereas the remaining needed the second attempt. Three patients needed intravenous ketamine of 0.25 mg/kg additionally for preoperative sedation. The sensory level was between T6 and T10 with a mean of T8.5. There were no intra-operative complications. In all patients, surgery was finished within the duration of anesthesia of approximately 60 min. There was no conversion to general anesthesia in any case, but a three patients required dose of 0.25 mg/kg of intravenous ketamine as a calming dose.

Conclusion:

Administration of age-based local anesthetic dosing of hyperbaric bupivacaine in the intra-thecal space by utilizing a new formula of age/5 (Partha formula) is successful in a pilot study in Indian children for infra-umbilical surgeries. There were no observed complications.

Comparison of Intrathecal Clonidine and Fentanyl as Adjuvant to Hyperbaric Bupivacaine in Subarachnoid Block for Lower Limb Orthopedic Surgery

Background:

Many studies are there using adjuvants such as clonidine and fentanyl with bupivacaine in the subarachnoid block for prolonging postoperative analgesia. However, literature is divided regarding the dosage and efficacy of both intrathecal adjuvants. Furthermore, these adjuvants have their own side effects. Hence, search for ideal intrathecal adjuvant between clonidine and fentanyl to bupivacaine goes on.

Aim:

The aim of the present study was to compare the effect of intrathecal clonidine and fentanyl as adjuvant to bupivacaine in the subarachnoid block for lower limb orthopedic surgery.

Materials and Methods:

It was a prospective randomized study in which eighty patients posted for lower limb orthopedic surgery were divided into two groups of forty each. Group C – Received intrathecal hyperbaric bupivacaine (2.5 ml) +50 μg clonidine (diluted to 0.5 ml). Group F – Received intrathecal hyperbaric bupivacaine (2.5 ml) + fentanyl 25 μg (diluted to 0.5 ml). Duration of postoperative analgesia, sensory and motor block characteristics, hemodynamic parameters, and side effects were recorded and analyzed.

Results:

Time for first dose of rescue analgesic was delayed in Group C (510.84 ± 24.10 min) in comparison to Group F (434.95 ± 19.16 min) which was statistically significant (P < 0.001). Duration of sensory and motor block was significantly prolonged in Group C compared to Group F (P < 0.001). Sedation was more in Group C than Group F (P < 0.001). Other block characteristics, hemodynamic, and side effects were comparable in both groups.

Conclusion:

Intrathecal clonidine as adjuvant to hyperbaric bupivacaine provided prolonged postoperative analgesia with more sedation in comparison to intrathecal fentanyl.

Accidental Epidural Injection of Rocuronium in a Pediatric Patient: A Case Report and Literature Review

Accidental administration of non-epidural drugs into the epidural or subarachnoid spaces may be associated with unexpected pain, morbidity, adverse effects, increased level of care, prolonged hospital stay, and mortality. We describe a 12-month-old admitted for secondary-stage hypospadias reconstruction. General anesthesia was induced with sevofiurane and a peripheral catheter was placed. Instead of ropivacaine, rocuronium (80 mg; 6.3 mg/kg) was injected into the epidural space by the caudal route. Surgery was uneventful and was completed 160 minutes after rocuronium was given. The patient exhibited paralysis with 1 of 4 twitches to the train-of-four with some posttetanic potentiation at the end of surgery. He was transferred to the pediatric intensive care unit for supportive ventilation and recovery. He did not experience oxygen desaturation or hypoventilation between the time of rocuronium administration and intubation. He was hemodynamically stable, without respiratory insufficiency, and his neurologic exam was normal, without motor or sensorial block. The patient was discharged home on the morning of the first postoperative day. Clinical examination 1 week after surgery revealed no lasting sequelae from the error.

[Central blockades in Pediatrics: A review of current literature]

Pediatric neuraxial anesthesia is an effective tool that can be used as a supplement or alternative to general anesthesia. However, there have always been doubts about its usefulness and risk-benefit ratio. The purpose of this review is to describe the current role of central blockades in pediatric patients, upgrade practical and safety aspects, and review the latest technological advances applied to this procedure.

Adjuncts should always be used in pediatric regional anesthesia

A number of different adjuncts to local anesthetics can be used to prolong and optimize postoperative pain relief following regional anesthesia in children. The present text provides a slightly opinionated but evidence-based argument in favor of this practice.