1. Paediatric spinal anaesthesia clinical pearls
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA,
Dip. Software statistics
PhD (physio)
Mahatma Gandhi medical college and research institute – Puducherry – India

2. History
Spinal anesthesia was probably the earliest form of regional anesthesia that was considered a useful practice for children
( Bainbridge, 1901 ; Tyrell-Gray, 1909 ).
Popularized in 1990 s

3. Why it came to lime light ??
Premature infants – possible hernia
Muscular and neuromuscular disease for abd. And lower limb surgery.

4. Other indications The safety and success of spinal
such as pyloromyotomy, gastrostomy placement,
myelomeningocele repair,
cardiac surgery, and genitourinary procedures.
Moreover, spinal anesthesia has been successfully used in high-risk infants and
for cardiac catheterization,

5. To consider spinal in ?? facial dysmorphia difficult intubation,
muscular dystrophy,
family history of malignant hyperthermia
or a full stomach with aspiration risk

6. Contraindications Coagulation abnormalities
Systemic sepsis or local infection at the puncture point
Uncorrected hypovolaemia
Parental refusal or an uncooperative child
Neurological abnormalities such as spina bifida,
increased intracranial pressure
Procedures lasting more than 90 minutes

7. Are there any differences ??

8. Where does spinal cord end ?
The conus medullaris lies at a lower level in infants;
therefore the L4-5 or L5-sacral interspace should be chosen for the dural puncture

9. Difference

10. Intercristal line ??
The intercristal line crosses the midline at the S1 interspace in neonates, and at the L5 interspace in older children

11. differences
The approach to the subarachnoid space requires a straighter trajectory of the needle than in older children.
The distance to the subarachnoid space is small,
cerebral spinal fluid (CSF) flow may be slow,
ligamentum flavum is thin

12. Difference
4 mL/kg (2 mL/kg in adults) with 50% being in the spinal canal compared with 25% in adults
Duration – short
Even bupivacaine 90 minutes

13. Technique Positioning – Flex back but extend neck Sedate ??
Enough local , EMLA 60 minutes before
Ready with airways

15. Technique Standard monitors, IV access
Distance from skin to subarachnoid space (cm) = x height (cm)
1 inch 22 g spinal needle
depth of 1 to 1.5 cm
distance in millimeters = (age in years
x2) + 10.
Aspirate and slowly inject
Don’t lift legs to place cautery

16. Sitting spinal – neonate

17. Technique
The ligamentum flavum is very soft in children and a distinctive “pop” may not be perceived when the dura is penetrated.
Be gentle and slow

18. Straight – 1 ml syringe

19. Characters of nerve fibres
Small nerve fibres
Nonmyelinated
Small distances between nodes of ranvier
Lumbar lordosis - Absent but in two years it may be present

20. Differences
fibrous sheaths around nerves are not well developed and myelination is not complete until about 2 years of age.
This makes immature nerves more sensitive to local anaesthetics and less concentrated solutions than are used in adults usually result in a dense block.

21. In term babies the length of the spinal cord is about 20 cm (in adults 65–70 cm).
This means that the length to weight ratio is four or five times higher in newborns than in adults.
so Dose differences

22. Assessing the block is difficult.
The response to cold spray can be useful,
observation of paradoxical respiratory muscle movement
loss of response to a low amperage tetanic stimulus.

23. Level ?? Pacifier nipple Spread of the block is less predictable
High level means –
no BP fall but apnea !!
Monitor 24 hours

24. Bupi and tetra
Heavy bupivacaine is recommended in a dose of mg/kg = mL/kg of 0.5% solution.
2 kg infant – hernia – 0.2 ml ??
6 kg infant – circumcision – 0.5 ml ??
14 kg 2 years – orchipexy – 1.5 ml
1% tetracaine, a dose of 0.5 mg/kg
Empty the needle

25. Other drugs
Doses ranging between 0.75 and 1.25 mg/kg of isobaric solution of levobupivacaine
addition of 100 μg clonidine to 20 ml bupi and inject the necessary dose Or
Add 1 μg / kg
Other drug dosage schedules

26. Doses in mg / kg Tetra Age Bupi Ropi Infants 0.5 – 1 1 - 7 0.3 – 0.5
> 7
0.2
0.4

27. Complications But – overall – very rare
Less than 6 months of age, immature hepatic metabolism of amide drugs
Failure rate – 10 – 20 %
Brady – ok but hypo - ??
PDPH – restlessness . Hearing loss !!
Potential traumatic puncture
But – overall – very rare

28. Causes of haemodynamic stability
immaturity of the sympathetic nervous system
smaller blood volume that is present in the lower extremities

29. Summary
Dose and drugs Position Dexterity Complications Spinal – safe In safe hands

30. Thank you all