Complications during spinal anesthesia in infants: high spinal blockade

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound-guided epidural anesthesia and sedation for open transvesical Cohen ureteric reimplantation surgery in 20 consecutive children: a prospective case series and proof-of-concept study

BACKGROUND

Epidural anesthesia is usually combined with general anesthesia (GA) for children undergoing sub-umbilical surgery and GA in children is associated with a potential for respiratory events. Aiming to reduce airway manipulation and the use of GA drugs, we designed a study of transvesical Cohen ureteteric reimplantion under epidural anesthesia in sedated, spontaneously breathing children.

METHODS

We enrolled 20 children (3-83 months, 6.3-25.0 kg) scheduled for open transvesical abdominal surgery with Pfannenstiel incision. Sedation was followed by ultrasound-guided epidural anesthesia. Increases in heart rate by > 15% and or patient movements upon skin incision were rated as block deficiencies. Intubation equipment for advanced airway management was kept on standby. The primary study endpoint was successful blockade, meaning that no sequential airway management was required for the spontaneous breathing patients during surgery. Secondary endpoints included any use of fentanyl/propofol intraoperatively and of postoperative analgesics in the recovery room.

RESULTS

All 20 blocks were successful, with no block deficiencies upon skin incision, no need for sequential airway management, and stable SpO2 levels (97-100%). Surgery took a median of 120.5 minutes (IQR: 89.3-136.5) and included one bolus of fentanyl in one patient 120 minutes into a protracted operation. No more systemic analgesia had to be provided in the recovery room.

CONCLUSIONS

Sedation and epidural anesthesia emerged as a useful alternative to GA from our consecutive case series.

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.

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.

Spinal anesthesia in children: A review

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

The seasonality of postoperative infection in spine surgery

OBJECT

Studies from many disciplines have found an association with the summer months, elevated temperature, humidity, and an increased rate of infection. The "July effect," a hypothesis that the inexperience of new house staff at the beginning of an academic year leads to an increase in wound complications, has also been considered. Finally, an increase in trauma-related admissions in the summer months is likely to result in an increased incidence of postoperative infections. Two previous studies revealed mixed results concerning perioperative spinal wound infections in the summer months. The purpose of this study was to determine the months and/or seasons of the year that display significant fluctuation of postoperative infection rate in spine surgery. Based on the idea that infection rates are susceptible to seasonal factors, the authors hypothesized that spinal infections would increase during the summer months.

METHODS

Inclusion criteria were all spine surgery cases at a single tertiary referral institution between January 2005 and December 2009; 8122 cases were included. Patients presenting with a contaminated wound or active infection were excluded. Infection rates were calculated on a monthly and seasonal basis and compared.

RESULTS

A statistically significant increase in the infection rate was present on both a seasonal and monthly basis (p = 0.03 and p = 0.024) when looking at the seasonal change from spring to summer. A significant decrease in the infection rate was seen on a seasonal basis during the change from fall to winter (p = 0.04). The seasonal rate of infection was highest in the summer (4.1%) and decreased to the lowest point in the spring (2.8%) (p = 0.03).

CONCLUSIONS

At the authors' institution, spine surgeries performed during the summer and fall months were associated with a significantly higher incidence of wound infection compared with the winter and spring. These data support the existence of a seasonal effect on perioperative spinal infection rates, which may be explained by seasonal variation in weather patterns and house staff experience, among other factors.

Recent developments in paediatric neuraxial blocks

Paediatric anaesthesia and paediatric regional anaesthesia are intertwined. Almost all surgeries unless contradicted could be and should be supplemented with a regional block. The main objective of this review is to elaborate on the recent advances of the central neuraxial blocks, such as application of ultrasound guidance and electrical stimulation in the pursuit of safety and an objective end point. This review also takes account of the traditional technique and understand the benefits as well the risk of each as compared with the recent technique. The recent trends in choosing the most appropriate peripheral block for a given surgery thereby sparing the central neuroaxis is considered. A penile block for circumcision or a sciatic block for unilateral foot surgery, rather than caudal epidural would have a better risk benefit equation. Readers will find a special mention on the recent thoughts on continuous epidural analgesia in paediatrics, especially its rise and fall, yet its unique importance. Lastly, the issue of block placements under sedation or general anaesthesia with its implication in this special population is dealt with. We conducted searches in MEDLINE (PubMed) and assessed the relevance of the abstracts of citations identified from literature searches. The search was carried out in English, for last 10 years, with the following key words: Recent advances in paediatric regional anaesthesia; ultrasound guidance for central neuraxial blocks in children; role of electrical stimulation in neuraxial blocks in children; complications in neuraxial block. Full-text articles of potentially relevant abstracts were retrieved for further review.

Is surgical case order associated with increased infection rate after spine surgery?

