Indian Journal of Anaesthesia 2008; 52 (3):264-270 Indian Journal of Anaesthesia, June

Special 2008
Article

Paediatric Spinal Anesthesia

Rakhee Goyal1, Kavitha Jinjil2, BB Baj3, Sunil Singh4 , Santosh Kumar5
Summary
Paediatric spinal anesthesia is not only a safe alternative to general anaesthesia but often the anaesthesia
technique of choice in many lower abdominal and lower limb surgeries in children. The misconception regarding its
safety and feasibility is broken and is now found to be even more cost-effective. It is a much preferred technique
especially for the common daycase surgeries generally performed in the paediatric age group. There is no require-
ment of any additional expensive equipment either and this procedure can be easily performed in peripheral centers.
However, greater acceptance and experience is yet desired for this technique to become popular.

Key words Paediatric spinal anaesthesia, Bupivacaine, Infraumbilical surgeries in children

Introduction volatile agents and muscle relaxants for general anaes-

thesia.
Regional anaesthesia in children was first studied
by August Bier in 1899. Since then, spinal anaesthesia In the last decade, it started being advocated again
was known to be practiced for several years with a by many centers due to increasing knowledge on phar-
series of cases published as early as in 1909-1910.1-3 macology, safety information and availability of spe-
In 1900, Bainbridge reported a case of strangulated cialized equipment for regional anaesthetic techniques
hernia repair under spinal anaesthesia in an infant of and monitoring in children. In the coming times, paedi-
three months.4 Thereafter, Tyrell Gray, a British sur- atric spinal anaesthesia will not only be used in cases
geon published a series of 200 cases of lower abdomi- where general anaesthesia is risky or contraindicated
nal surgeries in infants and children under spinal anaes- but also be the preferred choice in most lower abdominal
thesia in 1909-1910. After some years it fell into dis- and lower extremity surgeries in children.
use because of the introduction of various muscle re-
laxants and inhalational agents and was almost unused Anatomical and physiological differences
after World War II. in children

Thereafter, in 1983, in the American Society of There are certain features of paediatric anatomy
Anesthesiologists Regional Anesthesia Breakfast Panel, and physiology which are different from the adult and
Abajian et al started the “frenzy” of modern paediatric thus make the central neuraxial blockade a good alter-
spinal anaesthesia when they reported 78 cases in 81 native anaesthetic technique. The spinal cord ends at
infants. 5 The textbook of paediatrics by Leigh and Belton L3 level at birth and reaches L-1 by 6-12 months. The
also demonstrated that 10% of all anaesthetic proce- dural sac is at the S4 level at birth and reaches S2 by
dures practiced in children at the Vancouver General the end of the first year. The line joining the two supe-
Hospital were spinal techniques, including pulmonary rior iliac crests (inter-cristal line) crosses at L5-S1 in-
lobectomies and pneumonectomies.5 However, paedi- terspace at birth, L5 vertebra in young children and
atric spinal anaesthesia never achieved its popularity L3/4 interspace in adults. It is for this reason that the
because of continuous discoveries of newer and better lumbar puncture be done at a level below which the

1. Consultant, 2. Consultant, 3. Head of Department, 4. Consultant, 5.P.G.Student, Department of Anesthesiology and Critical
Care, Base hospital, New Delhi, Correspondence to: Rakhee Goyal, Department of Anesthesiology and Critical Care, Base
hospital, New Delhi, Email: rakhee_goyal@yahoo.co.in Accepted for publication on: 18.4.08

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Rakhee Goyal et al. Paediatric spinal anaesthesia

cord ends, safest being at or below the inter cristal line. critically ill and moribund neonates who present for
The bones of the sacrum are not fused posteriorly in surgery in grave haemodynamic instability.
children enabling an access to the subarachnoid space
even at this level. Pharmacology

