Spinal anesthesia in children with isobaric local anesthetics: report on 307 patients under 13 years of age.

BACKGROUND: Spinal anesthesia in expert hands is an excellent method for children for appropriate surgery. The aim of this study was to evaluate the effects of spinal anesthesia with isobaric solutions in 307 consecutive cases from May 2001 to August 2002. METHODS: In this prospective study, 307 patients from 0 to 12 years of age were scheduled for spinal anesthesia with enantiomeric mixture of bupivacaine (S75 : 25R) 0.5% or racemic bupivacaine 0.5% or lidocaine 2% without glucose, for surgery compatible with the technique. The following were assessed: latency of analgesia, motor block, maximum length and duration of sensory blockade, cardiovascular changes, incidence of headache or transient neurological symptoms and cost. RESULTS: The onset of sensory block occurred at 2.36 +/- 0.95 min. Duration of surgery was 1.29 +/- 0.83 h and the duration of stay in the postanesthesia care unit was 39.72 +/- 26.84 min. The highest level of analgesia ranged from T(9) to T(4) (mean T(6)). Onset of motor block was <2 min in all children and each had a modified Bromage score of 3 at the beginning of the surgery. At the end of the surgery 9% had score 3, 16%, score 2, 46%, score 1 and 29%, zero. Seventy five percent of all patients recovered from motor block 1 or zero at the end of the surgery. Patients older than 1 year were able to walk in 3.79 +/- 0.73 h. There was no case of oxygen desaturation. Hypotension and bradycardia occurred in one patient. Spinal anesthesia failed in five patients. Three children developed postdural puncture headache (PDPH), the youngest aged 2 years. PDPH in all three was mild or moderate. Transient radicular symptoms were not observed. The final cost of the spinal anesthesia was R dollars 49.00 compared with a mean cost of general anesthesia of R dollars 105.00. CONCLUSIONS: Spinal anesthesia continues to gain acceptance as an alternative to general anesthesia in children. There has also been an increased use of spinal anesthesia for other surgical procedures including lower extremity orthopedic procedures as well as specific surgery procedures above the umbilicus and in patients past the neonatal period. Spinal anesthesia in children is a special method suitable for use only by anesthesiologists, expert in administering spinal anesthesia for adults. It was 54% less than the cost of general anesthesia.

Raquianestesia com a mistura enantiomérica de bupivacaína a 0, 5 por cento isobárica (S75ðR25) em crianças com idades de 1 a 5 anos para cirurgia ambulatorial / Spinal anesthesia for outpatient pediatric surgery in 1 ð 5 years old children with 0.5 per cent isobaric enantiomeric mixture of bupivacaine (S75ðR25)

