P1.169: Single-shot Caudal Anesthesia Reduces Need for Intubation in Neonates

Background: The use of regional anesthetic, rather than general, for surgical procedures has many advantages for the premature infant including preservation of respiratory status, faster return to feeding, and better postoperative pain control. We have previously described the use of 3% 2-chloroprocaine administered via continuous caudal infusion to achieve successful analgesia for elective surgical procedures in neonates. However, the initiation and maintenance of this continuous infusion can be challenging, particularly for inexperienced practitioners who use the technique only infrequently. We therefore have changed our practice toward the use of a single-shot caudal injection to achieve a regional block. In this abstract, we describe the application of single-shot caudal injection to avoid general anesthesia for neonatal hernia repairs.

Methods: A retrospective chart review of all patients under 3 months corrected gestational age (cGA) who underwent elective inguinal hernia repair under single-shot caudal anesthetic between April 2020 and July 2024 was performed. Patient characteristics such as gestational age (GA), gender, hernia laterality, concurrent operations, operative details including operative time, anesthetic or operative complications, need for postoperative opioids, time to resumption of feeds, and length of stay were included. The primary outcome was need to intubate the patient.
A regional block was established via a caudal injection of 0.24% bupivicaine with 1:200,000 epinephrine at a dosage of 1mL/kg.

Results: 41 patients (38 males) were identified: Thirty patients underwent bilateral repair (six with circumcision). The majority of patients were born prematurely (mean GA 31.5 weeks; range 24-37 weeks). Post conceptual age at time of surgery ranged from 36-46 weeks (mean 41.2 weeks). Mean weight at time of surgery was 4.2kg (range 2.9-5.6kg). Analgesia by a single-shot caudal to achieve a regional block was achieved in all patients for the duration of each surgical procedure. The majority of patients also received dexmedetomidine during the procedure. Mean operative time was 51.3 minutes (Range 16-95 minutes). No patients required intubation. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day. No surgical complications or hernia recurrences were noted during the review period.

Conclusion: We have previously described the efficacy of a continuous caudal infusion to achieve adequate regional-only analgesia for open surgical procedures in conscious neonates. We now demonstrate that the much simpler technique of single-shot caudal injection can be just as effective as a continuous infusion in achieving a regional block for neonatal inguinal hernia repair. We found that the single-shot approach was greatly enhanced by the adjunct use of dexmedetomidine. Using this well-tested method, we have been able to avoid general anesthesia, opioid exposure, and intubation successfully in this vulnerable patient population.