J Med Cases
Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc
Journal website http://www.journalmc.org

Case Report

Volume 9, Number 2, February 2018, pages 64-67


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

Emily D. Geyera, David P. Martina, b, Tarun Bhallaa, b, Venkata R. Jayanthic, d, Joseph D. Tobiasa, b, e, Emmett E. Whitakera, b

aDepartment of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
bDepartment of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
cDivision of Pediatric Urology, Nationwide Children’s Hospital, Columbus, OH, USA
dDepartment of Urology, The Ohio State University College of Medicine, Columbus, OH, USA
eCorresponding Author: Joseph D. Tobias, Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA

Manuscript submitted December 21, 2017, accepted January 15, 2018
Short title: Combined Spinal and Caudal Epidural Anesthesia
doi: https://doi.org/10.14740/jmc2994w

Abstract▴Top 

With emerging evidence that specific anesthetic agents may affect neurocognitive outcomes, there has been renewed interest in the applications of spinal anesthesia in neonates and infants. Because of its short duration of action, spinal anesthesia in infants is generally limited to procedures lasting less than 70 - 75 min. To avoid this limitation, we report a technique combining spinal and caudal epidural anesthesia. We present two infants in whom this technique was used to provide surgical anesthesia (without general anesthesia or airway manipulation) for two cases lasting more than 90 min. The technique used is presented, its applications discussed, and previous reports reviewed.

Keywords: Regional anesthesia; Pediatric; Neurotoxicity; Safety

Introduction▴Top 

Spinal anesthesia (SA) became a popular technique during the 1980s when it was used as an alternative to general anesthesia (GA) as a means of avoiding postoperative apnea in high-risk, former preterm neonates [1]. However, with the introduction of sevoflurane into clinical practice, the risk of apnea was shown to be limited and interest in SA waned [2]. More recently, there have been numerous reports in the literature regarding the potential long-term neurocognitive effects of GA during infancy and the neonatal period [3, 4]. While there is insufficient prospective evidence to clearly prove a causal relationship, there has been a renewed interest in the use of SA as a means of avoiding GA during the potentially vulnerable time period. Given its limited duration of action, single-shot SA is applicable only for surgical procedures that can be accomplished in less than 70 - 75 min. We present two infants in whom a combined SA with a caudal epidural catheter technique was used to provide surgical anesthesia for cases lasting more than 90 min. The technique is presented, its applications discussed, and previous reports from the literature regarding the combined use of spinal and epidural anesthesia in the pediatric population reviewed.

Case Report▴Top 

Institutional Review Board approval is not required for presentation of case series with two or fewer patients at Nationwide Children’s Hospital (Columbus, OH).

Case 1

At the time of the surgery, the patient was a 2-year-old, 11.2 kg boy scheduled for first stage hypospadias repair. He had no allergies. His medication history was significant only for albuterol and cetirizine, which he took for wheezing (reactive airway disease) and seasonal allergies, respectively. There was also a history of previous problems with general anesthesia and an unexplained cardiac arrest during an orchidopexy. Although a thorough post-procedure cardiac evaluation was negative, the patient’s parents were motivated to avoid GA for subsequent procedures. For this first stage hypospadias repair, SA alone would not be sufficient due to the length of the procedure. Informed consent was obtained for combined spinal anesthesia and caudal epidural anesthesia with sedation. The patient’s vital signs on the morning of the procedure were unremarkable. In the preoperative area, LMX cream (4% topical lidocaine) was applied to the lumbar spine to minimize discomfort with placement of the spinal needle. After arrival to the operating room, the patient was placed in the sitting position. After sterile preparation, the intrathecal space was accessed on the first attempt using a 1.5 inch, 22-gauge spinal needle. Upon return of cerebrospinal fluid, 1.2 mL of 0.5% bupivacaine-epinephrine 1:200,000 with clonidine (11 µg) was administered. Following successful SA, the patient was then placed in the supine position, standard monitors were placed, and a 22-gauge peripheral intravenous catheter was placed in the right foot. Immediate sensory and motor block were noted. A single dose of dexmedetomidine (total of 12 µg in divided doses) was administered intravenously for sedation during caudal epidural catheter placement. The patient was placed in right lateral decubitus position for caudal epidural catheter placement. After sterile preparation, the caudal epidural space was accessed using an 18-gauge Tuohy needle. A 20-gauge caudal catheter was advanced 3 cm into the epidural space to allow sacral coverage. The needle was removed and the catheter secured. A test dose of lidocaine 1.5% with epinephrine 1:200,000 (1 mL) was negative. The patient was placed supine and the surgical procedure started under SA. Dexmedetomidine (0.5 - 1 µg/kg/h) was administered intravenously for intraoperative sedation. Approximately 1 h after the start of the surgical procedure, the caudal catheter was dosed with 3% chloroprocaine (1 mL/kg) followed by a continuous infusion of 3% chloroprocaine (1.5 mL/kg/h). The surgery was completed with excellent operating conditions. The patient was hemodynamically stable and required no supplemental oxygen throughout the procedure, which lasted approximately 2 h. The caudal catheter was removed in the operating room following completion of the surgery. The patient’s post-anesthesia care unit (PACU) stay was uncomplicated and he was discharged home that afternoon without incident. The parents were very satisfied with the care of their son, and they requested the same approach for his second-stage hypospadias repair, which was also performed successfully.

