Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 2328  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
CASE REPORT
Year : 2009  |  Volume : 53  |  Issue : 2  |  Page : 223-225 Table of Contents     

Combined Spinal Epidural Anaesthesia for Gastroschisis Repair


1 Lecturer, Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India
2 P.G.Student, Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India
3 Associate Professor, Department of Anaesthesiology, T N Medical College & B Y L Nair Hospital, Mumbai, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Nandini Dave
C-303, Presidential Towers, L B S Marg, Ghatkopar West, Mumbai-400 086
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 20640128

Rights and PermissionsRights and Permissions
 

Gastroschisis is a congenital anomaly with a high perioperative mortality. Administration of general anaesthesia to these high risk neonates is associated with several problems including postoperative apnoea and the need for mechanical ventilation. Central neuraxial blocks, and more recently, combined spinal epidural have been administered for major abdominal surgery in neonates. We present the case of a neonate posted for gastroschisis repair conducted under combined spinal epidural anaesthesia and discuss the several advantages of this technique.

Keywords: Gastroschisis, Combined spinal epidural


How to cite this article:
Gore M, Joshi K, Dave N. Combined Spinal Epidural Anaesthesia for Gastroschisis Repair. Indian J Anaesth 2009;53:223-5

How to cite this URL:
Gore M, Joshi K, Dave N. Combined Spinal Epidural Anaesthesia for Gastroschisis Repair. Indian J Anaesth [serial online] 2009 [cited 2020 Jul 12];53:223-5. Available from: http://www.ijaweb.org/text.asp?2009/53/2/223/60283


   Introduction Top


Gastroschisis is a congenital anomaly with abdomi­nal wall defect with protrusion of abdominal viscera out­side the abdominal cavity. The incidence is 2-4.9 per 10000 live births with a male preponderance [1] .Adminis­tration of general anaesthesia to this group of patients is associated with several problems including the need for postoperative ventilation. Central neuraxial block for gastroschisis repair in neonates is an alternative technique which has proven to be safe with minimal complications [2],[3],[4]. We report a case of a neonate with gastroschisis op­erated under combined spinal- epidural block and dis­cuss the advantages of the technique.


   Case Report Top


A 10-hour-old full term neonate, weighing 1.6 kg was posted for gastroschisis repair. On presentation his stomach, small and large intestine, gall bladder were lying outside the abdominal cavity with abdominal wall defect at the level of umbilicus. Neonate was moder­ately active with good cry. Pulse measured 130/minute; respiratory rate was 40/min. Cardiorespiratory system evaluation was normal. Biochemical investigations were also within normal limits. Preoperatively, 10% dextrose with added calcium gluconate (4 ml i.e. 36 mg elemen­tal calcium/ day) and potassium chloride (3.2 ml i.e. 6.4 meq/ day) at 80 ml/kg/day was administered. Car­dioscope, pulse oximeter, temperature probe and non invasive blood pressure cuff were attached. Atropine 0.1 mg was administered and the neonate was sedated with 1% sevoflurane by mask. Subarachnoid block was performed with neonate in left lateral position in L4­L5 interspace using 27G, 2 inches BD® spinal needle.0.5 mg 0.5% bupivacaine, Astra Zeneca® + 0.5 mcg of fentanyl to make a total volume of 0.2 ml was adminis­tered using a 1 ml Dispovan® tuberculin syringe (dead space 0.02 ml). Spinal needle was removed after 5 seconds of completion of drug injection to prevent loss of drug due to skin tracking. Subsequently caudal epi­dural was performed using 19G epidural needle (Portex R ) and 21G catheter was threaded 8 cm inside epidural space with tip lying approximately at T8 level. The catheter was then tunneled away from the site of entry to avoid soiling [Figure 1]. The entire procedure took 10 minutes. The onset of subarachnoid block was judged by lower extremity motor block and patient not crying on stretching of abdominal wall. Intraoperatively, the neonate maintained spontaneous respiration with supplemental oxygen at 2 liters/minute and 0.5% sevoflurane administered via J-R circuit [Figure 2]. Intra operatively, Ringer lactate was infused at 10 ml/kg/hr. (Total intraoperative fluid administered 22 ml). Supple­mental analgesia was given through epidural route 30 minutes after subarachnoid block with 2 ml of 0.25% bupivacaine. Primary closure of abdominal wall defect was completed in 80 minutes. Again 1 hour after 1st epidural bolus dose, 0.2% bupivacaine 0.5 ml was re­peated epidurally using a 1 ml tuberculin syringe(10 mg i.e.2 ml of 0.5% bupivacaine diluted to 5 ml with nor­mal saline served as the stock solution). Total intraop­erative dose of bupivacaine administered was 6.5mg.