Justificativa e objetivos - A bupivacaína comercialmente utilizada apresentaðse como mistura racêmica RS(ñ)bupivacaína. Embora o enantiômetro levógiro S(ð), levobupivacaína, seja menos tóxico para o sistema nervoso central e cardiovascular do que a R(+) bupivacaína, sua relativa eficácia ainda näo foi determinada na raquianestesia em crianças. O objetivo deste estudo prospectivo foi avaliar a mistura enantiomérica de bupivacaína S75ðR25 em 40 crianças, com idades entre 1 e 5 anos. Método - Participaram do estudo prospectivo 40 crianças com idades entre 1 e 5 anos, submetidas à raquianestesia com mistura enantiomérica de bupivacaína (S75ðS25) a 0,5 por cento isobárica na dose de 0,5 mg.kgðû. Foram avaliados os seguintes parâmetros: latência da analgesia, bloqueio motor, duraçäo dos efeitos, dispersäo cefálica da analgesia, alterações cardiovasculares, cefaléia e sintomas neurológicos transitórios. Resultados - O tempo de latência foi de 2,29 ñ 0,64 min. A duraçäo da analgesia foi de 4,13 ñ 0,89 h. O tempo de deambulaçäo foi de 3,50 ñ 0,81 h. O tempo de permanência na SRPA foi de 43,80 ñ 31,34 min. A duraçäo do bloqueio motor foi de 1,89 ñ 0,78 h. O nível sensitivo de bloqueio variou entre T9 e T4 (Moda=T6). O início do bloqueio motor foi menor que dois minutos em todas as crianças. Todos apresentaram bloqueio motor grau 3 (escala modificada de Bromage) no início da cirurgia. Mais de 55 por cento dos pacientes apresentaram bloqueio motor 1 ou ausência de bloqueio no final da cirurgia. Näo foi observada dessaturaçäo ou hipotensäo arterial. Bradicardia foi observada em um paciente. Ocorreram duas falhas. Cefaléia e SNT näo foram observados. Conclusões - A mistura enantiomérica da bupivacaína (S75-R25) a 0,5 por cento isobárica produz uma anestesia segura em pacientes de 1 a 5 anos em regime ambulatorial, com alto índice de sucesso, bloqueio motor de curta duraçäo de açäo, relativa baixa incidência de efeitos colaterais e a um custo menor. Cefaléia pósðpunçäo parece ser rara em pacientes abaixo de 5 anos quando se utilizam agulhas de fino calibre. Nossos resultados mostraram que a raquianestesia é segura e facilmente realizável em crianças de 1 a 5 anos em regime ambulatorial

[Spinal anesthesia for outpatient pediatric surgery in 1 - 5 years old children with 0.5% isobaric enantiomeric mixture of bupivacaine (S75-R25)]. / Raquianestesia com a mistura enantiomérica de bupivacaína a 0,5% isobárica (S75-R25) em crianças com idades de 1 a 5 anos para cirurgia ambulatorial.

BACKGROUND AND OBJECTIVES: Commercially available bupivacaine is a racemic mixture of S(-) and R(+) enantiomers. Although the S(-) bupivacaine enantiomer is less toxic than R(+) bupivacaine to cardiovascular and central nervous systems, its relative efficacy has not yet been determined in spinal anesthesia for pediatric surgery. The aim of this study was to evaluate the effects of spinal anesthesia with a 0.5% isobaric mixture of S(-) bupivacaine(75%) + R(+) bupivacaine(25%) in 40 children aged 1 to 5 years scheduled for outpatient surgery. METHODS: Participated in this prospective study 40 patients aged 1 to 5 years submitted to spinal anesthesia with 0.5 mg.kg-1 of a 0.5% isobaric mixture of 75% S(-) bupivacaine + 25% R(+) bupivacaine. The following parameters were observed: onset of analgesia, degree of motor block, duration of effects, cephalad spread of analgesia, cardiovascular changes, incidence of headache and transient neurological symptoms. RESULTS: Mean onset time was 2.29 +/- 0.64 min. Duration of analgesia was 4.13 +/- 0.89 h. Time to ambulate was 3.50 +/- 0.81 h. Mean PACU stay was 43.80 +/- 31.34 min. Motor block duration was 1.89 +/- 0.78 h. Sensory block level varied from T9 to T4 (Mode=T6). Motor block onset time was less than two minutes in all children, all reaching grade 3 motor block (modified Bromage scale) in the beginning of surgery. Over 55% of all patients recovered to motor block 1 or zero at the end of the surgery. No patient developed oxygen desaturation or arterial hypotension. Bradycardia was observed in one patient. There were two block failures. There were no headache or transient neurological symptoms. CONCLUSIONS: Isobaric 0.5% levobupivacaine (R25-S75) induces a safe spinal anesthesia in patients aged 1 to 5 years scheduled for outpatient procedures, with a high success rate, short-lasting motor block, relatively low incidence of side effects and at a lower cost. Headache seems to be rare in patients below five years of age when a thin needle is used. Our results have shown that spinal anesthesia is a safe and easy technique for children between 1 and 5 years of age in outpatient procedures.