Another feature which is unique in infants is that The most important concern with the use of in-
there is only one anterior concave curvature of the ver- trathecal local anaesthetics in infants and young chil-
tebral column at birth. The cervical lordosis begins in dren is the risk of toxicity. This age group is particularly
the first 3 months of life with the child’s ability to hold prone to direct toxicity to the spinal cord when admin-
the head upright. The lumbar lordosis starts as the child istered in large doses. Neonates with immature hepatic
begins to walk at the age of 6-9 months. Therefore, the metabolism and decreased plasma proteins like albu-
spread of isobaric local anaesthetic is different in in- min and α 1 acid glycoprotein have higher serum lev-
fants particularly as compared to adults. els of unbound amide local anaesthetics, which are nor-
mally highly protein bound (90%). A relatively higher
The subarachnoid space is incompletely divided cardiac output and regional blood flow in infants also
by the denticulate ligament laterally, and the subarach- increases the drug uptake from neuraxial spaces and
noid septum medially. The volume of cerebrospinal fluid can predispose them to local anaesthetic toxicity be-
CSF is 4 ml.kg-1 which is double the adult volume. sides decreasing the duration of action. Infants may have
Moreover, in infants half of this volume is in the spinal decreased levels of plasma pseudocholinesterase which
space whereas adults have only one-fourth. This sig- may augment local anaesthetic toxicity especially with
nificantly affects the pharmocokinetics of intrathecal the ester group.8 Various anaesthetics have been used
drugs. The spinal fluid hydrostatic pressure of 30-40mm for paediatric spinal anaesthesia but bupivacaine and
H2O in horizontal position is also much less than that in ropivacaine remain the drugs of choice.
adults.6
Indications
The neck can be in extension for lateral position-
ing while performing a lumbar puncture as cervical flex- Infraumbilical extraperitoneal surgeries like ing-
ion is of no benefit in children and in fact, may obstruct uinal hernia, circumcision, hypospadias, orchidopexy,
the airway during the procedure. It can also be per- cystoscopy, colostomy for imperforate anus, rectal bi-
formed in sitting position with the head extended. opsy and other perineal surgeries; lower extremity or-
thopaedic and reconstructive surgeries.
The physiological impact of sympathectomy is
minimal or none in smaller age groups. The fall in blood Preterm and former preterm infants less than 60
pressure and a drop in the heart rate are practically not weeks post-conceptual age/less than 3 Kg/hematocrit
seen in children less than five years. Therefore there is <30% and with other co-morbidities who are prone to
no role of preloading with fluids before a subarachnoid post-operative apnoea,9 bradycardia and desaturation
block. This may be due to the immature sympathetic after general anaesthesia.
nervous system in children younger than five–eight years
Neonates with respiratory diseases like bronchop-
or a result of the relatively small intravascular volume in
ulmonary dysplasias, hyaline membrane disease.
the lower extremities and splanchnic system limiting
venous pooling and relatively vasodilated peripheral Children with history of or high risk for malignant
blood vessels. 7 Infants respond to high thoracic spinal hyperthermia .
anaesthesia by reflex withdrawal of vagal parasympa-
thetic tone to the heart. It is one of the reasons why Children with acute respiratory conditions, chronic
spinal anaesthesia has been the technique of choice in disease of the airways like asthma or cystic fibrosis.

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 Indian Journal of Anaesthesia, June 2008