STUDY DESIGN

Retrospective database review.

OBJECTIVE

To determine whether surgical site infections are associated with case order in spinal surgery.

SUMMARY OF BACKGROUND DATA

Postoperative wound infection is the most common complication after spinal surgery, with incidence varying from 0.5% to 20%. The addition of instrumentation, use of preoperative prophylactic antibiotics, length of procedure, and intraoperative blood loss have all been found to influence infection rate. No previous study has attempted to correlate case order with infection risk after surgery.

METHODS

A total of 6666 spine surgery cases occurring between January 2005 and December 2009 were studied. Subjects were classified into 2 categories: fusion and decompression. Case order was determined, with each procedure labeled 1 to 5 depending on the number of previous cases in the room. Variables such as the American Society of Anesthesiologists score, number of operative levels, wound class, age, sex, and length of surgery were also tracked. A step-down binary regression was used to analyze each variable as a potential risk factor for infection.

RESULTS

Decompression cases had a 2.4% incidence of infection. Longer surgical time and higher case order were found to be significant risk factors for lumbar decompressions. Fusion cases had a 3.5% incidence of infection. Posterior approach and revision cases were significant risk factors for infection in cervical cases. For lumbar fusion cases, longer surgical time, higher American Society of Anesthesiologists score, and older age were all significant risk factors for infection.

CONCLUSION

Decompressive procedures performed later in the day carry a higher risk for postoperative infection. No similar trend was shown for fusion procedures. Our results identify potential modifiable risk factors contributing to infection rates in spinal procedures. Specific risk factors, although not defined in this study, might be related to contamination of the operating room, cross-contamination between health care providers during the course of the day, use of flash sterilization, and mid-day shift changes.

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.

Pediatric regional anesthesia: what is the current safety record?

The use of regional anesthetics, whether as adjuncts, primary anesthetics or postoperative analgesia, is increasingly common in pediatric practice. Data on safety remain limited because of the paucity of very large-scale prospective studies that are necessary to detect low incidence events, although several studies either have been published or have reported preliminary results. This paper will review the data on complications and risk in pediatric regional anesthesia. Information currently available suggests that regional blockade, when performed properly, carries a very low risk of morbidity and mortality in appropriately selected infants and children.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spinal anaesthesia in full-term infants of 0-6 months: are there any differences regarding age?

BACKGROUND AND OBJECTIVE

The aim of the study was to report our experience concerning the effectiveness, complications and safety of spinal anaesthesia, and to determine whether spinal anaesthesia was effective in full-term infants undergoing elective inguinal hernia repair.

METHODS

Sixty-eight full-term infants aged < 6 months were included in the study. Infants were divided into three groups; Group I (< 1 month, n = 20), Group II (> 1 and < 3 months, n = 26), and Group III (3-6 months, n = 22). All spinal blocks were performed under mask inhalation anaesthesia. A dose of bupivacaine 0.5% 0.5 mg kg(-1) was used for infants under 5kg and 0.4 mg kg(-1) for those over 5 kg. Heart rate, mean arterial pressure, respiratory rate and SPO2 were recorded before and after spinal anaesthesia at 5 min intervals. Time to onset of analgesia, time to start of operation, duration of operation, anaesthesia and hospitalization, postoperative analgesic requirement and complications were recorded.

RESULTS

Adequate spinal anaesthesia without sedation was better, time to obtain maximum cutaneous analgesia was shorter and need for sedation and postoperative analgesic requirement were significantly lower in Group I. Although heart rate, mean arterial pressure and respiratory rate decreased < 20% in all groups following spinal analgesia, the decrease in Group I was lower than the others.

CONCLUSIONS

Spinal anaesthesia is an effective choice in inguinal hernia repair for full-term infants aged < 1 month, providing excellent and reliable surgical conditions. However, this technique is not as useful for infants aged between 1 and 6 months.

Awake spinal or caudal anaesthesia in preterms for herniotomies: what is the evidence based benefit compared with general anaesthesia?

PURPOSE OF REVIEW

Postoperative apnoea is known to threaten preterm and ex-preterm infants undergoing surgery for inguinal hernia. Awake regional anaesthesia, initially spinal and later caudal anaesthesia have been suggested as effective techniques to avoid these complications. However, most herniotomies in this group of patients are still performed under general anaesthesia without deleterious consequences. Whereas some experts continue to claim advantages for awake regional over general anaesthesia for preterm infants, others consider awake regional anaesthesia to be an exclusive, technically difficult and unreliable technique of unconfirmed benefit.

RECENT FINDINGS

It is appropriate to weigh the scarce available evidence that has been accumulated since 1984, and put it into perspective with new developments in paediatric general anaesthesia. The actual clinical significance of postoperative apnoea and improvements in neonatal and perioperative care and monitoring must also be reconsidered.

