Update in Pediatric Regional Anesthesia

Infant Spinal Anesthesia: What’s Old is New Again

By Marian Murphy, DO; Robert Williams, MD
Division of Pediatric Anesthesia
Department of Anesthesiology
University of Vermont Medical Center
Burlington, Vermont

Spinal anesthesia (SA) is one of our oldest techniques that has been in use for over a century. Its first successful application for surgical anesthesia was performed by August Bier, MD in 1898, in which he described the procedure as “cocainizing the spinal cord.”(1) In the early 20th century, Lord H. Tyrrell Gray advocated for its use in infants requiring surgery, declaring that “…it will occupy an important place in the surgery of children in the future.”(2) However, as the safety and technique of general anesthesia (GA) improved, pediatric SA fell out of use.

It was not until the 1980s, when a study published by J. Christian Abajian, MD out of the University of Vermont Medical Center (UVMMC), demonstrated that infant SA was successfully reintroduced as an alternative technique to GA with reportedly fewer complications. (3) Since Dr. Abajian’s seminal study, numerous other publications from medical literature have supported its high efficacy, efficiency, and safety. We know that infants less than one year of age are at highest risk for complications associated with GA as compared with older children and adults.(4) Studies have repeatedly shown that infant SA exhibits a high degree of cardiovascular and respiratory stability and has been associated with a decreased incidence of hypotension, hypoxemia, bradycardia, and postoperative apnea compared with GA.(5) Though it has started to gain more popularity as an alternative to GA in infants, it is still an often underutilized technique in pediatric anesthesia today.

In 2016, the Food and Drug Administration issued a warning to the public that repeated or prolonged use of general anesthetic and sedation drugs during surgeries or procedures may negatively affect brain development in children younger than three years.(6) It is our opinion that not only does a spinal technique eliminate these concerns, as well as the other risks associated with GA, but the approach is relatively simple to perform with a high success rate after a little practice. In addition, it is more cost-effective than GA, increases parental satisfaction, shortens infant recovery and discharge times in the PACU, and also helps decrease operating room time and patient length of stay.(7,8,9) Not to mention, SA is better at blocking the neuroendocrine stress response to surgery (10), and for the environmentally conscious anesthesiologists, it significantly reduces greenhouse gas emissions if no volatile anesthetic is used. (11)

Our experience at the UVMMC has been that the use of supplemental sedation is rarely required in infants who have had a spinal. Some EMLA cream applied to the lower back at least one hour before the spinal is to be performed is typically all that is necessary for the patient to tolerate the spinal needle. Once complete, infants often fall into a sleep-like state, and in our practice, sedation is needed in less than 10% of cases. Perhaps just a little sucrose water and a pacifier to calm and soothe a fussy patient.

Contraindications to SA are similar to those in the adult population and include severe anatomical deformities, systemic sepsis or infection at the puncture site, underlying coagulopathy, increased intracranial pressure, parental refusal, and hemodynamic instability.(12) The major limitation for a single injection spinal technique in infants is its relatively brief duration of action, and is not typically recommended for a surgery duration of more than 90 minutes.(13)

Adverse effects from SA, including hypotension and bradycardia, are uncommon in neonates and infants despite the high levels of blockade required.(14) This is likely due to smaller venous capacitance in the lower limbs leading to less pooling, and to the immature sympathetic nervous system resulting in less dependence on vasomotor tone to maintain blood pressure.(12) Fluid loading to increase preload is not needed. Serious complications such as total spinal block, hematoma, infection, and neurologic deficits are extremely rare.(15)

One of the roadblocks to performing infant spinal blocks that we often hear from other pediatric anesthesiologists is that they have never done one before and it will be difficult to learn. I, too, had a similar thought when I started my first attending job at the UVMMC. I knew the pediatric anesthesia department was known for their infant spinal program, but I had never performed one during my fellowship training. Fortunately, under the guidance of Robert Williams, MD and Emmett Whitaker, MD, I was performing infant spinals independently within my first few days at UVMMC. Now, I routinely supervise and teach anesthesia residents how to do this procedure with a high degree of success. I strongly believe this is a technique all pediatric anesthesiologists should learn to perform proficiently and have in their anesthesia arsenal.

