Anemia of Prematurity - Portal Neonatal

Use a short beveled needle to minimize the likelihood of inadvertent intravascular or intramedullary
injection of the local anesthetic medication. A caudal anesthetic can be successfully administered in
96% of pediatric patients. Once the sacrococcygeal ligament has been penetrated with the regional
anesthetic needle, lower the angle of the needle, advance the needle no more than 3-5 mm, aspirate
the syringe to ensure the absence of cerebral spinal fluid or heme, and administer the local anesthetic.
Most commonly, bupivacaine is administered for single-dose caudal blocks. Effective concentrations
range from 0.125-0.25% bupivacaine. Volumes of 0.75-1 mL/kg are administered. Supplemental
analgesics may not be required for up to 12 hours postoperatively when the caudal is effective.
Placement of a caudal, lumbar, or even thoracic catheter for continuous postoperative pain
management has also been proven safe and effective in neonates. An epidural catheter may be
successfully placed via the caudal approach and advanced cephalad to the lumbar or thoracic level.
Using superficial anatomic landmarks as a guide, the level of the catheter may be accurately predicted.
This catheter may then be used for postoperative infusion of narcotics or local anesthetic infusions.
Epidural catheters have been successfully used for postoperative management of many major neonatal
surgical procedures that require laparotomy or thoracotomy, including hepatic resection, abdominal wall
defects (gastroschisis and omphalocele), tracheoesophageal fistula, congenital diaphragmatic hernia,
and coarctation of the aorta. After successful placement and an initial bolus dose of the epidural
catheter, pain management may be maintained with a continuous infusion of analgesic medications.
Epidural infusions provide an acceptable alternative to the intermittent top-up technique. Epidural
infusions are both safe and effective in term and preterm neonates. Postoperative epidural bupivacaine
infusions result in significantly less sedation, less depression of the respiratory rate, and improvement
in oxygenation without supplemental oxygen administration, while providing similar analgesia and
similar complication and hemodynamic profiles to a morphine infusion.
In 1992, Berde reported recommendations to facilitate safe use of epidural analgesia in pediatric
patients after analysis of more than 20,000 pediatric regional anesthetic procedures in 15 institutions.
Berde recommended bolus dosing of epidural bupivacaine not to exceed 2-2.5 mg/kg. Infusion rates of
0.2-0.25 mg/kg/h were recommended for neonates. This paper cautioned that children are probably not
more resistant to local anesthetic toxicity than adults, as had been previously thought. Neonates, in
particular, may be at risk for local anesthetic toxicity because of diminished plasma alpha1-acid
glycoprotein levels, which could result in a higher free fraction and slower clearance of bupivacaine.
Premonitory symptoms or signs of local anesthetic toxicity may be absent in neonates. Reduce infusion
rates for patients at risk for seizures.
When the epidural catheter level is too low to provide adequate analgesia at the incision site for a
neonatal patient, increasing the rate of the epidural infusion cannot safely overcome this low catheter
level. In one study, plasma bupivacaine levels continued to increase over a 48-hour infusion period,
reaching the upper limits of the safe range before the end of this 48-hour period. In addition, plasma
levels of bupivacaine were higher in neonates who were at higher risk for increased abdominal
pressure postoperatively. Furthermore, as with all drugs administered during the neonatal period,
interindividual variability in plasma bupivacaine levels were considerable in neonates receiving epidural
infusions. While plasma clearance is lower in neonates than in adults receiving epidural infusions, this
difference is even more dramatic in preterm neonates.
BIBLIOGRAPHY Section 10 of 10
• Altimier L, Norwood S, Dick MJ: Postoperative pain management in preverbal children: the
prescription and administration of analgesics with and without caudal analgesia. J Pediatr Nurs
1994 Aug; 9(4): 226-32[Medline].
• Ambuel B, Hamlett KW, Marx CM: Assessing distress in pediatric intensive care environments:
the COMFORT scale. J Pediatr Psychol 1992 Feb; 17(1): 95-109[Medline].
• American Academy of Pediatrics: Neonatal anesthesia. Pediatrics 1987 Sep; 80(3):
446[Medline].