Pediatric Spinal Anesthesia: What’s Old is New Again · 2020-02-18 · Pediatric Spinal...
Transcript of Pediatric Spinal Anesthesia: What’s Old is New Again · 2020-02-18 · Pediatric Spinal...
Pediatric Spinal Anesthesia: What’s Old is New Again
Ashlee E. Holman, MDAssistant Professor of Anesthesiology
Director of Pediatric Regional AnesthesiaPaul Reynolds, MD
Director of Pediatric AnesthesiologyDepartment of Anesthesiology
University of Michigan
Objectives1. To discuss the debate over anesthetic-
related neurotoxicity and its implications in pediatric anesthetic care
2. To review the history of pediatric spinal anesthesia
3. To describe the potential benefits of pediatric spinal anesthesia
4. To provide strategies for implementation of a successful pediatric spinal anesthesia program
Definitions• Anesthetic Neurotoxicity: Damage to
neuronal structures secondary to anesthetic or sedative medications resulting in short-term and long-term neurocognitive and behavioral impairments
• Apoptosis: The death of cells which occurs as a normal and controlled part of an organism's growth or development
Animal Studies
• Uemura 1985• Ikonomidou 1999• Jevtovic-Todorovic 2003
Animal Studies• Brambrink 2010,
2012• Creeley 2013
Animal Studies• Briner 2010• Amrock 2015• Lunardi 2010• Briner 2011• Zhu 2010• Stratmann 2009• Gao 2014• Loepke 2009• Deng 2014• Kanungo 2012
• Catano 2008• De Roo 2009• Sanchez 2011• Xiao 2016• Ju 2016• Paule 2011• Raper 2015• Capitanio 2012• Gentry 2013• Whitaker 2016
Animal Studies• Rizzi 2010• Slikker 2007• Qiu 2016• Shi 2010• Zou 2011• Liu 2015• Huang 2012• Lee 2014
And the list goes on…
Human Studies• Increased risk of
learning disabilities• Deficits in language
and abstract reasoning
• Communication and knowledge deficit
Flick 2011Ing 2012Graham 2016
FDA Statement 2016
“repeated or lengthy use of general anesthetic and sedation medications during surgeries or procedures in children younger than 3 years
or in pregnant women during their third trimester may affect the development of
children’s brains”
https://www.fda.gov/%20Drugs/DrugSafety/ucm532356.htm
Not so fast…..
Human Studies• No effect on IQ or
intelligence• No difference in
outcomes
Bartels 2009 (twin study)GAS Trial 2016MASK Study 2018
Human Studies• PANDA Trial 2016: no effect on IQ at 10
years of age
Human Studies
Human Studies• GAS Trial 2019: no difference in
outcomes between GA and SA at 5 years of age
Conclusions• Comparing studies in
infant animals and human children has limitations
• GAS Trial results are promising
• One brief exposure to GA is likely safe…
Conclusions• BUT for *longer
duration* or *multiple exposures*… conclusive, definitive evidence is not available
Pediatric Spinal Anesthesia What’s Old is New Again!
