RevBrasAnestesiol.2017;67(3):326---328
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Gastroschisis
repair
under
caudal
anesthesia:
a
series
of
three
cases
Neha
Kasat
∗,
Nandini
Dave,
Harick
Shah,
Swapnil
Mahajan
SethG.S.MedicalCollege&K.E.M.Hospital,DepartmentofAnesthesia,Mumbai,India
Received5May2016;accepted22July2016
Availableonline31August2016
KEYWORDS
Gastroschisis; Anesthesia,caudal; Infant,newborn
Abstract Gastroschisis is a congenital anomaly characterized by a defect in the anterior abdominalwallwithprotrusionofabdominalviscera.Perioperative mortalityisvery highin thesepatients.Traditionallygastroschisisrepairhasbeenperformedundergeneralanesthesia withendotrachealintubation,requiringpostoperativeintensivecareadmissionandmechanical ventilation.Caudalblockisanattractivealternativetogeneralanesthesia.Wepresentaseries ofthreeneonateswithgastroschisis,repairedsolelyundercaudalanesthesia.
©2016SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Gastrosquise; Anestesiacaudal; Lactentes, recém-nascido
Correc¸ãodegastrosquisesobanestesiacaudal:umasériedetrêscasos
Resumo Gastrosquise éuma anomaliacongênita caracterizadapor um defeito daparede abdominalanteriorcomprotrusãodevíscerasabdominais.Amortalidadenoperíodo perioper-atórioémuitoelevadanessespacientes.Tradicionalmente,acorrec¸ãodegastrosquisetemsido realizadasobanestesiageralcomintubac¸ãoorotraqueal,oquerequerinternac¸ãoemunidade deterapiaintensivaeventilac¸ãomecânicanopós-operatório.Obloqueiocaudaléuma alterna-tivaatraenteàanestesiageral.Apresentamosumasériedetrêscasosderecém-nascidoscom gastrosquisecorrigidaunicamentesobanestesiacaudal.
©2016SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mails:kasat.neha21@gmail.com,shahharick@gmail.com (N.Kasat).
Introduction
Gastroschisisisacongenitaldefectintheanterior abdomi-nalwallwithprotrusionofvisceraoutsideabdominalcavity. The incidence is 2---4.9 per 10,000 live births, with male
http://dx.doi.org/10.1016/j.bjane.2016.07.006
Gastroschisisrepairundercaudalanesthesia 327
preponderance.1 Administration of general anesthesia to
these neonates increases the likelihood of postoperative apnea and need for mechanical ventilation. To overcome theseproblems,centralneuraxialblocksarelookeduponas an alternative. Wereport aseriesof threeneonates with gastroschisis, where surgery was performed solely under caudalanesthesia.
Case
series
Neonateone
Day 2 premature neonate born at 34 weeks, weighing 1.5kg was posted for silo bag application for gastroschi-sis.Onexaminationpatient’ssmallintestinewasprotruding outside the abdominal wall. Neonate was active with good cry. Patients pulse rate was 130min−1 and respira-toryrate35min−1.Preoperativeassessmentdidnotreveal anysystemicabnormalities.Laboratoryinvestigationswere withinnormallimits.10%dextroseat120mL.kg−1.day−1was administeredfor2days.
Neonatetwo
Day 4 premature neonate born at 34 weeks, weighing 2kg was posted for silo bag application for gastroschi-sis. Small bowel and part of stomach were lying outside theabdominalcavity.Preoperativepulseratewas145min and respiratory rate 40min. Cardiorespiratory assessment and biochemical investigations were within normal lim-its. Multiple electrolyte solution was administered at 150mL.kg−1.day−1.
Neonatethree
A12houroldnewborn,bornat 36weeks,weighing2.1kg wasposted for complete reduction for gastroschisis. Part of small bowel and large bowel were protruding outside the abdomen. Neonate was active with good cry. Pulse was 144min with respiratory rate 45min. All investiga-tionswerewithinnormallimits.Dextrose10%wasgivenat 100mL.kg−1.day−1.
