Pediatric Spinal Anesthesia: What’s Old is New Again

Ashlee E. Holman, MDAssistant Professor of Anesthesiology

Director of Pediatric Regional AnesthesiaPaul Reynolds, MD

Director of Pediatric AnesthesiologyDepartment of Anesthesiology

University of Michigan

Objectives1. To discuss the debate over anesthetic-

related neurotoxicity and its implications in pediatric anesthetic care

2. To review the history of pediatric spinal anesthesia

3. To describe the potential benefits of pediatric spinal anesthesia

4. To provide strategies for implementation of a successful pediatric spinal anesthesia program

Definitions• Anesthetic Neurotoxicity: Damage to

neuronal structures secondary to anesthetic or sedative medications resulting in short-term and long-term neurocognitive and behavioral impairments

• Apoptosis: The death of cells which occurs as a normal and controlled part of an organism's growth or development

Animal Studies

• Uemura 1985• Ikonomidou 1999• Jevtovic-Todorovic 2003

Animal Studies• Brambrink 2010,

2012• Creeley 2013

Animal Studies• Briner 2010• Amrock 2015• Lunardi 2010• Briner 2011• Zhu 2010• Stratmann 2009• Gao 2014• Loepke 2009• Deng 2014• Kanungo 2012

• Catano 2008• De Roo 2009• Sanchez 2011• Xiao 2016• Ju 2016• Paule 2011• Raper 2015• Capitanio 2012• Gentry 2013• Whitaker 2016

Animal Studies• Rizzi 2010• Slikker 2007• Qiu 2016• Shi 2010• Zou 2011• Liu 2015• Huang 2012• Lee 2014

And the list goes on…

Human Studies• Increased risk of

learning disabilities• Deficits in language

and abstract reasoning

• Communication and knowledge deficit

Flick 2011Ing 2012Graham 2016

FDA Statement 2016

“repeated or lengthy use of general anesthetic and sedation medications during surgeries or procedures in children younger than 3 years

or in pregnant women during their third trimester may affect the development of

children’s brains”

https://www.fda.gov/%20Drugs/DrugSafety/ucm532356.htm

Not so fast…..

Human Studies• No effect on IQ or

intelligence• No difference in

outcomes

Bartels 2009 (twin study)GAS Trial 2016MASK Study 2018

Human Studies• PANDA Trial 2016: no effect on IQ at 10

years of age

Human Studies

Human Studies• GAS Trial 2019: no difference in

outcomes between GA and SA at 5 years of age

Conclusions• Comparing studies in

infant animals and human children has limitations

• GAS Trial results are promising

• One brief exposure to GA is likely safe…

Conclusions• BUT for *longer

duration* or *multiple exposures*… conclusive, definitive evidence is not available

Pediatric Spinal Anesthesia What’s Old is New Again!

History• 1898: 1st recorded

pediatric spinal anesthetic (Bier)

• 1904-1905: more widespread use

• 1940s-1950s: decrease in popularity

History• 1970s-1980s: resurgence in use

Apnea of Prematurity• 1990s-present: sporadic practice

Reliability and ease of GAInadequate trainingLitigation

Historically-Observed Advantages

• Optimal surgical conditions• Lack of “surgical shock” and hypotension• Localized anesthesia/analgesia• Less postoperative pain• Minimal PONV• Earlier return to feeding• Cheap alternative to GA in areas lacking

anesthesiologists

Spinal Anesthesia Review• Reliable anesthesia

from T4 (nipple line) to S5 (perineum)

• Motor, sensory, autonomic blockade

• Limited duration

Spinal Anatomy Review• Neonate/Infant

o Conus – L2-L3o Dural Sac – S2-S3

• Toddlero Conus – L1-L2

• Adulto Conus – L1o Dural Sac – S1

Spinal Anatomy Review• Tuffler’s Line

o Neonates: L5-S1o Infants: L4-L5o Toddlers: L4-L5o Adults: L3-L4

Benefits

• Long-Term• Short-Term• Immediate

Long Term Benefits

o Avoidance of potentially neurotoxic agents

o Prevention of surgically-induced hormonal stress response

Does regional anaesthesia improve outcome? Hopkins PM British Journal of Anaesthesia, 115 (S2): ii26–ii33 (2015)

