Combined use of neuraxial and general anesthesia during major abdominal procedures in neonates and infants

Abstract

SummaryWith the advent of ultrasound and improvements in equipment, the applications of regional anesthesia in the pediatric population have continued to expand. Although frequently used for postoperative analgesia or as a means of avoiding general anesthesia in patients with comorbid conditions, the adjunctive use of regional anesthesia during general anesthesia may effectively decrease the intraoperative requirements for intravenous and volatile agents, thereby providing a more rapid awakening and earlier tracheal extubation. More recently, the limitation of the requirements for volatile and other anesthetic agents may be desirable, given concerns regarding the potential impact of these agents on neurocognitive outcome in neonates and infants. Several authors have demonstrated the potential utility of combining a neuraxial technique (spinal or epidural anesthesia) with general anesthesia in neonates and infants undergoing intraabdominal procedures. We review the literature regarding the combined use of neuraxial and general anesthesia in neonates and infants during major abdominal surgery, discuss its potential applications in this population, and review the techniques of such practice.

The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine Recommendations on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia

“…23,24 Hyperbaric or isobaric bupivacaine, isobaric levobupivacaine, or ropivacaine can also be used. 25 The recommended dosage for hyperbaric bupivacaine is 1 mg/kg 0.5% in children weighing less than 5 kg, 0.4 mg/kg in children 5 to 15 kg, and 0.3 mg/kg in children weighing more than 15 kg.…”

Fluoroscopically guided tunneled trans-caudal epidural catheter technique for opioid-free neonatal epidural analgesia

“…Opioid-free epidural analgesia provides an awake, pain-free infant, who, like other children, may express frustration about hunger, temperature fluctuation, loneliness, etc., by crying. Parenteral or neuraxial opioids provide for a more sedated child, but excessive sedation in this vulnerable population may be linked to worse longterm neurocognitive outcomes, and any method to reduce excessive sedation should be considered by all members of the multidisciplinary team [17,18]. Secondly, multiple procedures, like circumcision or inguinal hernia repair, may often be done in addition to the primary thoracotomy or laparotomy.…”

Combined Spinal and Caudal Epidural Anesthesia for Prolonged Surgical Procedures in Pediatric-Aged Patients: A Report of Two Cases

“…Additionally, SA has been shown to lead to more effective blunting of the surgical stress response, lack of a need for airway management or supplemental oxygen, and limited need for parenteral opioids [10]. While SA has typically been limited to procedures lasting less than 70 -75 minutes, this report presents an effective technique combining spinal and caudal epidural anesthesia for two prolonged urologic procedures lasting more than 90 min.…”

“…2018;9(2):64-67 to potential anesthetic neurotoxicity. Although the use of continuous SA, continuous caudal anesthesia, and SA combined with epidural anesthesia have been previously described ( Table 1, [5][6][7][8][9]), the majority of these reports have used the technique for avoidance of GA in a high-risk child [5][6][7][8][9][10]. Our goal with the reported technique (SA plus placement of a caudal epidural catheter) was to develop a technique that could be offered as a viable alternative to GA for longer surgical procedures, especially given recent concerns of the potential long term neurocognitive effects of general anesthetic agents.…”