Anesth Analg 2003;96:412-413
© 2003 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Awake Caudal Anesthesia for Inguinal Surgery in One Conjoined Twin
Christian Seefelder, MD*,
,
David R. Hill, MD*,,
Robert C. Shamberger, MD
,
, and
Robert S. Holzman, MD*,
Departments of *Anesthesia and
Surgery, Children’s Hospital; and
Departments of Anaesthesia and
Surgery, Harvard Medical School, Boston, Massachusetts
Address correspondence and reprint requests to Christian Seefelder, MD, Department of Anesthesia, Children’s Hospital, 300 Longwood Ave., Boston, MA 02115. Address e-mail to christian.seefelder{at}tch.harvard.edu
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Abstract
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IMPLICATIONS: Conjoined twins have some cross-circulation, which makes general anesthesia for only one patient impossible. Using caudal anesthesia in the awake patient, we were able to provide anesthesia for an inguinal central venous catheter placement in one patient without having to unnecessarily anesthetize the other twin.
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Introduction
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Multiple reports of anesthetic considerations for separation surgery of conjoined twins have been published. We report a case in which we anesthetized one of a pair of conjoined twins for placement of a surgically tunneled femoral central line.
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Case Report
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The twins were joined at the upper abdomen (omphalopagus). They shared liver and small bowel and were born with an omphalocele, which was being managed nonsurgically. At the time of the procedure, the patients were 3 months old and together weighed 6.6 kg. Because of their position facing each other, previous intubations in the neonatal intensive care unit had been performed awake. From their anatomy, from imaging studies, and from neonatal intensive care unit reports about their response to sedation, we knew that there was crossed circulation at the level of liver and small bowel. Anesthetizing one patient would result in the gradual onset of anesthesia in the second twin. Because the surgeon planned placement of a femoral line, we decided to attempt caudal anesthesia for the patient, with sedation for the nonpatient twin.
Two anesthesia machines and anesthesia teams were available. Standard monitors were used for both patients. Dextrose-saline was infused at a maintenance rate through a peripheral IV line in each twin. The caudal area of the patient was prepared with povidone iodine solution and infiltrated with 1% lidocaine. A 22-gauge 1-in. catheter was inserted into the caudal epidural space. Aspiration was negative for cerebrospinal fluid and blood. Bupivacaine 3.5 mL 0.25% was injected. The cannula was left in place, connected to extension tubing, and a sterile dressing was applied (Fig. 1). The twins were positioned so that the patient was lower and semisupine to allow exposure of the right groin, and the nonpatient twin was semiprone. The nonpatient twin received 0.25 mg of midazolam, fell asleep, and remained asleep with stable vital signs for the rest of the time in the operating room. The patient tolerated the incision and all inguinal manipulations well. The patient was also given 0.25 mg of midazolam and fell asleep. The patient awoke when the catheter was tunneled cranially (to a skin level of T8 to T10), and the surgeon infiltrated the track with 3 mL of 1% lidocaine. A total of 5 mL of 2-chloroprocaine 3% was administered through the caudal epidural catheter over the 45-min duration of the surgery. Both twins tolerated the procedure well, without any postoperative sequelae.
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Figure 1. Conjoined twins in the operating room for placement of a right femoral line in the twin in front. The caudal epidural catheter is secured under a sterile dressing.
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Discussion
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Anesthetizing conjoined twins involves three major anesthetic considerations. First, two anesthesia teams need to be available, cooperating closely in a limited workspace with clearly separate and duplicate equipment and at times interfering with each other. Second, the degree and clinical significance of crossover between the two circulations must be considered. Drugs will always affect both twins, albeit at different time intervals after administration to one. Finally, care appropriate to the surgical procedure must be provided in this unique setting. Most published reports concern anesthesia for the separation of conjoined twins, including the use of combined general with epidural anesthesia (1,2).
Caudal epidural anesthesia has been used in awake infants for inguinal procedures (3–9). Because our twins required anesthesia for an inguinal procedure in one twin only, we attempted to minimize the anesthetic influence on the nonpatient twin by providing a neuraxial block to the patient. The choice for caudal and against spinal anesthesia was based on the patient’s anatomy: the sacral hiatus could easily be identified, whereas pronounced lumbar lordosis (to move away from the other twin) and the inability to bend anteriorly (because of the presence of the conjoined twin) made the spinal approach appear more difficult. Also, the ability to leave a caudal catheter in place would allow re-dosing.
The patient’s weight was assumed to be 3.3 kg, one half of the twins’ combined weight of 6.6 kg, and the epidural anatomy was assumed to be appropriate for the calculated weight. Therefore, approximately 1 mL/kg was used as the initial loading dose. Although bupivacaine was chosen as our initial local anesthetic, we decided to re-dose with 2-chloroprocaine to avoid any risk of bupivacaine toxicity. Chloroprocaine could also have been used as the primary drug for the caudal anesthesia (7). Local infiltration for the subcutaneous tunneling was performed with lidocaine because of its faster onset of action. Because of the joined circulation, we expected that plasma drug levels would eventually depend on a volume of distribution determined by both twins, albeit at an unknown time to steady-state. Therefore, liberal dosing of local anesthetic was allowed.
In summary, neuraxial block with a caudal catheter allowed femoral line placement in a conjoined twin without anesthetizing the nonpatient twin. Risks and problems associated with general anesthesia and airway management in omphalopagus twins were avoided.
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References
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- Freeman NV, Fahr J, Al-Khusaiby S. Separation of ischiopagus tetrapus conjoined twins in the Sultanate of Oman. Pediatr Surg Int 1997; 12: 256–60.[Medline]
- Greenberg M, Frenchville DD, Hilfiker M. Separation of omphalopagus conjoined twins using combined caudal epidural-general anesthesia. Can J Anaesth 2001; 48: 478–82.[Abstract/Free Full Text]
- Bouchut JC, Dubois R, Foussat C, et al. Evaluation of caudal anaesthesia performed in conscious ex-premature infants for inguinal herniotomies. Paediatr Anaesth 2001; 11: 55–8.[Medline]
- Broadman LM. Use of spinal or continuous caudal anesthesia for inguinal hernia repair in premature infants: are there advantages? Reg Anesth 1996; 21: 108–13.[Medline]
- Cassady JF Jr, Lederhaas G. An alternative for avoidance of general anaesthesia for infants when bilateral inguinal herniorrhaphy outlasts subarachnoid blockade. Paediatr Anaesth 2000; 10: 674–7.[Medline]
- 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]
- 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]
- Jöhr M, Seiler SJ, Berger TM. Caudal anesthesia with ropivacaine in an awake 1,090-g baby. Anesthesiology 2000; 93: 593.[Medline]
- Peutrell JM, Hughes DG. Epidural anaesthesia through caudal catheters for inguinal herniotomies in awake ex-premature babies. Anaesthesia 1993; 48: 128–31.[Medline]
Accepted for publication October 18, 2002.
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July 1, 2005;
101(1):
44 - 47.
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Abstract
Introduction
