Anesth Analg 2001;92:1439-1441
© 2001 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Single-Dose Caudal Anesthesia for Major Intraabdominal Operations in High-Risk Infants
Giovanni Cucchiaro, MD*,
Pascal De Lagausie, MD
,
Alla El-Ghonemi, MD*, and
Yves Nivoche, MD*
Departments of *Anesthesiology and Surgery, Hôpital Robert Debré, Paris, France
Address correspondence and reprint requests to Giovanni Cucchiaro, MD, Départément d’Anesthésie et Réanimation, Hôpital Robert, Debré, 48 Boulevard Sérurier, 75019 Paris, France.
 |
Introduction
|
|---|
Regional anesthesia in conscious infants has been widely used for surgical procedures in neonates. Single-dose spinal anesthesia is often used for lower-extremity procedures, inguinal hernia repair, and urologic procedures (1), as well as intraabdominal operations (2). Caudal epidural anesthesia has been used for extraabdominal procedures (3).
We present three case reports in which conscious neonates at high anesthetic risk because of prematurity, low birth weight, or associated pulmonary diseases underwent intraabdominal operations that used single-dose caudal anesthesia as their principle anesthetic.
|
Case Reports
|
|---|
Intraoperative monitors included electrocardiogram, pulse oximeter, and blood pressure cuff. The patients were placed in the left lateral decubitus position for their caudal anesthesia. After atropine 20 µg/kg and 0.2 mL of 0.5% lidocaine for local anesthesia, a 22-gauge needle was placed through the sacrococcygeal membrane into the epidural space. After negative aspiration, 1 mL/kg of bupivacaine 0.375% with 1:200,000 epinephrine and 1 µg/kg of clonidine were injected. The sensory level was assessed by reaction to skin pinch. The motor block was considered resolved upon recovery of hip flexion. Postoperative pain was evaluated by using the Objective Pain Scale.1
Case 1
A 2.3-kg female infant, delivered by cesarean section at 35 wk of gestation, was diagnosed with Donohue syndrome (leprechaunism) and atrial septal defect, and she had a right ovarian cyst that was resected under general anesthesia on Day 15 of life. The patient required 6 h of postoperative ventilatory support followed by a 24-h stay in the neonatal intensive care unit (NICU) for control of severe postoperative apnea and hypoxemia. The histologic examination revealed a granulosa cell tumor of the ovary. Five weeks later, while in the NICU (weight 2.5 kg) for severe anemia requiring multiple transfusions and for right upper-lobe pneumonia, she was diagnosed with a left ovarian mass. The patient was receiving total parenteral nutrition and was tachycardic, tachypneic, and oxygen dependent. An echocardiogram showed persistent atrial septal defect with ventricular septal hypertrophy. Caudal anesthesia was performed as described above. Motor block of the lower extremities was observed after 10 min. Because of the compromised general conditions of the patient, who had minimal-to-no reaction to skin pinch, it was impossible to properly evaluate the level of the sensory block. The ovariectomy was done through a Pfannenstiel (transverse-suprapubic) incision, and the surgical procedure lasted 25 min. Oxygen 1 L/min was given via face mask. No supplemental analgesia or sedation was necessary. Motor functions recovered 130 min after the block. The patient did not require postoperative analgesia, and because of her compromised general conditions, she returned to the NICU 3 h after the operation. The patient died 4 wk later of metastatic disease.
Case 2
A 2-mo-old boy, born at 29 wk of gestation (weight at birth 1.1 kg), required a laparotomy for acute intestinal obstruction. The patient had severe respiratory distress syndrome at birth; this required surfactant replacement therapy. He subsequently developed bronchopulmonary dysplasia and required prolonged mechanical ventilation. He also developed necrotizing enterocolitis, which resolved after 2 wk of total parenteral nutrition and broad-spectrum antibiotics. Caudal anesthesia was performed as previously described. A lower-extremities motor block was observed after 8 min, and the sensory level seemed to be at a T2-3 level. After a median incision from the pubis to the umbilicus, a stenosis of the ileocecal junction was discovered. Resection and ileocecal anastomoses were then performed. The operation lasted 110 min. The motor block had resolved by the time the patient was brought to the recovery room. Paracetamol (30 mg/kg) and nalbuphine (200 µg/kg) were started 10 h later and continued for 72 h. The patient was sent to a regular floor 2 h later with an apnea monitor.
