SPINAL ANESTHESIA IN INFANTS UNDERGOING UROLOGIC SURGERY >60 MINUTES
Francis A. Jefferson, MD, Bridget L. Findlay, MD, Patricio C. Gargollo, MD, Dawit T. Haile, MD, Candace F. Granberg, MD.
Mayo Clinic, Rochester, MN, USA.
BACKGROUND: Spinal anesthesia (SA) has been safely utilized in infants. There are limited data, however, regarding the safety and efficacy of SA in pediatric urologic surgery lasting >60 minutes. Only a handful of such cases have been reported, and these cases often used a combination of spinal and caudal anesthesia. We outlined the perioperative course for infants undergoing SA-only for urologic surgical procedures lasting >60 minutes.
METHODS: We retrospectively reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting >60 minutes between 05/2018-03/2021. All patients received preoperative intranasal dexmedetomidine (+/- intranasal fentanyl), LMX cream applied preoperatively over the low spine, 24% oral sucrose on pacifier as needed, and the patient’s arms were swaddled for the procedure. Room noise was limited, and sound machine was provided by our child life specialists. Success was defined as no conversion to general anesthesia (GA). Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected.
RESULTS: Of the 77 infants undergoing SA for urologic surgery lasting >60 minutes, 73 (95%) were successfully completed with SA-only. The 4 converted cases comprised 3 (75%) that required general anesthesia without intubation (mask inhalational) and 1 (25%) with intubation. Median patient age was 6 (IQR 5-7) months, and median time from start of spinal anesthesia to incision was 20 (IQR 17-24) minutes. The median procedure length was 95 (IQR 75-120) minutes. Following the initial preoperative intranasal dexmedetomidine +/- fentanyl, at least one additional dose of IV dexmedetomidine, fentanyl, or both was given in 19 (26%), 3 (4.1%), and 5 (6.8%) cases, respectively, at a median time of 90 (IQR 60-120) minutes into the procedure. Following incision closure, patients exited the OR after a median 10 (IQR 8-12) minutes and subsequently discharged after spending a median of 73 (IQR 61-96) minutes in the post-anesthesia care unit.
CONCLUSIONS: This is the first dedicated report of a SA-only approach to pediatric urologic surgical cases lasting >60 minutes. In this report, SA was safely utilized in infants undergoing urologic procedures lasting ≥60 minutes, with about one-third of patients receiving ancillary IV medications. In the 4 converted cases, only one patient was intubated. Non-medication measures (swaddling, oral sucrose, sound machine) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia. 
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