Journal of Anesthesia
Spinal anesthesia for surgery longer than 60 min in infants: experience
from the ﬁrst 2 years of a spinal anesthesia program
· Dmitry Tumin
· Emmett E. Whitaker
· Tarun Bhalla
· Venkata R. Jayanthi
· Joseph D. Tobias
Received: 20 February 2018 / Accepted: 23 May 2018
© Japanese Society of Anesthesiologists 2018
Purpose Spinal anesthesia (SA) is being increasingly used in infants to avoid the potential negative neurocognitive eﬀects
of general anesthesia (GA). However, SA has been reported to provide a relatively short duration of surgical anesthesia.
Methods We retrospectively reviewed SA cases for surgical procedures lasting more than 60 min in children up to 3 years
old. All patients received bupivacaine 0.5% (1 mg/kg up to 7 mg) with clonidine 1 µg/kg ± epinephrine. The primary outcome
was success of SA without subsequent conversion to GA.
Results Thirty-ﬁve patients met inclusion criteria (all males, age 7 ± 5 months, weight 8 ± 2 kg). Procedures included male
genital, groin and multiple site surgeries. Average surgical duration was 71 ± 12 min (range 60–111 min). SA was successful
in 31 of 35 patients (89%; 95% conﬁdence interval 78, 99%). The cause of failure was rarely due to the duration of surgery (1
of 4 patients). Six patients with successful SA required sedation with dexmedetomidine ± fentanyl. Diﬀerences in procedure
duration and patient characteristics were not statistically signiﬁcant between successful and failed SA.
Conclusions SA is a highly successful technique and may oﬀer an alternative to GA in children undergoing appropriate
surgery expected to last as long as 60–100 min.
Keywords Spinal anesthesia · Children · Clonidine · Epinephrine
An estimated 1.5 million infants undergo general anesthesia
(GA) each year in the USA . While there remains no clear
evidence of GA-induced neurotoxicity in humans , the
United States Food and Drug Administration (FDA) recently
issued a warning regarding the possible adverse eﬀects of
repeated or lengthy GA in children younger than 3 years of
age . To avoid the potential risks of GA, spinal anesthesia
(SA) is increasingly being used in infants undergoing appro-
priate surgical procedures [4, 5].
An important limitation to SA is that it provides a rela-
tively short duration of surgical anesthesia, generally thought
to be less than 60 min . Several studies have assessed the
utility of adjuncts to local anesthetic agents (LAA) to pro-
long the duration of SA [7–9]. Nevertheless, outcomes of SA
for longer cases remain uncertain. In a recently published
review of 93 SAs performed at our institution, we showed
that this technique was successful for procedures lasting as
long as 122 min . For the current clinical report, we
expand our analysis of SA outcomes in long (≥ 60 min)
surgical procedures at our hospital. Our primary aim is to
describe the incidence of success with SA in such cases.
Secondarily, we explore factors potentially associated with
success or failure of SA for longer procedures.
* Mehdi Trifa
Department of Anesthesiology, Pain Medicine, Nationwide
Children’s Hospital, 700 Children’s Drive, Columbus,
OH 43205, USA
Faculty of Medicine, University of Tunis El Manar, Tunis,
Department of Anesthesiology, Pain Medicine, The Ohio
State University College of Medicine, Columbus, OH, USA
Division of Pediatric Urology, Nationwide Children’s
Hospital, Columbus, OH, USA
Department of Urology, The Ohio State University College
of Medicine, Columbus, OH, USA