From Jenny Dolan, MD. MPH. FASA, Division Chief of Pediatric Anesthesia, Johns Hopkins All Children's Hospital on platelet transfusion
I was wondering if the authors of this review have a position regarding the threshold for transfusion when there is no intervention other than anesthesia for a diagnostic study, such as an MRI with propofol infusion, or an MRI that may require intubation.
From Lesley Silver MD FRCPC, Victoria General Hospital, Victoria BC, Canada on Spinal anesthesia in infants- pitfalls and tricks
The practice of spinal anesthesia in infants could be labeled as a “HALO” event- High Acuity, Low Occurrence, even if it comprises a routine part of one’s pediatric anesthesia arsenal as it has become for mine. For that reason at our institution, our OR team- especially including our anesthesia assistants, try to review each case for what went well, and what could be improved.
Of critical importance is keeping the infant calm before and during the injection, to avoid engorgement of the epidural veins, which increases the likelihood of blood in the hub of the needle. Applying monitors whilst the infant is cuddled in the nurse’s arms is helpful. In addition to the role of the person holding the infant during placement of the needle, is another person whose role is keeping the soother in the infant’s mouth, and making sure it is well saturated with 24% sucrose!
Other tricks: warming the bottle of iodine prep in the warming fridge overnight or several hours before, applying the cautery pad as soon as the spinal is in and the child’s back is still exposed in the sitting / lateral position, and being prepared for the inevitable bowel movement that will herald a successful block. Tylenol is a must as the technique does not provide long acting analgesia.
For neonates/former prems, I would advocate for 1mg/kg of 0.5% bupivacaine with “epi wash”, and no barbotage. Lower doses risk shorter duration, and with this dose we have had no issue completing bilateral inguinal hernia repairs. Whilst I personally have not had success with EMLA in neonates, I do think there is value in placing 0.2—0.3ml of 1% lidocaine with a 30 Ga needle prior to the spinal.
From Walter I. Weiss MD DABA FASA, Chief, Pediatric Anesthesiology, NYU Langone Hospital-Long Island
I’ve been using spinal anesthesia especially for those NICU babies waiting for their hernia repairs prior to discharge for more than 30 years. It was Chris Abajian who interviewed me when I was looking for a residency job and we stayed in touch after I went elsewhere. He guided me to do these in NYC.
I use exclusively 1% Tetracaine diluted with D10 1:1. Occasionally add an “Epi wash” if there are junior residents or med students involved. Reliably get about 2 hours out of it. If for some reason it’s wearing off I ask the surgeons to do the second side and leave the skin closure for last which they can always supplement with a little Lidocaine.
For years my younger colleagues seemed to come out of fellowship never have done these. The tide seems to be changing and they are all believers.
From Vikas O'Reilly-Shah, MD, PhD, FASA, Professor of Anesthesiology & Pain Medicine, University of Washington | Seattle Children's Hospital on sugammadex anaphylaxis
We and others have done a fair bit of work to look at anaphylaxis rates. It should be noted that the package insert rate for sugammadex was based on a study of 299 patients done at the request of the FDA in the runup to FDA approval, where one patient had an event (1/300; 0.3%). "The Clopper-Pearson 95% confidence interval for that study puts the rate between 0.0085% and 1.9%, an interval too wide to be of value in clinical decision-making)... Miyazaki and colleagues reported an estimated anaphylaxis rate of 0.059%, with a 95% confidence interval of 0.032–0.1%.17 At our institution, we have observed just one case of anaphylaxis in 5321 administrations, yielding a confidence interval of 0.004–0.135%." (Jabaley et al 2018). The crowdsourced rate of anaphylaxis in that study was estimated to be between 1:1000 and 1:20,000 (0.005–0.098%). Tadokoro et al 2018 looked at pediatric patients specifically and among 835 405 patients who underwent general anesthesia, identified 149 (0.018%) patients with anaphylactic shock and 472 (0.056%) with a combination of anaphylaxis associated signs/symptoms and skin lesions. Burbridge et al 2021 similarly found 2 events in a cohort of 19,821 patients. The American Society of Anesthesiologists, in its 2023 guidelines, reports a pooled incidence rate of 1.6 per 10,000 administrations (0.016%) based on available studies, but notes the strength of evidence is low and that rates may vary by population and reporting method.(Thilen et al 2023) Recent multicenter retrospective analyses in Australia estimated the incidence of sugammadex hypersensitivity (including anaphylaxis) at 0.004% (95% CI: 0.002–0.008%) (Crimmins et al).
Bottom line, the rates are far lower than reported on the package insert and, while it is important to maintain awareness of the possibility that anaphylaxis is occurring, in my view the risk/benefit calculus for the use of sugammadex remains strongly in favor of use.
Miyazaki Y, Sunaga H, Kida K, Hobo S, Inoue N, Muto M, Uezono S. Incidence of Anaphylaxis Associated With Sugammadex. Anesth Analg 2017. https://doi.org/10.1213/ANE.0000000000002562.
Tadokoro F, Morita K, Michihata N, Fushimi K, Yasunaga H. Association between sugammadex and anaphylaxis in pediatric patients: A nested case-control study using a national inpatient database. Paediatr Anaesth 2018;28:654–9. https://doi.org/10.1111/pan.13401.
Burbridge MA. Incidence of anaphylaxis to sugammadex in a single-center cohort of 19,821 patients. Anesth Analg 2021;132:93–7. https://doi.org/10.1213/ane.0000000000004752.
Jabaley CS, Wolf FA, Lynde GC, O’Reilly-Shah VN. Crowdsourcing sugammadex adverse event rates using an in-app survey: feasibility assessment from an observational study. Ther Adv Drug Saf 2018;9:331–42. https://doi.org/10.1177/2042098618769565.
Crimmins D, Crilly H, van Nieuwenhuysen C, Ziser K, Zahir S, Todd G, Ryan L, Heyworth-Smith D, Balkin L, Harrocks A, Booth AWG. Sugammadex hypersensitivity: a multicentre retrospective analysis of a large Australian cohort. Br J Anaesth 2025;134:72–9.https://doi.org/10.1016/j.bja.2024.07.042.
Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American society of anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: A report by the American society of anesthesiologists task force on neuromuscular blockade. Anesthesiology 2023;138:13–41. https://doi.org/10.1097/ALN.0000000000004379.