Short Term Benefitso Shorter hospital timeso Decreased risk of

emergence deliriumo Earlier return to

feedingo Quicker reuniting with

caregivers

Time/$$$ Benefits

• Timeo Faster OR turnovero Shorter operative, anesthesia, PACU, total

• Costo Reduction in direct operating, indirect, and

total costs

Immediate Benefits• Immediateo Hemodynamic stabilityo Respiratory stabilityo Decreased use of intraoperative medicationso Decreased use of opioids

Hemodynamic Stability• Minimal changes in BP and HR• Minimal hypotension• Decreased risk of hypotension in

comparison to GA• No change in cerebral oxygenation

General Anesthesia Risks• Hypoxemia• Aspiration• Bronchospasm• Laryngospasm• Stridor• 50% respiratory• 25% Cardiac

Jimenes 2007 Closed claims Study Anesth Analg. 2007 Jan;10

Medication Administration• Reduced medication

administrationo Decreased use of

opioidso Decreased overall

use of intraoperative medications

Safety• Complicationso Spinal failureo High spinalo Hematomao Infection

Infant Spinal Anesthesia Protocol

• Preoperativeo Appropriate case selectiono Discussion between anesthesiologist/parento Case cancellation criteria identical to GAo Premedicationo OR preparationo Surgical Attending present at induction

Lumbar Puncture; Sitting vs Lateral

Dose – up to 5kg = 1 mg/kg, > 5kg = 5 mgo Average dose for neonates = 1 mg/kgo Average dose for infants/toddlers = 0.5-0.7 mg/kg

Bupivacaine duration:o Plain = 30-45 minuteso With 1:200,000 epinephrine = 60-90 minuteso With 1:200,000 epinephrine, clonidine 1 mcg/kg = 60-120

minutes

Onset – 10-15 seconds

Local anesthetic cocktail; Bupivacaine

Infants and Local Anesthetics

o Limited hepatic metabolism until 9-12 months

o Reduced levels of alpha 1 acid glycoprotein until age 1

o Decreased epidural fat (less binding, faster blood absorption)

o Larger CSF volume/faster turnover

IV Placement- Reported on 1554 infants over a 25

year period

- Most IV’s placed after spinal anesthesia without problems

- Some required no IV

The safety and efficacy of spinal anesthesia for surgery in infants: the Vermont Infant Spinal Registry, Williams, RK et al; Anesth Analg. 2006 Jan

Sedation: GOAL = clean anesthetic

o Natural sleep (naptime)

o Sensory deafferentation – like baby yoga, supraspinal effects

• Neuromodulation via interruption of afferent and efferent signals between CNS/PNS

• Functional connectivity changes• Sedating effect

o Pacifier with sucrose

o Midazolam/Dexmedetomidine

Infant Spinal Anesthesia Protocol

• Postoperativeo Phase I “bypass”o Feed immediatelyo Phase II:

• LE movement• No need to void

Our Experience

Our Experience• GA Comparableo Patient BAo 5 week male, 4.4 kg, hydronephrosiso Procedure: cystoscopy w/ureterocele incision

Our Experience• SAo Patient RRo 6 month male, 7.7 kg, otherwise healthyo Procedure: circumcision/chordee repair

Our Experience• SAo Patient FCo 16 month male, 10.4 kg, HLHS s/p Norwood,

s/p Hemi-Fontano Procedure: circumcision

Development• Formation of standardized protocol• Educational program• Plan for training of anesthesiology,

surgical, and perioperative nursing staff• Collaboration• Mentorship

Education• Anesthesiologists, fellows, residents,

CRNAs, AAs• Surgeons, fellows, residents• Perioperative nursing staff (preoperative,

OR, PACU)• Child-life specialists

Education• Educational Programo Rationale for use of spinal anesthesia in

childreno Perioperative preparationo Physical techniqueo Identification and treatment of complications

Implementation• Anesthesia

o Championo Super Starso Interested faculty

• Surgeon Trainingo Championo Interested faculty

Summary• Many unanswered questions regarding

anesthetic neurotoxicity, results are promising

• Spinal anesthesia is safe in neonates and infants

• Getting Surgeon support is critical

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