Case 2

At the time of the surgery, the patient was a 16-month-old, 8.75 kg girl scheduled for bilateral ureteral reimplantation. The patient had a known history of Tetralogy of Fallot (TOF) status post repair, grade 4 primary vesicoureteral reflux, recurrent pyelonephritis, and difficult postoperative pain management. She had no allergies. Her medication history was significant only for trimethoprim-sulfamethoxazole for urinary tract infection prophylaxis. Preoperative laboratory studies were not performed and her vital signs on the morning of the procedure were unremarkable. An echocardiogram performed 2 months before the surgery revealed findings typical for a patient that had undergone TOF repair with normal biventricular function. The patient had previously received GA uneventfully, but her parents desired avoidance of GA due to her history of congenital heart disease. Informed consent was obtained for combined spinal anesthesia and caudal epidural anesthesia. In the preoperative area, LMX cream (4% topical lidocaine) was applied to the lumbar to minimize discomfort with the placement of the spinal needle. After arrival to the operating room, the patient was placed in the sitting position. After sterile preparation, the intrathecal space was accessed on the first attempt using a 1.5 inch, 22-gauge spinal needle. Upon return of cerebrospinal fluid, 1.2 mL of 0.5% bupivacaine with epinephrine 1:200,000 was administered. Following successful SA, the patient was placed in the supine position, standard monitors were placed, and a 22-gauge peripheral intravenous catheter was placed in the left foot. Immediate sensory and motor block were noted. The patient was then placed in the right lateral decubitus position for caudal epidural catheter placement. After sterile preparation, the caudal epidural space was accessed using an 18-gauge Tuohy needle. A 20-gauge epidural catheter was advanced 5 cm into the epidural space to allow for a T10-12 blockade. The needle was removed and the catheter secured. A test dose of lidocaine 1.5% with epinephrine 1:200,000 (1 mL) was negative. For the first 40 min of the procedure, the patient slept comfortably without need for additional medications. After 40 min, dexmedetomidine (8 µg) was administered intravenously for irritability with good effect. At 1 h post-incision, 0.2% ropivacaine (6 mL) was administered via the caudal epidural catheter and another dose of dexmedetomidine (4 µg) was administered intravenously. The procedure, which lasted approximately 2 h, was completed successfully. The patient was hemodynamically stable and required no supplemental oxygen throughout the operation. The caudal epidural catheter was removed in the operating room following completion of the surgery. Her PACU stay was uncomplicated, and she was discharged to home the next morning without incident.

Discussion▴Top 

Our institution has developed a SA program to offer an alternative to GA for appropriate cases in light of concerns related 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, [5-9]), the majority of these reports have used the technique for avoidance of GA in a high-risk child [5-10]. 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. The spinal plus caudal epidural catheter technique can be used to circumvent the temporal limitations of SA, and in theory can be used for any length surgical procedure. Herein we report our successful experience with the technique in two infants to illustrate the technical aspects of the procedure as well as options for medication dosing.

Table 1.
Click to view
Table 1. Previous Reports of Regional Anesthesia for Prolonged Surgical Procedures
 

Although SA in children is a relatively simple, elegant technique, it is not without limitations. As it is a single-shot technique, it can only be used for procedures that last approximately 1 hour [11, 12]. Adjunctive agents such as epinephrine or clonidine can be added to the local anesthetic agent that may extend that duration 20-30%, but the upper limit of duration remains 70 - 75 minutes [13]. Additionally, SA is generally reserved for pelvic and lower abdominal procedures. With this combined technique, it may be possible to perform more cephalad surgeries because a higher level of surgical anesthesia is possible with more cephalad placement of the tip of the epidural catheter.

In addition to avoiding potential neurotoxicity, SA provides several advantages over GA. SA provides superior intraoperative hemodynamic stability (decreased hypotension and bradycardia) when compared to GA [14]. 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. Combining methods of regional anesthesia can provide a surgical team with an extended window of time to perform surgical procedures. Furthermore, the surgical anesthesia provided by the initial SA provides effective anesthesia for placement of the caudal epidural catheter without the need for additional agents. Given the prolonged duration of the procedure, as noted in both of our patients, supplemental sedation may be required during the procedure given the cognitive level and limited ability of infants and children to remain quiet for a 2-h surgical procedure. Our experience with the technique and its efficacy have allowed us to expand its application outside of the neonatal and infant age range as our patients were 2 years and 16 months of age, respectively. Key to the success of this regional instead of general anesthesia program has been the cooperation of a well-trained, multidisciplinary team of surgeons, pediatric anesthesiologists, and nurses.

