Background and Objectives
The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic‐based techniques in premature and ex‐premature infants undergoing ...lower abdominal surgery.
Methods
All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, ed data, and appraised quality.
Results
Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of “awake” caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation.
The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7–18.4), intermediate for awake caudal (6.6%, 5.26–9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48–7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%–24%), intermediate for awake caudal (7.62%, 0%–60%), and lowest for CSEA (5.53%, 0%–14.3%).
High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals).
Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high‐quality randomized controlled trials, and the eight single‐center retrospective data reviews lacked sufficient data to perform meta‐analysis.
Conclusions
There is insufficient evidence to validate or refute the benefits of the use of “awake” caudal anesthesia in premature and ex‐premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block.
Introduction
Infant spinal anesthesia is an important technique in premature and ex‐premature infants undergoing lower abdominal surgery. Previous studies of infant spinal anesthesia report high ...failure rates, but fail to adequately identify contributing factors. The aim of this study is to retrospectively review spinal anesthetics from a quaternary anesthetic centre to determine overall spinal failure rate, incidence of second spinal attempts and adverse events associated with a second spinal anesthetic.
Methods
A retrospective review of infant spinal anesthetics performed between May 2016 and June 2023.
Results
Five hundred and fifty‐one infants (mean postmenstrual age 42.9 weeks and weight 3873 g) were included. The overall success rate on first attempt was 86.5% with a further 5.1% requiring a successful second spinal anesthetic after initial failure. Spinal anesthetic failure requiring conversion to general anesthesia occurred in 9.4% of cases The causes of failed spinal anesthetic were inability to access the subdural space (dry tap 4.2%), inadequate motor blockade (2.9%), and repeated bloody taps (2.2%). Spinal anesthetic failure was significantly increased in cases where the anesthetist was routinely performing less than 5 spinal anesthetics per year OR 2.21 (95% CI 1.28, 3.83, p = .004) but only weakly associated with years of pediatric anesthetic experience. Failure rates were 21.4% with styletted spinal needles and 9.2% for non styletted OR 2.68 (95% CI 1.23–5.86, p = .012). The incidence of perioperative apnoea was 6.7% with the highest rate in infants in which failed spinal anesthesia required conversion to general anesthesia (25%). There were 28 cases where initial spinal anesthetic failed to produce adequate anesthesia and a repeat spinal anesthetic was performed. Repeat spinal anesthesia was successful in 92.8% of cases with awake caudal anesthesia successful in 7.2% of cases. In three cases high spinal blockade occurred, one after a single spinal and two after a repeat spinal. Both repeat spinal high block cases required intubation and brief resuscitation.
Conclusion
Infant spinal anesthesia is associated with high success rates if experienced anesthetists are present or performing the block. Repeat spinal anesthesia may be associated with an increased incidence of high spinal block. Greater awareness of the slow onset of high block should promote techniques aimed at minimizing cephalad spread of local anesthetic including slight head up positioning during surgery.
Summary
Background
Long gap oesophageal atresia occurs in approximately 10% of all oesophageal atresia infants and surgical repair is often difficult with significant postoperative complications. Our ...aim was to describe the perioperative course, morbidity, and early results following repair of long gap oesophageal atresia and to identify factors which may be associated with complications.
Methods
This is a single center retrospective cohort study of consecutive patients with oesophageal atresia undergoing surgical repair at The Royal Children's Hospital Melbourne from January 2006 to June 2017.
Results
Two hundred and thirty‐nine consecutive oesophageal atresia infants included 44 long gap oesophageal atresia infants and 195 non‐long gap infants. A high rate of prematurity (24.7%), major cardiac (17%), and other surgically relevant malformations (12.6%) was found in both groups. The median age at oesophageal anastomosis surgery was 65.5 days for the long gap group vs 1 day for the oesophageal atresia group (mean difference 56.8 days, 95% CI 48.1‐65.5 days, P < .01). Surgery for long gap oesophageal atresia included immediate primary anastomosis (n = 10), delayed primary anastomosis (n = 11), oesophageal lengthening techniques (n = 12) and primary oesophageal replacement (n = 6). Long gap oesophageal atresia was not associated with an increased incidence of difficult intubation (OR 2.8, 95% CI 0.6‐22.1, P = .17), intraoperative hypoxemia (OR 1.6, 95% CI 0.6‐4.5, P = .32), or hypotension (OR 0.9, 95% CI 0.5‐1.8, P = .81). The surgical duration (177.7 vs 202.1 minute, mean difference 95% CI, 28 5.5‐50.4 minutes, P = .04) and mean duration of postoperative mechanical ventilation (107 vs 199.8 hours, mean difference 95% CI, 91.8 34.5‐149.1 hours, P < .01) were shorter for the non‐long gap group. Overall in‐hospital mortality was 7.5% (15.9% long gap vs 5.6% non‐long gap oesophageal atresia OR 1.1, 95% CI 0.4‐3.4, P = .85).