Besides these common indications, there are re- ever may be the drug and the route of administration, it
ports of successful spinal anaesthesia in complex sur- is important that it is customized for each type of pa-
geries like meningomyelocele, gastroschisis repair, open tient and surgery involved and also safe during the en-
heart surgery 10 etc in addition to light general anaes- tire perioperative period. 11
thesia.
Procedure, needles used, drug dose
Contraindications
The basic procedure of performing a subarach-
Refusal of the parents, progressive neurological noid block in children is similar to adults and full asep-
disease, uncontrolled convulsions, infection of the skin tic precautions are a must. It is important to access the
or subcutaneous tissue locally at puncture site, coagu- CSF through appropriate space as per the age of the
lation defects, true allergy to local anaesthetics and se- child as already discussed in order to avoid trauma to
vere hypovolemia are some of the contraindications to the spinal cord. Care should be taken as the child may
spinal anaesthesia in children. be asleep or inadequately sedated. However, additional
analgesia and sedation is generally required during lum-
Consent and risk-benefit aspect bar puncture. It may be supplemented with low dose
ketamine or a short acting drug like thiopental/propofol
Consent from the parents is an important issue intravenously or inhalational anaesthetics like oxygen-
before planning a central neuraxial blockade for chil-
nitrous oxide, sevoflurane or halothane during the pro-
dren. The consent should be informed and written, and
cedure. Anticholinergic drugs may be added to decrease
the various aspects of regional technique alongwith the
any undesired secretions. Application of 5% EMLA
risks involved must be explained in detail. There is also
(eutectic mixture of local anaesthetics-lidocaine and
an obvious need to assess the risk involved in the pro-
prilocaine) with an occlusive dressing on the appropri-
cedure on an individual case basis versus the benefits
ate and best palpated interspace about an hour before
expected depending on the nature and duration of sur-
surgery facilitates painless lumbar puncture without any
gery, general condition of the patient and the availabil-
additional parenteral sedation. EMLA should be used
ity of institutional care intra and postoperatively.
with caution in infants less than three months and those
NPO and premedication protocols receiving any methemoglobin inducing drugs like sul-
fonamides, phenytoin, phenobarbital, acetaminophen.12
The standard preoperative fasting guidelines are Intraoperatively, sedation can be augmented with
required to be followed before elective spinal anaes- midazolam upto 0.1mg.kg-1. Flavoured pacifiers for
thesia. 2-3 hrs fasting for clear fluids, 4 hrs for other young and music or books for older children may be
fluids and 6 hrs for solids is usually followed in most used in case the child is awake and cooperative.
centers.
The needles available for paediatric use range from
Adequate premedication is the key to a smooth 24-29 G, either short bevelled Quincke or Sprotte and
regional procedure in children. Various drugs via dif- Whitacre with or without introducer with a length shorter
ferent routes may be used to achieve a well sedated than that in adults. If specialised needles are unavail-
child who allows venous puncture, placement of moni- able or their cost is prohibitive, even hypodermic needle
tors and even a lumbar puncture. Oral combination of or the metal stillete of a small gauge intravenous can-
ketamine 4-6mg.kg-1, midazolam 0.4mg.kg-1 and atro- nula can be used without much difficulty. Correct place-
pine 0.03mg.kg-1 is quite effective and safe in most ment of the needle is ascertained by free flow of CSF.
cases.6 Other routes of premedication like rectal, sub- Some of the needles also have a magnifier hub for fast
lingual, nasal or intramuscular are also practiced. What- recognition of flashback of CSF. The child may be kept

266
Rakhee Goyal et al. Paediatric spinal anaesthesia

in the dependent side for a few minutes for lateralisation but the potential for toxicity with levobupivacaine is less.
of the block. A successful block usually takes about 2- Kokki et al performed a study on 40 children, aged 1–
5 mins and care should be taken that the leg is not lifted 14 yr, undergoing elective lower abdominal or lower
just after the block for placement of diathermy pads limb surgery levobupivacaine 5 mg.mL-1 at a mean dose
which often results in undesired cephalad spread of the of 0.3 mg.kg1 body weight, and found equivalent clini-
block. cal efficacy in spinal anaesthesia in children to that of
racemic bupivacaine.14, 15
The extent of the sensory block can be checked
by pin-prick or skin pinch and that of the motor block Ropivacaine 5mg.ml-1 has also been used in some
by Bromage scale.13 This may however be difficult to studies and found to be effective and safe in isobaric
check in a deeply sedated child and can only be done form. In a study of 93 children 1-17 years of age, Kokki
in the postanesthesia care unit (PACU) to check the H et al used 0.5mg.kg-1 (upto 20mg) in lateral decubi-
block regression. However, it can be clinically ascer- tus position and achieved good block performance.16
tained by lack of leg movement and diaphragmatic
breathing. Children very often fall asleep with the de- Baricity is one of the most significant factors to
afferentation following the block. affect the distribution of the local anaesthetic and hence
success and spread of the blockade. The effect of dif-
Intraoperative fluids only include deficit and main- fering degrees of hyperbaricity was evaluated by sev-
tenance amounts and preload need not be given as in eral workers in paediatric age group. It is not known
adults. The hypotensive cardiovascular response to whether hyperbaric local anaesthetic is better than iso-
sympathectomy is minimal or none in children. How- baric in children in contrast to adults where it is proven
ever, standard monitoring is mandatory and oxygen by to be more reliable, safe and effective.17 Isobaric
face mask is recommended in all cases. bupivacaine has also been used for spinal anaesthesia
in children and compared with its hyperbaric form.
All patients should be monitored in the PACU for Kokki H 18 compared bupivacaine 5 mg.ml-1, isobaric
vital signs, two-segment block regression, pain and any in saline 0.9% and hyperbaric in 8% glucose, for spinal
other side effect. Children should only be discharged anaesthesia in 100 children, aged 2-115 months for
when they are awake and able to walk unaided, the paediatric day case surgery. The success rate of the
vital signs are stable for at least 1 h, there is no pain, block was greater with hyperbaric bupivacaine (96%)
nausea/retching or vomiting, and are able to tolerate compared with isobaric bupivacaine (82%). Intense
clear fluids. motor block was associated with adequate sensory
block. Spread and duration of sensory block showed
Intrathecal drugs
a similar wide scatter in both groups. Cardiovascular
Among the various drugs approved by FDA for stability was good in both groups. The study gave an
paediatric intrathecal use, 0.5% bupivacaine and impression of a delayed onset time of spinal block, as
ropivacaine are common and popular. The doses used most of the nine children who required either fentanyl
are institutional though the standard protocol that I have or a sedative for a mild reaction to skin incision had
been practicing is 0.5% bupivacaine 0.1ml.kg-1 or complete block when transferred to the recovery room
0.5mg.kg-1 for infants weighing 0-5 Kg; 0.08ml.Kg-1 after operation.
or 0.4mg.kg-1 for 5-15Kg body weight and 0.06ml.kg-
1
or 0.3mg.kg-1 for >15 Kg weight.6 However, in an article published two years later
the same authors, Kokki H et al demonstrated that
Levobupivacaine has very similar PH) arma- bupivacaine in 0.9% glucose and in 8% glucose solu-
cokinetic properties to those of racemic bupiva-caine, tions are equally suitable for spinal anaesthesia in small

