Spinalanästhesie zur Operation von Leistenhernien bei respiratorisch gefährdeten Säuglingen

Zusammenfassung

12 respiratorisch gefährdete Säuglinge mit einem postkonzeptionellen Alter zwischen 36 und 58 Wochen und einem Körpergewicht zwischen 1,8 und 5,3 kg waren für eine Spinalanästhesie vorgesehen. Die Punktion war in 10 von 12 Fällen erfolgreich, die beiden anderen Kinder erhielten eine Vollnarkose. Die Anschlagszeit lag bei 9 von 10 Kindern zwischen 60 und 90 Sekunden, bei einem Kind (5,3 kg, 58 Wochen postkonzeptionell) trat die Wirkung erst nach 10 Minuten auf. Die Wirkdauer lag zwischen 60 und 90 Minuten. Durch die Spinalanästhesie wurden keine therapiebedürftigen Komplikationen hervorgerufen. Ein Kind, das Midazolam und Lachgas zur Sedierung erhielt, zeigte kurzfristige Apnoen, die mit taktilen Reizen und Theophyllingabe beherrscht werden konnten. Die Spinalanästhesie stellt nach unseren ersten Erfahrungen bei respiratorisch gefährdeten Kindern eine gute Alternative zu einer Allgemeinanästhesie bei Operationen im Leistenbereich dar.

Summary

11 former premature babies born at a mean gestational age of 32 weeks (range 27-34 weeks) and one baby born at term with congenital diaphragmatic hernia scheduled for inguinal hernia repair were selected to receive a spinal anaesthesia after informed written consent was obtained from one of the parents. At birth, 10 infants were intubated and received assisted ventilation; the remaining two were on nasal CPAP for 24 hours after birth. The mean post-conceptual age of the former premature infants on the day of surgery was 39 weeks (range 36-43 weeks), the mean weight was 2.2 kg (range 1.8 to 3.6 kg). One boy with congenital diaphragmatic hernia who was intubated for 19 days after birth aged 4 months on the day of operation and weighed 5.3 kg. None of the children was oxygen-dependent on the day of surgery. Spinal anaesthesia was performed in 3 children in the lateral decubitus and in 9 children in the sitting position. In each group, there was one case when spinal anaesthesia could not be performed due to a bloody spinal tap. These children received general anaesthesia, one of them in combination with a caudal block. The 9 former premature received 0.6 ml isobaric bupivacaine 0.5 %, and the child born on term with diaphragmatic hernia 0.8 ml isobaric bupivacaine 0.5 %. The onset of the motor blockade in the former preterm infants was within 60 - 90 seconds, while in the older child the onset was 10 minutes. With the given dose, the operation could be performed without any problems. The duration of the motor blockade varied between 60 and 90 minutes, when the first movements of the legs could be observed. Three of ten children with successful spinal anaesthesia had to be sedated with midazolam (0.1 mg/kg b.w., i.v.); one of these received additionally nitrous oxide. This child developed apnoeic spells of less then 10 seconds without desaturation or bradycardia, which were treated with i.v. theophyllin (2 mg/kg b.w.) and tactile stimulation. No further problems were observed in the postoperative period. All the other children were pacified by means of a pacifier dipped in glucose 10 %. In all children the ECG, the non-invasive blood pressure, the oxygen saturation and the temperature were monitored. Furthermore, the observation of the muscle tone of the arms and the continuous auscultation with a precordial stethoscope were mandatory. We never observed any significant haemodynamic or respiratory changes due to the spinal anaesthesia. We conclude that spinal anaesthesia is a useful alternative to general anaesthesia in children at high risk for respiratory complications. The positive effects of spinal anaesthesia are counteracted by sedation.