Spinal anesthesia is performed by injecting local anesthetic directly into the CSF of the subarachnoid space of the medulla spinalis.

Background
Spinal anesthesia is performed by injecting local anesthetic directly into the CSF of the subarachnoid space of the medulla spinalis.
Spinal anesthesia (SA) in children was first performed in the 1909, but it is not routinely performed until the 1980. It has several advantages and disadvantage compared to the general anesthesia (GA), one of the most important advantage, is the avoidance of post operative apnoe which can occur after general anesthesia. One of the most commonly

Objective
To Describe a safe spinal anesthetia management in pediatric patient with inguinal hernia
Case :
A 2 years old male child with right inguinal hernia, the patient was generally in a good condition, and was scheduled for elective hernia repair under subarachnoid block anesthesia with the physical status ASA II.
Patient data
Gender                                : Male
Age                        : 2 y.o
Body weight       : 10 kg
Preanesthetic physical examination
Airway                  : Patent airway, no evidence of digestive tract obstruction
Breathing            : RR 25x/min
                                  No signs of pulmonary rales
                                  SpO2 99% (room air)
Circulation           : Normal hydration status
                                  HR 110-116 bpm
                                  No signs of cardiac anomaly
Disability              : GCS E4 V5 M6
Exposure             : Axiler temperature 36.8 oC
Laboratory Result :
Hb 10,4 mg/dl, HCT 32 Leuco 11,3 Trombocyte  452.000 Erithrocyte 5,52
PT 12,4 APTT 29,8 INR 0,97 HbsAg Non Reactive
Anesthetic management
Preload :
EMLA cream was applied 60 minutes prior admission to the OR
Sedation using ketamin 5 mg iv (single shot) and midazolam 0,5 mg iv (single shot) and maintained at 0,6 mg/hour (1 µg/kg/min)
SAB approach :
                Position : Left lateral decubitus 
                Paramedian at Lumbar 4-5 space
Local anesthetic : Hyperbaric Bupivacain (0,5%)  5 mg without adjuvant
Maintenance :
                Fluid : D5% 1/2 NS at 60 ml/hour
                Respiratiom : O2 LPM via nasal canule
Blood loss : estimated 5 cc
Operation time : 10.00 - 10.55
Hemodynamic Monitoring
Recovery Room : 11.00-11.20
Patient was discharge after fully awake and able to move his legs freely, there is no significant event during the observation in the recovery room
Post operative
Patient was transferred back to the pediatric ward
Analgetics : novalgin 150 mg / 8 hours

DISCUSSION
To be able to perform a safe Spinal anesthesia in pediatric patient, an anesthesiologist must first understand the anatomical and physiological characteristics of this spesific population. And in this patient we would like to highlight several issues :
1.       Conus medullaris in children ends at L2/3 , so to avoid adverse event, puncture should be performed below those ending, preferably at L4/5 or L5/S1 interspace. The truffier line corresponds to L4/5 or L5/S1 interspace, which made it an applicable landmark, as in adult.
2.       Children in general are more prone to hypothermia, and since the spinal anesthesia will cause vasodilation by blocking the sympathetic nerve, preparation such as using warming underpad, and setting the room temperature to a warmer degree must be made to prevent hypothermia.
3.       The patient was already aware of his surrounding, so administration of benzodiazepine, in this case midazolam at the dose of 0,05mg/kg was chosen due to its anterograde amnesia, anxiolysis, and sedative properties. But since it can cause respiratory insuffiency, close monitoring and oxygen supplementation was mandatory.
4.       5mg of hyperbaric bupivacain 0,5% was chosen as it was the commonly used local anesthetics in this age population.
5.       The patient was discharge and transferred to the ward after he was able to move his lower limbs freely, and regained full consciousness.
Conclusion
Hernia is one of the most commonly seen pediatric case that required surgical intervention, and while it is still considered new compared to the already established general anesthesia, spinal anesthesia, if performed carefully with proper preparation and thorough understanding of the surrounding issues might prove beneficial.

Keywords :
Pediatric , Hernia , Spinal Anesthesia













References :
1. Coté, CJ.,  Lerman, J., Todres, I.D. A practice of anesthesia for infants and children. Saunders. Philadelphia : 2009. Chapter 42 : Regional Anesthesia ; p. 867-910
2.  Hadzic, A. Textbook of regional anesthesia and acute pain management. McGraw-Hill, Medical Pub. Division : 2007. Chapter 54 Regional anesthesia in pediatric patients

3. Troncin, R. , Dadure, C. Paediatric Spinal Anaesthesia. Update in anesthesia. Available at : http://update.anaesthesiologists.org/2009/06/01/paediatric-spinal-anaesthesia/