Awake caudal anesthesia in ex-premature infants undergoing lower abdominal surgery: A narrative review.

BACKGROUND AND OBJECTIVES: The aim of this narrative review is to evaluate the literature describing the use of caudal anesthetic-based techniques in premature and ex-premature infants undergoing lower abdominal surgery. METHODS: All available literature from inception to August 2023 was retrieved according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from Medline, PubMed, Embase, and the Cochrane Library. Two authors reviewed all references for eligibility, abstracted data, and appraised quality. RESULTS: Of the 211 articles identified, 45 met our inclusion criteria yielding 1548 cases with awake caudal anesthesia. The review included 558 (36.0%) cases of awake caudal anesthesia, 837 cases (54.1%) of "awake" caudal anesthesia with sedation, and 153 cases (9.9%) of combined spinal caudal epidural anesthesia without sedation. The overall anesthetic failure rate was 7.2% (71.9:1000 caudals). Failure rates were highest for CSEA (13.7%, 7.7-18.4), intermediate for awake caudal (6.6%, 5.26-9.51), and lowest for sedated caudal anesthesia (5.85%, 4.48-7.82). The incidence (range) of perioperative apnea was highest for sedated caudal anesthesia (8.16, 0%-24%), intermediate for awake caudal (7.62%, 0%-60%), and lowest for CSEA (5.53%, 0%-14.3%). High spinal anesthesia occurred in 0.84%, or 8.35:1000 caudals overall. The incidence was highest in awake caudal anesthesia cases (1.97% or 19.7:1000 caudals), intermediate with caudal with sedation (1.07% or 10.7:1000 caudals), and lowest in CSEA (0.7% or 6.6:1000 caudals). Our review was confounded by incomplete data reporting and small sample sizes as most were case reports. There were no high-quality randomized controlled trials, and the eight single-center retrospective data reviews lacked sufficient data to perform meta-analysis. CONCLUSIONS: There is insufficient evidence to validate or refute the benefits of the use of "awake" caudal anesthesia in premature and ex-premature infants. The high doses of local anesthetics used, the high failure rate, and the increased incidence of high spinal anesthesia would suggest that the techniques offer no real advantages over awake spinal anesthesia or general anesthesia with a regional block.

Oesophageal atresia: Are "long gap" patients at greater anesthetic risk?

BACKGROUND: Long gap oesophageal atresia occurs in approximately 10% of all oesophageal atresia infants and surgical repair is often difficult with significant postoperative complications. Our aim was to describe the perioperative course, morbidity, and early results following repair of long gap oesophageal atresia and to identify factors which may be associated with complications. METHODS: This is a single center retrospective cohort study of consecutive patients with oesophageal atresia undergoing surgical repair at The Royal Children's Hospital Melbourne from January 2006 to June 2017. RESULTS: Two hundred and thirty-nine consecutive oesophageal atresia infants included 44 long gap oesophageal atresia infants and 195 non-long gap infants. A high rate of prematurity (24.7%), major cardiac (17%), and other surgically relevant malformations (12.6%) was found in both groups. The median age at oesophageal anastomosis surgery was 65.5 days for the long gap group vs 1 day for the oesophageal atresia group (mean difference 56.8 days, 95% CI 48.1-65.5 days, P < .01). Surgery for long gap oesophageal atresia included immediate primary anastomosis (n = 10), delayed primary anastomosis (n = 11), oesophageal lengthening techniques (n = 12) and primary oesophageal replacement (n = 6). Long gap oesophageal atresia was not associated with an increased incidence of difficult intubation (OR 2.8, 95% CI 0.6-22.1, P = .17), intraoperative hypoxemia (OR 1.6, 95% CI 0.6-4.5, P = .32), or hypotension (OR 0.9, 95% CI 0.5-1.8, P = .81). The surgical duration (177.7 vs 202.1 minute, mean difference [95% CI], 28 [5.5-50.4 minutes], P = .04) and mean duration of postoperative mechanical ventilation (107 vs 199.8 hours, mean difference [95% CI], 91.8 [34.5-149.1 hours], P < .01) were shorter for the non-long gap group. Overall in-hospital mortality was 7.5% (15.9% long gap vs 5.6% non-long gap oesophageal atresia OR 1.1, 95% CI 0.4-3.4, P = .85). CONCLUSION: Long gap oesophageal atresia infants have a similar incidence of perioperative complications to other infants with oesophageal atresia. Current surgical approaches to long gap repair, however, are associated with longer anesthetic exposures and require multiple procedures in infancy to achieve oesophageal continuity.

