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Departments of Anesthesia and Pediatrics; College of Medicine, University of Vermont; Burlington, Vermont; Robert.Williams{at}vtmednet.org
In Response:
We thank Dr. Mayhew (1) for his comments on our study (2) and agree that spinal anesthesia appears to be underutilized for otherwise appropriate surgical procedures in infants.
Although we acknowledge that the relatively short duration of action of spinal anesthetics in infants may ultimately limit its utility, the minimal expected duration of surgical anesthesia typically ranges from 60 to 90 min (3). The duration of neuraxial blockade may be further prolonged by using a combined spinal/epidural technique, or by the addition of intrathecal clonidine (4,5). In our patients (2), the duration of tetracaine spinal anesthesia was sufficient for a variety of surgical procedures performed by numerous surgeons and trainees. The need to convert to general anesthesia because of insufficient duration of anesthesia was just 1.2%.
The administration of supplemental sedation increases the risk of postoperative apnea. For this reason we prefer soothing and stroking our patients to pharmacological sedation, and most of our patients (76%) did not require supplemental sedation. The use of sedation does not negate the other beneficial aspects of the technique. When compared with general anesthesia, spinal anesthesia is associated with a dramatic decrease in the incidence of postoperative hypoxia, bradycardia, and hypotension (6). Even though infants are notorious for respiratory complications, the vast majority of our infants (96%), underwent the entire surgical process from start to finish breathing room air, and oxyhemoglobin desaturation was extremely rare (<0.6%).
Over the past two decades, more than 1500 infants underwent surgery in our institution without requiring active airway management. The cardiovascular and respiratory stability of infant spinal anesthesia is compelling. We endorse Dr. Mayhew’s call for a national survey to identify the barriers that impede widespread use of infant spinal anesthesia.
REFERENCES
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