|Year : 2019 | Volume
| Issue : 2 | Page : 92-95
Spinal anaesthesia in paediatric orthopaedic services: A five year experience in a Nigeria hospital
Idehen Hanson Osazuwa, O Imarengiaye Charles
Department of Anaesthesiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Submission||24-Jul-2018|
|Date of Acceptance||28-Nov-2018|
|Date of Web Publication||20-Jun-2019|
Dr. Idehen Hanson Osazuwa
Department of Anaesthesiology, University of Benin Teaching Hospital, Benin City, Edo State
Background: The role of spinal anesthesia (SA) as a primary anesthetic technique in children is not a common practice in many centers in Nigeria. The reason for the poor utilization might be due to lack of expertise in pediatric SA, fear of adverse effect such as spinal cord injury. Objectives: This study is a retrospective audit of the anesthetic technique in the pediatric age group in a private orthopedic hospital in Nigerian. The outcome of this study will help reduce the misconception regarding its practicability and safety. Materials and Methods: This is a 5-year single center retrospective study of the anesthetic choice for surgeries on the lower limb in the pediatric age group in an orthopedic hospital. The survey extended from 2012 to 2016 and all relevant information obtained from the medical records of the surgical theatres of the hospital as well as anesthetic records of the patients. The children were assigned to four groups: I – neonates; II – infants 1 month–2 years; III – children 2–12 years; and IV – 12–16 years. Results: A total of 156 patients' records were reviewed. Spinal-induced hypotension occurred only in 4 patients (2.56%). All the 4/44 patients (9.09%) who had hypotension were in the adolescent age group. Conclusion: This study showed the feasibility of SA and good safety profile in the pediatric age group.
Keywords: Outcome, pediatric, spinal anesthesia
|How to cite this article:|
Osazuwa IH, Charles O I. Spinal anaesthesia in paediatric orthopaedic services: A five year experience in a Nigeria hospital. Sahel Med J 2019;22:92-5
|How to cite this URL:|
Osazuwa IH, Charles O I. Spinal anaesthesia in paediatric orthopaedic services: A five year experience in a Nigeria hospital. Sahel Med J [serial online] 2019 [cited 2020 Feb 28];22:92-5. Available from: http://www.smjonline.org/text.asp?2019/22/2/92/260839
| Introduction|| |
Pediatric spinal anesthesia (SA) was initially carried out on moribund former preterm infant. It is safe and effective as well in older children. Literatures on the effective utilization of caudal block in the pediatric age groups in Nigeria are numerous,,, unlike pediatric SA. The reason for the poor utilization might be due to lack of expertise, fear of adverse effect such as spinal cord injury.
Advantages of pediatric SA include minimal cardiorespiratory disturbance, economical in centers with limited resources, stable hemodynamics, and less incidence of post dura puncture headache.,,,
This audit was conducted to determine the effectiveness of pediatric SA.
| Materials and Methods|| |
This is a 5-year retrospective study of the anesthetic choice for surgeries on the lower limb in the pediatric age group, carried out in private Orthopaedic Centre in Nigeria. The survey extended from 2012 to 2016 and all relevant information obtained from the medical records of the surgical theaters of the hospital as well as anesthetic records of the patients Ethical approval, protocol no ADM/E 22/A/VOL. VII/14755 dated 6th June 2019 from University of Benin Teaching Hospital, Benin, Nigeria located in the same State with the private hospital as the private hospital has no ethics committee. Permission to carry out the study was however granted from the management of the hospital before the commencement of this retrospective study.
Data are presented as percentages (qualitative data) and means/standard deviation (quantitative data). Simple descriptive analysis was carried out.
The children were assigned into four groups: I – neonates; II – infants 1 month–2 years; III – children 2–12 years; and IV – 12–16 years. Routine pediatric care involves 2–4 h fast before surgery and premedication with midazolam. Monitors were attached and baseline vital signs taken and recorded. Intravenous access gained and ketamine 1 mg/kg were administered intravenously if the child was restless. The patient was placed in the lateral decubitus/sitting position with chin extended. The lumbar spine was punctured in the interspace at or below the intercristal line using a 24-gauge, 9-cm disposable spinal needle.
SA was achieved with hyperbaric (8% glucose) bupivacaine 0.5% at a dose of 0.1 mL/kg, not exceeding 2 mL; the local anesthetic was injected over a period of 15–30 s. Intraoperative vital signs were monitored, blood pressure monitored every 2 min in the first 10 min and then every 5 min till the end of the surgery. A 20% reduction in the baseline systolic blood pressure was taken as being hypotensive. The spread of blockade was tested by means of pinpricks, and intravenous ketamine was given in aliquots (10 mg) for sedation. The SA was considered to be completely successful if the child was assessed to be free of pain during the surgical procedure and if no supplementary agents were used.
| Results|| |
A total of 156 cases were done during this period. There were more males compared to females (59.5% to 40.4%). Total number of cases done in each year (2012–2016) is shown in [Table 1]. Patients' age and gender are shown in [Table 2]. Type of surgical procedure is shown in [Table 3]. Patient's hemodynamic parameter is shown in [Table 4], only the adolescent age group that had hypotension. Tachycardia was the most common complication all others are shown in [Table 5].
| Discussion|| |
This study showed widespread utilization of pediatric SA under ketamine sedation with minimal side effects for surgical cases amenable to it. This implies that pediatric SA has good prospect and safety for its utilization in the pediatric age group. The outcome of this study and some others,, argue against the misconception about the feasibility of subarachnoid block in children despite the stiff opposition to its use.
