ANESTHESIA AND ANALGESIA . . . Current Researches VOL.54, No. 3, ~ Y - J U N E1975 ,
387
Regional Anesthesia in Children ESTELA MELMAN, M . D . * t JUANA PENUELAS A., M.D. JESUS MARRUFO E., M.D. Mexico, D.F.7
Regional anesthesia employing the spinal, epidural, or caudal approach was used to anesthetize 200 children, varying in age from 17 days to 15 years. Lidocaine in concentrations varying according to age was used. Ketamine
(1 to 2 mg./kg.) was given in the majority of cases to ensure a quiet patient prior t o block. No major anesthetic complications or deaths were attributable to the anesthetic technic. The caudal approach proved easiest.
T
the hiatus and the dural sac is much smaller. Consequently, less tissue is traversed in a child when the caudal approach is used.
HE use of regional anesthesia in adults is well established. However, the use of conduction anesthesia, particularly the spinal, epidural, or caudal approach, in the pediatric age group has received minimal acceptance. We recently surveyed the literature for the past 20 years and found only a few papers devoted to regional anesthesia in infants and chi1dren.l-5
Since 1970, conduction anesthesia, utilizing the spinal, epidural, or caudal approach, has been employed in our institution for pediatric surgical patients. A clinical evaluation of our experience with these technics is the subject of this paper. You will recall that until the 3rd month of gestation, the spinal cord occupies the entire vertebral canal. Subsequently, the vertebrae grow faster than the cord, such that at birth, the spinal cord ends at L,. In contrast, the adult spinal cord ends between L,.,.GThe dural sac ends at S,.,, while the sacrococcygeal hiatus lies beyond the lower extension of the dural sac. Although the limits of the child’s sacral hiatus are the same as in an adult, the distance between
METHODS Patient Selection.-Two hundred case records (table 1) from the general and orthopedic services were randomly selected and divided into three groups (table 2) with respect to the block technic used. Technics.-Infants under 6 months of age received no premedication. Over 6 months, premedication consisted of 0.5 mg./kg. of diazepam or 5 mg./kg. of sodium pentobarbital. A third group (over 6 years) received 0.3 mg./kg. of diazepam plus 0.5 mg./kg. of pentazocine. The procedure for anesthetizing each child was as follows: 1. To help ensure a quiet patient, 1 to 2 mg./kg. of ketamine intravenously (I.V.) was used in all caudal block patients (group 111) and in 84 of the 100 groups I and 11. Following this, an I.V. infusion of lactated Ringer’s solution was started in all patients.
*Professor
?Department of Anesthesia, Hospital Infanta de Mexico, Mexico, D.F. Paper received: 9/24/74 Accepted for publication: 12/16/74
.
ANESTHESIA AND ANALGESIA . Current Researches VOL.54, NO.3, MAY-JUNE, 1975
388
TABLE 1 Ages of 200 Children Given Regional Block Epidural and rubdural
Newborn 1 mo.2 yr.
TABLE 3 Concentration of Lidocaine Employed for Epidural and Caudal Block
Caudal Age
16
26
24
Infants
1% 1.5%
2%
2-6 yr.
29
25
2-6 yr.
6-12 yr.
25
17
6-13 yr.
20 100
18 100
12-15 yr.
TABLE 2 Surgical Procedures in Children Under Regional Block Subdural (group I 1
Umbilical herniorrhaphy Inguinal herniorrhaphy
Epidural (group
Ill
Caudal (group
III)
3
Orchidopexy
6
7
Appendectomy
2
Cystostomy Correction of hypospadias Exploratory laparotomy Ileal loop Ureteral reimplantation Tenotomp and transposition of muscles (lower limb) Arthrotomy Osteotomy and osteosynthesis
8
2 3 2
3
2 4 1 -
42
58
3. Five percent hyperbaric lidocaine, 1.5 to 2.5 mg./kg., with adrenalin was used in all spinal blocks. For epidural and caudal blocks, lidocaine was used, as shown in table 3.
With epidural (performed at L3.4or L5) and caudal blocks, the time of onset was 10 to 20 minutes. The block height obtained was similar to that of the subarachnoid a p proach. With the caudal approach, the level obtained was often as high as T,. Minimal changes in vital signs were observed with these approaches. The duration of the block generally varied according to age; however, in smaller children, the duration was shorter even with the use of adrenalin.
2
Neuromyotmy
technic. In caudal blocks, a 20-gauge, 1-inch hypodermic needle was employed; the piercing of the sacrococcygeal membrane identified the peridural space.
RESULTS Of the 200 cases reported here, there was no anesthetic mortality or morbidity. Those patients having spinal anesthesia had an immediate onset of the block. Although exact height of the block in infants was difficult to ascertain, it appeared to reach the level of To,reaching T4 in one case. There were no instances of hypotension or alterations in either heart rate or respiratory rate. General anesthesia was used in 4 cases with unexpected prolongation of the surgical procedure.