Conflict of Interest

None.

Financial Support

None.

Author Contributions

All authors contributed equally to this manuscript.


References▴Top 
  1. Welborn LG, Rice LJ, Hannallah RS, Broadman LM, Ruttimann UE, Fink R. Postoperative apnea in former preterm infants: prospective comparison of spinal and general anesthesia. Anesthesiology. 1990;72(5):838-842.
    doi pubmed
  2. William JM, Stoddart PA, Williams SA, Wolf AR. Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. Br J Anaesth. 2001;86(3):366-371.
    doi pubmed
  3. Davidson AJ. Anesthesia and neurotoxicity to the developing brain: the clinical relevance. Paediatr Anaesth. 2011;21(7):716-721.
    doi pubmed
  4. Blaylock M, Engelhardt T, Bissonnette B. Fundamentals of neuronal apoptosis relevant to pediatric anesthesia. Paediatr Anaesth. 2010;20(5):383-395.
    doi pubmed
  5. Williams RK, McBride WJ, Abajian JC. Combined spinal and epidural anaesthesia for major abdominal surgery in infants. Can J Anaesth. 1997;44(5 Pt 1):511-514.
    doi pubmed
  6. Somri M, Tome R, Yanovski B, Asfandiarov E, Carmi N, Mogilner J, David B, et al. Combined spinal-epidural anesthesia in major abdominal surgery in high-risk neonates and infants. Paediatr Anaesth. 2007;17(11):1059-1065.
    doi
  7. Arora MK, Nagaraj G, Lakhe ST. Combined spinal-epidural anesthesia for a child with Freeman-Sheldon syndrome with difficult airway. Anesth Analg. 2006;103(6):1624.
    doi pubmed
  8. Tobias JD. Anesthetic care for the child with Morquio syndrome: general versus regional anesthesia. J Clin Anesth. 1999;11(3):242-246.
    doi
  9. Tobias JD, Lowe S, O’Dell N, Pietsch JB, Neblett WW, 3rd. Continuous regional anaesthesia in infants. Can J Anaesth. 1993;40(11):1065-1068.
    doi pubmed
  10. Goeller JK, Bhalla T, Tobias JD. Combined use of neuraxial and general anesthesia during major abdominal procedures in neonates and infants. Paediatr Anaesth. 2014;24(6):553-560.
    doi pubmed
  11. Frawley G, Bell G, Disma N, Withington DE, de Graaff JC, Morton NS, McCann ME, et al. Predictors of failure of awake regional anesthesia for neonatal hernia repair: data from the general anesthesia compared to spinal anesthesia study - comparing apnea and neurodevelopmental outcomes. Anesthesiology. 2015;123(1):55-65.
    doi pubmed
  12. Williams RK, Adams DC, Aladjem EV, Kreutz JM, Sartorelli KH, Vane DW, Abajian JC. The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry. Anesth Analg. 2006;102(1):67-71.
    doi pubmed
  13. Rochette A, Raux O, Troncin R, Dadure C, Verdier R, Capdevila X. Clonidine prolongs spinal anesthesia in newborns: a prospective dose-ranging study. Anesth Analg. 2004;98(1):56-59, table of contents.
    doi pubmed
  14. Ing C, Sun LS, Friend AF, Kim M, Berman MF, Paganelli W, Li G, et al. Differences in intraoperative hemodynamics between spinal and general anesthesia in infants undergoing pyloromyotomy. Paediatr Anaesth. 2017;27(7):733-741.
    doi pubmed


This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Journal of Medical Cases is published by Elmer Press Inc.

 
Home     |     Log In     |      About     |      Search     |      Current     |      Archives     |      Submit      |     Subscribe


 

     

Aims and Scope

Current Issues

Conflict of Interest

About Publisher

Editorial Board

Archives

Copyright

Company Profile

Editorial Office

Misconduct and Retraction

Permissions

Company Registration

Contact Us

Abstracting and Indexing

ICMJE

Ownership

Instructions to Authors

Access

Declaration of Helsinki

Contact Publisher

Submission Checklist

Reprints

Terms of Use

Company Address

Submit a Manuscript

Open Access Policy

Privacy Policy

Browse Journals

Publishing Fee

Publishing Policy

Disclaimer

Recent Highlights

Peer-Review Process

Publishing Quality

Code of Ethics

Advertising Policy

Manuscript Tracking

Advanced Search

For Librarians

Careers

Publishing Process

Publication Frequency

For Reviewers

Propose a New Journal

       
       

Journal of Medical Cases, monthly, ISSN 1923-4155 (print), 1923-4163 (online), published by Elmer Press Inc.     
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)


This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.journalmc.org   editorial contact: editor@journalmc.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.

DECLARATION: THIS JOURNAL SITE OUTLOOK IS DESIGNED BY THE PUBLISHER AND COPYRIGHT PROTECTED. DO NOT COPY!