Case 3
A 3.4-kg baby girl, born at 39 wk of gestation, was diagnosed with an ovarian cyst at 33 wk of gestation. A radiogram of the abdomen done at birth showed a coincidental small right pneumothorax, which was evacuated with a needle. Three hours later, she was brought to the operating room. Caudal anesthesia was performed as previously described. A lower-extremities motor block was obtained 9 min later, and the sensory level seemed to be at T3-5. After a Pfannenstiel incision, an intestinal duplication was discovered. Resection and ileoileal anastomoses were then performed. The operation lasted 90 min, and the patient did not require further analgesia or anesthesia. The motor block had resolved by the time the patient was brought to the recovery room. The postoperative course was uneventful. The first doses of propacetamol (30 mg/kg) and nalbuphine (200 µg/kg) were given 8 h after the caudal block. Both medications were continued for 48 h.
|
Discussion
|
|---|
We described the use of caudal anesthesia, with a combination of bupivacaine and clonidine, as the sole anesthetic management in three ASA III neonates who underwent complex intraabdominal operations. We chose a concentration of 0.375% bupivacaine to obtain an adequate muscle relaxation and a dose of 1 mL/kg to obtain an adequate sensory level (3). There were no clinical or electrocardiographic signs of cardiac or neurologic toxicity. We added clonidine to potentiate the intraoperative analgesia induced by the local anesthetic and prolong the extent of postoperative analgesia (as previously reported) (4,5). Patients did not require intraoperative supplemental analgesia, and the first dose of pain relief medication was given as early as eight hours after the caudal block.
The use of single-dose caudal anesthesia in conscious neonates has been previously reported only for extraabdominal operations, inguinal hernia repair, and urologic (1,6) and anorectal procedures (7). Several authors have described the use of spinal anesthesia with tetracaine for prolonged intraabdominal operations (8,9). However, tetracaine is not commercially available in France, and the duration of surgical anesthesia after subarachnoid bupivacaine varies between 70 and 84 minutes (10). We felt that this might be too short for potentially complex intraabdominal procedures, and we preferred to use a caudal block. We used doses and concentrations that have been shown to provide adequate anesthesia for up to 150 minutes (3), at least during extraabdominal operations. There are few reports on the use of a combined spinal and epidural technique to obtain a prolonged surgical anesthesia and for postoperative pain control (11,12). However, clonidine, because of its effects on both the intensity and quality of analgesia (13,14), might obviate the need for a caudal catheter, with the potential associated risks (15,16). We used a large dose of bupivacaine (3.75 mg/kg). However, there are clinical data indicating that the plasma levels of bupivacaine, after a single caudal administration of 3.25–3.7 mg/kg in children, are well below 4 µg/mL, which is considered to be toxic (17,18).
Postoperative monitoring for apnea is imperative in this group of patients, regardless of the anesthetic technique used but particularly after the use of clonidine (19–21). Further studies are needed to demonstrate the clinical advantages of this technique compared with spinal or general anesthesia in this patient population.
|
Footnotes
|
|---|
1Broadman LM, Rice LJ, Hannallah RS. Testing the validity of an objective pain scale for infant and children [abstract]. Anesthesiology 1988;69:A770. 
|
References
|
|---|
-
Aguemon AR, Terrier G, Lansade A, et al. Anesthésie caudale et rachianesthésie dans la chirurgie sous-ombilicale chez l’enfant. Cah Anesthésiol 1996; 44: 455–63.[Medline]
-
Williams RK, McBride WJ, Abajian JC. Combined spinal and epidural anesthesia for major abdominal surgery in infants. Can J Anaesth 1997; 44: 511–4.[Abstract/Free Full Text]
-
Gunter JB, Watcha MF, Forestner JE, et al. Caudal epidural anesthesia in conscious premature and high-risk infants. J Pediatr Surg 1991; 26: 9–14.[ISI][Medline]
-
Constant I, Gall O, Gouyet L, et al. Addition of clonidine or fentanyl to local anesthetics prolong the duration of surgical analgesia after single shot caudal block in children. Br J Anaesth 1998; 80: 294–8.[Abstract/Free Full Text]
-
Bauvoir C, Rochette A, Raux O, et al. Clonidine prolongation of caudal anesthesia in children [abstract]. Anesthesiology 1998; 81: A1347.