13
Perineoplasty
Anoplasties Rectal myomectomy Rectosigmoidoscopy Exploration of lower urinary tract Pyloromyotomy Excision of papillomata Total
Lidowine and epinephrine, 1 :200,000 ( 6 to 8 rng./ka.)
0
100
2. For subdural puncture, a 22 to 24gauge, 1.5-inch needle was used. For epidural blocks, a regular Tuohy needle (17gauge) was employed, the epidural space being identified by the “hanging-drop”
Additional sedation during operation depended upon the premedicant drug. Children given diazepam plus pentazocine or sodium pentobarbital required no further sedation while those receiving no premedication or given diazepam alone required additional sedation. In children requiring additional sedation, 1 to 2 mg./kg. of ketamine was found most satisfactory.
DISCUSSION We consider regional anesthesia by the caudal, epidural, or spinal approach to be
Regional Anesthesia . . . Melman, et a1
safe and effective in pediatric surgery. Furthermore, this technic appears to offer excellent relaxation, with no hypotension and with minimal alterations of respiratory and heart rates. Administration of ketamine prior to the initiation of the block helped facilitate the technic used. We do not recommend regional anesthesia for upper abdominal surgery, especially in infants in whom intercostal and accessory breathing muscles are poorly developed. Furthermore, block levels as high as T, or T, may cause hypoxia, with secondary restlessness. Hence, we believe that regional anesthesia in infants and children by the technics here described should be limited to operations of the lower abdomen and extremities. Based on our experience of ease of performance as well as lack of inadvertent dural puncture, we recommend the caudal approach. With regard to the shorter duration of block in infants, even with lidocaine plus adrenalin, our findings are in agreement with those reported by Ruston,? who related this shorter duration to the higher metabolic rate in infants as well as to a greater anesthetic absorption by the higher vascular supply of the spine.
REFERENCES
389 has had minimal acceptance by American anesthesiologists, its use in the U.S.A. being apparently limited to a few teaching institutions on a research basis. The article presented by Dr. Melman and associates is an interesting account of their experience with these technics. It also raises several questions and points worthy of discussion. First, we do not know whether the patients included in this study were predominantly private or state. If state cases predominated, this might explain a higher degree of acceptance for block technics. I think this same pattern might hold true for patients in our country, as the average American parent might not readily accept block anesthesia for his child. I believe that the only regional anesthesia in pediatrics that is readily accepted in this country is the axillary block or the Bier block. Generally speaking, these blocks are restricted to teenagers and the two pre-teen years.
I am not knowledgeable about Mexican medicolegal policies. Maybe they are not as comprehensive or as detailed as in the United States and Mexican anesthesiologists may not be as concerned about possible malpractice suits as we are. For these reasons, I doubt that pediatric regional anesthesia of the types discussed in this paper will have much acceptance in this country.
1. Sievers R: Peridural anesthesia for cystoscopy in the child. Arch Klin Chis 185:359-369, 1936
These patients are relatively heavily sein addition to the ketamine used dated, 2. Ruston FG: Epidural anaesthesia in pediatric prior to performing the block. In light of surgery. Anesth & Analg 36(3) :76-82, 1957 the limited degree of cooperation that can 3. Spiegel P: Caudal anesthesia in pediatric be expected of an infant or young child, it surgery: a preliminary report. Anesth & Analg 41: is clear why this pharmacologic approach 218-221, 1962 is necessary. Furthermore, most children 4. Baquero PO, Vazquez OF: Anesthesia caudal would become extremely apprehensive and en pediatria. Rev Mex Anesth 24:lOl-117, 1965 fearful when they realized the loss of sensa5. Touloukian RJ, Wugmeister M, Pickett LK, tion or ability to move a part of their body. et al: Caudal anesthesia for neonatal anoperineal However, heavy sedation in the presence of and rectal operations. Anesth & Analg 50:565-568, a high block level of anesthesia can easily 1971 lead to hypoxia. This is especially true in 6. Crosby CE, Humphrey T, Laner WE: Correinfants and small children where the interlative Anatomy of the Nervous System. First edition. costal muscles and accessory breathing musNew York, The Marmillan Company, 1962 cles are not fully developed.