Perioperative course was uneventful. Blood loss was minimal. Neonate was shifted to PACU and ob­served closely for signs of respiratory distress. Subse­quent analgesic doses by epidural route were given at 6 hour intervals with 0.2% 0.5 ml bupivacaine. The epidural catheter was removed after 24 hours.


   Discussion Top


The practice of regional blocks for paediatric pa­tients is well established. It has been proven to be an effective modality in paediatric surgery. It offers excel­lent relaxation without hypotension with minimal alter­ations in respiratory rate and heart rate.

Data since 1978 in Vermont infant spinal registry states that success rate for spinal anaesthesia has in­creased over the years to 97.4% [5] . They report a shorter induction time as compared to general anaesthesia and a low complication rate.

Management of high risk neonates undergoing major surgery presents various challenges. Respiratory status is often precarious. Respiratory depression and post operative apnoea are well known complications of gen­eral anaesthesia in this group of patients. Major abdomi­nal surgeries under general anaesthesia often require post operative ventilatory support. Regional anaesthesia of­fers a chance to avoid these complications [6] .

Spinal anaesthesia to begin with gives a good dense block and good relaxation. It also gives a quiet child to insert the epidural catheter. Duration of sub­arachnoid block in neonates is short due to higher meta­bolic rate and greater anaesthetic absorption due to higher vascular supply to spine. For prolonged surgery and post operative analgesia combination of spinal­epidural technique is therefore advantageous [4],[7]. Epi­dural analgesia also avoids need for opioid analgesic injections in post operative period and the associated respiratory depression. Other advantages of regional anaesthesia include reduction of post operative stress response and decreased incidence of post operative hypoxemia and bradycardia.

Especially important in gastroschisis repair is re­laxation of abdominal wall provided by the spinal which allows for optimal reduction. The total closure of ab­dominal wall defect would result in tightness during abdominal movements during spontaneous respiration. In spontaneously breathing neonate this respiratory embarrassment is easily evident which thereby allows surgeon to decide on the feasibility of primary closure [8] .

Both, continuous infusion and intermittent top-up doses of local anaesthetic via epidural route have been used in neonates, however keeping in view the variable pharmacokinetics of bupivacaine, intermittent top -ups are considered the better option [9] .

In conclusion, we report the safe administration of combined spinal epidural to a neonate for gastroschisis repair and recommend it as a suitable alternative to general anaesthesia.



 
   References Top

1.Klein MD. Congenital defects of the abdominal wall. In:Textbook of Paediatric Surgery. 6 th edn (Eds Grosfeld JL, O'Neill Jr JA, Coran AG, Fonkalsrud EW, Caldamone AA) 2006; Ch. 73 pp. 1157-1171 Mosby Elsevier, Philadelphia.  Back to cited text no. 1      
2.Tobias JD.Spinal anaesthesia in infants and children.Paediatric Anaesthesia 2000; 10:5-16.  Back to cited text no. 2      
3.Kachko L,Simli E, Tzatlin E,Efrat R et al.Spinal anaesthe­sia in neonates and infants-a single centre experience of 505 cases.Pediatric Anaesthesia 2007;17:647-653.  Back to cited text no. 3      
4.Somri M,Tome R,Yanovski B,Aelfandiarov E, et al.Combined spinal-epidural anaesthesia in major ab­dominal surgery in high-risk neonates and infants.Paediatric Anaesthesia 2007;17:1059-1065.  Back to cited text no. 4      
5.Williams RK, Adams DC, Aladjem EV, Kreutz JMM, et al. The safety and efficacy of spinal anesthesia for surgery in infants: The Vermont Infant Spinal Registry Anesth Analg 2006; 102:67-71.  Back to cited text no. 5      
6.Walther-Larsen S, Rasmussen LS. The former preterm infant and risk of post-operative apnoea: recommenda­tions for management. Acta Anaesthesiologica Scandinavica 2006; 50: 888-93.  Back to cited text no. 6      
7.Williams RK,Mcbride WJ,Abajian JC.Combined spinal and epidural anesthesia for major abdominal surgery in infants.Canadian Journal of Anaesthesia 1997;44:511-514.  Back to cited text no. 7      
8.Vane DW, Abajian JC, and Hong AR.Spinal anaesthesia for primary repair of gastroschisis: A new and safe tech­nique for selected patients.Journal of Paediatric surgery 1994;29:1234-1235.  Back to cited text no. 8      
9.Bosenberg AT.Epidural analgesia for major neonatal surgery. Paediatric Anesthesia 1998;8: 479-483.  Back to cited text no. 9      


    Figures

  [Figure 1], [Figure 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1891    
    Printed74    
    Emailed1    
    PDF Downloaded438    
    Comments [Add]    

Recommend this journal