Spinal anesthesia for pediatric urological surgery: reducing the theoretic neurotoxic effects of general anesthesia.
Emmett E. Whitaker, MD, Daniel G. DaJusta, MD, Seth A. Alpert, MD, Christina B. Ching, MD, Daryl J. McLeod, MD, Venkata R. Jayanthi, MD.
Nationwide Children's Hospital, Columbus, OH, USA.
Background: Spinal anesthesia (SA) is an effective technique that has been used in children for years. With growing concern with regard to the risks of general anesthesia (GA) in children < 2 years of age, we developed an SA program for lower abdominal, genital and/or groin procedures requiring less than 90 minutes in infants and children. We present our initial experience with this program.
Methods: We prospectively collected data on all children undergoing SA at our institution. We recorded demographics, procedure, time required for placement of the spinal anesthetic, length of surgery, success of lumbar puncture, success of attaining adequate surgical anesthesia, need for supplemental systemic sedation, conversion to GA and perioperative complications.
The technique of the SA involves initial application of anesthetic cream (LMX® 4%) to the lumbar region a minimum of 30 minutes prior to the procedure to minimize puncture-associated pain. Sedation prior to the spinal was considered for older children, but is generally not required for children less than 12 months. A 25 or 22 gauge spinal needle was used, depending on the anesthesiologist’s preference. Bupivicaine 0.5% 1 mg/kg was injected followed by placement of a peripheral intravenous catheter in a lower extremity. After ensuring surgical anesthesia, the procedure was performed as per routine. Subsequent sedation was administered only if required for patient comfort and/or optimization of surgical conditions.
Results: Beginning in Sept 2015, we performed SA in 39 consecutive children (38 boys, 1 girl) with a mean age of 7.3 months (27 days-24 months). Procedures performed included: circumcision (13), hidden penis/circumcision (5), chordee release/circumcision (4), distal hypospadias (6), orchidopexy (8), hernia/hydrocele (2) and labial abscess drainage (1). Placement of the SA was successful in 36/39 (92%). Due to inability to achieve lumbar puncture (cerebrospinal fluid was not obtained), SA was abandoned in 3 patients and GA was administered. The average time required to place the SA was 1.4 minutes (1-3). The average time for the surgical procedure was 40 minutes (11-92). Two of 39 received sedation for the spinal procedure itself specifically due to their age (both were 2 years of age). 31 of 39 (80%) required no additional sedation and received no systemic anesthetic agents. There were no anesthetic or surgical complications.
Conclusions: SA is a safe and efficacious technique for routine pediatric urological procedures. Ideal candidates are children less than 12 months, though we are currently expanding our program to include older children and/or those undergoing surgery of longer duration. The option of SA may allay the common parental fear of anesthesia since the child requires no airway management, may not need any systemic anesthetics, and opioids may be completely avoided intraoperatively. SA should be considered for cases such as neonatal torsion when the risks of GA are often weighed against the risks of non-intervention, since the risk of GA can be eliminated when SA is used.
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