Conclusion
Long gap oesophageal atresia infants have a similar incidence of perioperative complications to other infants with oesophageal atresia. Current surgical approaches to long gap repair, however, are associated with longer anesthetic exposures and require multiple procedures in infancy to achieve oesophageal continuity.
Aims
Calcific uraemic arteriolopathy (CUA) or calciphylaxis is most commonly seen in end‐stage renal disease and is associated with significant morbidity and mortality. The aim of this study was to ...determine whether hyperbaric oxygen therapy (HBOT) is effective in healing calciphylaxis lesions and to determine if there are any patient factors that can predict wound healing and patient survival.
Methods
We identified by retrospective review all cases of CUA referred to our institution for treatment with HBOT. We documented the clinical and biochemical parameters of this patient population, the size and distribution of the lesions as well as wound outcomes and patient survival following treatment.
Results
A total 46 patients were identified with CUA associated with renal failure. Of the 46 patients, only 34 received a full course of HBOT. The balance was deemed unsuitable for treatment or was unable to tolerate treatment and was palliated. Of the 34 patients that received a full course of HBOT, 58% showed improvement in their wound scores, with more than half of these patients having complete healing of their wounds. The balance did not benefit from the therapy and had a very poor prognosis. Those that benefited from HBOT survived on average for more than 3 years. The only factor significantly associated with improved wound healing and survival was diabetes.
Conclusion
This retrospective analysis suggests a role for HBOT in the treatment of CUA with more than half of the treated patients benefiting and surviving for an average of more than 3 years.
Summary at a Glance
Calciphylaxis is often a pre‐terminal event in dialysis dependent kidney disease, with obese and diabetic patients at highest risk. The role of hyperbaric oxygen therapy (HBOT) in the treatment of calciphylaxis has been unclear, with the therapy often being used as a last therapeutic resort. This paper is possibly the largest case series of HBOT use for the treatment of calciphylaxis and provides useful insights into its place in managing the disease.
A number of high profile conjoined twin separations have been extensively covered by the world media. Anaesthesia for conjoined twins is a procedure rarely experienced by paediatric anaesthetists. ...The increased survival of the twins has prompted discussion as to the most appropriate selection of patients, teams and hospitals to provide exceptional anaesthetic care.
The number of conjoined twins presenting for surgery remains low with many infants not surviving foetal or early neonatal life. Anaesthetic management of less common conjoined infants such as craniopagus twins has highlighted the benefit of careful patient selection, extensive preoperative investigations and meticulous multidisciplinary team planning. The role of simulation of possible adverse perioperative events has been highlighted. Three dimensional anatomical models and virtual reality systems have permitted surgical planning in advance of actual intervention. A number of legal and ethical concerns have been reported especially in the setting of emergency separation where surgery is likely to contribute to death of one of the twins.
There appears to be an expanding role for international teams with extensive separation experience becoming involved in international teleconferencing to improve patient management in low-resource countries. Whether the perioperative outcome is better when the conjoined twins are transferred to major centres for surgery or teams operate in the twin's country of origin remains to be seen.
Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related ...complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists.
Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.
The aim of this review is to identify clinical conditions currently treated in a pediatric population referred to the Alfred hyperbaric unit, to describe outcomes, and detail any complications ...occurring during treatment or transfer between units.
Retrospective, noncontrolled, clinical study.
Adult hyperbaric unit in a university hospital.
Children aged <16 yrs referred for hyperbaric oxygen therapy between January 1998 and December 2010.
Hyperbaric oxygen therapy at pressures from 2.0 to 3.0 atmospheres absolute.