SUMMARY

The available evidence does not allow unequivocal conclusions to be drawn or recommendations to be made. Awake regional anaesthesia for herniotomies in preterm infants has been found to be superior in most studies; however, it requires technical expertise and dedication on the part of the anaesthetist and surgeon. When light general anaesthesia with modern anaesthetic agents such as sevoflurane or desflurane is combined with a caudal block, postoperative apnoea is very rare, and can easily be recognized and managed with good postoperative monitoring and therapy.

Benefit and risks of local anesthetics in infants and children

Regional anesthesia has become a routine part of the practice of anesthesiology in infants and children. Local anesthetic toxicity is extremely rare in infants and children; however, seizures, dysrhythmias, cardiovascular collapse, and transient neuropathic symptoms have been reported. Infants and children may be at increased risk from local anesthetics compared with adults. Larger volumes of local anesthetics are used for epidural anesthesia in infants and children than in adults. Metabolism and elimination of local anesthetics can be delayed in neonates, who also have decreased plasma concentrations of alpha(1)-acid glycoprotein, leading to increased concentrations of unbound bupivacaine. Most regional anesthetic procedures in infants and children are performed with the patient heavily sedated or anesthetized; because of this, and because a test dose is not a particularly sensitive marker of intravenous injection in the anesthetized patient, detection of intravascular local anesthetic injection is extremely difficult. The same local anesthetics used in adult anesthetic practice are also used in infants and children. Because of its extremely short duration of action, chloroprocaine has been used primarily for continuous epidural techniques in infants and children. The use of tetracaine has generally been limited to spinal and topical anesthesia. Lidocaine (lignocaine) has been used extensively in infants and children for topical, regional, plexus, epidural and spinal anesthesia. The association between prilocaine and methemoglobinemia has generally restricted prilocaine use in infants and children to the eutectic mixture of local anesthetics (EMLA). Because of its greater degree of motor block compared with other long-acting local anesthetics, etidocaine has generally been limited to plexus blocks in infants and children. Mepivacaine has been used for both plexus and epidural anesthesia in infants and children. Because postoperative analgesia is often the primary justification for regional anesthesia in infants and children, bupivacaine, a long-acting local anesthetic, is the most commonly reported local anesthetic for pediatric regional anesthesia. Given the lower toxic threshold of bupivacaine compared with other local anesthetics, the risk-benefit ratio of bupivacaine may be greater than that of other local anesthetics. Two new enantiomerically pure local anesthetics, ropivacaine and levobupivacaine, offer clinical profiles comparable to that of bupivacaine but without its lower toxic threshold. The extreme rarity of major toxicity from local anesthetics suggests that widespread replacement of bupivacaine with ropivacaine or levobupivacaine is probably not necessary. However, there are clinical situations, including prolonged local anesthetic infusions, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring a large mass of local anesthetic, where replacement of bupivacaine with ropivacaine, levobupivacaine or (for continuous techniques) chloroprocaine appears prudent.

Spinal anaesthesia for inguinal herniotomy in preterm infants sedated with nitrous oxide: a comparison of lumbar puncture in the lateral or sitting position

This study compares spinal anaesthesia for inguinal herniotomy in preterm infants in the lateral or sitting position. Thirty patients were randomly divided into two equal groups. One hour before spinal anaesthesia, a eutetic mixture of local anaesthetic cream was applied to the lower lumbar spine. Sedation with nitrous oxide 50% in oxygen was given to all patients before and during induction of spinal anaesthesia, and throughout surgery. Lumbar punctures were performed at the L4-5 interspace using a 2.5 cm 22 G needle. Isobaric bupivacaine 0.5% with epinephrine 1 : 200 000 at a bupivacaine dose of 1 mg.kg-1 was injected in the lateral or sitting position. Measurements included heart rate, blood pressure, oxygen saturation, maximum sensory block height and duration of motor block and analgesia. There were no statistically significant differences between the groups in any measured parameters. Median [range] maximum block height was T5[T4-T7] in the lateral group and T5[T4-T5] in the sitting group. The median [range] duration of motor blockade was 67 [50-85] min in the lateral group and 63 [50-80] min in the sitting group. Our results indicate that in preterm infants sedated with nitrous oxide, spinal anaesthesia for inguinal herniotomy performed with isobaric bupivacaine 0.5% at a dose 1.0 mg.kg-1 in the lateral or sitting position is equally effective and is associated with minimal side effects.

Practical pediatric regional anesthesia

In children, regional anesthetic techniques are safe and effective adjuncts to general anesthesia and for postoperative pain relief. Application of the techniques described in this article will contribute to improved care for pediatric patients undergoing surgical procedures. The judicious choice of local anesthetics, along with the blockades of targeted nerves, decrease the need for supplemental analgesics in the recovery phase.

