First Realizations of Spinal Anesthesia in Neonates and Infants - Preterms or Ex prematures - in Antananarivo, Madagascar

Objective: The aim of this study was to describe the rst realizations of spinal anesthesia in neonates and infants (preterms or ex prematures) in Antananarivo - Madagascar, because spinal anesthesia – a low cost technique – can limit respiratory complications and postoperative apnea and also general anesthesia can present perioperative risks for pediatric patients. Results: In a retrospective, descriptive, seven-year (2013 to 2019) period study, conducted in the University Hospital Joseph Ravoahangy Andrianavalona, data les of 69 babies planned to have spinal anesthesia were recorded. These pediatric patients were predominantly male (sex ratio = 2.8) and 37 [28 - 52] days old. The smallest anesthetized child weighed 880 g; the youngest was 4 days old. Twenty-seven (27) of them were premature and 20.3% presented respiratory diseases. They were mostly scheduled for hernia repair (97.1%). Spinal anesthesia was performed, with a Gauge 25 Quincke spinal needle, after 2 [1 - 2] attempts with hyperbaric bupivacaine of 4 [3.5 - 4] mg. Failure rate was 5.8% needing general anesthesia conversion. The heart rate was stable throughout perioperative period and no complications were observed.


Introduction
Spinal anesthesia (SA) is a part of anesthesia for sub umbilical and lower limb surgeries [1]. The rst spinal anesthesia in children had been practiced by Bier in the 19th century (1898), then by Bainbridge (1901) and Gray (1909) [1,2]. In the middle of 20th century, this regional anesthesia technique was abandoned, because of considerable improvements of general anesthesia (GA) [2]. Nowadays, it tends to be more practiced in children, as much in the newborns as in the preterms in order to prevent and to reduce respiratory complications, apnea and bradycardia [1][2][3]. Hernia repairs are the most concerned surgeries which could be done under spinal anesthesia; this latter also provides perioperative analgesia [1,4,5].
In Antananarivo -Madagascar, at the Hospital University of Joseph Raseta Andrianavalona (CHU JRA), general anesthesia (particularly inhalatory GA with halothane then sevo urane) is the more used in pediatric anesthesia. Since 2013, spinal anesthesia has started to be performed at the CHU JRA.
The aim of this study was to present the rst realizations of spinal anesthesia, in newborns and infants (preterms / ex-prematures) and to determine its feasibility and its potential harmlessness, in Antananarivo.

Methods
A retrospective, observational, descriptive study was conducted; by collecting data from scheduled sub umbilical pediatric surgeries under spinal anesthesia, from 2013 to 2019 (seven-year period), at the CHU JRA. This latter is the surgical reference center of Madagascar, particularly in pediatric surgery.

Results
Over the period observed, 69 babies were planned to have spinal anesthesia ( Figure S1) for their surgery. The patients were predominantly male (sex ratio = 2.8) and 37 [28-52] days old. The smallest anesthetized child weighed 880 g and the youngest was 4 days old. They were weighing 2400  g at birth and 3450 [2800-4240] g on the day of the anesthesia consultation. Twenty-seven (27) of them were preterms, with a corrected age of 40.5 [37-42] CWA. Fourteen children (20.3%) had a medical history of respiratory diseases. The Table 1 summarizes the characteristics of the patients.
Informed consent was obtained from the parents, after explanation of SA technique and possible signi cant risk of GA, during the anesthesia consultation (AC)of their child. This AC was carried out and validated by a team of two anesthesiologists (who also carry out the spinal anesthesia, in order to limit the bias in performance).
Were studied (i) the gender, (ii) the perinatal parameters (weeks of amenorrhea (WA) at birth, prematurity, causes of prematurity), birth weight, (iii) the parameters during the AC: age of the patient [in days and in  a Respiratory diseases = meconial amniotic uid inhalation at birth, bronchiolitis; b Others = intrauterine growth restriction (IUGR), neonatal infection, gastroesophageal re ux; c +/-other conditions (preeclampsia, twin pregnancy); d PROM = premature rupture of fetal membranes.
The length between the AC and the intervention was 5 [3][4][5][6][7][8][9][10][11][12][13] days. The indications for the interventions are shown in Table 2. They were dominated by hernias (inguinal, inguinoscrotal and ovarian). The duration of the surgical procedure was 27.5 [17.5-40.0] minutes ranging from 10 to 65 minutes. For all children, a prior intravenous cannulation (G24) was placed and xed in the upper limbs, for perioperative perfusion. For all the patients, the performers of spinal anesthesia were two medical anesthetists with prior training in this technique. The child was kept with a curved back, in a sitting or lateral decubitus position, by a trained assistant. The spinal puncture was performed in the intersection between Tu er's line and the vertebral axis. The used material was an 80 mm -G25 Quincke spinal needle (the thinnest needles available at the CHU JRA). The attempts of punctures were 2 [1][2]. The GA conversion was 5.8%. The dose of bupivacaine administered was 4 [3.5-4] mg. The technique was successful when the re ux of cerebrospinal uid was present and the in ltration of the local anesthetic was easy. Then, the patient was placed directly in a 45° head up tilt -head up. Spinal anesthesia was also considered successful, when the patient no longer moved his lower limbs, and/or presented relaxation of the anal sphincter, and also in the absence of GA conversion or complementary local anesthesia (by the surgeon) throughout the surgical procedure. If SA was successful, a paci er dipper in sugar water was given to the baby.
The heart rate was stable throughout anesthesia and surgical procedure; a slight decrease in this frequency was observed after spinal in ltration (Fig. 1).
For all pediatric patients of this study, oral paracetamol (acetaminophen) was administered in recovery room where duration of stay was 70 [60-120] minutes. No peroperative and postoperative complications were observed.

