Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. Postoperative apnea in former preterm infants: prospective comparison of spinal and general anesthesia. Postoperative apnea, bradycardia, and oxygen desaturation in formerly premature infants: prospective comparison of spinal and general anesthesia. Prospective, randomized trial comparing general with spinal anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison between spinal and general anaesthesia. A prospective randomised trial comparing spinal anaesthesia using hyperbaric cinchocaine with general anaesthesia for lower limb vascular surgery. General versus spinal anaesthesia for elective caesarean sections: effects on neonatal short-term outcome. A prospective randomised study. Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery. High-dose caffeine suppresses postoperative apnea in former preterm infants.
We prospectively studied the post-operative recovery profile of 28 ex-premature infants undergoing inguinal herniotomy. All infants had a post-conceptual age of less than 46 weeks at the time of surgery and were randomized to receive either sevoflurane (group 1, 14 patients) or spinal anaesthesia (group 2, 14 patients). All patients received supplemental caudal analgesia before skin incision. Cardiorespiratory function was continuously recorded in all patients before and after surgery. A blinded observer analysed each paired recording for predefined episodes of apnoea, hypoxaemia or bradycardia and the reports were used to compare the two groups. Spinal anaesthesia was attempted unsuccessfully in four patients in group 2. Five patients in group 1 demonstrated an 'excess' number of episodes (median 4, range 3-12) of clinically silent post-operative cardiorespiratory complications. ('Excess' in our study was defined as a 3-fold or greater increase in the number of post-operative episodes of bradycardia or apnoea relative to pre-operative occurrence). Three of these patients had pre-existing abnormal respiratory function and accounted for 80% of the episodes (26/32) of post-operative bradycardia and all five episodes of post-operative apnoea identified. All episodes of bradycardia and apnoea were temporally unrelated. None of the remaining patients in group 2 demonstrated an unacceptable number of post-operative cardiorespiratory complications. Our limited study suggests that general anaesthesia with an inhalational agent such as sevoflurane may induce or unmask abnormalities of cardiopulmonary function in predisposed infants. Spinal anaesthesia may be preferable but it is potentially stressful for the infant and associated with a clinically significant failure rate. Thirty-six former preterm infants undergoing inguinal hernia repair were studied. All were less than or equal to 51 weeks postconceptual age at the time of operation. Patients were randomly assigned to receive general or spinal anesthesia. Group 1 patients received general inhalational anesthesia with neuromuscular blockade. Group 2 patients received spinal anesthesia using 1% tetracaine 0.4-0.6 mg/kg in conjunction with an equal volume of 10% dextrose and 0.02 ml epinephrine 1:1000. In the first part of the study, infants randomized to receive spinal anesthesia also received sedation with im ketamine 1-2 mg/kg prior to placement of the spinal anesthetic (group 2 A). The remainder of group 2 patients did not receive sedation (group 2 B). Respiratory pattern and heart rate were monitored using an impedance pneumograph for at least 12 h postoperatively. Tracings were analyzed for evidence of apnea, periodic breathing and/or bradycardia by a pulmonologist unaware of the anesthetic technique utilized. None of the patients who received spinal anesthesia without ketamine sedation developed postoperative bradycardia, prolonged apnea, or periodic breathing. Eight of nine infants (89%) who received spinal anesthesia and adjunct intraoperative sedation with ketamine developed prolonged apnea with bradycardia. Two of the eight infants had no prior history of apnea. Five of the 16 patients (31%) who received general anesthesia developed prolonged apnea with bradycardia. Two of these five infants had no prior history of apnea. When infants with no prior history of apnea were analyzed separately, there was no statistically significant increased incidence of apnea in children receiving general versus spinal anesthesia with or without ketamine sedation. Because of the small numbers of patients studied, and the multiple factors that may influence the incidence of postoperative apnea (e.g., prior history of neonatal apnea), standard postoperative respiratory monitoring of these high-risk infants is still recommended following all anesthetic techniques. Eighteen formerly premature infants scheduled for inguinal herniorrhaphy and who were less than 51 wk postconceptional age were assigned to either the general anesthesia group (GA: atropine, halothane, and nitrous oxide) or the spinal anesthesia group (SA: hyperbaric tetracaine). Twelve-hour, three-channel continuous recordings of respiratory rate (chest wall impedance), electrocardiogram (ECG), and hemoglobin O2 saturation (SpO2) were obtained preoperatively and after surgery. These were analyzed for short (11-15s) and long (> 15 s) apnea spells, periodic breathing, and episodes of hemoglobin oxygen desaturation and bradycardia. Infants in the GA group had lower postoperative minimum SpO2 (68.7% +/- 11.4%) and minimum heart rate (79 bpm +/- 19) than infants in the SA group (80.7% +/- 9.2%, and 109 bpm +/- 30, respectively; P < 0.05) and had lower postoperative minimum SpO2 and minimum heart rate than they had preoperatively (79.0% +/- 13.7%, and 93 bpm +/- 31, respectively; P < 0.05); pre- and postoperative studies in the SA group did not differ. There were no differences in the incidence of postoperative central apnea. We conclude that spinal anesthesia reduces postoperative hemoglobin oxygen desaturation and bradycardia in formerly premature infants undergoing inguinal herniorrhaphy. There are no randomized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace. This study examined both markers of neonatal hypoxia and maternal hemodynamics.
