Awake caudal anesthesia in ex-premature infants undergoing lower abdominal surgery
A narrative review.
Pediatric Anesthesia
Submitted July 2024 by Dr John Burnett
Read by 83 Journal Watch subscribers
It is well known that ex-premature infants are a high risk patient group, particularly with regard to perioperative apnoea. A question that is front of mind for most paediatric anaesthetists is “how can we use regional anaesthesia safely and effectively to improve outcomes for this vulnerable group of patients?”
We know that spinal anaesthesia for infant hernia repair compared to GA is associated with a lower risk of apnoea, however it does have an appreciable failure rate. Additionally, for success it requires a relatively short surgical time and, although not necessarily borne out in the literature, many clinicians opine that there is a learning curve involved in performing spinals in this group.
Awake caudal anaesthesia is proposed as a potential solution to these limitations.
The aim of this narrative review was to determine, from the available literature, whether awake caudal anaesthesia is a feasible and reliable procedure with low complication rates in ex-prem infants having abdominal surgery.
The authors (both with significant knowledge and experience in awake regional techniques) concluded that there was insufficient evidence to validate or refute the benefits of the use of awake caudal anaesthesia in premature and ex-prem infants.
The overall quality of the data was poor, with 45 reports analysed in total, including 8 RCTs as well as non-randomised prospective and retrospective series. There was significant heterogeneity and incomplete data reporting, overall preventing a systematic review.
The review included 558 (36%) cases of awake caudal, 837 (54.1%) cases of “awake” caudal with sedation and 153 (9.9%) cases of combined spinal caudal epidural (CSEA) without sedation.
Main findings:
1) Marked variability in approaches to “awake” caudal anaesthesia. Original description of awake was using no sedation, but more recently the technique seems to involve sedation for initiation and/or throughout (for example with sevoflurane, propofol or dexmedetomidine)
2) Slow onset of surgical anaesthesia (although only 35% of papers reported onset times)
3) Overall failure rates and perioperative apnoea rates were considered high:
- Failure rates were highest for CSEA (13.7%), intermediate for awake caudal (6.6%) and lowest for “awake” caudal with sedation (5.85%). Non-significant differences.
- The incidence of perioperative apnoea was highest for “awake” caudal with sedation (8.16%), intermediate for awake caudal (7.62%) and lowest for CSEA (5.53%). These differences were not significant.
4) It was noted that large doses (often more than max recommended) of local anaesthetic was common and there was a significantly higher rate of high spinal blocks in the larger series.
