caudal or spinal anesthesia with infant, no GA

[ethilo]

Curious if anyone has experience with using caudals or spinals to avoid GA in young infants. If I remember it's supposed to reduce rates of post-op apnea.

Specifically, I'm wondering how the logistical sequence of events works.

For one - I could see putting EMLA cream on the coccyx in pre-op then easily doing a caudal or a spinal awake... but how would you get an IV? I was pondering: could you do the caudal/spinal then place a foot IV once the legs are numb? But then you'd have to do the caudal/spinal without an IV in place.

I almost think doing a caudal without an IV would be reasonable. I'd feel less good about doing a spinal without an IV.

Anyone have any inputs on this? Part of my motivation is that our anesthesia machines suck at delivering low tidal volumes for neonates and I just want to find another way of doing it avoiding the machine all together.

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[deleted162650]

Neonates gets IVs awake all the time in the NICU, ED, etc. What’s the problem??

 

[ethilo]

Neonates gets IVs awake all the time in the NICU, ED, etc. What’s the problem??

pediatric pre-op RNs with specific expectations / workflow that will refuse to place IVs on kids <40 kg and are highly unskilled at IV placement when they do try.

 

[deleted162650]

pediatric pre-op RNs with specific expectations / workflow that will refuse to place IVs on kids <40 kg and are highly unskilled at IV placement when they do try.

Why can’t you place it yourself in the OR then do your regional??

 

[Justice4all]

Current fellow. EMLA cream for spinal. IV after spinal in lower extremity. Some precedex. Spinal last approx 80 mins. Mostly for urological procedures and can add a caudal catheter if a long procedure.

 

[sigrhoillusion]

Current fellow. EMLA cream for spinal. IV after spinal in lower extremity. Some precedex. Spinal last approx 80 mins. Mostly for urological procedures and can add a caudal catheter if a long procedure.

Former fellow, but what I've read is that regional only confers reduced apnea in the immediate post-op period, like the PACU. Regardless of technique, all ex-premies are at increased risk and should be monitored. And if you add any sedation to the regional technique it essentially is equivalent to a general in terms of apnea risk. The surgeons where I work prefer a sleeping baby, so pretty much all of them get general. And they are all monitored appropriately post-op.

 

[jonessoda1212]

Current fellow. EMLA cream for spinal. IV after spinal in lower extremity. Some precedex. Spinal last approx 80 mins. Mostly for urological procedures and can add a caudal catheter if a long procedure.

This, IV after spinal is in in legs. Babies don't have the same hemodynamic effects that adults do with spinals. Usually add clonidine to the spinal, +/- precedex IV depending on temperament of child, though most fall right asleep. Very large determinant of success is surgeon buy in.

 

[kidthor]

Very large determinant of success is surgeon buy in.

The surgeon buy-in is key.

At my large academic peds hospital, almost none of the surgeons would buy into a spinal / awake baby combo. This population at our hospital gets GA (perhaps also with a SS caudal) and stay the night.

 

[Libertas]

This, IV after spinal is in in legs. Babies don't have the same hemodynamic effects that adults do with spinals. Usually add clonidine to the spinal, +/- precedex IV depending on temperament of child, though most fall right asleep. Very large determinant of success is surgeon buy in.

Lazy to find the studies, but I am fairly sure neonatal neuraxial clonidine significantly increases apnea risks. I do love clonidine in my caudals, but I don't typically give for neonates.

 

[Libertas]

I don't currently do neonatal spinals in my practice nor do my partners, other than rare specific needs. Once concern with some of the techniques are total LA dosing, especially when you combine a premature infant, emla cream/local injection, and a large spinal dose.

If I were hard pressed, my preferred technique would probably involve a jtip (0.2ml of lidocaine) and then a caudal catheter dosed with 3% chloroprocaine. Caudal chloroprocaine is described as alternative to spinal in this population. There are almost no risk of overdose with chloroprocaine.

 

[Libertas]

I'm curious; what are people giving as their spinal dose?

 

[GAnoAW]

0.4mL 0.75% bupi

 

[Justice4all]

Defn agree with surgeon buy-in.Max 1.2 ml 0.5% bupi for spinal. They do well.bypass phase 1. Back to their parents and feeding.
For caudals chloroprocaine with clonidine and minimal respiratory adverse event. Can thread the catheter up thoracic level for major abdominal sx with no opioids .

 

[ethilo]

Forgive my naivete, but why would the surgeon care? Other than the kids arms might swing and tap on the drapes, or making noise. I guess a crying baby would certainly ruin one's concentration...

 

[Libertas]

Because they have to be physically present and motivated to prep/cut. It requires active surgeon participation to complete the surgery in the duration of a spinal (as opposed to rounding, chatting up the nurses, letting the resident prep position and start)

 

[ghastly75]

surgeon buy in key, realistic about time, under an hour ideal.
Emla
Prefer lateral position
Surgeon in room scrubbed
Dose : I use Bup .75% hyperbaric 1mg/kg
Oral sucrose on pacifier
hands tied down
PIV in lower extremity
Dexmed on hand if need sedation

Recently, had preterm 25 weeker, bad lungs , now 40 weeks for bilateral hernia and circ.
Did all above plus placed caudal catheter after spinal for insurance .
Went fine-
back to NICU , everyone happy.

 

[somedumbDO]

surgeon buy in key, realistic about time, under an hour ideal.
Emla
Prefer lateral position
Surgeon in room scrubbed
Dose : I use Bup .75% hyperbaric 1mg/kg
Oral sucrose on pacifier
hands tied down
PIV in lower extremity
Dexmed on hand if need sedation

Recently, had preterm 25 weeker, bad lungs , now 40 weeks for bilateral hernia and circ.
Did all above plus placed caudal catheter after spinal for insurance .
Went fine-
back to NICU , everyone happy.

We do sab almost exclusively at our shop for neonatal hernias. I never did one in fellowship but learned from one of my partners.

nurse positions baby upright, we have special 1 inch styletted needles, little lido w tb syringe skin, .75-1 mg/kg of TETRICAINE w a epi wash give you an hour- 1.5 hr w neonate. Failure rate in my hands 5-10% then I go caudal.
Piv usually in from nicu, if not I start one after sab is in, in lower ext. after sab most kids just take a nap.

No clonidine increases apnea.

I changed my practice because most of these kids need a hernia surgery then going home. Some times if you do geta it takes weeks to get them home. W sab they are home in 24 hrs.

 

[GAnoAW]

Ghastly, This is exactly what I do (though I prefer sitting).

I also have nurse have bovie pad ready and place it on the baby as soon as the spinal is in. Before I do the block, I remind everyone no lifting baby’s legs after we position to avoid high spinal.