Spinals for pediatric cases

[twoliter]

Is anyone doing spinals for any peds cases? There was a talk at SPA 2016 about it (I missed it), so it seems like it's becoming more of a thing. I met one of my former residency attendings there who said he had started doing it for inguinal hernia repairs (on select cases). I'd like to look into it some more.

 

[Arch Guillotti]

Is anyone doing spinals for any peds cases? There was a talk at SPA 2016 about it (I missed it), so it seems like it's becoming more of a thing. I met one of my former residency attendings there who said he had started doing it for inguinal hernia repairs (on select cases). I'd like to look into it some more.

No!

 

[twoliter]

No!

Technically speaking, someone is.

 

[JobsFan]

Neonatal hernias

 

[HalO'Thane]

Hernias, circumcisions, cystoscopies on those sickly former 23 week old preemies with BPD, ROP, 02 dependence, etc. Works great on babies.

 

[anesthesiadoc]

They were doing a lot of these in Vermont while I was a fellow in Boston. The GAS (GA vs spinal) study looking at differential neuro cognitive outcomes led to a spike in doing these in Boston too, but it was a limited number of folks who were doing them, and most of them were directly involved in the study. When it works it's great, but there is a failure rate where you have to convert to GA. Thankfully because the sympathetic system is so underdeveloped in those neonates we didn't see much in the way of sympathectomy of hypotension, just the occasional high spinal. I don't do them since I left the Mecca. GA works every time in those little guys. No issues with PONV or intraop awareness either


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[HalO'Thane]

I don't feel that every neonate should undergo a spinal for procedures below the umbilicus and I am still skeptical on the neurocognitive data that is out there about General Anesthesia for kids as most of the outcomes have been found on rats and other non-humans. I do think it is just another tool to have in our repertoire, particularly if you think the infant may have a difficult airway or other comorbidities. You do you need to select the right case with the right surgeon on board. A good spinal will last you about 90 minutes so if you think the surgeon is too slow or the surgery may be more complicated then it may not be the way to go.

 

[somedumbDO]

Do them for all neonatal hernias w the associated comorbidities. Works amazingly well. Won't go back to ga. Surprisingly never did them in fellowship, learned how to do them in PP from one of my partners.

 

[urge]

Do them for all neonatal hernias w the associated comorbidities. Works amazingly well. Won't go back to ga. Surprisingly never did them in fellowship, learned how to do them in PP from one of my partners.

What needle are you using?

What are you injecting and how much?

 

[urge]

There was a talk at SPA 2016 about it (I missed it

At the ASA they showed some video of a baby sucking on his pacifier while having surgery.

What they didn't show was the baby screaming in pain while they placed it.

 

[somedumbDO]

Have circulating nurse hold kid upright w back arched. I use a little lido for skin w tb syringe. 22g b bevel feel pop. 0.75mg/kg tetricaine w equal volume amount of d10. One of my partners uses a butterfly needle I personally prefer the bigger needle.

 

[urge]

Have circulating nurse hold kid upright w back arched. I use a little lido for skin w tb syringe. 22g b bevel feel pop. 0.75mg/kg tetricaine w equal volume amount of d10. One of my partners uses a butterfly needle I personally prefer the bigger needle.

Is tetracaine for spinal still available in the US?

 

[Arch Guillotti]

Is tetracaine for spinal still available in the US?

yes

 

[Lurch]

Have circulating nurse hold kid upright w back arched. I use a little lido for skin w tb syringe. 22g b bevel feel pop. 0.75mg/kg tetricaine w equal volume amount of d10. One of my partners uses a butterfly needle I personally prefer the bigger needle.

Wow. 22g seems like a big freakin needle for a baby. Am I missing something?

 

[SaltyDog]

Wow. 22g seems like a big freakin needle for a baby. Am I missing something?

You don't have to worry about a PDPH in a kid that can't sit up yet.

 

[somedumbDO]

My n=50ish never had a problem.

 

[Maverikk]

Heard Vermont was the center for peds spinals. One fellowship guy there said you could do a spinal, hold the kids legs up, get a total spinal, intubate/IV, then enough fentanyl, gas to just tolerate the tube, claimed almost no hemodynamic changes. Did it in sicko premies for big surgeries. Seemed crazy to me, then again the premies I've seen paralyzed and intubated with 0.1 MAC of gas because that's all they could tolerate seems crazy to me. Anyone else ever seen this?

 

[JobsFan]

key decision in sick neonates is whether you're extubating at the end.
if not, high dose fentanyl (50mcg/kg in divided doses) and no volatile works well.
you will not get sued for awareness.

 

[Arch Guillotti]

key decision in sick neonates is whether you're extubating at the end.
if not, high dose fentanyl (50mcg/kg in divided doses) and no volatile works well.
you will not get sued for awareness.

That seems like a lot.

 

[nimbus]

That seems like a lot.

Yeah what about OIH?

 

[IlDestriero]

Fentanyl vec is a popular anesthetic in the NICU for bedside procedures in the critically ill.


