Paediatric spinal anesthesia In the dependent side for a few minutes for lateralisation of the block.

A successful block usually takes a bout 2-5 mins and care should be taken that the leg is not lifted just after the block for placement of diathermy pads which often results in undesired cephalad spread of the block. The extent of the sensory block can be checked by pin-prick or skin pinch and that of the motor block by Bromage scale. This may however be difficult to check in a deeply sedated child and can only be done in then postanesthesia care unit (PACU) to check the block regression. However, it can be clinically ascertained by lack of leg movement and diaphragmatic breathing. Children very often fall asleep with the deafferentation following the block. Intraoperative fluids only include deficit and maintenance amounts and preload need not be given as in adults. The hypotensive cardiovascular response to sympathectomy is minimal or nane in children. However, standard monitoring is mandatory and oxygen by face mask is recommended in all cases. All patients should be monitored in the PACU for vital signs, two-segment block regression, pain and any other side effect. Children should only be discharged when they are awake and able to walk unaided, the vital signs are stable for at least 1 h, there is no pain, nausea/retching or vomiting, and are able to tolerate clear fluids. Intrathecal drugs Among the various drugs approved by FDA for paediatric intrathecal use, 0.5% bupivacaine and ropivacaine are common and popular. The doses used are institutional though the standard protocol that I have been practicing in 0.5% bupivacaine 0.1ml.Kg-1 or 0.5mg.Kg-1 for infants weighing 0-5 Kg; 0.08ml.Kg-1 or 0.4mg.Kg-1 for 5-15Kg body weight and 0.06 ml.kg1 or 0.3mg.kg-1 for >15Kg weight. Levobupivacaine has very similar (PH) armacokinetic properties to those or racemic bipiva-caine, but the potential for toxicity with levobupivacaine is less. Kokki et al performed a study on 40 children, aged 1-14 yr, undergoing elective lower abdominal or lower limb surgery levobupivacaine 5 mg.mL-1 at a mean dose of 0.3 mg.Kg-1 body weight, and found equivalent clinical efficacy in spinal anaesthesia in children to that of racemic bupivacaine. Ropivacaine 5 mg.ml-1 has also been used in some studies and found to be effective and safe in isobaric form. In a study of 93 shildren 1-17 years of age, kokki H et al used 0.5mg.kg-1 ( upto 20mg) in lateral decubitus position and achieved good block performance. Baricity is one of the most significant factors to affect the distribution of the local anaesthetic and hence success and spread of the blockade. The effect of differing degress of hyperbaricity was evaluated by several workers in paediatric age group. It is not known whether

hyperbaric local anaesthetic is better than isobaric in children in contrast to adults where it is proven to be more reliable, safe and effective. Isobaric bupivacaine has also been used for spinal anaesthesia in children and compared with its hyperbaric form. Kokki H compared bupivacaine 5 mg.ml-1, isobaric in saline 0.9% and hyperbaric in 8% glucose, for spinal anaesthesia in 100 children, aged 2-115 months for paediatric day case surgery. The success rate of the block was greater with hyperbaric bupivacaine (96%) compared with isobaric bupivacaine (82%). Intense motor block was associated with adequate sensory block. Spread and duration of sensory block showed a similar wide scatter in both groups. Cardiovascular stability was good in both groups. The study gave an impression of a delayed on set time on spinal block, as most of the nine children who required either fentanyl or a sedative for a mild reaction to skin incision had complete block when transferred to the recovery room after operation. However, in an article published two years later the same author, kokki H at al demonstrated that bupivacaine in 0.9% glucose in 8% glucose solutions are equally suitable for spinal anaesthesia in small children. Similar success rate, spread and duration of the sensory and motor block are achieved with both baricities of bupivacaine. Various studies have been done with child in lateral or sitting position for a subarachnoid block. In a study on 30 preterm infants for inguinal herniotomy, vila et al found spinal anaesthesia to be equally effective in both lateral and sitting position. Duration is an important and a limiting factor for paediatric spinal anaesthesia especially in infants and younger children. Spinal anaesthesia alone for this reason is therefore generally restricted to one hour duration surgeries only. The duration is longer with larger doses in infants and varies directly with the age of the child. It has been seen that the duration of long acting local anaesthetics like bupivacaine is only about 45 min in neonates and 75-90 min in children upto five years. There is no difference in duration by adding epinephrine to bupivacaine. Additives Since the duration of spinal anaesthesia does not cover most of the postoperative period, it is essential to add intravenous or rectal acetaminophen or ketoprofen routinely to all patients. Profound postoperative analgesia can be achieved by adding a low dose local anaesthetic with or without an opioid (fentanyl), clonidine 1-2 g.kg-1 or any other additive in caudal space at the time of performing the subarachnoid block. A caudal catheter can also be placed and local anaesthetic plus opioid added for prolonged analgesia postoperatively. Complications The complications related to spinal anaesthesia are usually either due to the needle used to perform the procedure (backache ,headache, nerve or vascular injury and infection) or the drugs injected (high or total spinal, drug toxicity). However, little data is available regarding the incidence as compared to adults.

