Infant spinal anesthesia: a narrative review

Background and Objective: Spinal anesthesia involves the injection of local anesthetic into the subarachnoid space. It is differentiated from caudal or epidural anesthesia by the location, level of the block, and potency of local anesthetic. It typically lasts less than 90 minutes. We aim to highlight information relevant to practitioners, other than anesthesiologists, who interact with infants receiving spinal anesthesia outside of the perioperative period (hospitalists, surgeons, neonatologists, etc.). Methods: We performed a literature search utilizing MeSH, Cochrane, Google Scholar, and PubMed for articles between January 1st, 1990, and December 31st, 2022. Additional articles were found via references from the original search. Key Content and Findings: The success rate of spinal anesthesia is as high as 95.4% in experienced providers. There is a low incidence of traumatic insertion, postdural puncture headaches (PDPHs), and infection. Infants tolerate high thoracic levels of spinal anesthesia with minimal hemodynamic changes and negligible effects in cerebral oxygen saturation. This technique obviates the need for induction, airway management, and emergence from volatile anesthetics, resulting in an overall decrease in operating room time. Based on our review of the results of three major studies [General Anesthesia Spinal (GAS) trial, Pediatric Anesthesia Neurodevelopment Assessment (PANDA), and Mayo Anesthesia Safety in Kids (MASK)], we found no difference in neurodevelopmental outcomes in healthy children with brief exposure to general anesthesia [volatile or intravenous (IV)] compared to regional anesthesia (neuraxial or peripheral). A statistically significant difference was seen in children exposed to longer duration of general anesthesia. Patients receiving spinal anesthesia without any sedation had fewer episodes of early postoperative apnea (POA) and required less interventions for resolution of apneic episodes than the general anesthesia group. No difference was seen in the incidence of late apnea and overall apneic episodes. Conclusions: Spinal anesthesia appears to be a safe and effective choice in the infant population. Our review did not find a significant difference between the effects of general anesthesia compared to spinal anesthesia for healthy, term infants undergoing a single anesthetic. However, for patients requiring staged/ multiple procedures or who have significant comorbidities, a spinal anesthetic may be a better option. An individualized, careful discussion should occur to determine the optimal anesthetic approach for each patient.