Awake caudal anaesthesia in neonates/young infants for improved patient safety

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.

Lipid emulsion treatment for local anesthetic systemic toxicity in pediatric patients: A systematic review

BACKGROUND

Local anesthetic systemic toxicity (LAST) is rare, but fatal; the current widely used treatment is lipid emulsion (LE). The goal of this study was to analyze and review case reports on LE treatment for LAST in pediatric patients.

METHODS

We performed a systematic review using case reports on LE treatment for LAST in pediatric patients, searching PubMed and Scopus databases to March 2023 using the following keywords: ("local anesthetic toxicity" OR "local anesthetic systemic toxicity" OR LAST") AND ("newborn" OR "infant" OR "child" OR "children" OR "adolescent" OR "pediatric") AND ("lipid emulsion" OR "Intralipid").

RESULTS

Our search yielded 21 cases, revealing that nearly 43% patients with LAST were less than 1 year old, and most cases were caused by bupivacaine (approximately 67% cases). "Inadvertent intravascular injection" by anesthesiologists and "overdose of local anesthetics" mainly by surgeons were responsible for 52% and 24% cases of LAST, respectively. LAST occurred in the awake state (52%) and under general anesthesia (48%), mainly causing seizures and arrhythmia, respectively. Approximately 55% of patients received LE treatment in <10 minutes after LAST, mainly improving cardiovascular symptoms. A 20% LE (1.5 mL/kg) dose followed by 0.25 mL/kg/minutes dose was frequently used. LE and anticonvulsants were mainly used in the awake state, whereas LE with or without vasopressors was mainly used under general anesthesia. LE treatment led to full recovery from LAST in 20 cases; however, 1 patient died due to underlying disease.

CONCLUSION

Consequently, our findings reveal that LE is effective in treating pediatric LAST.

Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.