Anesthesia
management
Intraoperativemonitorsincludedcardioscope,preandpost ductalpulse-oximeters,temperatureprobeandnoninvasive bloodpressure.
All cases were conducted under caudal block only. Inhalationinduction usingsevofluranewithfacemask was performed to maintain immobility of neonates while giv-ingcaudal.After givingleftlateral positionandunder all aseptic precautions, a combination of 0.5% bupivacaine (2mg.kg−1) and 2% lignocaine with adrenaline (1:200000) 7mg.kg−1wasgiven.Totaldrugvolumeadministeredinall caseswas1.25mL.kg−1;thelocalanestheticdrug combina-tion wasdiluted withNormal Saline (NS) to make up the calculated volume.No other drug wasgiven.Oxygen was supplemented throughnasal prongs at 1L.min−1 and con-tinuousendtidalCO2monitoringwasperformed.Analgesia
wassupplementedwithInj.Paracetamol7.5mg.kg−1. Peri-operative fluids consisted of 10mL.kg−1 of 10% dextrose formaintenanceand15mL.kg−1ofNSusedasreplacement fluid.Vitalsremainedstableperioperatively.Theneonates were spontaneously breathing throughout. Silo bag appli-cation was performed in first twocases whereas primary closurewasperformedinthirdcase.The procedurelasted for60min,75min and90min respectively. Bloodloss was minimal in all cases. All three neonates were shifted to NICUbreathingspontaneouslywithoutanyneedfor intuba-tionorventilatorsupport,andwereobservedforrespiratory depression,apneaandsignsofdevelopmentofcompartment syndrome.
Discussion
Majorabdominalsurgeriesinneonatesaremostlyperformed undergeneralanesthesiawithendotracheal intubation,or generalanesthesiawith regionalblockade. However, gen-eralanesthesiaincreasesthelikelihoodofcomplicationslike requirementforprolongedmechanicalventilationand mor-bidityassociatedwithprolonged ventilation, especiallyin high-riskprematureneonates.2
Regionalanesthesiahasbeenadvocatedforhighrisk new-bornsthatarerequiredtobreathespontaneouslyfollowing surgery. It can be considered as an effective anesthetic technique in awake or sedated neonates and infants as an alternative to general anesthesia for gastrointestinal surgery. In this series of three cases, single shot cau-dal anesthesia was given successfully for gastroschisis repair.
Caudal anesthesia is associated with minimal cardio respiratory alteration, and offers hemodynamic stability withgoodmusclerelaxation.Itdecreasestheneedfor peri-operativeopioid analgesicsandthe associatedrespiratory depression.Otheradvantagesincludereductionofsurgical stressresponseanddecreasedincidenceofpost operative hypoxemiaand bradycardia. Alsoa spontaneously breath-ingneonateallowssurgeontodecide onthefeasibilityof primaryclosure.Respiratorydistressduetoincreased intra-abdominalpressurecanthusberecognizedearly.3Thelower
limbpulseoximeterhelpssurgeonstoguidetheextent of bowelrepositionintotheabdomenwhichwillbetolerated by the neonate without compromising circulation in the lowerlimb.
Spinal anesthesia can also be used as an anesthesia modalityforgastroschisisrepair.3,4Itsdisadvantageisthatit
isdifficulttojudgethespinallevelinneonatesanditsshort duration of action. Repositioning of abdominal contents increasesintra-abdominalpressure,therebyincreasingthe chance of high or total spinal leading to respiratory dis-tress. Caudal anesthesia further helps in avoiding these complications.
Combined spinal epidural has also been reported as a safeanesthesiatechniquefor gastroschisisrepair. Butthis approachis timeconsuming, and has other problems like technicaldifficulties, failureto threadepidural catheters andaccidentaldislodgementofcatheters.5
328 N.Kasatetal.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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