Pediatric hyperbaric oxygen therapy in Victoria, 1998-2010.

OBJECTIVES: The aim of this review is to identify clinical conditions currently treated in a pediatric population referred to the Alfred hyperbaric unit, to describe outcomes, and detail any complications occurring during treatment or transfer between units. DESIGN: Retrospective, noncontrolled, clinical study. SETTING: Adult hyperbaric unit in a university hospital. PATIENTS: Children aged <16 yrs referred for hyperbaric oxygen therapy between January 1998 and December 2010. INTERVENTIONS: Hyperbaric oxygen therapy at pressures from 2.0 to 3.0 atmospheres absolute. MEASUREMENTS AND MAIN RESULTS: Fifty-four patients with a median age at presentation of 15 yrs (range, 0.25-16 yrs) received 668 treatment sessions (mean, 12.4; 95% confidence interval, 9.2-15.5). Fourteen patients were identified as having successfully completed treatment while managed in intensive care units. There were 44 events in 668 treatments (6.6%) in the pediatric group and 12 events in 126 treatments (9.6%) in the pediatric intensive care unit group. There were two oxygen toxicity convulsion (0.3%), two episodes of progressive hypoxemia (0.3%), and four episodes of brief hypotension (0.6%). CONCLUSIONS: Provision of hyperbaric oxygen to children with significant illness is feasible and associated with a low risk of complications. The most difficult aspect of managing pediatric hyperbaric oxygen therapy is in the coordination of the treatment with ongoing surgical and intensive care management. The lack of pediatric staff and facilities in major hyperbaric units necessitates multiple transfers for appropriate treatment.

Levobupivacaine caudal anesthesia in children: a randomized double-blind comparison with bupivacaine.

BACKGROUND: Levobupivacaine is the pure S-enantiomer of bupivacaine. Despite obvious benefits in the event of accidental intravascular injection there has been no studies demonstrating a clinically significant benefit to levobupivacaine over racemic bupivacaine for pediatric regional anesthesia. Given the similar pharmacokinetic profiles of both drugs the studies to date have been underpowered to demonstrate what is likely to be a small difference in clinical effectiveness. Our aim was to determine if there are significant differences in the clinical effectiveness of levobupivacaine compared with racemic bupivacaine for caudal anesthesia in children having lower abdominal surgery. A secondary aim was to determine if there are differences in the incidence of postoperative motor blockade between these agents. METHODS: Three hundred and ten children ranging in age from 1 month to 10.75 years in age having lower abdominal surgery were enrolled. Patients were randomized in a double blind manner to receive a caudal block with either 0.25% bupivacaine (n = 152) or 0.25% levobupivacaine (n = 155) to a total volume of 1 ml x kg(-1). Motor blockade (modified Bromage scale) and postoperative pain or distress (FLACC behavioral scale for postoperative pain) were measured at predetermined time points during the subsequent 120 min. RESULTS: There were no significant adverse effects attributable to levobupivacaine. Success rates were defined as a lack of hemodynamic response to first surgical incision and low postoperative pain scores. At a mean duration of 5 min between block completion and first incision success for 1 ml x kg(-1) of 0.25% bupivacaine was 91% and 94% for 0.25% levobupivacaine. Satisfactory postoperative analgesia was present in 98% of patients after bupivacaine caudal anesthesia and 97.5% for levobupivacaine. At 30 min following caudal anesthesia the incidence of postoperative motor block with racemic bupivacaine was 84% and decreased to 7% at 120 min. For levobupivacaine motor block at 30 min postcaudal was present in 85% and decreased to 11% at 120 min. CONCLUSIONS: Levobupivacaine is an effective agent for caudal anesthesia in children at a recommended dose of 2.5 mg x kg(-1). The rapidity of onset was suitable for establishment of surgical anesthesia and postoperative analgesia was achieved in greater than 97.5% of patients. It appears to be of equivalent potency to racemic bupivacaine in children requiring lower abdominal surgery.