Guest Discussion FREDERICK W. ERNST, M.D. Anesthesiologist-in-Chief Children’s Hospital Department of Pediatrics University of Alabama Birmingham, Alabama Regional anesthesia in pediatric patients by the caudal, epidural, oE spinal approach
Would not an inhalation anesthetic provide easier control of the respiratory parameters and avert some of this polypharmacologic approach? In my opinion, an inhalational anesthetic agent is preferable, especially halothane, the agent which is used in 85 to 90 percent of all general anesthetic procedures in our institution. There is still need for further research in
387
Regional Anesthesia in Children ESTELA MELMAN, M . D . * t JUANA PENUELAS A., M.D. JESUS MARRUFO E., M.D. Mexico, D.F.7
Regional anesthesia employing the spinal, epidural, or caudal approach was used to anesthetize 200 children, varying in age from 17 days to 15 years. Lidocaine in concentrations varying according to age was used. Ketamine
(1 to 2 mg./kg.) was given in the majority of cases to ensure a quiet patient prior t o block. No major anesthetic complications or deaths were attributable to the anesthetic technic. The caudal approach proved easiest.
T
the hiatus and the dural sac is much smaller. Consequently, less tissue is traversed in a child when the caudal approach is used.
HE use of regional anesthesia in adults is well established. However, the use of conduction anesthesia, particularly the spinal, epidural, or caudal approach, in the pediatric age group has received minimal acceptance. We recently surveyed the literature for the past 20 years and found only a few papers devoted to regional anesthesia in infants and chi1dren.l-5
Since 1970, conduction anesthesia, utilizing the spinal, epidural, or caudal approach, has been employed in our institution for pediatric surgical patients. A clinical evaluation of our experience with these technics is the subject of this paper. You will recall that until the 3rd month of gestation, the spinal cord occupies the entire vertebral canal. Subsequently, the vertebrae grow faster than the cord, such that at birth, the spinal cord ends at L,. In contrast, the adult spinal cord ends between L,.,.GThe dural sac ends at S,.,, while the sacrococcygeal hiatus lies beyond the lower extension of the dural sac. Although the limits of the child’s sacral hiatus are the same as in an adult, the distance between
METHODS Patient Selection.-Two hundred case records (table 1) from the general and orthopedic services were randomly selected and divided into three groups (table 2) with respect to the block technic used. Technics.-Infants under 6 months of age received no premedication. Over 6 months, premedication consisted of 0.5 mg./kg. of diazepam or 5 mg./kg. of sodium pentobarbital. A third group (over 6 years) received 0.3 mg./kg. of diazepam plus 0.5 mg./kg. of pentazocine. The procedure for anesthetizing each child was as follows: 1. To help ensure a quiet patient, 1 to 2 mg./kg. of ketamine intravenously (I.V.) was used in all caudal block patients (group 111) and in 84 of the 100 groups I and 11. Following this, an I.V. infusion of lactated Ringer’s solution was started in all patients.
*Professor
?Department of Anesthesia, Hospital Infanta de Mexico, Mexico, D.F. Paper received: 9/24/74 Accepted for publication: 12/16/74
.
ANESTHESIA AND ANALGESIA . Current Researches VOL.54, NO.3, MAY-JUNE, 1975
388
TABLE 1 Ages of 200 Children Given Regional Block Epidural and rubdural
Newborn 1 mo.2 yr.
TABLE 3 Concentration of Lidocaine Employed for Epidural and Caudal Block
Caudal Age
16
26
24
Infants
1% 1.5%
2%
2-6 yr.
29
25
2-6 yr.
6-12 yr.
25
17
6-13 yr.
20 100
18 100
12-15 yr.
TABLE 2 Surgical Procedures in Children Under Regional Block Subdural (group I 1
Umbilical herniorrhaphy Inguinal herniorrhaphy
Epidural (group
Ill
Caudal (group
III)
3
Orchidopexy
6
7
Appendectomy
2
Cystostomy Correction of hypospadias Exploratory laparotomy Ileal loop Ureteral reimplantation Tenotomp and transposition of muscles (lower limb) Arthrotomy Osteotomy and osteosynthesis
8
2 3 2
3
2 4 1 -
42
58
3. Five percent hyperbaric lidocaine, 1.5 to 2.5 mg./kg., with adrenalin was used in all spinal blocks. For epidural and caudal blocks, lidocaine was used, as shown in table 3.
With epidural (performed at L3.4or L5) and caudal blocks, the time of onset was 10 to 20 minutes. The block height obtained was similar to that of the subarachnoid a p proach. With the caudal approach, the level obtained was often as high as T,. Minimal changes in vital signs were observed with these approaches. The duration of the block generally varied according to age; however, in smaller children, the duration was shorter even with the use of adrenalin.
2
Neuromyotmy
technic. In caudal blocks, a 20-gauge, 1-inch hypodermic needle was employed; the piercing of the sacrococcygeal membrane identified the peridural space.
RESULTS Of the 200 cases reported here, there was no anesthetic mortality or morbidity. Those patients having spinal anesthesia had an immediate onset of the block. Although exact height of the block in infants was difficult to ascertain, it appeared to reach the level of To,reaching T4 in one case. There were no instances of hypotension or alterations in either heart rate or respiratory rate. General anesthesia was used in 4 cases with unexpected prolongation of the surgical procedure.