The effective utilization of pediatric SA could be attributed the expertise of the attending anesthetist, who is a specialist in regional anesthesia. Lack of expertise in pediatric regional anesthesia is one of the numerous reasons for the nonutilization in the pediatric age group. However, before providing any pediatric regional anesthetic, the provider should not only be experienced in the specific regional anesthesia technique but also be comfortable with pediatric patient care, because almost all pediatric regional anesthesia are done while the child is either heavily sedated or under general anesthesia.
The overall incidence of hypotension which was almost negligible (2.56%) however, the infants and children age groups had no episode of hypotension. The adolescent age group like in the adult population where hypotension is the most common side effect after SA had an incidence of 9.09%. The absence of hypotension in the infant and children age groups could be as a result of intravenous ketamine used for sedation and maintenance of anesthesia in these younger age groups. This is because ketamine causes increases in blood pressure by indirectly secreting catecholamine. Second, because of the underdeveloped sympathetic nervous and third, as a result of the relatively small intravascular volume in the lower extremities and splanchnic system limiting venous pooling and a relatively vasodilated peripheral blood vessels, could be some of the reasons responsible for this observation.
The apparent lack of widespread application of SA in children may be related to the surgeon's preference for general anesthesia for procedures amenable to SA. Some pediatric surgeons prefer general anesthesia to neuraxial blocks particularly for hypospadias repair. The engorgement of the penile shaft (corpus carvanosus) due to SA causes excessive bleeding which ultimately prolongs the duration of surgery. In addition, because of the fear of wound breakdown from engorged penile veins may also discourage the use of SA. Others claim that SA does not give sufficient muscle relaxation needed for surgery. However, the degree of muscle relaxation needed is minimal, and this study has shown that SA can be used for pediatric surgeries when amenable to it. However, its suitability or otherwise for hypospadias repair is to be ascertained through another study.
Few authors in Nigeria have shown the practicability of SA in the pediatric age group. The work done by Rukewe et al., was in a tertiary institution a high resource setting. However, our study is novel in the practice of pediatric SA in a low-resource setting. Regional anesthesia has been shown to be cheap, available, and affordable. This may translate to a huge advantage particularly in emerging economy like Nigeria, where resources are limited, for example, oxygen supply, lack of postoperative analgesics, and insufficient postoperative nursing. There is no requirement for any additional expensive equipment either, and these procedures can be easily performed in peripheral/rural centers. Thus, the use of SA in this population of patients may reduce the overall cost of surgical care. Conversely, the low utilization of pediatric spinal in most tertiary/secondary centers in Nigeria is far beyond limited resources, as we do have what it takes to perform pediatric SA and yet do not perform it.
The choice of anesthesia for any surgical procedure is guided by the indication and duration for surgery. Often procedures such as arthroplasties, Achilles tendon repairs; lower limb amputations can be completed in about 90minutes and therefore suitable for SA. Short duration of SA in the pediatric age group is due to incomplete myelination which allows for better penetration of local anesthetic into the nerve fiber. Nevertheless, myelination is completed at about the 12 years. However, this short duration seems to be a limitation to the use of pediatric SA, but most pediatric surgeries do not go beyond this duration of 90 min, and so its use should be encouraged. In some centers, surgical anesthesia/analgesia is prolonged with the use of combined spinal caudal anesthesia using 0.8 mg/kg of bupivacaine followed immediately by a caudal block using 0.1% bupivacaine.
Regional techniques (SA) can either be done awake or asleep. Proponents for inducing anesthesia in an awake state, argue that the patient is a monitor of him or herself by self-reporting excruciating pains if there is intraneural deposition or paresthesia when the needle impinges on a nerve root. Pediatric SA is usually carried out in the sleep state because children will not cooperate with the anesthesiologist. However, there was no complication as a result of inducing anesthesia in the sleep state either because patients were too young to report such.
The patient can either be placed lateral or in sitting position when performing SA. However, it is important that the neck is extended to prevent airway obstruction in either of the position. Nevertheless, patients that are held in the sitting position during lumbar puncture allow for better observation of respiration and also provide a higher CSF pressure at L3/L4 and L4/L5 enhancing CSF flow when the dura is punctured.
Assessing the level of blockade may prove difficult in infants and young children, particularly if the patients have received sedation or those in whom the block is being performed under general anesthesia. In infants, pinprick or their response to cold stimuli (e.g., an alcohol swab) may be used as well as observation of their rate and pattern of ventilation. Ultimately, successful or adequate SA will be determined by the ability of the child to tolerate the surgical stimulus at the beginning of surgery.
The position the patient assumes after SA may determine the spread of LA and subsequent the height of the block. Care should, therefore, be taken to avoid placing the patient in the trendelenburg position following the block as this will result in an extremely high or total spinal, as may occur when placing a electrocautery grounding pad on an infant's back by lifting the lower extremities. In the event of a rapidly rising level of blockade, the patient may be placed in reverse trendelenburg.
Most children may require additional procedural sedation (ketamine at a dose of 1 mg/kg) as a struggling, agitated child during lumbar puncture may put the patient at an increased risk of injury to delicate neurovascular structures and should be avoided. A common downside cited in the use of neuraxial blocks in children is the necessity for concurrent application of procedural sedation/general anesthesia.
The presence of these clinical settings such as patient refusal, progressive neurological disease, uncontrolled convulsions, infection of the skin or subcutaneous tissue locally at puncture site, coagulation defects, true allergy to local anesthetics, and severe hypovolemia were excluded before the conduct of spinal technique. Specifically, the young may not have the appropriate capacity to consent to regional anesthesia; therefore, the guardian/parental consent should be sort at all times.
| Conclusion|| |
This retrospective study reviewed the use of SA in an independent private surgical practice for a variety of surgical procedures amenable to it in the pediatric age group. The use of SA in children is feasible with a good side effect profile.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]