The Successful Awake Caudal Anesthesia for Bilateral Inguinal Hernia Repair in Triple Premature Infants: Case report and Review of Literature

Introduction: Inguinal hernia is a more frequent problem in male infants with an increased incidence in twin ones. Prematurity is considered as a risk factor. During open surgery of hernia under general anesthesia, there is a high incidence of apnea especially in the preterm infants. Caudal anesthesia could been a more effective approach for induction of anesthesia and analgesia. Case presentation: Here, we presented three two-months-old infants (3.5-3.9 kg) for inguinal hernia repair, simultaneously who were born at 35 weeks’ gestation al age. They were undergone bilateral inguinal hernia repair with single shot awake caudal anaesthesia. Conclusion: Although herrniorraphy is a common procedure in preterm infants, the induction of simultaneous caudal anesthesia for this procedure is rare event. On the other hand, the complications of anestethic techniques such as apnea are important.Indeed, triple infants with based same genetic background didn’t show any undesirable events after anaesthesia.


INTRODUCTION
The repair of inguinal hernia has been remained as the most common procedure in pediatric surgery. The incidence of inguinal hernia varies from 0.8% to 4.4 %. Approximately 11.5% of children have a positive family history. The incidence increases in twins and reaches to 10.6% in males and 4.1% in female twins [1]. It has direct association with prematurity, it means the estimated incidence in premature infants is 10% to 30% versus 3% to 5% in term newborns [2]. The caudal anesthesia is a common procedure in pediatric anesthesia due to its excellent safety, partially acceptable and easy method, administration as an adjuvant method to general anesthesia and providing postoperative analgesia .The wake caudal anesthesia results in better patient's safety and reducing of general anesthesia-induced potential long-term neurotoxic effects in young children. However, regional anesthesia is associated with advantages in newborns such as prevention of respiratory failure and rapid recovery rate [3]. The awake caudal block for repair of hernia play import- ant role in preterm infants because of good success rate, fast recovery rate and lower requirements of analgesics in postoperative period [4]. Here, we describe awake caudal epidural anesthesia in a premature neonates undergoing bilateral inguinal herniorraphy. Based on previous randomized controlled trials, we could not provide valid evidences about caudal epidural anesthesia or spinal versus general anesthesia effects on incidence of post-operative apnea(-PA), bradycardia or declining of oxygen saturation in awake premature neonates undergoing inguinal herniorraphy under awaked regional anesthesia. The regional Anesthesia could reduce PA in preterm infants [5].

CLINICAL CASE REPORT
We present three two-months-old siblings undergoing surgery for inguinal hernia repair by successful awake caudal block. Their weight were 3500, 3600 and3900 grams, respectively. They had prematurity history at 35 weeks, gestational age and delivered by caesarean section. They were

Metaanalysis
The effect of, rapidly acting, quickly metabolized general anesthetic drugs with regard to the risk of postoperative apnea and neurotoxicity has not so far been established in randomized trials. There is potential complications from postoperative apnea and direct brain toxicity from anaesthetic drugs superimposed upon pre existing altered brain development in preterm infants . This necessitate the examination of neurodevelopmental outcomes in the context of large randomised controlled trials of general, compared with regional, anesthesia, in former preterm infants undergoing for inguinal hernia repair . Claudia M. Mueller [ 3week male 2002 1case Awake regional anaesthesia for inguinal hernia repair in former preterm infants is suggested to avoid life threatening respiratory complications known to occur after general anesthesia. Caudal epidural anesthesia is becoming a more popular technique and to prolong duration of anesthesia and reduce postoperative analgesics consumption , clonidine has been added into local anesthetic solution . they report a former preterm infant, who had two awake caudal anaesthetics for herniotomy within 3 weeks. The first was uneventful with bupivacaine 0.25% at 35 weeks post conceptual age. but at 38 weeks, the baby suffered from intra and postoperative apneas after inadvertent administration of bupivacaine 0.125% plus clonidine. Hemodynamic changes,analgesia and apnea were evaluated up to 24 h.in this study patient surgeries were done successfully with out any complication .

