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Combined spinal/caudal catheter anesthesia: extending the boundaries of regional anesthesia for complex pediatric urological surgery

      Summary

      Background

      Spinal anesthesia (SA) is an established anesthetic technique for short outpatient pediatric urological cases. To avoid general anesthesia (GA) and expand regional anesthetics to longer and more complex pediatric surgeries, the authors began a program using a combined spinal/caudal catheter (SCC) technique.

      Study design

      The authors retrospectively reviewed the charts of all patients scheduled for surgery under SCC between December 2016 and April 2018 and recorded age, gender, diagnosis, procedure, conversion to GA/airway intervention, operative time, neuraxial and intravenous medications administered, complications, and outcomes. The SCC technique typically involved an initial intrathecal injection of 0.5% isobaric bupivacaine followed by placement of a caudal epidural catheter. At the discretion of the anesthesiologist, patients received 0.5 mg per kilogram of oral midazolam approximately 30 min prior to entering the operating room. One hour after the intrathecal injection, 3% chloroprocaine was administered via the caudal catheter to prolong the duration of surgical block. Intra-operative management included either continuous infusion or bolus dosing of dexmedetomidine, as needed, for patient comfort and to optimize surgical conditions. Prior to removal of caudal catheter in the post-anesthesia care unit, a supplemental bolus dose of local anesthesia was given through the catheter to provide prolonged post-operative analgesia.

      Results

      Overall, 23 children underwent attempted SCC. SA was unsuccessful in three patients, and surgery was performed under GA. The remaining 20 children all had successful SCC placement. There were 11 girls and nine boys, with a mean age of 16.5 months (3.3–43.8). Surgeries performed under SCC included seven ureteral reimplantations, two ureterocele excisions/reimplantations, two megaureter repairs, four first-stage hypospadias repairs, one distal hypospadias repair, one second-stage hypospadias repair, two feminizing genitoplasties, and one open pyeloplasty. Average length of surgery was 109 min (range 63–172 min). Pre-operative midazolam was given in 13/20 (65%). All SCC patients were spontaneously breathing room air during the operation, and there were no airway interventions. Only one SCC patient received opioids intra-operatively. There were no intra-operative or perioperative complications.

      Discussion

      This pilot study shows that the technique of SCC allows one to do more complex urologic surgery under regional anesthesia than what would be possible under pure SA alone. The main limitations of the study include the relatively small number of patients and the small median length of the operative procedures. As a proof of concept, however, this does show that complex genital surgery bladder level procedures such as ureteral reimplantation can be performed under regional anesthesia.

      Conclusion

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      Keywords

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      References

        • Bilotta F.
        • Evered L.A.
        • Gruenbaum S.E.
        Neurotoxicity of anesthetic drugs: an update.
        Curr Opin Anaesthesiol. 2017; 30: 452-457
        • Disma N.
        • Mondardini M.C.
        • Terrando N.
        • Absalom A.R.
        • Bilotta F.
        A systematic review of methodology applied during preclinical anesthetic neurotoxicity studies: important issues and lessons relevant to the design of future clinical research.
        Paediatr Anaesth. 2016; 26: 6-36
        • Coleman K.
        • Robertson N.D.
        • Dissen G.A.
        • Neuringer M.D.
        • Martin L.D.
        • Cuzon Carlson V.C.
        • et al.
        Isoflurane anesthesia has long-term consequences on motor and behavioral development in infant rhesus macaques.
        Anesthesiology. 2017 Jan; 126: 74-84
        • Gorelick P.B.
        • Zych D.
        James Leonard Corning and the early history of spinal puncture.
        Neurology. 1987; 37: 672-674
        • Bier A.
        Experiment regarding the cocainization of the spinal cord.
        Zentralbl Chir. 1899; 51: 361-369
        • Whitaker E.E.
        • Wiemann B.Z.
        • DaJusta D.G.
        • Alpert S.A.
        • Ching C.B.
        • McLeod D.J.
        • et al.
        Spinal anesthesia for pediatric urological surgery: reducing the theoretic neurotoxic effects of general anesthesia.
        J Pediatr Urol. 2017; 13: 396-400
        • Trifa M.
        • Tumin D.
        • Whitaker E.E.
        • Bhalla T.
        • Jayanthi V.R.
        • Tobias J.D.
        Spinal anesthesia for surgery longer than 60 min in infants: experience from the first 2 years of a spinal anesthesia program.
        J Anesth. 2018 Aug; 32: 637-640
        • Ing C.
        • Sun L.S.
        • Friend A.F.
        • Roh A.
        • Lei S.
        • Andrews H.
        • et al.
        Adverse events and resource utilization after spinal and general anesthesia in infants undergoing pyloromyotomy.
        Reg Anesth Pain Med. 2016; 41: 532-537
        • Sun L.S.
        • Li G.
        • Miller T.L.
        • Salorio C.
        • Byrne M.W.
        • Bellinger D.C.
        • et al.
        Association between a single general anesthesia exposure before age 36 Months and neurocognitive outcomes in later childhood.
        Jama. 2016; 315: 2312-2320
        • Davidson A.J.
        • Disma N.
        • de Graaff J.C.
        • Withington D.E.
        • Dorris L.
        • Bell G.
        • et al.
        Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial.
        Lancet. 2016; 387: 239-250