|LETTERS TO EDITOR
|Year : 2018 | Volume
| Issue : 1 | Page : 126-127
Awake caudal anesthesia for anoplasty in a preterm newborn with complex cyanotic congenital heart disease
Murali Thiriloga Sundary, Srinivasan Parthasarathy, Kusuma Srividya Radhika
Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||15-Mar-2018|
Murali Thiriloga Sundary
Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sundary MT, Parthasarathy S, Radhika KS. Awake caudal anesthesia for anoplasty in a preterm newborn with complex cyanotic congenital heart disease. J Anaesthesiol Clin Pharmacol 2018;34:126-7
|How to cite this URL:|
Sundary MT, Parthasarathy S, Radhika KS. Awake caudal anesthesia for anoplasty in a preterm newborn with complex cyanotic congenital heart disease. J Anaesthesiol Clin Pharmacol [serial online] 2018 [cited 2020 Feb 23];34:126-7. Available from: http://www.joacp.org/text.asp?2018/34/1/126/227583
Preterm newborns with congenital heart disease present a high risk for general anesthesia. They pose a challenge to the anesthesiologist when they present for non-cardiac surgeries. A low birth weight newborn, born at 35 weeks of gestation was diagnosed with complex cyanotic congenital heart disease with features of Fallot's physiology with an SpO2 of 75% in room air and a pH of 7.20, pCO2 of 26 mmHg, and pO2 of 51 Hg. The baby was scheduled for anoplasty at 5 days of birth. On the day of procedure, the intravenous (IV) line was in place and infective endocarditis prophylaxis administered 1 h prior to the procedure. Standard intraoperative monitoring including nasopharyngeal temperature was done. The operating room temperature was set at 25°C, and infant warmer was in place. IV atropine was used as a premedicant and IV phenylephrine was kept ready. Ringer's lactate 4 ml/kg was used as a maintenance fluid. The baby's weight at the time of surgery was 1.9 kg. Adequate preparation to administer general anesthesia with intubation and controlled ventilation was instituted. Two milliliter of 0.25% bupivacaine with 1 in 200,000 adrenaline was given in caudal epidural space with 23G hypodermic needle. Efficacy of the block was confirmed by pinprick stimulation at sub umbilical level. We avoided the use of perioperative sedatives during the procedure. A pacifier was kept in the child's mouth to keep the child calm and immobile during surgery. Meticulous care was taken to de-air the IV sets and syringes before administration of fluid or drugs. The surgery lasted for 50 min in supine position. Motor recovery was achieved after 90 min. There was no requirement of additional analgesic for up to 8 h in the postoperative period.
Newborns with congenital heart disease undergoing noncardiac surgeries have a higher incidence of anesthesia-related adverse events when compared to normal newborns. General anesthesia might precipitate hypercyanotic spells, the transition to fetal circulation, heart failure, worsening pulmonary hypertension, hypothermia, laryngospasm, postoperative apneic spells, etc. Thus whenever feasible, the neuraxial block is an acceptable alternative. It attenuates the stress response to abdominal surgeries and provides excellent postoperative pain relief with no or minimal need for narcotics, thereby decreasing the risk of postoperative hypoventilation/apnea. Newborns tolerate the high levels of neuraxial blockade, as high as T4 level without impairment of hemodynamics.
Spinal anesthesia is an alternative to caudal block. However we chose caudal anesthesia, as it is technically less difficult and has a higher success rate. Ultrasound guided caudal anesthesia would be ideal to perform in these cases, as infants with anorectal anomalies may have associated spinal cord anomalies, tethered cord, etc.
We conclude that caudal anesthesia may be considered as an alternative anesthetic technique for major infra-umbilical surgeries in newborns with cyanotic congenital heart disease.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Armitage EN. Regional anaesthesia in paediatrics. Clin Anesthesiol 1985;3:553-8.
Baum VC, Barton DM, Gutgesell HP. Influence of congenital heart disease on mortality after noncardiac surgery in hospitalized children. Pediatrics 2000;105:332-5.
Huang JJ, Hirshberg G. Regional anaesthesia decreases the need for postoperative mechanical ventilation in very low birth weight infants undergoing herniorrhaphy. Paediatr Anaesth 2001;11:705-9.
Oberlander TF, Berde CB, Lam KH, Rappaport LA, Saul JP. Infants tolerate spinal anesthesia with minimal overall
autonomic changes: Analysis of heart rate variability in former Wpremature infants undergoing hernia repair. Anesth Analg 1995;80:20-7.
Hoelzle M, Weiss M, Dillier C, Gerber A. Comparison of awake spinal with awake caudal anesthesia in preterm and ex-preterm infants for herniotomy. Paediatr Anaesth 2010;20:620-4.