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 Indian Journal of Anaesthesia, June 2008

children. Similar success rate, spread and duration of paediatric patients and some authors have even chal-
the sensory and motor block are achieved with both lenged its existence. In his study on 200 children using
baricities of bupivacaine. 19 two different sizes spinal needles of 25 G and 29 G
Quinke, Kokki et al 21 found that 10 had PDPH with
Various studies have been done with child in lat- no difference regarding the type of needle used. The
eral or sitting position for a subarachnoid block. In a failure rate of attempted spinal anaesthesia was 4% and
study on 30 preterm infants for inguinal herniotomy, Vila even when the subarachnoid space was reached and
et al found spinal anaesthesia to be equally effective in the local anaesthetic injected, the overall success rate
both lateral and sitting position. 20 of the technique was only 91%.
Duration is an important and a limiting factor for Transient neurological symptom (TNS) has been
paediatric spinal anaesthesia especially in infants and reported by some authors following spinal anaesthesia
younger children. Spinal anaesthesia alone for this rea- due to direct toxicity of large doses of local anaesthetics.
son is therefore generally restricted to one hour dura-
In his study on 95 patients using 0.5% isobaric
tion surgeries only. The duration is longer with larger
ropivacaine, Kokki et al16 reported mild to moderate
doses in infants and varies directly with the age of the
TNS in four children which was transient and was not
child. It has been seen that the duration of long acting
followed by any permanent neurological sequelae. In
local anaesthetics like bupivacaine is only about 45 min
another study by the same author similar results were
in neonates and 75-90 min in children upto five years.
found with 0.5% bupivacaine.17
There is no difference in duration by adding epineph-
rine to bupivacaine. A one year study of 24,409 regional blocks in
children by the French-Language Society of Pediatric
Additives
Anesthesiologists, 22 the largest known study on com-
Since the duration of spinal anaesthesia does not plications, revealed a complication rate of 1.5 per 1000
cover most of the postoperative period, it is essential in the 60% of children receiving central neuraxial blocks.
to add intravenous or rectal acetaminophen or However, most of these cases were those of caudal
ketoprofen routinely to all patients. Profound postop- and some of epidural technique.
erative analgesia can be achieved by adding a low dose
local anaesthetic with or without an opioid (fentanyl), Advantages
clonidine 1-2µg.kg-1 or any other additive in caudal
Spinal anaesthesia produces a reliable, profound
space at the time of performing the subarachnoid block.
and uniformly distributed sensory block with rapid on-
A caudal catheter can also be placed and local anaes-
set and good muscle relaxation, and it results in more
thetic plus opioid added for prolonged analgesia post-
complete control of cardiovascular and stress responses
operatively.
than epidural or opioid anaesthesia.23 It is ideal for day-
Complications case surgeries and is safe and cost-effective. There is
no additional requirement of any special drug or equip-
The complications related to spinal anaesthesia ment for the procedure. Because of these benefits, spi-
are usually either due to the needle used to perform the nal anaesthesia has gained acceptance for children un-
procedure (backache, headache, nerve or vascular in- dergoing surgery in the lower part of the body.24
jury and infection) or the drugs injected (high or total
spinal, drug toxicity). However, little data is available Comparison with general anaesthesia
regarding the incidence as compared to adults.
General anaesthesia may be associated with sev-
Post dural puncture headache (PDPH) is rare in eral life-threatening complications especially in preterm,

