Pushing the Boundaries of Regional Anesthesia for Complex Urological Surgery
Rama Jayanthi, MD, Chief, Urology
In an effort to extend more regional anesthetic options to children undergoing urological procedures — and to obviate concerns about airway safety and theoretical neurocognitive effects of general anesthesia in the very young — a team of anesthetists and surgeons at Nationwide Children’s Hospital developed a Spinal Anesthesia Program that now includes formal protocols for the use of combined spinal/caudal catheter (SCC) anesthesia. The combined approach has made it possible to perform even lengthy, complex procedures, such as ureteral implantation, under regional anesthesia.
“In most places, it’s almost expected that any child who comes to the operating room has general anesthesia,” says Rama Jayanthi, MD, chief of Urology at Nationwide Children’s and lead author on a Journal of Pediatric Urology study detailing his team’s experience in SCC. “We’re suggesting that doesn’t have to be the case. There are options. One can do more complex surgeries under regional anesthesia, and there may be some advantages to doing so.”
Spinal anesthesia, which involves a single anesthetic injection into the subdural space, provides localized, lower-body anesthesia for 60-90 minutes. In 2015, surgeons at Nationwide Children’s began employing it for routine procedures lasting less than 90 minutes such as circumcisions and revisions, orchidopexy, hernia repair and distal hypospadias repairs.
The study team began to place a caudal epidural catheter in selected cases to prolong the duration of the surgical block, refining their protocol as they gained experience. Now, 60 minutes after spinal anesthesia is administered, children receive an automatic bolus of chloroprocaine through the caudal catheter. This maintains pain relief, allowing for seamless anesthesia as the spinal block recedes. Children also receive an intravenous bolus of dexmedetomidine prior to catheter placement, as well as a gradual infusion throughout the surgery.
The study included 23 children, with a mean age of 16.5 months, in whom they attempted SCC. Spinal anesthesia was unsuccessful in three children, who were switched successfully to general anesthesia. The remaining 20 patients completed operations such as ureteral implantations, ureterocele excisions and reimplantations, megaureter repairs, first- and second-stage hypospadias repairs, feminizing genitoplasties and open pyeloplasty. All SCC children spontaneously breathed room air and completed surgery without airway intervention or other complications.
“Successfully starting a program requires a surgeon who is motivated and an anesthetist who wants to push the envelope,” says Dr. Jayanthi. “I hope other hospitals will pursue this. We should be accepting that SCC may have specific advantages, with minimal use of systemic medications and lack of airway manipulation.”
CITATION:
Jayanthi VR, Spisak K, Smith AE, Martin DP, Ching CB, Bhalla T, Tobias JD, Whitaker E. Combined Spinal/Caudal Catheter Anesthesia: Extending the Boundaries of Regional Anesthesia for Complex Pediatric Urological Surgery. Journal of Pediatric Urology. 2019 Apr 11. pii: S1477-5131(19)30079-8.
