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Spinal anesthesia in infants undergoing urologic surgery duration greater than 60 minutes

      Summary

      Introduction

      Spinal anesthesia (SA) has been safely utilized in infants. There are limited data regarding the safety and efficacy of SA in pediatric urologic surgery lasting ≥60 min. We outlined the perioperative course for infants undergoing single-injection 0.5% plain bupivacaine SA-only for urologic procedures lasting ≥60 min.

      Objective

      To characterize the safety and efficacy of SA for urologic surgery in infants lasting ≥60 min.

      Methods

      We reviewed our prospectively maintained database of infants undergoing SA for urologic procedures lasting ≥60 min from May 2018 to March 2021. Patients received preoperative intranasal dexmedetomidine, some received intranasal fentanyl, and all patients received lidocaine cream applied preoperatively over the lumbar spine. Oral sucrose on a pacifier was provided as needed, and the patient's arms were swaddled for the procedure. Success was defined as no conversion to general anesthesia. Time points for start/end of spinal injection, procedure duration, wheels in/out of operating room (OR), and discharge were collected.

      Results

      Of 245 cases conducted with SA during the study period, 76 (31%) infants underwent surgery lasting ≥60 min. Of these, 73 (96%) were successfully completed with SA alone. In the 3 cases converted to general anesthesia, 2 (67%) required mask anesthesia after 96 and 169 min (for the last <10 min of surgery), and one was converted to intubation before start of surgery. Median patient age was 6 (IQR 5–7) months, and median procedure length was 95 (IQR 75–120) minutes. Following initial preoperative intranasal dexmedetomidine ± fentanyl, at least one additional dose of IV sedative was given in 27 (36%) cases at a median time of 90 (IQR 60–120) minutes into surgery. Following 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 recovery.

      Discussion

      We describe pediatric urologic surgical cases lasting ≥60 min that employed single-injection intrathecal bupivacaine alone without adjunct intrathecal agents. In this report, SA was safely utilized in infants undergoing urologic procedures lasting at least 60 min, with about 40% of patients receiving additional IV dexmedetomidine and fentanyl. Non-medication measures (swaddling, oral sucrose) were important for maximizing patient comfort. Communication between surgeon and anesthesia as cases progress is key to maintaining adequate anesthesia.

      Conclusion

      Summary figure
      Graphical Abstract1Obtaining spinal access in an infant prior to urologic surgery. Lidocaine 1% is injected into superficial skin over planned spinal access site (A). Spinal access is obtained (B), free flow of cerebrospinal fluid documented (C), and single-injection spinal anesthesia using 0.5% bupivacaine is administered (D).

      Keywords

      Abbreviations:

      SA (Spinal anesthesia), FDA (Food and Drug Administration), OR (Operating room), PACU (Post-anesthesia care unit), CSF (Cerebrospinal fluid), IV (Intravenous)
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      References

        • Kachko L.
        • Birk E.
        • Simhi E.
        • Tzeitlin E.
        • Freud E.
        • Katz J.
        Spinal anesthesia for noncardiac surgery in infants with congenital heart diseases.
        Paediatr Anaesth. 2012; 22: 647-653
        • Lambertz A.
        • Schalte G.
        • Winter J.
        • Roth A.
        • Busch D.
        • Ulmer T.F.
        • et al.
        Spinal anesthesia for inguinal hernia repair in infants: a feasible and safe method even in emergency cases.
        Pediatr Surg Int. 2014; 30: 1069-1073
        • Jones L.J.
        • Craven P.D.
        • Lakkundi A.
        • Foster J.P.
        • Badawi N.
        Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy.
        Cochrane Database Syst Rev. 2015; 6: CD003669
        • Williams R.K.
        • Adams D.C.
        • Aladjem E.V.
        • Kreutz J.M.
        • Sartorelli K.H.
        • Vane D.W.
        • et al.
        The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry.
        Anesth Analg. 2006; 102: 67-71
        • FDA Drug Safety Communication
        FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women.
        U.S. Food & Drug Administration, 2016 (updated 03/08/2018. Available from:)
        • 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
        • Handlogten K.
        • Warner L.
        • Granberg C.
        • Gargollo P.
        • Thalji L.
        • Haile D.
        Implementation of a spinal anesthesia and sedation protocol that reliably prolongs infant spinal anesthesia: case series of 102 infants who received spinal anesthesia for urologic surgery.
        Paediatr Anaesth. 2020; 30: 1355-1362
        • Oddby E.
        • Englund S.
        • Lonnqvist P.A.
        Postoperative nausea and vomiting in paediatric ambulatory surgery: sevoflurane versus spinal anaesthesia with propofol sedation.
        Paediatr Anaesth. 2001; 11: 337-342
        • Ing C.
        • Sun L.S.
        • Friend A.F.
        • Kim M.
        • Berman M.F.
        • Paganelli W.
        • et al.
        Differences in intraoperative hemodynamics between spinal and general anesthesia in infants undergoing pyloromyotomy.
        Paediatr Anaesth. 2017; 27: 733-741
        • Ebert K.M.
        • Jayanthi V.R.
        • Alpert S.A.
        • Ching C.B.
        • DaJusta D.G.
        • Fuchs M.E.
        • et al.
        Benefits of spinal anesthesia for urologic surgery in the youngest of patients.
        J Pediatr Urol. 2019; 15 (49.e1-.e5)
        • 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; 32: 637-640
        • 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
        • Jayanthi V.R.
        • Spisak K.
        • Smith A.E.
        • Martin D.P.
        • Ching C.B.
        • Bhalla T.
        • et al.
        Combined spinal/caudal catheter anesthesia: extending the boundaries of regional anesthesia for complex pediatric urological surgery.
        J Pediatr Urol. 2019; 15: 442-447
        • Batra Y.K.
        • Rakesh S.V.
        • Panda N.B.
        • Lokesh V.C.
        • Subramanyam R.
        Intrathecal clonidine decreases propofol sedation requirements during spinal anesthesia in infants.
        Paediatr Anaesth. 2010; 20: 625-632
        • Schnabel A.
        • Poepping D.M.
        • Pogatzki-Zahn E.M.
        • Zahn P.K.
        Efficacy and safety of clonidine as additive for caudal regional anesthesia: a quantitative systematic review of randomized controlled trials.
        Paediatr Anaesth. 2011; 21: 1219-1230