Fifty-four patients with a median age at presentation of 15 yrs (range, 0.25-16 yrs) received 668 treatment sessions (mean, 12.4; 95% confidence interval, 9.2-15.5). Fourteen patients were identified as having successfully completed treatment while managed in intensive care units. There were 44 events in 668 treatments (6.6%) in the pediatric group and 12 events in 126 treatments (9.6%) in the pediatric intensive care unit group. There were two oxygen toxicity convulsion (0.3%), two episodes of progressive hypoxemia (0.3%), and four episodes of brief hypotension (0.6%).
Provision of hyperbaric oxygen to children with significant illness is feasible and associated with a low risk of complications. The most difficult aspect of managing pediatric hyperbaric oxygen therapy is in the coordination of the treatment with ongoing surgical and intensive care management. The lack of pediatric staff and facilities in major hyperbaric units necessitates multiple transfers for appropriate treatment.
Summary
Background
Early negative postoperative behavior (e‐PONB) is common in children and manifests itself as emergence agitation (EA), emergence delirium (ED), and pain. The objective of this ...prospective double blind, randomized, placebo‐controlled trial was to determine whether IV clonidine or IV fentanyl prior to surgery modifies e‐PONB in children.
Methods
Ninety children scheduled for subumbilical surgery under sevoflurane anesthesia supplemented with regional anesthesia were randomized to either receive IV clonidine 2 mcg·kg−1, IV fentanyl 2 mcg·kg−1 or placebo (IV saline) before surgery. Primary outcome measures were the incidence of EA, ED and pain during the first hour after awakening. Secondary outcome measures were side effects such as nausea and vomiting and delayed discharge from PACU.
Results
Eighty‐seven children (n = 29 per group) completed the study. EA was present in 10 children (six clonidine, none fentanyl, and four placebo, P = 0.04) whereas ED was observed in 20 children (nine clonidine, three fentanyl, and eight placebo P = 0.13). Sixteen children who received placebo had a CHIPPS score of ≥4 compared with nine children in fentanyl group and 18 children receiving clonidine (P = 0.04). Ten children receiving fentanyl vomited during the first postoperative day, compared with six children in placebo group and none in clonidine group (P = 0.003). Discharge from PACU was not affected.
Conclusions
IV fentanyl before surgery but not IV clonidine modifies e‐PONB in children undergoing lower abdominal surgery under general anesthesia supplemented with regional anesthesia. The use of fentanyl in this population was also associated with reduced pain scores after awakening but with significantly greater incidence of PONV.
Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has, however, come at the cost of increased number of infants with prematurity related ...complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia, necrotising enterocolitis, sepsis, periventricular leukomalacia, intraventricular haemorrhage, cerebral palsy, hypoxic ischaemic encephalopathy and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Individual congenital conditions requiring surgical intervention in the neonatal period are uncommon. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries and infant physiology. It is important to consider contributing anaesthetic factors during the perioperative period that may affect cerebral perfusion and neurocognitive outcome, such as alterations in haemodynamics and ventilation. Outside of the neonatal period, the most common surgical procedures performed in ex-premature infants are inguinal hernia repair and ophthalmologic procedures due to retinopathy of prematurity. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.
Spinal anaesthesia in the neonate Frawley, Geoff, MBBS, FANZCA; Ingelmo, Pablo, MD
Best practice & research. Clinical anaesthesiology,
09/2010, Letnik:
24, Številka:
3
Journal Article
Recenzirano
Postoperative apnoea in ex-premature infants is inversely proportional to gestational age at birth and postmenstrual age (PMA). Spinal anaesthesia is an important technique in ex-premature infants as ...it reduces the risk of postoperative apnoea, provided intra-operative sedation is avoided. Recent studies have provided more data on recommended doses of local anaesthetics for infant spinal anaesthesia as well as adjuvants used to prolong the duration of surgical anaesthesia. Spinal anaesthesia is also used for surgical procedures other than inguinal hernia repair. There are a variety of reasons why awake regional is not the preferred technique for ex-premature infants undergoing lower abdominal surgery in many centres, and there is also controversy over the appropriate anaesthetic technique for outpatient surgery in infants <60 weeks PMA. A pragmatic decision analysis on the selection of anaesthetic techniques for inguinal hernia repair in infants is presented.
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