Medical Professional Publications

Can Spinal Replace General Anesthesia in Pediatric Urology Patients?

Columbus, OH — November 2017

As research continues to illuminate the possibility of neurotoxic effects from general anesthesia in pediatric patients, surgeons and anesthesiologists at Nationwide Children’s Hospital have already sought out an alternative among children 2 years of age and younger: spinal anesthesia. Their methods boast a high success rate, reduced need for systemic sedatives and a more efficient operating process from preparation to recovery.

Spinal anesthesia offers a viable low-risk alternative to general anesthesia for a wide range of pediatric urology procedures, according to a recent publication spearheaded by V. Rama Jayanthi, MD, chief of the Section of Urology at Nationwide Children’s Hospital, and Emmett Whitaker, MD, attending anesthesiologist at Nationwide Children’s, in partnership with their colleagues in both departments.

Out of 105 pediatric urology procedures using spinal anesthesia (on children ages 19 days to 24 months, with a mean age of 7.4 months), overall success was 84 percent, including placement and no need to convert to general anesthesia during the operation. Furthermore, in 75 of the 88 children who had a successful lumbar puncture, no additional sedation was required. The technique offers motor and sensory block coverage for 90 minutes or more when using a customized combination of bupivacaine, epinephrine and clonidine.

Drs. Whitaker and Jayanthi are optimistic that this substantial reduction in the need for general anesthetic and other systemic drugs could offer complete avoidance of potential neurotoxic effects for many patients, including children for whom the risks of general anesthesia are weighed against the risk of nonintervention due to comorbidities.

“Spinal anesthesia also reduces time to the reunion with parents,” Dr. Jayanthi says. “Once the surgery is complete, children are back in their parents’ arms within 10 or 15 minutes.”

Children can bypass the post-anesthesia care unit (PACU) and go directly to phase II/step-down care unless hospitalization is required for some other reason. Nationwide Children’s data, together with that of other institutions, indicate that the technique is safe and effective for many types of surgery and that the success rate is high.

“Pain control is excellent and anecdotally, parent satisfaction is high,” Dr. Whitaker says. “Many high-risk elements of general anesthesia in small children can be avoided. The data also support an improvement in operating room efficiency as well as reduced postoperative pain scores, faster recovery times and far less need for airway management or supplemental oxygen.”

According to Dr. Jayanthi, urologic procedures amenable to spinal anesthesia include circumcisions/revisions, inguinal hernia/hydrocele, orchidopexy, neonatal torsion and cytoscopic procedures such as valve ablation, stent removal and ureterocele puncture. “But anything below the abdomen could be considered for spinal anesthesia,” he says.

Using spinal anesthesia, the team has successfully performed proximal hypospadias, nonpalpable (intraabdominal testis), ureterostomy, ureteral reimplantation and vesicostomy. Dr. Jayanthi suggests that additional possibilities include use in the MRI suite and orthopedics.

The doctors attribute their success to two key factors: planning and partnership.

“We prepared for a year before we did our first spinals. We talked to everybody,” Dr. Whitaker says. “That is what enabled us to start and continue successfully.” The team developed a protocol, created a custom spinal anesthesia kit and discussed the procedures with all of the key stakeholders, from post-operative nursing assistants to the entire surgical and anesthesiology teams, including fellows.

“The best outcomes are based on a team approach,” Dr. Jayanthi says. “As a surgeon, I consider my anesthesia colleagues as partners in the care of the child. We have to talk about the kids and work together to figure out the right things to do to care for the children.”

Reference:
Whitaker EE, Wiemann BZ, DaJusta DG, Alpert SA, Ching CB, McLeod DJ, Tobias JD, Jayanthi VR. Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia. Journal of Pediatric Urology. 2017 Jul 14. [Epub ahead of print].

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