Recently, I took care of an 8-hour-old neonate who required emergency surgery for testicular torsion. I suggested to the pediatric urology surgery attending that we perform the procedure under SA, and he agreed. When I reached the mother-baby unit, both the patient’s mother and father appeared very distressed and in tears. The look of relief on both of their faces was priceless when I told them that their baby would likely not require an endotracheal tube because we would do SA. The surgery and anesthetic both went well, and the patient recovered in the NICU overnight. When I went to see the patient the next day, both parents were at his bedside. They happily reported that the patient was doing well and that he started breast feeding almost immediately after the surgery.

As pediatric anesthesiologists, we know we are taking care of someone’s most precious gift: their child. That is why the success of our infant spinal program is not only about the many benefits for the patient, but also the satisfaction of the parents. Parents are understandably nervous for their infant to undergo anesthesia. Knowing their child will likely not require an endotracheal tube or need many of our anesthetic agents and medications, including volatile gases, does help ease some of their anxiety. When we can return a happy, wide awake baby back to his or her parents, we know we have done what is in the best interests of everyone.

REFERENCES

1. Bier, A. Experiments on the cocainization of the spinal cord. Deutsche Zeitschrift fur Chirurgie 1899; 51:361-9.
2. Gray T. A. Study of spinal anesthesia in children and infants. Lancet 1909;3:913–7.
3. Abajian JC, Mellish R, Browne A, et al. Spinal anesthesia for surgery in the high risk infant. Anesth Analg 1984;63:359–62.
4. Sartorelli K, Abajian JC, Kreutz J, et al. Improved outcome utilizing spinal anesthesia in high risk infants. J Pediatr Surg 1992;27:1022–5.
5. Williams RK, Adams DC, Aladjem EV, Kreutz JM, Sartorelli KH, Vane DW, Abajian JC. The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry. Anesth Analg. 2006 Jan;102(1):67-71.
6. Woodcock, J. FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. 2016: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-review-results-new-warnings-about-using-general-anesthetics-and
7. Morris MT, Morris J, Wallace C, et al. An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings. Global Spine J. 2019;9(4):368-374.
8. Gonano, C, Leitgeb, U, Sitzwohl, C, et al. Spinal Versus General Anesthesia for Orthopedic Surgery: Anesthesia Drug and Supply Costs, Anesth Analg. 2006 Feb;102(2):524-9.
9. Ing C, Sun LS, Friend AF, et al. Adverse Events and Resource Utilization After Spinal and General Anesthesia in Infants Undergoing Pyloromyotomy. Regional Anesthesia and Pain Medicine. 2016 Jul-Aug;41(4):532-7.
10. Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD. Influence of spinal and general anesthesia on the metabolic, hormonal, and hemodynamic response in elective surgical patients. Med Sci Monit. 2014;20:1833-40.
11. Kuvadia M, Cummis CE, Liguori G, et al. 'Green-gional' anesthesia: the non-polluting benefits of regional anesthesia to decrease greenhouse gases and attenuate climate change Reg Anesth Pain Med. 2020;45:744-745.
12. Troncin, R, Dadure, C. Pediatric spinal anesthesia. Update in Anaesthesia. 2009;25,1:22-4.
13. Williams, RK, Abajian, C. Spinal anesthesia in infants. Tech Reg Anesth Pain Manag. 1999;3:170-6.
14. Oberlander TF, Berde CB, Lam KH, et al. Infants tolerate spinal anesthesia with minimal overall autonomic changes: analysis of heart rate variability in former premature infants undergoing hernia repair. Anesth Analg. 1995;80:20-7.
15. Koch BL, Moosbrugger EA, Egelhoff JC. Symptomatic spinal epidural collections after lumbar puncture in children. AJNR Am J Neuroradiol. 2007;Oct;28(9):1811-6.