Epidural versus general anesthesia for open pyloromyotomy in infants: A retrospective observational study
In this paper, the authors performed a retrospective review of infants undergoing open pyloromyotomy under thoracic epidural with sedation (EA group) or general anaesthesia with rapid sequence induction (GA group) between 2007 and 2017. The aim was to compare the 2 approaches for desaturations, bradycardia, operating room occupancy time and durations of surgery.
At the study institution, infants in the GA group were administered general anaesthesia with rapid sequence induction using the standard propofol 2-3mg/kg, rocuronium 0.6mg/kg and fentanyl 5micrograms/kg. Infants in the EA group were sedated with a dose of propofol (1-2mg/kg) with supplementary doses of 0.5mg/kg if required. The infants were administered oxygen/air (FiO2 0.5) and positioned in the left lateral position for the single shot epidural puncture, where 0.75mL/kg of ropivacaine 0.38% (2:1 mixture of ropivacaine 2mg/mL and ropivacaine 7.5mg/mL) was delivered into the T10-T11 interspace.
The authors concluded that in skilled hands, using a single-shot epidural technique in a self-ventilating infant was associated with fewer and less severe desaturations and shorter changeover times in the operating theatre compared to general anaesthesia.
Take home message
In my practice, I would normally perform an inhalational induction for pyloromyotomy, which has been demonstrated to be a safe technique that does not increase risk of gastric aspiration1. Having never attempted a thoracic epidural on an infant before, I wouldn’t be changing my technique based on this paper. The epidural technique requires a volume of practice to develop and maintain competence and a second anaesthetist is required to be present for establishing the block, presenting a workforce challenge. It wasn’t very clear if the time taken to perform and establish the block was included in the total operating room occupancy time. The mixture of local anaesthetic used also lends itself to increased risk of error.
- Scrimgeour GE, Leather NW, Perry RS, Pappachan JV, Baldock AJ. Gas induction for pyloromyotomy. Paediatr Anaesth. 2015;25(7):677-680. doi:10.1111/pan.12633
Reviewed by Scott Ma