-
Tobias JD, Flannagan J, Brock J, Brin E. Neonatal regional anesthesia: alternative to general anesthesia for urologic procedures. Urology 1993; 41: 362–5.[ISI][Medline]
-
Touloukin RJ, Wugmeister M, Pickett LK. Caudal anesthesia for neonatal anoperineal and rectal operations. Anesth Analg 1971; 50: 565–8.[Free Full Text]
-
Harnik EV, Hoy GR, Potolicchio S, et al. Spinal anesthesia in premature infants recovering from respiratory distress syndrome. Anesthesiology 1986; 64: 95–9.[ISI][Medline]
-
Gingrich BK. Spinal anesthesia for a former premature infant undergoing upper abdominal surgery. Anesthesiology 1993; 79: 189–90.[ISI][Medline]
-
Parkinson SK, Little WL, Malley RA, et al. Use of hyperbaric bupivacaine with epinephrine for spinal anesthesia in infants. Reg Anesth 1990; 15: 86–8.[ISI][Medline]
-
Williams RK, McBride WJ, Abajian JC. Combined spinal and epidural anesthesia for major abdominal surgery in infants. Can J Anaesth 1997; 44: 511–4.
-
Henderson K, Sethna NF, Berde CB. Continuous caudal anesthesia for inguinal hernia repair in former preterm infants. J Clin Anesth 1993; 5: 129–33.[ISI][Medline]
-
Klimscha W, Chiari A, Michalek-Sauberer A, et al. The efficacy and safety of clonidine/bupivacaine combination in caudal blockade for pediatric hernia repair. Anesth Analg 1998; 86: 54–61.[Abstract]
-
Lee JJ, Rubin AP. Comparison of a bupivacaine-clonidine mixture with plain bupivacaine for caudal analgesia in children. Br J Anaesth 1994; 72: 258–62.[Abstract/Free Full Text]
-
Lenox WC, Kost-Byerly S, Shipley R, Yaster M. Pediatric caudal epidural catheter sequestration: an unusual complication. Anesthesiology 1995; 83: 1112–4.[ISI][Medline]
-
Strafford MA, Wilder RT, Berde CB. The risk of infection from epidural analgesia in children: a review of 1620 cases. Anesth Analg 1995; 80: 234–8.[Abstract]
-
Ecoffey C, Dubousset AM, Samii K. Lumbar and thoracic epidural anesthesia for urologic and upper abdominal surgery in infants and children. Anesthesiology 1986; 65: 87–90.[ISI][Medline]
-
Takasaki M. Blood concentrations of lidocaine, mepivacaine and bupivacaine during caudal analgesia in children. Acta Anaesthesiol Scand 1984; 28: 211–4.[ISI][Medline]
-
Braschan C, Krumpholz R, Likar R, et al. Can a dose of 2 mcg/kg caudal clonidine cause respiratory depression in neonates? Paediatr Anaesth 1999; 9: 81–3.[ISI][Medline]
-
Watcha MF, Thach BT, Gunter JB. Postoperative apnea after caudal anesthesia in an ex-premature infant. Anesthesiology 1989; 71: 613–5.[ISI][Medline]
-
Tobias JD, Burd RS, Helikson MA. Apnea following spinal anesthesia in two former pre-term infants. Can J Anaesth 1998; 45: 985–9.[Abstract/Free Full Text]
Accepted for publication January 26, 2001.
This article has been cited by other articles:
|
|
|
|
 
T. Uejima, S. Suresh, and G. Cucchiaro
Is 0.375% Bupivacaine Safe in Caudal Anesthesia in Neonates and Young Infants? * Response
Anesth. Analg.,
April 1, 2002;
94(4):
1041 - 1041.
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Reports