Discussion
The present study represents the rst series of spinal anesthesia performed in pediatric patients, in a hospital center in Madagascar. Over a seven-year period, 69 children were scheduled for spinal anesthesia, with a GA conversion following failure rate of 5.8%.

Incidence, clinical features and indications of pediatric spinal anesthesia
The indication of spinal anesthesia was mainly limited to the situations where general anesthesia leaded a great risk for the child, especially respiratory risk [1,4,6]). After the decline of caudal anesthesia in the years 1990-2000, SA had an upsurge of 2.1 to 3.6% in regional anesthesia techniques, even if spinal anesthesia in newborns (or even in premature infants) is controversial [3,7]. Plus, SA is the "gold standard" technique in the former preterm infant (< 60 weeks PCA) for lower abdominal and lower extremities surgeries under 90 minutes duration [2]. In a work by Williams R.K. et al. [8] spinal anesthesia was performed in 95.4% of children. In France, this technique represents 18% of regional anesthesia in preterms and 5% in newborns [3]. In Finland, 400 to 500 spinal anesthesias are performed annually [6]. As related in the present study, rst spinal anesthesias in Antananarivo were performed in 2013, with 69 cases in seven years, for surgeries ranging 10 to 65 minutes.
The success of the technique was estimated on the re ux of cerebrospinal uid (CSF) which was 97.1% in the present study, almost similar to the rate of 97.4% reported by Williams R.K. et al. [8]. One lumbar puncture was perfomed in 47.3% and general anesthesia conversion was 5.8%. Sedation is often necessary, during insu cient block and the conversion to general anesthesia is indicated in case of failure of the technique [3]. Dohms K. et al. [9] nd a failure rate of 7.5% and in 28% cases, more than two punctures were needed and 16% required supplemental anesthesia. In Kachko L.'s [4] study, general anesthesia conversion occurred in 1.04%.
The success of the spinal anesthesia was estimated and based on the motor skills of the lower limbs and the relaxation of the anal sphincter (when present), as well as the effectiveness of the surgical gesture. The use of general anesthesia after spinal puncture was 2.9% due to the quality of the product. Since the Bromage score is not assessable in this population category, the effectiveness of spinal anesthesia can be assessed by the possibility of performing the surgical procedure [10].
The dose of bupivacaine used in our series is 4 [3.5-4] mg. The most commonly used local anesthetics are 0.5% tetracaine and 0.5% bupivacaine; the usual dose is 0.6-0.8 mg / kg to reach average levels, and 1 mg / kg for higher levels (thoracic) [1]. These two molecules act during 90 to 120 minutes [1].
2. Spinal anesthesia, safe and real alternative to general anesthesia? Spinal anesthesia offers an interesting and reassuring alternative if tracheal intubation should be avoided by the underlying pathologies such as bronchopulmonary dysplasia or respiratory diseases [1,7]. Indeed, spinal anesthesia can avoid apnea or bradycardia and have minimum cardiorespiratory complications [2,6,10,11]. In the cases presented, most of the children presented an anesthetic risk in case of general anesthesia, due in particular to respiratory diseases and very young age (20.3% of rhinobronchitis, and 39.1% of prematurity). This situation motivated indication of spinal anesthesia in the CHU JRA.
Spinal anesthesia offers a good balance between safety and perioperative risks and seems to be a secured technique for the operated child, as long as compliance with contraindications is observed [5,6,11]. SA is more effective in blunting the neuroendocrine stress and adverse effects of surgery and provides additional effective intraoperative analgesia [2,12].
Spinal anesthesia in children allows remarkable cardiovascular stability [13,14]. The frequency of complications is 30% [1]. Ventilation and oxygenation are not generally compromised, even in patients at high risk, in preterm and expremature [13,14]. SA has a moderate risk of apnea and bradycardia (RR = 0.72), desaturation (RR = 0.82) and a low risk of needing postoperative respiratory assistance (RR = 0.09) [12].
In this work, no bradycardia of less than 100 bpm was observed, probably due to the very slow in ltration of the anesthetic and the 45° head up tilt position of the patient directly after in ltration. No other complications arose during these SA.

Conclusion
Spinal anesthesia is a regional anesthesia technique widely used in developed countries, and is very interesting, especially in newborns and preterms. In Madagascar, this technique should be extended, due to its low cost and the safety that this technique offers, especially avoiding respiratory complications and apnea.

Limitations
The monocentric and retrospective nature of this study are the main limits and the presented results do not re ect the whole Malagasy population.