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 2 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/