IN BRIEF

Pushing the Boundaries of Regional Anesthesia for Complex Urological Surgery

July 2, 2019

Physician-researchers extend the possibilities for regional anesthesia using combined spinal/caudal catheter anesthesia, allowing even complex, time-consuming pediatric urological surgeries to be completed without general anesthesia.

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 (GA) 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 V. 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.”

Dr. Jayanthi explains that parents in particular really like the option to avoid GA. While Dr. Jayanthi calls GA “incredibly safe,” he notes that parents often have more concerns about anesthesia than the surgery itself.

“We have amazing anesthetists who are great at what they do and it’s all very safe, but it’s an understandable parental concern — their child has lots of medications in their system and we are putting them to sleep, with a tube down their throat and a machine breathing for them,” says Dr. Jayanthi. “What’s beautiful about SCC is that a child can have the same operation with just minimal amounts of sedation. They are breathing on their own, most of the time just room air. It’s just remarkable what can be done with SCC.”

Spinal anesthesia, which involves a single anesthetic injection into the subdural space, provides localized, lower-body anesthesia for 60-90 minutes. It is an established technique first used in the late 1800s, and 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. To keep patients comfortable and calm enough for the procedures, children also receive an intravenous bolus of dexmedetomidine – an antianxiety, pain and sedative medication – prior to catheter placement, as well as a gradual infusion throughout the surgery.

The study included the team’s experience with 23 children, with a mean age of 16.5 months, in whom they attempted SCC. The approach could effectively be used at any age — and is indeed employed in many adult surgeries — but Dr. Jayanthi feels that fear and anxiety may still make GA the most appropriate choice for older children and teens.

Spinal anesthesia was unsuccessful in three children, who were switched successfully to GA. 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.

On average, surgeries lasted 109 minutes (maximum of 172 minutes). Theoretically, however, the SCC technique could extend effective regional anesthesia for as long as needed through the catheter bolus every 60 minutes. Dr. Jayanthi predicts that the SCC approach will become routine for lower-body procedures in pediatrics in time.

The original SCC team at Nationwide Children’s has had success encouraging additional urology surgeons, anesthetists, and other experts, including surgeons from the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s, to attempt the approach. They continue to monitor outcomes and regularly share their experience at conferences.

“To get a program started successfully, it requires a surgeon who is really 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. And families love it.”

 

Reference:

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, https://doi.org/10.1016/j.jpurol.2019.04.004.

Photo credit: Nationwide Children’s