--
Il Destriero

 

[dhb]

key decision in sick neonates is whether you're extubating at the end.
if not, high dose fentanyl (50mcg/kg in divided doses) and no volatile works well.
you will not get sued for awareness.

Wouldn't like that for my kid

 

[somedumbDO]

Sab is the way to go, doesn't change resp mechanics, kids go to sleep right after the spinal, walk up to nicu is a lot easier without a vent or neonatal ambu bag

 

[WholeLottaGame7]

Wouldn't like that for my kid

Why not? How much do you remember from your neonatal period? If the kid is comfortable and not moving, why add agents that you don't need and have deleterious hemodynamic effects?

 

[JobsFan]

Why not? How much do you remember from your neonatal period? If the kid is comfortable and not moving, why add agents that you don't need and have deleterious hemodynamic effects?

And jury still out on long term cognitive effects of volatile

 

[dhb]

Why not? How much do you remember from your neonatal period? If the kid is comfortable and not moving, why add agents that you don't need and have deleterious hemodynamic effects?

Well you make my point: high dose fentanyl is an uneeded agent.

 

[hudsontc]

I did a handful of these hernias under spinal during fellowship and never had any issues. Having good help for positioning and a quick surgeon are the keys to success with these, IMO.

 

[JobsFan]

Well you make my point: high dose fentanyl is an uneeded agent.

A lot of the sick neonates are ex premies they develop complications and by the time they are term PCA ... they are not opioid naive and soak it up surprisingly well. High dose fentanyl gives very good hemodynamic stability.

 

[dhb]

A lot of the sick neonates are ex premies they develop complications and by the time they are term PCA ... they are not opioid naive and soak it up surprisingly well. High dose fentanyl gives very good hemodynamic stability.

Well i obviously don't do PICU but what would you give premies opioids for?

 

[WholeLottaGame7]

Well you make my point: high dose fentanyl is an uneeded agent.

Are you arguing that they don't need high-dose fentanyl, or that they don't need any fentanyl?

If it's the former, it just all depends on the situation, but oftentimes they don't.

If it's the latter, why not? Do they not have a sympathetic response to surgical stimulus?

 

[nimbus]

If it's the latter, why not? Do they not have a sympathetic response to surgical stimulus?

That question was answered affirmatively by Lowenstein in the 1970s.

 

[WholeLottaGame7]

That question was answered affirmatively by Lowenstein in the 1970s.

I know that, it was a Socratic question.

 

[JobsFan]

Well i obviously don't do PICU but what would you give premies opioids for?

Often it's used for sedation

 

[nimbus]

I know that, it was a Socratic question.

I know you know. I was just being a smarta**

 

[WholeLottaGame7]

I know you know. I was just being a smarta**

I know you know I know...?

Back on topic, one of the Vermont guys came and gave a grand rounds at our institution; was pretty interesting. Most of our group are interested, but the problem is the length of surgical procedures at a teaching hospital. Almost would have been/will be better if the GAS study would definitely show a difference in outcomes and we could play the "patient safety" card.

 

[IlDestriero]

The patient safety card won't fix a slow surgeon though. How long are they taking for a hernia repair? If one of our surgical fellows took more than an hour for a hernia they'd get annihilated by the attending surgeon.


--
Il Destriero

 

[WholeLottaGame7]

The patient safety card won't fix a slow surgeon though. How long are they taking for a hernia repair? If one of our surgical fellows took more than an hour for a hernia they'd get annihilated by the attending surgeon.


--
Il Destriero

No fellows, just attendings and residents. One of the attendings is slow, the others probably could do it if they were working solo.

 

[SaltyDog]

the problem is the length of surgical procedures at a teaching hospital

Soooo, IT catheter it is then?

 

[dhb]

Often it's used for sedation

Poor choice imho, that was what i was getting to: i see patients in the ICU run on 2-5cc/h of sufenta for "sedation" which amazes me since i use 1cc/h for an open heart surgery.

 

[JobsFan]

Poor choice imho, that was what i was getting to: i see patients in the ICU run on 2-5cc/h of sufenta for "sedation" which amazes me since i use 1cc/h for an open heart surgery.

And what would you recommend - I'm pretty sure the specialist neonatologist running the nicu have their reasons for using opioid sedation


http://www.thelancet.com/pdfs/journals/lanres/PIIS2213-2600(15)00331-8.pdf

https://www.ucsfbenioffchildrens.org/pdf/manuals/50_Pain.pdf --- opioids get a fair bit of use in these guidelines that are a bit closer to home for you too

Or see pg 243 from gosh in the U.K.
https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/neonatal-guidelines/neonatal-guidelines-2015-17#page290

 

[dhb]

And what would you recommend

Like i said i don't do PICU but i certainly don't give sufenta for "sedation" in adult patients that don't have a painfull stimulus.

 

[JobsFan]

Like i said i don't do PUCU but i certainly don't give sufenta for "sedation" in adult patients that don't have a painfull stimulus.

that's fine, I'll leave the cardiac adults to you ...