                Seventy patients were randomized to general (n = 35) or spinal anesthesia (n = 35). The general anesthesia group received thiopentone, magnesium sulfate, and suxamethonium intravenously before intubation, followed by 50% nitrous oxide in oxygen, 0.75-1.5% isoflurane, and morphine after delivery. The target end-tidal partial pressure of carbon dioxide (Pco2) was 30-34 mmHg. The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 microg fentanyl at the L3-L4 interspace. Heart rate and blood pressure were measured at specific time points. Hypotension was treated with ephedrine. Maternal arterial and neonatal umbilical arterial blood gas samples were taken at delivery. Resuscitation requirements were recorded.
                In both groups, hemodynamic measures remained within acceptable limits. Spinal anesthesia patients required more ephedrine (13.7 vs. 2.7 mg). Maternal Paco2 was lower in the spinal group (28.9 vs. 32.4 mmHg). One-minute Apgar scores were lower after general anesthesia. Base deficit was greater (7.13 vs. 4.68 mEq/l) and neonatal umbilical arterial pH was lower (7.20 vs. 7.23) after spinal anesthesia. Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg, neonatal umbilical arterial base deficit was greater after spinal anesthesia. There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation.
                In preeclamptic patients with a nonreassuring fetal heart trace, spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established. Maternal hemodynamics were similar and acceptable with either anesthetic technique. The incidence of inguinal hernia is higher in premature infants, particularly in low birth weight neonates. This latter group may also incur increased postoperative respiratory complications and inpatient admissions. The purpose of this study was to compare the effects of general and spinal anaesthesia on postoperative respiratory morbidity and on the length of hospital stay in high-risk infants undergoing inguinal herniorrhaphy. Forty patients, all high-risk infants who underwent unilateral or bilateral herniorrhaphies, were randomly assigned to receive general anaesthesia (n = 20) or spinal anaesthesia (n = 20). There was a significant difference in respiratory morbidity between the two groups, as well as a significant difference in the inpatient hospital stay. The present study suggests that spinal anaesthesia can be used safely for high-risk infants, preterm or formerly preterm, undergoing inguinal hernia repair. One hundred and one patients were randomly allocated to have their peripheral vascular surgery performed under general anaesthesia (51 patients) or spinal anaesthesia (50 patients). Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group (72% vs 31%) and a higher incidence of hypertension in the general anaesthesia group (22% vs 0%). Blood loss was significantly less in the spinal group (560, SD 340, ml vs 792, SD 440, ml). Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia, and one had a myocardial infarct. Two patients in the spinal group had myocardial infarcts, both had been treated for bradycardia and hypotension intraoperatively, and one died. There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group (33% vs 16%). There was no significant difference between the groups in the incidence of postoperative confusion, or lower limb amputation rate or need for further surgery prior to hospital discharge. To compare neonatal short-term outcome in patients who underwent spinal, general anaesthesia and conversion from spinal to general anaesthesia.
                One hundred seventy-nine pregnant women undergoing elective caesarean section were allocated randomly to general (n=89) or spinal anaesthesia (n=90) and compared with 63 patients who required conversion to general anaesthesia. Umbilical cord artery pH, Apgar score as well as its individual parameter and need for assisted ventilation were evaluated.
                No differences were found in pH values (p=0.35), while the need for assisted ventilation differed significantly (p=0.001). The rate of depressed newborns was 1.1% in the spinal group, 25.9% in the general group and 12.7% in the conversion group with a significant difference for all comparisons. At 5-min, all newborns were vigorous. At 1 min, a higher score for each parameter was found in spinal group with respect to general group, while 'activity', 'grimace' and 'respiration' showed a higher score in conversion group than in general group. At 5 min, a difference was found only for 'activity'.
                All kinds of anaesthesia seem to be safe, but loco-regional blockade shows more advantages on the neonatal outcome also when a conversion is necessary. This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery.
                Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test.
                Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.).
                In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia. Thirty-two former preterm infants (less than or equal to 44 weeks postconceptual age) undergoing inguinal hernia repair were prospectively studied. General inhalational anesthesia with neuromuscular blockade was used. No barbiturates or opioids were given. Infants were randomly divided into two groups. Group 1 received iv caffeine 10 mg/kg immediately after induction of anesthesia. Group 2 received iv saline. Respiratory pattern, heart rate, and SpO2 were monitored using an impedance pneumograph and a pulse oximeter, respectively, for at least 12 h postoperatively. Tracings were analyzed for evidence of apnea, periodic breathing, and/or bradycardia by a pulmonologist unaware of the drug given. None of the patients who received caffeine developed postoperative bradycardia, prolonged apnea, or periodic breathing, and none had postoperative SpO2 less than 90%. In the control group 13 (81%) developed prolonged apnea 4-6 h postoperatively. Fifty percent of the patients had SpO2 less than 90% at the time. This study shows that iv caffeine 10 mg/kg is effective in the control of apnea in otherwise healthy expremature infants between 37 and 44 weeks of postconceptual age. It is still recommended, however, that all infants at risk be monitored for at least 12 h for apnea and bradycardia following general anesthesia.
There is no reliable evidence from the trials reviewed concerning the effect of spinal as compared to general anaesthesia on the incidence of post-operative apnoea, bradycardia, or oxygen desaturation in ex-preterm infants undergoing herniorrhaphy. The estimates of effect in this review are based on a total population of only 108 patients or fewer. 
A large well designed randomised controlled trial is needed to determine if spinal anaesthesia reduces post-operative apnoea in ex-preterm infants not pretreated with sedatives. Adequate blinding, follow up and intention to treat analysis are required.