268
Rakhee Goyal et al. Paediatric spinal anaesthesia

former preterm, those with co-morbidities like sepsis, on the day of surgery and it becomes a difficult deci-
necrotising enterocolitis, anaemia (hematocrit<30%), sion to cancel the surgery. Spinal anaesthesia is rela-
severe respiratory disease like respiratory distress syn- tively safer in all these instances where spontaneous
drome, bronchopulmonary dysplasias, cystic fibrosis airway can be maintained by the patient.
etc. All these neonates are at much higher risk of ap- Kokki et al also conducted a study on forty chil-
noea, bradycardia and desaturation after general ana- dren, age 2-5 years undergoing paediatric surgery and
esthesia.9 Spinal anaesthesia is a safe, reliable and simple compared spinal with general anaesthesia.26 Time spent
technique in a high risk infant. In 1984, Abajian et al in the operation room was shorter in the spinal anaes-
sparked an interest in this group and since then all the thesia group because the children were awake and could
reports have ascertained this fact.24 immediately be transferred. The haemodynamic pat-
tern and respiratory function were stable during spinal
In the healthy children, most of the procedures anaesthesia. Arterial desaturation (< 90%), vomiting,
are performed as day-case surgeries like herniotomy, sore throat and micturition difficulties were the adverse
circumcision, minor urological and orthopaedic proce- events associated with general anaesthesia. Three pa-
dures. Spinal anaesthesia is a very good alternative for tients were restless after spinal anaesthesia.
such cases were the child can be returned to the family In a study of 30 cases aged 7 months to 13 years
and a lot of stress to the parents is avoided. Since less at the Children’s National Medical Centre, Washing-
general anaesthetic drugs including parenteral opioids ton, open heart surgery was performed under high sub-
are used, the risk of postoperative respiratory depres- arachnoid block along with light general anaesthesia by
sion is minimal. The stress response to surgery is also Finkel JC et al and haemodynamic stability was found
limited and recovery is fast. to be maintained intra operatively in all cases.10

Kokki et al studied 100 children for paediatric Spinal anaesthesia has been found to be more cost
day-case surgery and found the technique safe and ef- effective as compared to general anaesthesia. The drugs
and equipment required are much less and cheaper be-
fective. 18 In his 10 years of experience of paediatric sides the length of hospital stay which is also usually
orthopaedic surgery, Bang-Vojdanovski B concluded shorter.27
that spinal anaesthesia is a suitable anaesthetic tech-
nique for paediatric surgery. 25 This method of anaes- Paediatric spinal anaesthesia may have been con-
thesia may avoid the increased incidence of postop- ceptualized a century ago but its golden years are yet
erative respiratory complications associated with gen- to come. Overall patient safety, feasibility and reliabil-
eral anaesthesia. ity are the key features of this technique which will only
become better with greater use, experience and re-
Intraoperative laryngo and bronchospasm are not search.
uncommon even in healthy infants and children besides References
episodes of coughing, breath-holding, endotracheal tube
obstruction and atelectasis. Moreover, with the increas- 1. Gray HT. A study of spinal anesthesia in children and
ing incidence of upper respiratory infections, commonly infants from a series of 200 cases. I Lancet 1909; 2:913-
916.
3-8 times in a year in paediatric age group there will
always be a risk of a hyper-reactive airway under gen- 2. Gray HT. A study of spinal anesthesia in children and
infants from a series of 200 cases. II Lancet 1909; 2:991-
eral anaesthesia. Besides, there are no preoperative 994.
tests feasible which would rule out any mild-moderate
3. Gray HT. A study of spinal anesthesia in children and
respiratory infection in children. Most of the times, the infants from a series of 200 cases. III Lancet 1910; 1:1611-
clinician has to rely only on the history provided by the 1615.
parents. More commonly the symptoms appear only 4. Bainbridge WS. A report of twelve operations on infants

