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Lumbar epidural anaesthesia for inguinal hernia repair in low birth weight infants

Canadian Journal of Anaesthesia volume 40, Article number: 670 (1993) Cite this article

Abstract

In view of the complications of general, spinal, and caudal anaesthesia for inguinal hernia repair in high-risk neonates, an evaluation of lumbar epidural anaesthesia (LEA) was undertaken to assess its technical feasibility, effectiveness and incidence of complications. In 18 consecutive cases, gestational age 26 ±2.6 wk, birth weight 877 ±310 g, 16 (89%) had bronchopulmonary dysplasia and 12 (67%) were oxygen-dependent at the time of surgery. Using a standard loss of resistance technique and a 4.0 cm 20 G epidural needle, the epidural space was positively identified on the first attempt in 16 (89%), and on the second attempt in 2 patients (11%). Reflux of 0.9% saline used to identify the epidural space was blood tinged in two cases. Epidural analgesia was achieved in all cases with bupivacaine 0–25% with and without 1:200,000 epinephrine, 0.75 ml · kg−1 for the first two cases, and subsequently 1.0 ml · kg−1~’. In 15 patients (83%), good operating conditions were achieved with epidural analgesia alone. Inhalational anaesthesia supplementation was necessary in three cases (17%). In the first two patients, the level of analgesia (T8) was insufficient to control the response to traction on the hernial sac. In one infant, analgesic to T4, whose surgery was inadvertently delayed for four hours, inhalation anaesthesia was needed to control restlessness rather than pain. Ten infants were analgesic to T2, four to T4, two to T6 and two to Tg. Intraoperative periodic breathing was seen in seven infants (39%), four with oxyhaemoglobin desaturation to 75%, and two to 85%. All responded to increased F1O2. No adverse haemodynamic effects were seen. Apnoeic spells in the first 24 hr after surgery occurred in three infants; one of these infants also had apnoeic spells during the previous 24 hr. Otherwise, there were no postoperative complications. We conclude that LEA was technically easy, and provided good operating conditions for most neonates in this study.

Résumé

Etant donné l’importance des complications de l’anesthésie générale, rachidienne et caudale réalisées pour la cure de hernie inguinale du nouveau-né à haut risque, une évaluation de l’anesthésie épidurale lombaire est entreprise pour en évaluer la faisabilité technique, l’efficacité et la morbidité. Dans 18 cas consécutifs, d’âge conceptionnel de 26 ±2,6 semaines, pesant à la naissance 877 ±310 g, dont 16 (89%) souffrent de dysplasie bronchopulmonaire et 12 (67%) survivent sous oxygène au moment de la chirurgie. Avec une technique standard de perte de résistance et une aiguille épidurale 20 G de 4,0 cm, l’espace épidural est repéré au premier essai dans 16 cas (89%) et au deuxième chez deux patients (11%). Le reflux de soluté physiologique 0,9% utilisé pour le repérage revient teinté de sang chez deux patients. Dans tous les cas, l’anesthésie épidurale est réalisée avec de la bupivacaïne 0,25% avec et sans épinéphrine, 0,75 ml · kg−1 pour les deux premiers cas et par la suite 1,0 ml · kg−1. Chez 15 patients (83%), de bonnes conditions opératoires sont obtenues avec l’épidurale seule. Dans trois cas, on doit supplémenter avec de l’anesthésie inhalatoire (17%). Chez les deux premiers patients, le niveau d’analgésie (T8) est insuffisant pour abolir la reaction à la traction du sac herniaire. Chez un patient, analgésié à T4, pour qui la chirurgie doit être retardée pour une heure, l’anesthésie inhalatoire est requise plutôt pour contrôler l’agitation que la douleur. Le niveau analgésié atteint T2 chez dix enfants, T4 chez quatre, T6 chez deux et T8 chez deux. Une respiration périodique peropératoire survient chez sept patients (39%) dont quatre avec désaturation à 75%, et deux à 85% Ils réagissent bien à une augmentation de la FiO2. On ne constate pas de réactions hémodynamiques défavorables. Des périodes d’apnée pendant les 24 hres qui suivent la chirurgie se manifestent chez trois enfants; un de ceuxci avait eu des périodes d’apnée pendant les 24 hres précédentes. On ne constate pas d’autres complications postopératoires. Nous concluons que l’épidurale lombaire est facile techniquement et a produit de bonnes conditions chirurgicales chez la plupart des nouveaux-nés inclus dans l’étude.

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Affiliations

  1. Department of Anaesthesia, University of Western Ontario, St. Joseph’s Health Centre, Canada

    Anthony C. Webster, J. D. McKishnie, J. T. Watson & W. Donald Reid

  2. Department of Neonatal and Perinatal Medicine, University of Western Ontario, St. Joseph’s Health Centre, Canada

    Anthony C. Webster, J. D. McKishnie, J. T. Watson & W. Donald Reid

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  1. Anthony C. Webster
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  2. J. D. McKishnie
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Webster, A.C., McKishnie, J.D., Watson, J.T. et al. Lumbar epidural anaesthesia for inguinal hernia repair in low birth weight infants. Can J Anaesth 40, 670 (1993). https://doi.org/10.1007/BF03009705

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Key words

  • anaesthetic techniques: lumbar epidural
  • anaesthesia: paediatric