Spinal Anesthesia in Infants

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1 The heart and science of medicine. UVMHealth.org/Childrens Spinal Anesthesia in Infants Robert Williams, MD Professor of Anesthesia and Pediatrics College of Medicine University of Vermont

2 Conflicts of Interest Nothing to Declare

3 Spinal anesthesia in infants It s a very different animal than general anesthesia

4 Objectives Describe the potential advantages of infant spinal anesthesia in regards to cardiovascular stability, hypoxemia, postoperative apnea and potential risks of anesthetic neurotoxicity. Describe the types of surgical procedures amenable to infant spinal anesthesia. Understand the equipment, types of local anesthesia and doses utilized for inguinal hernia repair during infancy.

5 Infant Spinal Anesthesia Why? How? When and where? -just for hernias?

6 Why do infant spinals? Not necessarily for reasons related to neurotoxicity.. There are more than enough reasons to consider a form of awake regional anesthesia in young infants independent of neurotoxicity concerns

7 Why do infant spinals? The usual suspects.? 1. Impressive respiratory stability 2. Diminished risk of apnea 3. Cardiovascular stability

8 Respiratory stability Compared to general anesthesia, infant spinal anesthesia has a documented decrease in intra/post op episodes of Apnea Hypoxemia Bradycardia Laryngospasm Post op Croup

9 In Vermont, 95% of infants only require room air during surgery. Respiratory stability

10 BP stability is remarkable Dohi, et al Anesthesiology 1979 Even very high levels of block for PDA repair cause minimal changes in BP. Williams, et al Ped Anesth, 1997

11 Cardiovascular stability confirmed by GAS study Infants randomized to RA had a substantially greater mean minimum systolic blood pressure (70.7 vs mmhg) and were less likely to need an intervention for hypotension during anesthesia (7 vs. 19%) Davidson et al, Anesthesiology 2015 Allows luxury of placing the IV in lower extremity after induction of anesthesia if desired

12 The GAS study changes everything.. But not for neurotoxicity reasons Data from Vermont and other centers has essentially been very large case reviews Now, there is a rigorously controlled comparative trial Including centers without a large experience in awake regional anesthesia in infants.

13 GAS study impact on medical community and the public. Researchers determine best anesthesia option for infants ASA Website Press Release: Chicago May 14, 2015 Infants undergoing some types of surgery could have better recovery if they receive regional anesthesia rather than general anesthesia, according to two studies published in the Online First edition of Anesthesiology, the official medical journal of the American Society of Anesthesiologists (ASA ). Researchers explored the differences between the two types of anesthesia by measuring the presence of apnea, a breathing complication, following hernia surgery. Our research provides the strongest evidence to date on how babies should have anesthesia for hernia repair the most common procedure among infants, said Andrew Davidson, M.D., study author and associate professor, Royal Children s Hospital, Melbourne, Australia. We found that spinal anesthesia is safer than general anesthesia.

14 GAS study: Proof of Concept. It can be efficiently accomplished in locations other than Vermont Awake regional anesthesia is more efficient than GA and requires less anesthesia time It can be done in any pediatric center, including centers (and surgeons)with minimal previous experience

15 Spinal anesthesia is particularly efficient at the end of surgery No time is required for emergence, extubation and stabilization prior to transport

16 Spinal anesthesia efficiency (cont.) In Vermont, an average of six minutes from end of surgery to departure from OR Williams, et al Anesth Analgesia 2006 Significantly less anesthesia time for children undergoing pyloromyotomy under SA than GA Kachko et al J ped Surg

17 Efficiency also confirmed in GAS study i.e. It can t be that hard Shorter anesthesia time in awake RA arm RA: 51 min GA: 66 min p<.0001

18 Minimal PACU care and resources used GAS results: In infants with successful RA: Time to first feeds shorter Less opioid analgesia in first hour

19 Is spinal anesthesia practical everywhere? Historic success rate in Vermont Infant Spinal Registry is around 95% Replicated in GAS study (when allowance for IV sedation is considered) 19

20 Agents and doses Tetracaine limited by availability Ropivicaine- Sufficient motor block? Hyperbaric Bupivicaine-duration too short Isobaric Bupivicaine 0.5% 1 mg/kg as used in GAS study (0.2ml/kg) Max dose mg

21 TB syringe for accurate dosing 22 or 25 g needles (I have never used more than 1 cc of LA for any infant spinal)

22 Positioning is key.

23 We typically place the iv after induction (in a foot) Sweete Eze (a.k.a. Baby Crack ), also helps keep a more mellow OR environment.

24 Our OR s are always prepared for conversion to GA. I have personally not needed to place an LMA or intubate a SA infant in well over a decade (at least). But, I am always prepared.

25 Most of our cases are performed by residents.

26 Able videos.. Let s go to the tape

27 Other applications Achilles Tendon Repair Pyloromyotomy Vascular access in IR Gastrostomy, colostomy, etc.

28 More Videos..