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Anesthesiology. 2015 Jul;123(1):55-65. doi: 10.1097/ALN.0000000000000708.

Predictors of Failure of Awake Regional Anesthesia for Neonatal Hernia Repair: Data from the General Anesthesia Compared to Spinal Anesthesia Study--Comparing Apnea and Neurodevelopmental Outcomes.

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From the Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia (G.F., A.J.D.); Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Victoria, Australia (G.F., A.J.D.); Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia (G.F., A.J.D.); Department of Anaesthesia, Royal Hospital for Sick Children, Glasgow, United Kingdom (G.B., N.S.M.); Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy (N.D.); Department of Anaesthesia, Montreal Children's Hospital, Montreal, Quebec, Canada (D.E.W.); Department of Anesthesia, McGill University, Montreal, Quebec, Canada (D.E.W.); Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands (J.C.d.G.); Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, United Kingdom (N.S.M.); Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts (M.E.M.); Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia (S.J.A.); Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom (O.B.); Department of Anesthesiology and Paediatric Intensive Care, Ospedale Pediatrico "Vittore Buzzi," Milan, Italy (A.W.); and Department of Neurology, Boston Children's Hospital, Boston, Massachusetts (D.B.).



Awake regional anesthesia (RA) is a viable alternative to general anesthesia (GA) for infants undergoing lower abdominal surgery. Benefits include lower incidence of postoperative apnea and avoidance of anesthetic agents that may increase neuroapoptosis and worsen neurocognitive outcomes. The General Anesthesia compared to Spinal anesthesia study compares neurodevelopmental outcomes after awake RA or GA in otherwise healthy infants. The aim of the study is to describe success and failure rates of RA and report factors associated with failure.


This was a nested cohort study within a prospective, randomized, controlled, observer-blind, equivalence trial. Seven hundred twenty-two infants 60 weeks or less postmenstrual age scheduled for herniorrhaphy under anesthesia were randomly assigned to receive RA (spinal, caudal epidural, or combined spinal caudal anesthetic) or GA with sevoflurane. The data of 339 infants, where spinal or combined spinal caudal anesthetic was attempted, were analyzed. Possible predictors of failure were assessed including patient factors, technique, experience of site and anesthetist, and type of local anesthetic.


RA was sufficient for the completion of surgery in 83.2% of patients. Spinal anesthesia was successful in 86.9% of cases and combined spinal caudal anesthetic in 76.1%. Thirty-four patients required conversion to GA, and an additional 23 patients (6.8%) required brief sedation. Bloody tap on the first attempt at lumbar puncture was the only risk factor significantly associated with block failure (odds ratio = 2.46).


The failure rate of spinal anesthesia was low. Variability in application of combined spinal caudal anesthetic limited attempts to compare the success of this technique to spinal alone.

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