Awake caudals and epidurals should be used more frequently in neonates and infants

Abstract

The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.

Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach

“…61e63 These blocks allow for pain relief without the risks of systemic side effects of opioids such as cardiorespiratory impairment. 64 They allow for earlier extubation, decreased perioperative apnea and respiratory morbidity, decreased exposure to volatile anesthetic agents, lower perioperative response to stress, and better pain relief. 62 They can also be used as the sole anesthetic agent in awake patients for minor surgeries (inguinal hernia repair, circumcision, orchidopexy, hydrocele, hypospadias repair, rectal surgery, or lower extremity surgery) or for procedures (chest tubes, proctoscopy, colonoscopy, cystoscopy, or nonsurgical reduction of intussusception).…”

“…62 They can also be used as the sole anesthetic agent in awake patients for minor surgeries (inguinal hernia repair, circumcision, orchidopexy, hydrocele, hypospadias repair, rectal surgery, or lower extremity surgery) or for procedures (chest tubes, proctoscopy, colonoscopy, cystoscopy, or nonsurgical reduction of intussusception). 63,64 Placement of neuraxial blockade requires an experienced provider with good technique for appropriate placement and careful attention to pediatric analgesic dosing to prevent local anesthetic toxicity that may result in seizures or dysrhythmias. 62,63 Topical Analgesic Agents…”

Safeguarding Infant Brains: A Multidisciplinary Challenge—Results of a Survey, Update on Current Scientific Evidence, and Recommendations on How to Deal with Possible Anesthetic Drug Neurotoxicity

“…23 Other awake regional anesthesia techniques, such as caudal or epidural anesthesia, are currently under consideration for a growing number of surgical procedures, among them is laparoscopic surgery. 27 Awake regional anesthesia techniques applied in young infants require close cooperation between pediatric surgeons and anesthesiologists.…”

Ultrasound-guided caudal approach to combined spinal-epidural for major abdominal surgery in high risk premature newborns

“…Spinal anesthesia is a well-accepted anesthetic technique for ex-premature infants undergoing lower abdominal surgery. Its major advantages over general anesthesia are the minimization of postoperative apnea risk and the need for ventilatory support [1].The practice of general anesthesia (GA) might have a negative impact regarding those issues.Ultrasound equipment has enabled the development of new anesthetic approaches to neuraxial anesthesia.After obtaining written parental consent to publish, we report the case of an ex-premature infant submitted to supraumbilical abdominal surgery under ultrasound-guided trans-caudal, combined spinal-epidural anesthesia. Fig.…”

“…Spinal anesthesia is a well-accepted anesthetic technique for ex-premature infants undergoing lower abdominal surgery. Its major advantages over general anesthesia are the minimization of postoperative apnea risk and the need for ventilatory support [1].…”