LETTER TO EDITOR
Year : 2013 | Volume
| Issue : 1 | Page : 98-99
Spinal anesthesia for hernia surgery in a child with laryngomalacia
Rohini Bhat Pai1, Sameer Desai1, Raghavendra Rao1, Venkatesh Annigeri2
1 Deparment of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
2 Deparment of Pediatric Surgery, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
Rohini Bhat Pai
Deparments of Anaesthesiology, SDM College of Medical Sciences, Dharwad, Karnataka
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||30-Mar-2013|
|How to cite this article:|
Pai RB, Desai S, Rao R, Annigeri V. Spinal anesthesia for hernia surgery in a child with laryngomalacia. Saudi J Anaesth 2013;7:98-9
|How to cite this URL:|
Pai RB, Desai S, Rao R, Annigeri V. Spinal anesthesia for hernia surgery in a child with laryngomalacia. Saudi J Anaesth [serial online] 2013 [cited 2020 Jul 5];7:98-9. Available from: http://www.saudija.org/text.asp?2013/7/1/98/109852
Spinal anesthesia has been accepted as a safe option for inguinal hernia repair surgery in ex-premature infants, mainly for reducing the incidence of apnea.  We report the use of spinal anesthesia in an infant with laryngomalacia with stridor to minimize the airway-related complications.
A four-month preterm male baby, weighing 3.4 kg was posted for inguinal and umbilical hernia repairs. A history of noisy breathing and respiratory distress was present since birth. On examination, there was stridor which was more pronounced with crying and decreased with sleep. There was no change in the stridor with position. An initial presumptive diagnosis of congenital laryngomalacia was made. The cardiovascular system was within normal limits. Examination of the airway showed mild retrognathia. Investigations for history of failure to thrive revealed metabolic acidosis with renal tubular acidosis (RTA) type II and respiratory compensation. The child was on sodium bicarbonate, calcium, and potassium chloride syrup for the management of RTA. On the day of surgery, serum calcium was 0.60 mmol/L (normal range: 1.1-1.3 mmol/L).
The child was fasted for four hours. After intravenous atropine 0.06 mg, sevoflurane in 100% oxygen (O 2 ) was used for induction, with continuous positive airway pressure (CPAP) applied using Jackson Rees circuit. After attaining the required depth of anesthesia and ensuring adequate mask ventilation, the inhalational agent was changed to halothane in 100% O 2 . Mask ventilation was easy and stridor disappeared under anesthesia. Then, direct laryngoscopy performed using Miller blade 0 showed long floppy epiglottis curling on itself and collapsing on the posterior pharyngeal wall. With external laryngeal manipulation, arytenoids were seen, which were drawn inward with each inspiration, thus confirming the diagnosis of laryngomalacia. Due to all these airway changes, intubation was perceived to be difficult but mask ventilation was successful with CPAP.
A decision was taken to perform hernia surgery under spinal anesthesia. Halothane was turned off. After free flow of cerebrospinal fluid (CSF), 0.6 mL of hyperbaric bupivacaine 0.5% was injected into the subarachnoid space. Adequate spontaneous ventilation was ensured by providing O 2 and air through Jackson Rees circuit with CPAP. The surgery lasted 30 minutes and spinal anaesthesia lasted 45 minutes (as indicated by hip flexion). The child was monitored in the postanesthesia care unit for four hours and later sent to the ward. He was discharged from the hospital uneventfully.
Laryngomalacia is the most common cause of stridor in the newborn. The definitive diagnosis of laryngomalacia is made by direct laryngoscopy in a spontaneously breathing child, as the vocal cords collapse during the inspiratory phase of spontaneous ventilation.
General anesthesia was administered for initial evaluation of the airway in our case as previous studies have shown more accurate diagnosis of laryngomalacia with a drug-assisted technique using anesthesia than a clinic-based awake laryngoscopy. 
As induction of inhalation is preferred in children with a difficult but 'uncompromised airway', sevoflurane was used so that the child could be induced rapidly and later changed over to halothane so that adequate time was available for laryngoscopy. Laryngeal mask airway (LMA) was not used in our case as it has a higher rate of failure and may not be able to protect the airway against reflux that is commonly seen in these patients.
Laryngospasm and laryngeal edema are common causes of postextubation upper airway obstruction in children.  Endotracheal intubation in neonates can lead to subglottic edema, especially common after traumatic intubation or those lasting longer than one hour.  Subglottic edema of 1 mm in neonates can reduce the laryngeal cross-section by 35%. Patients with congenital or acquired airway pathology are known to have difficult extubation and difficult reintubation. 
Our child had been treated for hypocalcemia but was still hypocalcemic on the day of surgery. This could have increased the incidence of perioperative laryngospasm and bronchospasm. Also, the neuromuscular blockade may have been prolonged in the presence of hypocalcemia, necessitating postoperative ventilation.
The use of regional anesthesia must be made with caution in children with difficult airways, depending on the skill of the anesthesiologist. Hence, we decided to proceed with regional anesthesia, keeping ourselves prepared for a difficult airway in case of any complication.
In conclusion, spinal anesthesia can be used in a child with a difficult airway aiming to reduce the airway manipulation-related complications. We should always be prepared for the management of a difficult airway in an emergency.
| References|| |
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