J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 7, Number 11, November 2016, pages 493-497

Spinal Anesthesia for Urologic Surgery in an Infant With Palliated Single Ventricle Physiology

**Table 1.** Previous Reports of Spinal Anesthesia in Infants With Congenital Heart Disease
Authors and reference	Study design and cohort	Outcomes
HLHS: hypoplastic left heart syndrome; CHD: congenital heart disease; GA: general anesthesia; MAP: mean arterial pressure; SA: spinal anesthesia.
Peterson et al [28]	Retrospective review of regional anesthesia combined with GA in 220 patients over a 4-year period.	Tracheal extubation in 89% in the operating room. 95% had pain scores ≤ 4.0 at all postoperative intervals. Adverse effects included emesis (39%), pruritus (10%), urinary retention (7%), transient paresthesia (3%), and respiratory depression (1.8%). The incidence of hematoma was 0. The adverse effect rate was lower in thoracic epidural approach compared or others (caudal, lumbar epidural, spinal). Duration of stay was not affected.
Hammer et al [29, 30]	Retrospective review of 50 consecutive cases: 25 with epidural and 25 with SA combined with GA.	No significant hemodynamic changes were noted. Postoperative analgesia effects of the technique were reported in a subsequent publication.
Sacrista et al [31]	Case report of a 38-week gestation, 2,880 g infant with HLHS and anorectal atresia for colostomy under SA.	SA with 0.8 mL of 0.5% isobaric bupivacaine instead of GA. No significant hemodynamic changes were noted.
Finkel et al [32]	During GA with isoflurane, 30 patients (7 months to 13 years) with CHD received SA with hyperbaric tetracaine and morphine. Cephalad spread was promoted by 30° Trendelenburg positioning.	No significant hemodynamic changes were noted. Although not specifically studied, intraoperative maintenance requirements for isoflurane were low (0.5-1%).
Katznelson et al [33]	Cohort study of 12 infants less than 6 months of age undergoing diagnostic cardiac catheterization under SA with 1 mg/kg of 0.5% bupivacaine.	No significant changes in hemodynamic or respiratory variables comparing perioperative vitals. Six patients required additional sedation with midazolam or ketamine. Discharge time was 33 ± 12 minutes.
Tobias [34]	Case report of a 3-week-old, 3.6 kg infant with Blalock-Taussig shunt palliation of CDH, undergoing combined GA and SA for anorectoplasty.	Sevoflurane GA combined with SA (tetracaine and morphine). No significant hemodynamic changes were noted.
Kachko et al [35]	Retrospective review and comparison of 84 infants (42 with CHD and 42 without) undergoing non-cardiac surgery using SA (0.5 - 1 mg/kg of 0.5% bupivacaine).	No between-group differences in MAP and heart rate changes after SA. Mild decrease in MAP from baseline of 20%. Apnea without desaturation occurred in 1 patient.
Shenkman et al [36]	Retrospective review of 43 infants with non-cyanotic CHD for inguinal herniorrhaphy under SA with 1 mg/kg of tetracaine or bupivacaine.	No clinically significant hemodynamic changes. One patient was converted to GA due to the length of the procedure, two required supplemental oxygen.
Williams et al [23]	Retrospective review of 14 patients undergoing surgical closure of patent ductus arteriosus under deliberate high SA (tetracaine 2.4 mg/kg) with mechanical ventilation.	Two patients had inadequate spinal level and received isoflurane. Half received no supplementation. Average maximal decrease in MAP was 7.8 mm Hg with one patient having a decrease of 20 mm Hg and a heart rate decrease to 125 from 180 beats/min, responsive to fluid and atropine treatment.

Table 1. Previous Reports of Spinal Anesthesia in Infants With Congenital Heart Disease

Authors and reference

Study design and cohort

Outcomes

HLHS: hypoplastic left heart syndrome; CHD: congenital heart disease; GA: general anesthesia; MAP: mean arterial pressure; SA: spinal anesthesia.

Peterson et al [28]

Retrospective review of regional anesthesia combined with GA in 220 patients over a 4-year period.

Tracheal extubation in 89% in the operating room. 95% had pain scores ≤ 4.0 at all postoperative intervals. Adverse effects included emesis (39%), pruritus (10%), urinary retention (7%), transient paresthesia (3%), and respiratory depression (1.8%). The incidence of hematoma was 0. The adverse effect rate was lower in thoracic epidural approach compared or others (caudal, lumbar epidural, spinal). Duration of stay was not affected.

Hammer et al [29, 30]

Retrospective review of 50 consecutive cases: 25 with epidural and 25 with SA combined with GA.

No significant hemodynamic changes were noted. Postoperative analgesia effects of the technique were reported in a subsequent publication.

Sacrista et al [31]

Case report of a 38-week gestation, 2,880 g infant with HLHS and anorectal atresia for colostomy under SA.

SA with 0.8 mL of 0.5% isobaric bupivacaine instead of GA. No significant hemodynamic changes were noted.

Finkel et al [32]

During GA with isoflurane, 30 patients (7 months to 13 years) with CHD received SA with hyperbaric tetracaine and morphine. Cephalad spread was promoted by 30° Trendelenburg positioning.

No significant hemodynamic changes were noted. Although not specifically studied, intraoperative maintenance requirements for isoflurane were low (0.5-1%).

Katznelson et al [33]

Cohort study of 12 infants less than 6 months of age undergoing diagnostic cardiac catheterization under SA with 1 mg/kg of 0.5% bupivacaine.

No significant changes in hemodynamic or respiratory variables comparing perioperative vitals. Six patients required additional sedation with midazolam or ketamine. Discharge time was 33 ± 12 minutes.

Tobias [34]

Case report of a 3-week-old, 3.6 kg infant with Blalock-Taussig shunt palliation of CDH, undergoing combined GA and SA for anorectoplasty.

Sevoflurane GA combined with SA (tetracaine and morphine). No significant hemodynamic changes were noted.

Kachko et al [35]

Retrospective review and comparison of 84 infants (42 with CHD and 42 without) undergoing non-cardiac surgery using SA (0.5 - 1 mg/kg of 0.5% bupivacaine).

No between-group differences in MAP and heart rate changes after SA. Mild decrease in MAP from baseline of 20%. Apnea without desaturation occurred in 1 patient.

Shenkman et al [36]

Retrospective review of 43 infants with non-cyanotic CHD for inguinal herniorrhaphy under SA with 1 mg/kg of tetracaine or bupivacaine.

No clinically significant hemodynamic changes. One patient was converted to GA due to the length of the procedure, two required supplemental oxygen.

Williams et al [23]

Retrospective review of 14 patients undergoing surgical closure of patent ductus arteriosus under deliberate high SA (tetracaine 2.4 mg/kg) with mechanical ventilation.

Two patients had inadequate spinal level and received isoflurane. Half received no supplementation. Average maximal decrease in MAP was 7.8 mm Hg with one patient having a decrease of 20 mm Hg and a heart rate decrease to 125 from 180 beats/min, responsive to fluid and atropine treatment.