The effects of caudal local anesthesia blockade on the Bispectral Index during general anesthesia in children.

BACKGROUND: Peripheral deafferentation induced by epidural or spinal anesthesia reduces the degree of cortical arousal in adults. This study aimed at determining if caudal blockade decreases the level of arousal, as measured by Bispectral Index (BIS) in unstimulated children, and to determine if this effect differed between age groups. METHODS: Hospital ethics committee approval and parental consent was obtained. Children (age between 24 months and 5 years) and infants (between 6 and 24 months of age) were recruited if they were scheduled for below umbilical surgery that would usually require caudal local anesthesia blockade. Before the procedure, subjects within each age group were randomized to either caudal group (1 ml.kg(-1) 0.25% bupivacaine), or control group (no caudal). In all groups, anesthesia was induced with sevoflurane and maintained at a constant endtidal concentration of 1.5% sevoflurane without N(2)O. Five minutes after induction a baseline BIS was recorded (BIS(1)). In the caudal groups, a caudal block was then performed while in the control groups no block was performed. Fifteen minutes later, the BIS was again recorded (BIS(2)). The change in BIS over this time period was the primary outcome (BIS(Delta)). After measurement, subjects in the control groups received a caudal block before the start of surgery. RESULTS: Twenty-nine infants and 18 children completed the study protocol. In children, BIS(Delta) was significantly different between the caudal group and control (-5.7 vs -0.7, P = 0.04). In infants, no significant difference was detected in BIS(Delta) between caudal and control groups. CONCLUSIONS: Caudal blockade decreased the degree of arousal, as measured by BIS, in unstimulated children aged 2-5 years. No change in arousal was detected in infants.

Levobupivacaine spinal anesthesia in neonates: a dose range finding study.

BACKGROUND: Our aim was to determine the clinical efficacy of levobupivacaine for awake spinal anesthesia in ex-premature infants having lower abdominal surgery. The secondary aim was to determine the minimum local analgesic dose (MLAD) defined as the median effective local anesthetic dose for spinal anesthesia in neonates. METHODS: Fifty neonates < 55 weeks postconceptional age having lower abdominal surgery were enrolled. The dose of levobupivacaine was determined by up-down sequential allocation. The first infant received 1.25 mg x kg(-1) 0.5% levobupivacaine with subsequent doses determined by the response of the previous patient. Dose interval was 0.25 mg x kg(-1). RESULTS: There were no significant adverse effects attributable to levobupivacaine. Success rates for 1.25, 1, 0.75 and 0.5 mg x kg(-1) were 100, 83, 81 and 46%, respectively. Mean duration (95% confidence interval) of lower limb motor blockade was 81.7 min (75.8-87.6 min). Duration of anesthesia far exceeded surgical duration in all but one case. The up-down sequences were analyzed with the Dixon and Massey method. The motor block MLAD (95% confidence interval) was 0.48 mg x kg(-1) (0.42-0.54). Probit analysis was used to compare calculated ED50 and to calculate an ED95 by extrapolation of data into the clinical range. The ED(50) (95% C.I.) was 0.52 mg x kg(-1) (0.30-0.73). The calculated ED95 was 1.14 mg x kg(-1) (0.78-1.50). These values were confirmed by logit analysis. CONCLUSIONS: Levobupivacaine is an effective agent for spinal anesthesia in neonates at a recommended dose of 1 mg x kg(-1). It appears to be of equivalent potency to racemic bupivacaine for motor blockade in ex-premature infants requiring lower abdominal surgery.