In This Article
- Massachusetts General Hospital specialists have developed a new protocol for spinal anesthesia in infants receiving certain pediatric urology surgeries
- Spinal anesthesia is a safe alternative to general anesthesia, as it avoids intubation, intravenous narcotics, and risks such as apnea, nausea, and vomiting
- The protocol has led to excellent outcomes, reduced operative times, and faster recovery times
Massachusetts General Hospital has established a new program that offers a safe regional anesthesia (spinal) alternative to general anesthesia in very young infants undergoing certain types of outpatient urologic surgery, including hernia repair and correction of penile abnormalities.
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"This program first started in high-risk premature babies undergoing hernia repairs and urological procedures. They tend to have immature respiratory systems and when they undergo general anesthesia, they have a high risk of postoperative apnea. They may have trouble being extubated, which could lead to prolonged hospitalization," says Chang Amber Liu, MD, MSC, director of pediatric regional anesthesia at Mass General. "But when we use spinal anesthesia for these babies, we spare them the general anesthesia and intubation. It has proven to be a good way to reduce all these potential problems."
The Infant Spinal Anesthesia Protocol
The Infant Spinal Anesthesia Program evolved from a detailed protocol developed by Dr. Liu, along with Jack Elder, MD, chief of the Division of Pediatric Urology at Mass General for Children. This strategy eliminates the need for airway instrumentation, avoids risks associated with general anesthesia, increases efficiency in the operating room, and shortens recovery time.
The protocol was originally used only on high-risk babies, but Dr. Liu believed it would be useful in ambulatory surgery on a broader population of infants. She teamed up with Dr. Elder to perform a case series and develop a protocol for infant ambulatory urologic procedures. When it was successful, they started to involve additional types of procedures, including:
- Correction of penile abnormalities such as penile torsion, penile chordee, and hidden penis
- Hypospadias repair to correct the position of the urethra
- Surgery to correct undescended testicle, inguinal hernia, and a variety of other genital and bladder problems
The detailed spinal anesthesia protocol is intended for patients younger than 10 months who weigh less than 10 kilograms.
"The technique is easier when the baby is held sitting up," Dr. Elder explains. "We insert the needle and inject the medicine into the intrathecal space. Then we turn the room lights down, and we use special green lights that are less harsh for the baby but allow our team to see. We use a drape to separate the surgical field from the baby and keep conversation to a minimum, so most babies fall asleep while we're working and they don't feel anything. At the end of the procedure, sometimes we elevate the head of the table 20 to 30 degrees and let the baby feed from a bottle to keep them peaceful. Then when we're done, they go right to the recovery room, they're immediately fed and are discharged pretty quickly."
Drs. Liu and Elder have used the protocol successfully on 145 babies to date, and the youngest patient was one day old. They've refined the protocol over time to be as safe, efficient and effective as possible. But it was a significant adjustment for the surgical teams.
"This approach is totally different. It can be hard for people to learn new things and get used to it until they practice it a lot," Dr. Liu says. "It took a lot of coaching. But the perioperative team started to love it once they saw how well the babies were doing."
Benefits of Spinal Anesthesia in Pediatric Urology Procedures
The entire Mass General team has since embraced the protocol because of its many benefits:
- All patients have maintained a natural airway
- No patients have required postoperative airway management or pain management
- All babies were brought to the PACU awake and ready to feed if they had not already been fed during the procedure
- Postoperative pain scores are lower with the spinal anesthesia protocol than with general anesthesia
- Babies have lower risks associated with general anesthesia, such as apnea, bradycardia, oxygen desaturation, and nausea and vomiting
- The protocol has reduced OR time and PACU recovery time, reuniting infants with their parents more quickly
Expanding the Use of Spinal Anesthesia in Infants
Drs. Liu and Elder continue to grow and improve the Infant Spinal Anesthesia Program. By studying brain waves of babies receiving surgery under spinal anesthesia, they found the patterns closely resemble those during natural sleep. They aim to further improve parent satisfaction and refine discharge criteria.
In addition, they are exploring methods to extend operative time under spinal anesthesia to more than three hours when necessary.
Meanwhile, Drs. Liu and Elder are sharing the protocol, with outcomes published in Paediatric Anaethesia and the Journal of Pediatric Surgery. They've also presented the protocol and results at annual meetings such as the American Urological Association, Pediatric Anesthesiology, the American Association of Genitourinary Surgeons, and the Brazilian Association of Pediatric Urologists. The program is now a robust model for other institutions looking to offer a lower-risk option to their smallest patients.
"Imagine your baby has a natural nap during their complex surgery, and then they wake up ready to be discharged after their surgery is done. It's just amazing," Dr. Liu says. "Our team really believes in this and has really dedicated themselves to it."
Learn more about the Infant Spinal Anesthesia Program
Refer a patient to the Department of Urology