Spinal anaesthesia for insertion of a peritoneal dialysis catheter in a neonate

A 5-day-old neonate born at term presented in renal failure for insertion of a peritoneal dialysis catheter. This was successfully achieved with spinal anaesthesia, with no intra- or postoperative complications. Regional techniques are considered suitable for an increasing variety of procedures in patients in whom the risks of general anaesthesia are significant.

Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison between spinal and general anaesthesia

The incidence of inguinal hernia is higher in premature infants, particularly in low birth weight neonates. This latter group may also incur increased postoperative respiratory complications and inpatient admissions. The purpose of this study was to compare the effects of general and spinal anaesthesia on postoperative respiratory morbidity and on the length of hospital stay in high-risk infants undergoing inguinal herniorrhaphy. Forty patients, all high-risk infants who underwent unilateral or bilateral herniorrhaphies, were randomly assigned to receive general anaesthesia (n = 20) or spinal anaesthesia (n = 20). There was a significant difference in respiratory morbidity between the two groups, as well as a significant difference in the inpatient hospital stay. The present study suggests that spinal anaesthesia can be used safely for high-risk infants, preterm or formerly preterm, undergoing inguinal hernia repair.

Antinociceptive activity of midazolam in sheep

The purpose of this study was to examine the effects of midazolam on the nociceptive threshold responses in sheep. The intravenous administration of midazolam (0.1-0.3 mg/kg) produced a significant dose-dependent elevation of the mechanical and thermal nociceptive thresholds. The intravenous administration of flumazenil (20 micrograms/kg) markedly attenuated the antinociceptive activity of midazolam in the mechanical nociceptive test, whereas intravenous naloxone (0.2 mg/kg) had no significant effect on midazolam-mediated analgesia. The intrathecal administration of midazolam (1 mg), via chronically implanted cervical subarachnoid catheters, produced a significant elevation in the mechanical threshold responses. These results indicate that midazolam has antinociceptive actions in the sheep and suggest that this effect is, at least partially, mediated at the spinal level.

Pediatric neuraxial blockade

Regional anesthetic techniques for children have recently enjoyed a justified resurgence in popularity. Intraoperative blockade of the neuraxis, whether by the spinal or epidural route, provides excellent analgesia with minimal physiologic alteration and, with an indwelling catheter, can provide continuous pain relief for many days postoperatively. As a supplement to general anesthesia, local anesthetic blockade of the neuraxis decreases the total amount of general anesthetic required for surgery, hastens emergence, and allows for a better postoperative experience by providing a pain-free emergence from general anesthesia. Although some practitioners contend that a regional block on an already anesthetized child adds to the risk of the general anesthetic itself, in experienced hands the risks are negligible and the benefits dramatic. In this review of caudal and lumbar epidural and subarachnoid blockade in infants and children, anatomy, physiologic alterations, and pharmacology pertinent to the three types of neuraxial blockade are described, with the aim of providing the practicing anesthesiologist with the foundation needed to perform these blocks with relative confidence.

Inguinal herniorrhaphy in young infants: perianesthetic complications and associated preanesthetic risk factors

STUDY OBJECTIVES

(1) To prospectively observe and tabulate all perianesthetic complications in young infants undergoing herniorrhaphy with general anesthesia and (2) to identify all major postnatal complications and determine which, if any, might be significant risk factors for perianesthetic complications.

DESIGN

Prospective case control study.

SETTING

Columbus, Ohio, Children's Hospital, a teaching and tertiary referral center.

PATIENTS

One hundred two consecutive infants 60 weeks postconceptual age (PCA) or younger undergoing herniorrhaphy with general anesthesia.

INTERVENTIONS

None

MEASUREMENTS AND MAIN RESULTS

All perianesthetic complications occurring during anesthesia, in the postanesthesia care unit (PACU), during the remaining hospital stay, and within 30 days of anesthesia were recorded, and a detailed postnatal history was compiled. Fifty-five percent of 60 preterm infants [37 weeks gestational age (GA) or younger] and 50% of 42 term infants (older than 37 weeks GA) experienced at least one perianesthetic complication. Following discharge from the PACU, in-house complications were confined to the preterm group. Significant risk factors included a history of apnea, bradycardia, and ventilatory support for at least 24 hours after birth, mainly for respiratory distress syndrome.

CONCLUSIONS

In a teaching hospital, prospectively observed perianesthetic complications can occur in more than 50% of infants 60 weeks PCA or younger undergoing herniorrhaphy with inhalation anesthesia. Infants younger than 49 weeks PCA with a significant preanesthetic risk factor should be monitored overnight for apnea and bradycardia.