A 3-month-old, former 28 week gestational age premature male presents for inguinal herna repair. Parents would like to discuss the benefits of spinal anesthesia versus general anesthesia for the procedure. Which of the following is NOT true regarding benefits of spinal or regional anesthesia versus general anesthesia for infants undergoing inguinal hernia repair?
Correct!
Wrong!
Question of the Month - March 2022
Correct Answer -
B. Regional anesthesia reduces late postoperative apnea events as compared to general anesthesia
Spinal anesthesia in neonates and infants has been well studied and shown to be an effective, safe method of anesthesia for procedures <1-2 hours in duration. Multiple studies have demonstrated a low complication rate with spinal anesthesia.
The General Anesthesia compared to Spinal Anesthesia (GAS) study was a multi-nation, multi-institution prospective randomized trial published in 2015. This study randomized 722 infants >26 weeks post menstrual age up to 60 weeks post menstrual age undergoing either unilateral or bilateral inguinal herniorrhaphy into a regional anesthesia (RA) arm and a general anesthesia (GA) arm. The RA arm received one of the following options: spinal alone, spinal with caudal, spinal with ilioinguinal or caudal alone. No sedation or GA was given in the RA arm. The GA arm received sevoflurane for induction and maintenance of general anesthesia supplemented with either caudal block or ilioinguinal block. No opioids or nitrous oxide was allowed intraoperatively. The primary outcome was observed apnea within 12 hours of surgery or until discharge. Apnea was defined as a pause in breathing for more than 15 seconds or more than 10 seconds with an associated desaturation to <80% or bradycardia of a 20% decrease from baseline. Early apnea was defined as apnea occurring within the first 30 minutes postoperatively. Late apnea is defined as occurring between 30 min and 12 hours postoperatively.
The overall rate of at least one postoperative apneic episode in the study was 3%. Ten occurred in the RA arm and 15 in the GA arm. While there was no statistical significance of late apneas between the two study arms, RA did reduce the risk of early postoperative apnea, the degree of post operative desaturation, and the level of needed intervention required for treatment of apnea. This would imply that RA led to less frequent and less clinically significant apneas. Early apneas were also found to be a predictor of late apneas, although more than half of the infants with late apneas had no documented early apnea.
Hemodynamically, patients randomized to the RA arm were also found to have the following advantages: a greater minimum systolic blood pressure (70.7 vs 54.8), less likely to need an intervention for hypotension (7 vs 19%), higher minimum intraoperative heart rate (133.9 vs 127.6 beats per min), and a higher documented temperature (36.1°C vs 36.0°C) . Anesthesia time was shorter in the RA arm (51 vs 66min). In 20% of patients in the RA arm, there was a need for general anesthesia or other sedatives, therefore a backup plan is imperative.
Discussion with the parents regarding risks of a spinal anesthetic versus a general anesthetic should highlight the above advantages: a lower rate of early apneas (but no difference in overall apnea rate), shorter duration of anesthesia, improved blood pressure, and overall low complication rate. This is assuming the anesthesiologist is comfortable with the procedure and possess the knowledge and skill level to perform a spinal anesthetic in this patient population.
References:
1. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2015 Jun 9;2015(6): CD003669
2. Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Barbara Ehret C, Berger T, Schalte G. Inguinal hernia repair in preterm neonates: evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systemic review and meta-analysis. BMJ Open 2019 Oct 8;9(10):e028728
3. Andrew J. Davidson, Neil S. Morton, Sarah J. Arnup, Jurgen C. de Graaff, Nicola Disma, Davinia E. Withington, Geoff Frawley, Rodney W. Hunt, Pollyanna Hardy, Magda Khotcholava, Britta S. von Ungern Sternberg, Niall Wilton, Pietro Tuo, Ida Salvo, Gillian Ormond, Robyn Stargatt, Bruno Guido Locatelli, Mary Ellen McCann; Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study—Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38–54
Spinal anesthesia in neonates and infants has been well studied and shown to be an effective, safe method of anesthesia for procedures <1-2 hours in duration. Multiple studies have demonstrated a low complication rate with spinal anesthesia.
The General Anesthesia compared to Spinal Anesthesia (GAS) study was a multi-nation, multi-institution prospective randomized trial published in 2015. This study randomized 722 infants >26 weeks post menstrual age up to 60 weeks post menstrual age undergoing either unilateral or bilateral inguinal herniorrhaphy into a regional anesthesia (RA) arm and a general anesthesia (GA) arm. The RA arm received one of the following options: spinal alone, spinal with caudal, spinal with ilioinguinal or caudal alone. No sedation or GA was given in the RA arm. The GA arm received sevoflurane for induction and maintenance of general anesthesia supplemented with either caudal block or ilioinguinal block. No opioids or nitrous oxide was allowed intraoperatively. The primary outcome was observed apnea within 12 hours of surgery or until discharge. Apnea was defined as a pause in breathing for more than 15 seconds or more than 10 seconds with an associated desaturation to <80% or bradycardia of a 20% decrease from baseline. Early apnea was defined as apnea occurring within the first 30 minutes postoperatively. Late apnea is defined as occurring between 30 min and 12 hours postoperatively.
The overall rate of at least one postoperative apneic episode in the study was 3%. Ten occurred in the RA arm and 15 in the GA arm. While there was no statistical significance of late apneas between the two study arms, RA did reduce the risk of early postoperative apnea, the degree of post operative desaturation, and the level of needed intervention required for treatment of apnea. This would imply that RA led to less frequent and less clinically significant apneas. Early apneas were also found to be a predictor of late apneas, although more than half of the infants with late apneas had no documented early apnea.
Hemodynamically, patients randomized to the RA arm were also found to have the following advantages: a greater minimum systolic blood pressure (70.7 vs 54.8), less likely to need an intervention for hypotension (7 vs 19%), higher minimum intraoperative heart rate (133.9 vs 127.6 beats per min), and a higher documented temperature (36.1°C vs 36.0°C) . Anesthesia time was shorter in the RA arm (51 vs 66min). In 20% of patients in the RA arm, there was a need for general anesthesia or other sedatives, therefore a backup plan is imperative.
Discussion with the parents regarding risks of a spinal anesthetic versus a general anesthetic should highlight the above advantages: a lower rate of early apneas (but no difference in overall apnea rate), shorter duration of anesthesia, improved blood pressure, and overall low complication rate. This is assuming the anesthesiologist is comfortable with the procedure and possess the knowledge and skill level to perform a spinal anesthetic in this patient population.
References:
1. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2015 Jun 9;2015(6): CD003669
2. Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Barbara Ehret C, Berger T, Schalte G. Inguinal hernia repair in preterm neonates: evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systemic review and meta-analysis. BMJ Open 2019 Oct 8;9(10):e028728
3. Andrew J. Davidson, Neil S. Morton, Sarah J. Arnup, Jurgen C. de Graaff, Nicola Disma, Davinia E. Withington, Geoff Frawley, Rodney W. Hunt, Pollyanna Hardy, Magda Khotcholava, Britta S. von Ungern Sternberg, Niall Wilton, Pietro Tuo, Ida Salvo, Gillian Ormond, Robyn Stargatt, Bruno Guido Locatelli, Mary Ellen McCann; Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study—Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38–54
SPPM 12th Annual Meeting