Spinal Anaesthesia in Infants

Paediatric Anaesthesia Department

Guidelines for Spinal Anaesthesia in Infants

1. Indications

For surgery below the umbilicus in small infants with a history of prematurity or respiratory disease

N.B. General anaesthesia in these infants may be associated with post-operative apnoeas and prolonged ventilation may exacerbate their respiratory disease

2. Anaesthetic problems

Technical due to small size of patient.

Limited duration of block - usually 45-75 mins. It is important that the surgeon is scrubbed and ready as the block is being performed. An operation likely to exceed 50 mins is a contraindication to spinal block.

Spinal cord ends at L3 (c.f. L2 in adult) so block is safer if performed at L4 or below.

Haemodynamic changes are minimal but i.v. access should be obtained prior to performing the block.

3. Assessment

Careful assessment of airway and potential for respiratory problems.

Prior discussion with the surgeon may be required regarding laparoscopic surgery under general anaesthesa versus open procedure with a spinal anaesthetic.

4. Preparation

Normal preoperative fasting. No premedication.

5. Preparation of anaesthetic equipment

Observe all special precautions for infants. Fully check anaesthetic machine as if a GA was to be performed.

6. Performance of block

Gain i.v. access Go through positioning of the patient with the assistant involved before gowning. Gently but firmly restrain patient in the sitting position. Avoid overzealous neck flexion. The lateral position may be used but generally the sitting position is more satisfactory. Scrub, gown and glove. Prepare and drape. Prior application of local anaesthetic cream may be used as an alternative to local infiltration to the skin. Use plastic hubbed spinal needle - 25 gauge, 2.5cm preferable but 22 gauge needle is also available. Insert at L4-5 until CSF is obtained. Aspiration may be necessary to detect CSF with a 25 gauge needle. Slowly inject 0.5% plain bupivacaine. Slight aspiration to confirm position may be done but avoid excessive barbotage. Leave needle in place for 5 secs after completion of injection then remove. Dose regime: 0.5 to 0.75mls 0.5% plain bupivacaine for 2 - 5 kg infant. Monitoring- pulse oximetry, ECG, NIBP

7. Maintenance

Turn to supine position.

Motor function in the lower limbs should cease within about 1 minute. It is best to keep infant level. Watch out for the nurse picking up the infant by the ankles to put the diathermy plate on. A dummy, perhaps dipped in glycerine, may help to settle the child. Upper limbs may need to be restrained to avoid the child inadvertently reaching into the surgical field.

8. Homeostasis

Minimal changes expected but guided by monitoring.

9. Recovery

Patient stays in Recovery until motor function returns to the legs. Routine observations. The child may be nursed in any position in Recovery and may receive a feed whilst still in Recovery.

10. Post-operative management

Appropriate apnoea monitoring should be carried out post-operatively for 18 - 24 hours.

Back to Paediatric Anaesthesia Protocols and Guidelines

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