CORRESPONDENCE

Response to epidural anesthesia in neonates forpyloromyotomy and accompanying editorial

SIR—We read with great interest the paper by Wills-

chke et al., (1) ‘Management of hypertrophic pyloric

stenosis with ultrasound guided single shot epidural

anesthesia—a retrospective analysis of 20 cases’ as well

as the accompanying editorial by Bosenberg and

Lonnquvist (2). We agree with the editorialists that the

procedure described by the authors, while impressive,

is not very practical for most pediatric anesthesia prac-

titioners. Willschke et al. overstate the problems asso-

ciated with general anesthesia and intubation for

pyloric stenosis, while the dangers of propofol sedation

for neonates with potentially full stomachs are mini-

mized. On the other hand, we feel that the editorialists

go too far in their criticism and appear to question the

practicality of many regional anesthetic techniques in

infants. We have published two case reports describing

modifications of the caudally threaded epidural cathe-

ter technique in two syndromic infants who required

palliative surgeries and in whom it was requested that

general anesthesia with endotracheal intubation be

avoided (3,4). We therefore believe that there is defi-

nitely a role for advanced regional anesthesia tech-

niques in infants and neonates and that the

contributions of investigators such as Willschke are

extremely important.

Willschke et al. point out in their discussion that

caudal anesthesia, in their experience, does not provide

reliable spread above the T12 level, even with volumes

approaching 1.5 mgÆkg)1. Our experience with caudal

blocks is different. For the past 3 years, we have

successfully performed caudal blocks in children

requiring umbilical (T10) and supraumbilical sensory

levels for umbilical and epigastric hernia repair. By

simply administering the caudal block in the head-

down (Trendelenberg) position we have observed that

excellent umbilical and supraumbilical anesthesia can

be obtained (unpublished data). We generally tilt the

table 30 degrees, use 1.25–1.5 mlÆkg)1 of 0.2% bupiva-

caine and keep the child in the head-down position for

several minutes during the surgical prep. This simple

technique, to our knowledge, has not been previously

described in conjunction with caudal blocks. We do

not know whether this technique would provide reli-

able anesthesia for pyloromyotomy, but levels above

T10 are readily achievable.

As pointed out in the editorial, most pediatric

anesthesia practitioners are more comfortable with cau-

dally-threaded thoracic epidural catheters than direct

thoracic epidurals in infants. A safer alternative to

Willschke’s approach might have been to apply EMLA

cream over the sacral hiatus and attempt caudal

placement and advancement of an epidural catheter to

a thoracic level using ultrasound for confirmation.

We appreciate the efforts and innovations of Wills-

chke et al. and recognize the attention they have

brought to regional anesthesia for the pediatric popu-

lation. Although we disagree with the use of thoracic

epidurals for pyloromyotomy, we believe there is defi-

nitely a role for regional anesthesia in the care of neo-

nates and infants. Should the ongoing studies

comparing the neurocognitive effects of general anes-

thesia with regional anesthesia in infants yield results

favoring regional, studies such as Willschke’s will take

on a new significance.

Donald SchwartzMaureen McNeely

Department of Anesthesiology,Baystate Medical Center,

Springfield, MA, USAEmail: donald.schwartz@bhs.org

doi:10.1111/j.1460-9592.2011.03556.x

References

1 Willschke H, Machata AM, Rebhandl W

et al. Management of hypertrophic pylorus

stenosis with ultrasound guided single shot

epidural anaesthesia – a retrospective analysis

of 20 cases. Pediatr Anesth 2011; 21: 110–

115.

2 Bosenberg A, Lonnquvist PA. The potential

future or just a way of trespassing the safety

limits of pediatric regional anesthesia. Pediatr

Anesth 2011; 21: 95–97.

3 Schwartz DA, Patel D, Connelly NR. Cau-

dally threaded epidural catheter following a

single-shot caudal block in a high-risk neo-

nate: a combined caudal-epidural technique.

J Clin Anesth 2010; 22: 305–307.

4 Schwartz D, King A. Caudally threaded tho-

racic epidural catheter as the sole anesthetic

in a premature infant and ultrasound confir-

mation of the catheter tip. Pediatr Anesth

2009; 19: 808–810.

Pediatric Anesthesia 21 (2011) 907–913 ª 2011 Blackwell Publishing Ltd 907