Regional anaesthesia in high-risk infants

Abstract

We were impressed with the number of problems reported by Webster et al., in their experience providing spinal anaesthesia for high-risk neonates, l Also we have encountered some complications and reviewed our experience over a four-year period.We attempted to perform spinal anaesthesia for inguinal hernia repair in 62 expremature infants with a mean weight of 2.9 kg and a mean postconceptual age of 42 wk. Tetracaine with epinephrine was used for all patients, usually in a dose of 0.4 mg. kg -1 and a minimum of 1 mg. Placement of the block was done in the lateral decubitus position.We were unable to locate CSF in six patients. In four infants the sensory level achieved was inadequate to perform the procedure, and general anaesthesia was required. In two infants, the sensory level was sufficient to repair the symptomatic hernia, but it receded too quickly to allow exploration of the asymptomatic side. Two infants developed respiratory insufficiency associated with high segmental blocks and required tracheal intubation. Two infants developed hypotension shortly after the block was placed which responded to fluid boluses. One infant with no preoperative history of apnoea and who received no sedation had apnoeic episodes intraoperatively. Twenty of the infants required some sedation intraoperatively, usually ketamine, but rarely morphine, fentanyl, thiopentone or nitrous oxide. There were no intraoperative respiratory complications in those patients who received sedatives.Postoperatively, five of the infants had apnoeic episodes within the first 24 hr of surgery. One episode was temporally related to the use of morphine for postoperative analgesia. The other four infants had preoperative histories of apnoea, and had received no sedatives in the perioperative period.While we believe that regional anaesthesia in this highrisk population is preferable to general anesthesia, we have found that spinal anaesthesia is not without complications. Since reviewing these 62 cases, we discovered that increasing the dosage of tetracaine has provided higher sensory levels and a longer duration of block. The technical problems of the difficult or failed spinal are not so easily rectified. We have found that placing caudals is usually easier and associated with a high success rate. z3 The onset of sensory blockade is slower, and muscle relaxation is not as profound with caudal anaesthesia as with spinal anaesthesia. Despite this, our surgeons have been pleased with the uniformly successful blocks. We now routinely initially attempt caudal blockade using 0.375% bupivicaine with 1:200,000 epinephrine unless there is a contraindication. Extradural blood patch for post-lumbar puncture headaches in cancer patientsTo the Editor: We were recently asked to evaluate a 19-yr-old girl who was severely debilitated by a headache 24 hr after diagnostic lumbar puncture. The patient with a diagnosis of embryonal cell rhabdomyosarcoma required a lumbar puncture in accordance with her assigned treatment protocol to survey for evidence of central ner...

Complications in regional anaesthesia

“…One study which showed that regional anaesthesia was used less commonly in paediatric cases than in adults (Morray et al 1993) raises the complex issue of anaesthesia decision making in terms of outcome. When faced with the choice of anaesthesia for inguinal herniotomy in an ex-premature infant with bronchopulmonary dysplasia (Bailey, Valley & Peacock 1992;Peutrell & Hughes 1994), it might be asked: what is the greater risk, neurological complications associated with regional blockade or apnoea and prolonged intubation following general anaesthesia?…”