Post dural puncture headache (PDPH) is rare in paediatric patients and some outhors have even challenged its existence. In his study on 200 children using two different sizes spinal needles of 25 G and 29 G Quinke, kokki et al found that 10 had PDPH with no difference regarding the type of needle used. The failure rate of attempted spinal anaesthesia was 4% and even when the subarachnoid space was reached and the local anaesthetic injected, the overall success rate of the technique was only 91%. Transient neurological symptom (TNS) has been reported by some authors following spinal anaesthesia due to direct toxicity of large doses of local anaesthetics. In his study on 95 patients using 0.5% isobaric ropivacaine, kokki et al reported mild to moderate TNS in four children which was transient and was followed by any permanent neurological sequelae. In another study by the same author similar results were found with 0.5% bupivacaine. A one year study of 24,409 regional blocks in children by the French-Language society of pediatric Anesthesiologists, the largest known study on complications, revealed a complication rate of 0.5 per 1000 in the 60% of children receiving central neuraxial blocks. However, most of these cases were those of caudal and some of epidural technique. Advantages Spinal anaesthesia produces a reliable, profound and uniformly distributed sensory block with rapid onset and good muscle relaxation, and it results in more complete control of cardiovascular and stress responses than epidural or opioid anaesthesia. It is ideal for day case surgeries and is safe and cost-effective. There is no additional requirement of any special drug or equipment for the procedure. Because of these benefits, spinal anaesthesia has gained acceptance for children undergoing surgery in the lower part of the body. Comparison with general anaesthesia General anaesthesia may be associated with several life-threatening complications especially in preterm, former preterm, those with co-morbidities like sepsis, necrotizing enterocolitis, anaemia (hematocrit<30%), severe respiratory disease like respiratory distress syndrome, bronchopulmonary dysplasias, cystic fibrosis etc. all these neonates are at much higher risk of apnoea, bradycardia and desaturation after general anaesthesia. Spinal anaesthesia is a safe, reliable and simple technique in a high risk infant. In 1984, Abajian et al sparked an interest in this group and since then all the reports have ascertained this fact. In the healthy children, most of the procedures are performed as day-case surgeries like herniotomy, circumcision, minor irological and orthopaedic procedures. Spinal anaesthesia is a very good alternative for such cases were the child can be returned to the family and a lot of stress to the parents is avoided. Since less general anaesthetic drugs including parenteral opioids are used, the risk of postoperative respiratory depression is minimal. The stress response to surgery is also limited and recovery is fast.

Kokki et al studied 100 children for paediatric day-case surgery and found the technique safe and effective. In his 10 years of experience of paediatric orthopaedic surgery. BangVojdanovski B concluded that spinal anaesthesia is a suitable anaesthetic technique for paediatric surgery. This method of anaesthesia may avoid the increased incidence of postoperative respiratory complications associated general anaesthesia. Intraoperative laryngo and bronchospasm are not uncommon even in healthy infants and children besides episodes of coughing, breath-holding, endotracheal tube obstruction and atelectasis. Moreover, with the increasing incidence of upper respiratory infections, commonly 38 times in a year in paediatric age group there will always be a risk of a hyper-reactive airway under general anaesthesia. Besides, there are not preoperative tests feasible which would rule out any mild-moderate respiratory infection in children. Most of the times, the clinician has to rely only on the history provided by the parents. More commonly the symptoms appear only on the day of surgery and it becomes a difficult decision to cancel the surgery. Spinal anaesthesia is relatively safer in all these instances where spontaneous airway can be maintained by the patient. Kokki et al also conducted a study on forty children, age 2-5 years undergoing paediatric surgery and compared spinal with general anaesthesia. Time spent in the operation room was shorter in the spinal anaesthesia group because the children were awake and could immediately be transferred. The haemodynamic pattern and respiratory function were stable during spinal anaesthesia. Arterial desaturation (<90%), vomiting, sore throat and micturition difficulties were the adverse events associated with general anaesthesia. Tree patients were restless after spinal anaesthesia. In a study of 30 cases aged 7 months to 13 years at the Childrens National M edical Centre, Washington, open heart surgery was performed under high subarachnoid block along with light general anaesthesia by Finkel JC et al and haemodynamic stability was found to be maintained intra operatively in all cases. Spinal anaesthesia has been found to be more cost effective as compared to general anaesthesia. The drugs and equipment required are much less and cheaper besides the length of hospital stay which is also usually shorter. Paediatric spinal anaesthesia may have been conceptualized a century ago but its golden years are yet to come. Overall patient safety, feasibility and reliability are the key features of this technique which will only become better with greater use, experience and research.