269
 Indian Journal of Anaesthesia, June 2008

and young children during spinal anesthesia. Arch, 18. Kokki H, Tuovinen K, Hendolin H. Spinal anaesthesia
Pediatr 1901; 18:570-574. for paediatric day-case surgery: a double-blind, random-
5. Jo Rice L, Brilton J. Anestesia Raqu¡za Neonatal. Cli.Anest ized, parallel group, prospective comparison of isobaric
de N.A.1992; 1:135-136. and hyperbaric bupivacaine. Br J Anaesth 1998; 81:502-
6.
6. Dalens Bernard J. Regional Anesthesia in children. In:
Miller RD (Ed.). Anesthesia, 6th ed. New York: Churchill 19. Kokki H, Hendolin H. No difference between bupivacaine
Livingstone Inc 2005: 1719-1762. in 0.9% and 8% glucose for spinal anaesthesia in small
7. Sethna N F, Berde CB. Pediatric Regional Anesthesia. In: children. Acta Anaesthesiol Scand 2000; 44:548-51.
Gregory GA (Ed.). Pediatric Anesthesia, 4 th ed. New York: 20. Vila, R, Lloret, J, Munar, F. Spinal anaesthesia for in-
Churchill Livingstone Inc, 2002: 267-316. guinal herniotomy in preterm infants sedated with ni-
8. Finster M. Toxicity of local anesthetics in the fetus and trous oxide: a comparison of lumbar puncture in the lat-
newborn. Bull NY Acad Med1976; 52:222-5. eral or sitting position. Anaesthesia 2002; 57:1164-1167.
9. Cote CJ, Zaslavsky A, Downes JJ. Postoperative apnoea 21. Kokki H, Hendolin H. Comparison of 25 G and 29 G
in former preterm infants after inguinal herniorrhaphy. Quincke spinal needles in paediatric day case surgery. A
Anesthesiology 1995; 82:809-812. prospective randomized study of the puncture charac-
10. Finkel JC, Boltz MG, Conran AM. Haemodynamic changes teristics, success rate and postoperative complaints.
during high spinal anaesthesia in children having open Paediatr Anaesth 1996; 6:115-119.
heart surgery. Paediatr Anaesth 2003; 13:48-52. 22. Glaufre E, Dalens B, Gombert A. Epidemiology and mor-
11. Cravero JP, Blike GT. Review of pediatric sedation. Anesth bidity of regional anesthesia in children: a one year pro-
Analg 2004; 99:1355-64. spective study of the French-Language Society of Pedi-
12. Gourrier E, Karoubi P. Use of EMLA cream in a depart- atric Anesthesiologists. Anesth Analg 1996; 83: 904-12.
ment of neonatology. Pain 1996; 68:431-434. 23. Wolf AR, Doyle E, Thomas E. Modifying infant stress
13. Bromage PR. A comparison of the hydrochloride and car- responses to major surgery: spinal vs extradural vs opioid
bon dioxide salts of lidocaine and prilocaine in epidural analgesia. Paediatr Anaesth 1998; 8:305–11.
analgesia. Acta Anaesthesiol Scand 1965; 16:55–69. 24. Abajian C, Paul Mellish RW. Spinal anesthesia for sur-
14. Hannu Kokki, Paula Ylönen. Levobupivacaine for Pedi- gery in high risk infant. Anesth Analg 1984; 63: 359-62.
atric Spinal Anesthesia. Anesth Analg 2004; 98:64-67. 25. Bang Vojdanovski B. 10 years of spinal anesthesia in
15. Foster RH, Markham A. Levobupivacaine: a review of its infants and children for orthopedic surgery. Our clinical
pharmacology and use as a local anaesthetic. Drugs 2000; experience. Anaesthesist 1996; 45:271-7.
59: 551-9. 26. Kokki H, Hendolin H, Vainio J, Partanen J. Pediatric sur-
16. Hannu Kokki, Paula Ylo¨nen, Merja Laisalmi. Isobaric gery. A comparison of spinal anesthesia and general an-
Ropivacaine 5 mg/mL for Spinal Anesthesia in Children. esthesia. Anaesthesist 1992; 41:765-8.
Anesth Analg 2005; 100:66 –70.
27. Carlos C, Melvin E. First 300 Cases of Pediatric Regional
17. Kokki H. Spinal anesthesia in infants and children. Best Anesthesia in Venezuela (Caudal, Spinal And Peridural).
Pract Res Clin Anesthesiol 2000; 14:687-707. The Internet Journal of Anesthesiology 2000;4:4-10.

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