History• 1898: 1st recorded
pediatric spinal anesthetic (Bier)
• 1904-1905: more widespread use
• 1940s-1950s: decrease in popularity
History• 1970s-1980s: resurgence in use
Apnea of Prematurity• 1990s-present: sporadic practice
Reliability and ease of GAInadequate trainingLitigation
Historically-Observed Advantages
• Optimal surgical conditions• Lack of “surgical shock” and hypotension• Localized anesthesia/analgesia• Less postoperative pain• Minimal PONV• Earlier return to feeding• Cheap alternative to GA in areas lacking
anesthesiologists
Spinal Anesthesia Review• Reliable anesthesia
from T4 (nipple line) to S5 (perineum)
• Motor, sensory, autonomic blockade
• Limited duration
Spinal Anatomy Review• Neonate/Infant
o Conus – L2-L3o Dural Sac – S2-S3
• Toddlero Conus – L1-L2
• Adulto Conus – L1o Dural Sac – S1
Spinal Anatomy Review• Tuffler’s Line
o Neonates: L5-S1o Infants: L4-L5o Toddlers: L4-L5o Adults: L3-L4
Benefits
• Long-Term• Short-Term• Immediate
Long Term Benefits
o Avoidance of potentially neurotoxic agents
o Prevention of surgically-induced hormonal stress response
Does regional anaesthesia improve outcome? Hopkins PM British Journal of Anaesthesia, 115 (S2): ii26–ii33 (2015)
Short Term Benefitso Shorter hospital timeso Decreased risk of
emergence deliriumo Earlier return to
feedingo Quicker reuniting with
caregivers
Time/$$$ Benefits
• Timeo Faster OR turnovero Shorter operative, anesthesia, PACU, total
• Costo Reduction in direct operating, indirect, and
total costs
Immediate Benefits• Immediateo Hemodynamic stabilityo Respiratory stabilityo Decreased use of intraoperative medicationso Decreased use of opioids
Hemodynamic Stability• Minimal changes in BP and HR• Minimal hypotension• Decreased risk of hypotension in
comparison to GA• No change in cerebral oxygenation
General Anesthesia Risks• Hypoxemia• Aspiration• Bronchospasm• Laryngospasm• Stridor• 50% respiratory• 25% Cardiac
Jimenes 2007 Closed claims Study Anesth Analg. 2007 Jan;10
Medication Administration• Reduced medication
administrationo Decreased use of
opioidso Decreased overall
use of intraoperative medications
Safety• Complicationso Spinal failureo High spinalo Hematomao Infection
Infant Spinal Anesthesia Protocol
• Preoperativeo Appropriate case selectiono Discussion between anesthesiologist/parento Case cancellation criteria identical to GAo Premedicationo OR preparationo Surgical Attending present at induction
Lumbar Puncture; Sitting vs Lateral
Dose – up to 5kg = 1 mg/kg, > 5kg = 5 mgo Average dose for neonates = 1 mg/kgo Average dose for infants/toddlers = 0.5-0.7 mg/kg
Bupivacaine duration:o Plain = 30-45 minuteso With 1:200,000 epinephrine = 60-90 minuteso With 1:200,000 epinephrine, clonidine 1 mcg/kg = 60-120
minutes
Onset – 10-15 seconds
Local anesthetic cocktail; Bupivacaine
Infants and Local Anesthetics
o Limited hepatic metabolism until 9-12 months
o Reduced levels of alpha 1 acid glycoprotein until age 1
o Decreased epidural fat (less binding, faster blood absorption)
o Larger CSF volume/faster turnover
IV Placement- Reported on 1554 infants over a 25
year period
- Most IV’s placed after spinal anesthesia without problems
- Some required no IV
The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry, Williams, RK et al; Anesth Analg. 2006 Jan
Sedation: GOAL = clean anesthetic
o Natural sleep (naptime)
o Sensory deafferentation – like baby yoga, supraspinal effects
• Neuromodulation via interruption of afferent and efferent signals between CNS/PNS
• Functional connectivity changes• Sedating effect
o Pacifier with sucrose
o Midazolam/Dexmedetomidine
Infant Spinal Anesthesia Protocol
• Postoperativeo Phase I “bypass”o Feed immediatelyo Phase II:
• LE movement• No need to void
Our Experience
Our Experience• GA Comparableo Patient BAo 5 week male, 4.4 kg, hydronephrosiso Procedure: cystoscopy w/ureterocele incision
Our Experience• SAo Patient RRo 6 month male, 7.7 kg, otherwise healthyo Procedure: circumcision/chordee repair
Our Experience• SAo Patient FCo 16 month male, 10.4 kg, HLHS s/p Norwood,
s/p Hemi-Fontano Procedure: circumcision
Development• Formation of standardized protocol• Educational program• Plan for training of anesthesiology,
surgical, and perioperative nursing staff• Collaboration• Mentorship
Education• Anesthesiologists, fellows, residents,
CRNAs, AAs• Surgeons, fellows, residents• Perioperative nursing staff (preoperative,
OR, PACU)• Child-life specialists
Education• Educational Programo Rationale for use of spinal anesthesia in
childreno Perioperative preparationo Physical techniqueo Identification and treatment of complications
Implementation• Anesthesia
o Championo Super Starso Interested faculty
• Surgeon Trainingo Championo Interested faculty
Summary• Many unanswered questions regarding
anesthetic neurotoxicity, results are promising
• Spinal anesthesia is safe in neonates and infants
• Getting Surgeon support is critical
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