13
Perineoplasty
Anoplasties Rectal myomectomy Rectosigmoidoscopy Exploration of lower urinary tract Pyloromyotomy Excision of papillomata Total
Lidowine and epinephrine, 1 :200,000 ( 6 to 8 rng./ka.)
0
100
2. For subdural puncture, a 22 to 24gauge, 1.5-inch needle was used. For epidural blocks, a regular Tuohy needle (17gauge) was employed, the epidural space being identified by the “hanging-drop”
Additional sedation during operation depended upon the premedicant drug. Children given diazepam plus pentazocine or sodium pentobarbital required no further sedation while those receiving no premedication or given diazepam alone required additional sedation. In children requiring additional sedation, 1 to 2 mg./kg. of ketamine was found most satisfactory.
DISCUSSION We consider regional anesthesia by the caudal, epidural, or spinal approach to be
Regional Anesthesia . . . Melman, et a1
safe and effective in pediatric surgery. Furthermore, this technic appears to offer excellent relaxation, with no hypotension and with minimal alterations of respiratory and heart rates. Administration of ketamine prior to the initiation of the block helped facilitate the technic used. We do not recommend regional anesthesia for upper abdominal surgery, especially in infants in whom intercostal and accessory breathing muscles are poorly developed. Furthermore, block levels as high as T, or T, may cause hypoxia, with secondary restlessness. Hence, we believe that regional anesthesia in infants and children by the technics here described should be limited to operations of the lower abdomen and extremities. Based on our experience of ease of performance as well as lack of inadvertent dural puncture, we recommend the caudal approach. With regard to the shorter duration of block in infants, even with lidocaine plus adrenalin, our findings are in agreement with those reported by Ruston,? who related this shorter duration to the higher metabolic rate in infants as well as to a greater anesthetic absorption by the higher vascular supply of the spine.
REFERENCES
389 has had minimal acceptance by American anesthesiologists, its use in the U.S.A. being apparently limited to a few teaching institutions on a research basis. The article presented by Dr. Melman and associates is an interesting account of their experience with these technics. It also raises several questions and points worthy of discussion. First, we do not know whether the patients included in this study were predominantly private or state. If state cases predominated, this might explain a higher degree of acceptance for block technics. I think this same pattern might hold true for patients in our country, as the average American parent might not readily accept block anesthesia for his child. I believe that the only regional anesthesia in pediatrics that is readily accepted in this country is the axillary block or the Bier block. Generally speaking, these blocks are restricted to teenagers and the two pre-teen years.
I am not knowledgeable about Mexican medicolegal policies. Maybe they are not as comprehensive or as detailed as in the United States and Mexican anesthesiologists may not be as concerned about possible malpractice suits as we are. For these reasons, I doubt that pediatric regional anesthesia of the types discussed in this paper will have much acceptance in this country.
1. Sievers R: Peridural anesthesia for cystoscopy in the child. Arch Klin Chis 185:359-369, 1936
These patients are relatively heavily sein addition to the ketamine used dated, 2. Ruston FG: Epidural anaesthesia in pediatric prior to performing the block. In light of surgery. Anesth & Analg 36(3) :76-82, 1957 the limited degree of cooperation that can 3. Spiegel P: Caudal anesthesia in pediatric be expected of an infant or young child, it surgery: a preliminary report. Anesth & Analg 41: is clear why this pharmacologic approach 218-221, 1962 is necessary. Furthermore, most children 4. Baquero PO, Vazquez OF: Anesthesia caudal would become extremely apprehensive and en pediatria. Rev Mex Anesth 24:lOl-117, 1965 fearful when they realized the loss of sensa5. Touloukian RJ, Wugmeister M, Pickett LK, tion or ability to move a part of their body. et al: Caudal anesthesia for neonatal anoperineal However, heavy sedation in the presence of and rectal operations. Anesth & Analg 50:565-568, a high block level of anesthesia can easily 1971 lead to hypoxia. This is especially true in 6. Crosby CE, Humphrey T, Laner WE: Correinfants and small children where the interlative Anatomy of the Nervous System. First edition. costal muscles and accessory breathing musNew York, The Marmillan Company, 1962 cles are not fully developed.
Guest Discussion FREDERICK W. ERNST, M.D. Anesthesiologist-in-Chief Children’s Hospital Department of Pediatrics University of Alabama Birmingham, Alabama Regional anesthesia in pediatric patients by the caudal, epidural, oE spinal approach
Would not an inhalation anesthetic provide easier control of the respiratory parameters and avert some of this polypharmacologic approach? In my opinion, an inhalational anesthetic agent is preferable, especially halothane, the agent which is used in 85 to 90 percent of all general anesthetic procedures in our institution. There is still need for further research in
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