Regional Anesthesia

SPINAL ANESTHESIA FOR NEONATES/EX-PREMIE'S

neonatal spinal needle, 22g, short

L4-5 interspace, no higher

inject slowly

use TB syringe

add volume for dead space of needle

hold needle in for 5 seconds after injection complete

5% tetracaine in D5W = equal volumes of 1% tetracaine in water + D10W

Premie -- 0.8-1.0 mg/kg

minimum dose 1 mg

rapid T2 - T4 block, 60-90 minutes

CAUDAL ANALGESIA

*May be used up to age 5-6 years.

Level with Volume of Anesthetic

1. Armitage

Lumbar 0.5 ml/kg
Low Thoracic 1.0 ml/kg
Mid Thoracic 1.25 ml/kg
2. Spear

Mid Thoracic 1.6 ml/kg

% concentration: Trade off between motor and sensory block. Gunter (Anesthesiology 75:57, 1991) showed that 0.175% bupivacaine gives good postoperative analgesia without motor block. [Note: Ropivacaine may be an excellent alternative, but studies are pending.]

EPIDURAL ANALGESIA

*May be used after 1 year of age.
For local anesthetic/opioid mixtures

Bolus Infusion (starting rate)

Age ml/kg/seg ml/kg/hr

< 1 yr 0.04-0.05 0.1-0.2

1-7 yr 0.03-0.04 0.1-0.4

> 7 yrs 0.02-0.03 0.1-0.4

Bupivacaine 0.1% + 3 mcg/ml fentanyl
Bupivacaine 0.1% + 10 mcg/ml fentanyl

LUMBAR/CAUDAL EPIDURAL OPIOIDS

Morphine Bolus: 30 - 40 mcg/kg q 8-12 hrs
Fentanyl 5 mg/ml load and infuse as above

INTRATHECAL MORPHINE

1.5 - 2.0 mcg/kg

EPIDURAL/INTRATHECAL NARCOTICS - SIDE EFFECTS

Respiratory depression
FiO2 ± assisted ventilation
Naloxone 5 mcg/kg IVP
Reduce/discontinue infusion
Pruritis
Naloxone 5 mcg/kg IVP
Diphenhydramine 0.125 - 0.25 mg/kg IV q 6 hrs up to 25 mg
Propofol 0.1 mg/kg X one bolus, may repeat once at 15 minutes
Reduce dose
Nausea ± vomiting
Metaclopramide 0.15 mg/kg q 8 hrs
Dolesteron 0.35 mg/kg IV q 8 hrs up to 12 mg
Naloxone 5 mcg/kg IVP
NPO
Urinary retention
Straight catheter
Naloxone 5 mcg/kg IVP

"A man who trims himself to suit everybody will soon whittle himself away." -Charles Schwab (1862-1939), industrialist