Donald H. Lambert Boston, Massachusetts Spinal - Epidural - [Combined Spinal Epidural]
Response to epidural anesthesia in neonates for pyloromyotomy and accompanying editorial
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Transcript of Response to epidural anesthesia in neonates for pyloromyotomy and accompanying editorial
CORRESPONDENCE
Response to epidural anesthesia in neonates forpyloromyotomy and accompanying editorial
SIR—We read with great interest the paper by Wills-
chke et al., (1) ‘Management of hypertrophic pyloric
stenosis with ultrasound guided single shot epidural
anesthesia—a retrospective analysis of 20 cases’ as well
as the accompanying editorial by Bosenberg and
Lonnquvist (2). We agree with the editorialists that the
procedure described by the authors, while impressive,
is not very practical for most pediatric anesthesia prac-
titioners. Willschke et al. overstate the problems asso-
ciated with general anesthesia and intubation for
pyloric stenosis, while the dangers of propofol sedation
for neonates with potentially full stomachs are mini-
mized. On the other hand, we feel that the editorialists
go too far in their criticism and appear to question the
practicality of many regional anesthetic techniques in
infants. We have published two case reports describing
modifications of the caudally threaded epidural cathe-
ter technique in two syndromic infants who required
palliative surgeries and in whom it was requested that
general anesthesia with endotracheal intubation be
avoided (3,4). We therefore believe that there is defi-
nitely a role for advanced regional anesthesia tech-
niques in infants and neonates and that the
contributions of investigators such as Willschke are
extremely important.
Willschke et al. point out in their discussion that
caudal anesthesia, in their experience, does not provide
reliable spread above the T12 level, even with volumes
approaching 1.5 mgÆkg)1. Our experience with caudal
blocks is different. For the past 3 years, we have
successfully performed caudal blocks in children
requiring umbilical (T10) and supraumbilical sensory
levels for umbilical and epigastric hernia repair. By
simply administering the caudal block in the head-
down (Trendelenberg) position we have observed that
excellent umbilical and supraumbilical anesthesia can
be obtained (unpublished data). We generally tilt the
table 30 degrees, use 1.25–1.5 mlÆkg)1 of 0.2% bupiva-
caine and keep the child in the head-down position for
several minutes during the surgical prep. This simple
technique, to our knowledge, has not been previously
described in conjunction with caudal blocks. We do
not know whether this technique would provide reli-
able anesthesia for pyloromyotomy, but levels above
T10 are readily achievable.
As pointed out in the editorial, most pediatric
anesthesia practitioners are more comfortable with cau-
dally-threaded thoracic epidural catheters than direct
thoracic epidurals in infants. A safer alternative to
Willschke’s approach might have been to apply EMLA
cream over the sacral hiatus and attempt caudal
placement and advancement of an epidural catheter to
a thoracic level using ultrasound for confirmation.
We appreciate the efforts and innovations of Wills-
chke et al. and recognize the attention they have
brought to regional anesthesia for the pediatric popu-
lation. Although we disagree with the use of thoracic
epidurals for pyloromyotomy, we believe there is defi-
nitely a role for regional anesthesia in the care of neo-
nates and infants. Should the ongoing studies
comparing the neurocognitive effects of general anes-
thesia with regional anesthesia in infants yield results
favoring regional, studies such as Willschke’s will take
on a new significance.
Donald SchwartzMaureen McNeely
Department of Anesthesiology,Baystate Medical Center,
Springfield, MA, USAEmail: [email protected]
doi:10.1111/j.1460-9592.2011.03556.x
References
1 Willschke H, Machata AM, Rebhandl W
et al. Management of hypertrophic pylorus
stenosis with ultrasound guided single shot
epidural anaesthesia – a retrospective analysis
of 20 cases. Pediatr Anesth 2011; 21: 110–
115.
2 Bosenberg A, Lonnquvist PA. The potential
future or just a way of trespassing the safety
limits of pediatric regional anesthesia. Pediatr
Anesth 2011; 21: 95–97.
3 Schwartz DA, Patel D, Connelly NR. Cau-
dally threaded epidural catheter following a
single-shot caudal block in a high-risk neo-
nate: a combined caudal-epidural technique.
J Clin Anesth 2010; 22: 305–307.
4 Schwartz D, King A. Caudally threaded tho-
racic epidural catheter as the sole anesthetic
in a premature infant and ultrasound confir-
mation of the catheter tip. Pediatr Anesth
2009; 19: 808–810.
Pediatric Anesthesia 21 (2011) 907–913 ª 2011 Blackwell Publishing Ltd 907