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candidate for bilateral inguinal hernia repair. In past medical history, twin of them had icterus. There was no symptoms and signs of pathologic events in preoperative visit. After obtaining informed consent of parents, finally we chose awake caudal anaesthesia technique. In operation room, the basic monitoring include following options: body temperature, electrocardiogram, non-invasive blood pressure, saturation of arterial oxygenation. Then, they received mild sedation with 0.3 mg IV midazolam and few drops of oral dextrose 50%. In lateral decubitus position, after preparation and drape of sacro-coccygeal space, caudal block was performed by 22-gauge needle by 3.5 ml, 3.6ml and 3.9 ml of bupivacaine 0.25% and 1/200000epinephrine.We precisely monitored patients during surgery. At the end of surgery, patients admitted to post anaesthesia care unite and discharged to ward after complete recovery. Oral feeding was started just after entrance to ward.

DISCUSSION
It is most obviously thst the approach to inguinal hernia is considered as routine event but the simultanous procedure on three siblibgs by awake caudal anesthesia is a rare oc-curence9 that siblings.
A retrospective chart review of all patients at a single institution who underwent elective surgery with continuous caudal epidural block was performed. From thirty patients (27 males, three females): 28 patients underwent inguinal hernia repairs. Caudal anesthesia was performed via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter. (3) The important point of our article is that the patient had not received any anesthestetic drug for induction or maintenance of anesthesia & analgesia and they had only received mild sedation by small dose of midazolam. The key point is that awake caudal was successful in all of three infant without any complications. There are few paper in literature about awake caudal that author had study all of them.
The Sixty-three patients were included in a clinical trial from April 2015 to September 2016 and were divided into three groups of 21 each: patients in group I were given intrathecal bupivacaine only at a dose of 0.4 mg/kg bupivacaine 0.5%; patients in group II were given intrathecal bupivacaine plus dexmedetomidine at a dose of 0.4 mg/kg bupivacaine 0.5% with 0.25 μg dexmedetomidine for every 1 mg bupivacaine; and patients in group III were given caudal bupivacaine 0.5% at a dose of 3 mg/kg. Our primary outcome measures were duration of analgesia (time from the block to first dose of analgesia or observed pain score ≥12) and frequency of analgesic consumption, whereas the secondary outcome measures were onset of block (time from performing block until recording sensory loss using the pin prick method and motor loss, which was recorded using the modified Bromage scale), level of block, effects on hemodynamics, and occurrence of complications. (7) In present case report, we gave an example of triple premature infants who were at 5-6 week's geospatial age (i.e. 43 week's GA). Indeed, the incidence rate of apnea decrease as inverse correlation with increasing age and birth weight. Therefore, AOP effects are observed in 7% of infants with GA 35-84 weeks. On the other hand, the prevalence of AOP is higher in first degree relatives, it means the possible role of genetic susceptibility (e.g. 87% vs 62% for dizygotic twins of the sane see GA<36 weeks), especial lay in male infants (Picone), Gharavi et al evaluated apnea in 100 infants with postconeptual age <60 week undergoing herniorraphy and reported 20.7% case of postoperative apnea (18% in infants with GA of 35.64±2.73 weeks). These infants reviewed anesthesia by sevoflurane, remifentayl, atracurium and 60% N2o (Gharvi). The Geze et al suggested awake caudal anesthesia due to avoidance anestethic undesirable effects after surgery (Geze). It is estimated the incidence of inguinl hernia as 10-30% of premature infants (khan), and then we could figure up the hernionrraphy is common procedure in preterm infants based on GA. Therefore, we presented triple former premature infects undergoing surgery by awake caudal anaesthesia by bupivacaine 0.25%. The monitored value inter-and post-operative didn't demonstrate apnea in these babies. It's most obvious that the regional method are preferred to general anaesthetic approaches ever though in former preterm infants due to safety of regional anaesthetic.

CONCLUSION
The premature infants have particularly high incidence of inguinal hernias. In these infants, caudal epidural anaesthesia have been successfully used to avoid general anaesthesia and airway management devices.Awake caudal block had been used successfully in our patients because they were in high risk of apnea after general anesthesia due to their prematurity.