Nationwide Children's Hospital, Division of Urology, 700 Children's Drive, Columbus, OH 43205, USA.
Nationwide Children's Hospital, Division of Urology, 700 Children's Drive, Columbus, OH 43205, USA.
J Pediatr Urol. 2019 Feb;15(1):49.e1-49.e5. doi: 10.1016/j.jpurol.2018.08.011. Epub 2018 Aug 17.
Increasing concerns regarding potential negative effects of early use of inhalational and intravenous anesthetics on neurocognitive development have led to a growing interest in alternative forms of anesthesia in infants. The study institution's outcomes with spinal anesthesia (SA) for urologic surgery in infants aged less than 90 days are reported and their outcomes with a matched cohort of patients who underwent general anesthesia (GA) are compared.
This is a retrospective single-center analysis. Patients aged less than 90 days who underwent SA for four urologic surgeries (inguinal hernia repair, scrotal exploration, posterior urethral valve ablation, and ureterocele puncture) were identified from the study institution's SA database. An age- and procedure-matched control cohort was identified from a list of patients who underwent the aforementioned four procedures under GA since 2013. Outcomes of interest included success rate of SA, complications from spinal placement, narcotic use, need for supplemental medications and oxygen, and length of hospital stay.
Forty patients were identified; 20 in the SA and 20 in the GA group. Mean patient age was 54 (standard deviation, 35) days. There were no significant differences between the groups in age, gender, weight, history of prematurity, or presence of comorbidities. Eighty percent of SA patients had successful SA; reasons for conversion to GA included failure of spinal needle placement (75%) and agitation during operative procedure (25%). Ninety-six percent of patients who received GA (primarily or converted) had an endotracheal tube (ETT) placed. No patient in the SA group had a complication from spinal needle placement. Patients in the SA group were less likely to receive narcotics during the operative procedure (P = 0.001) and also had a lower mean morphine equivalent dose/kilogram (P = 0.002). Patients in the SA group were also less likely to receive any supplemental medications during the operative procedure (P = 0.001), particularly intravenous corticosteroids (P < 0.001). There were no significant differences in the length of hospital stay.
The use of SA has clear advantages for this medically vulnerable population. For the majority of patients, it obviates the need for ETT placement and airway management and avoids the potential negative effects of GA on neurocognitive development. It also decreases the use of narcotics and other supplemental medications. In scenarios in which the benefit of surgery must be weighed against the risk of GA, such as neonatal torsion, SA may allow a paradigm shift in the timing of surgery.
由于人们对早期使用吸入和静脉麻醉对神经认知发育的潜在负面影响的担忧日益增加，因此人们对婴儿的替代麻醉形式产生了浓厚的兴趣。本文报道了本研究机构在 90 天以下婴儿行泌尿科手术时应用脊髓麻醉（spinal anesthesia，SA）的结果，并与同期行全身麻醉（general anesthesia，GA）的患者进行了比较。
这是一项回顾性单中心分析。从本研究机构的 SA 数据库中确定了年龄小于 90 天、因 4 种泌尿科手术（腹股沟疝修补术、阴囊探查术、后尿道瓣膜切除术和输尿管囊肿穿刺术）接受 SA 的患者。从 2013 年以来接受上述 4 种手术 GA 的患者名单中，确定了年龄和手术相匹配的对照组。感兴趣的结局包括 SA 的成功率、脊髓置管相关并发症、阿片类药物使用、需要补充药物和氧气的情况，以及住院时间。
共确定了 40 例患者，20 例在 SA 组，20 例在 GA 组。患者的平均年龄为 54（标准差 35）天。两组在年龄、性别、体重、早产儿史或合并症方面无显著差异。80%的 SA 患者 SA 成功；转为 GA 的原因包括脊髓针放置失败（75%）和手术过程中躁动（25%）。96%接受 GA（主要或转为 GA）的患者均放置了气管内导管（endotracheal tube，ETT）。SA 组无脊髓针放置相关并发症。SA 组患者在手术过程中更不可能使用阿片类药物（P=0.001），吗啡等效剂量/公斤也较低（P=0.002）。SA 组患者在手术过程中也更不可能使用任何补充药物（P=0.001），尤其是静脉皮质类固醇（P<0.001）。两组的住院时间无显著差异。
对于这群医学上脆弱的人群，SA 的应用具有明显优势。对于大多数患者，它避免了 ETT 放置和气道管理，避免了 GA 对神经认知发育的潜在负面影响，也减少了阿片类药物和其他补充药物的使用。在手术的益处必须与 GA 的风险相权衡的情况下，如新生儿扭转，SA 可能会改变手术时机的观念。
