Describe about anagesia in specific situation

1. ANAESTHETIC IMPLICATIONS IN
CLASSIC BLADDER EXSTROPHY REPAIR
IN PAEDIATRIC PATIENTS
A CASE REPORT AND DISCUSSION
BY:
DR. PRIYAL GUPTA

2. CASE PRESENTATION
• Name: Rudra
• Age: 4 months
• Sex: male
• Address: S/O Mr. Sujit Kumar, Sitamarhi, Bihar
• Chief complaints: passage of urine through a deformity in lower
abdomen since birth
• H/O present illness:
– defect in the lower abdomen since birth
– passage of urine through the defect with regular soakage of
clothes and bedding
– Feeding adequate and normal, regular passage of stools
• H/O past illness: nothing significant

3. • Birth history: Full term, normal vaginal delivery, cried at birth,
no asphyxia or respiratory distress, birth weight 3kg
• No drug history, milestones and immunization complete till
date
• General examination: well built, good nutrition
no apparent congenital defects on head to toe examination
no pallor/ icterus/ cyanosis/ lymphadenopathy/ clubbing/
pedal oedema, weight= 8kg
• Vitals: PR- 100/min, regular, rhythm normal, volume
adequate,no radio-radial or radio femoral delay
BP- 80/50
Temperature- normal
• Airway examination: patent oral cavity, adequate neck
movement, no obvious cranio-facial anomaly

4. • Systemic examination:
– CNS- vigorous, active, crying
– Respiratory system- chest B/L clear, no added sounds
– CVS- S1, S2 normal, no murmur heard
– Abdomen: -not distented, infraumbilical abdominal
wall defect present
-exposed bladder mucosa
-ureteric and urethral opening seen
-complete dorsal defect in penis
-B/L inguinal swelling noted
-gonads normally descended
• Written and explained consent was taken from the parents.

5. INVESTIGATIONS
• Hb- 12g/dL
• TLC- 6800 cells/mm3
• DLC: N66, L25, M5, E3, B1
• Platelets: 1.9 lacs/mm3
• BT: 3m 15s, CT: 6m 30s
• S. urea: 34mg/dL
• S. creatinine: 0.8mg/dL
• S. sodium: 138mEq/L
• S. potassium: 4.0mEq/L
• S. calcium: 4.4mEq/L
• USG KUB: within normal limits
• 2D ECHO study: no significant abnormality
• DTPA scan: B/L normal functioning kidneys
• Blood sent for cross-matching

6. • Monitors attached: Pulseoximetry, NIBP, 5-lead ECG,
capnography and temperature probe.
• A 24g i.v. canula was present (done by the surgical team pre-
operatively) and Ringers lactate was started using a burette.
• A second i.v. line was taken after induction and intubation.
• Premedicated with Inj Atropine 0.2 mg i.v., Inj. Fentanyl 16µg
i.v. and induced with Inj. Thiopentone 40mg i.v. Inj. Atracurium
8mg i.v. was used for muscle relaxation.
• Intubated without any complications with a 4mm ID ET tube
and put on the ventilator with O2, N2O, isoflurane and
atracurium 1mg for maintenance.

7. • A 22G epidural catheter was carefully secured at the L2-L3
vertebral level after proper positioning
• After position for surgery was made, fractionated dose of
0.25% bupivacaine 6ml with 8µg fentanyl was given
through the epidural catheter.
• Epidural top-up was done twice using 0.125% bupivacaine
at 0.5mL/kg.
• Fentanyl 1µg/kg was given with the first 2 doses
• The last epidural top-up was done half hour before
completion of surgery with 0.5mL/kg of 0.125%
bupivacaine.

8. • The surgery lasted for approximately 8 hours
• Intermittent ABG analysis was done.
• Patient was covered appropriately with blankets and cotton
padding, warm i.v. fluids were used and OT temperature
maintained.
• The child was fed breast milk at 5AM in the morning and
anaesthetic induction done at approximately 9:30AM.
• The 4-2-1 Holliday Segar formula was used for intra-op fluid
calculation.

9. • After pelvic osteotomy and approximation properly
matched PRBC was given.
• Total intra-op fluid in 8 hours: 1000mL crystalloid + 100mL
packed cells
• Paracetamol 60mg was given via infusion
• D5% in 0.45% normal saline was given as per maintenance
rates in the latter half of the surgery.
• Total blood loss: approx. 175mL (surgical field, mops and
drain collection taken into consideration)

10. ABG ANALYSIS
ABG just after induction
and securing of epidural
ABG after 3 hours of 1st
report
ABG 1 hour before the
end of surgery
pH- 7.42 pH- 7.34 pH- 7.38
PO2- 200 mmHg PO2- 180 mmHg PO2- 202 mmHg
PCO2- 40 mmHg PCO2- 33mmHg PCO2- 35 mmHg
SO2- 99% SO2- 98% SO2- 99%
HCO3- 22 HCO3- 18 HCO3- 20
Na+- 140 Na+- 138 Na+- 133
K+- 4.5 K+- 3.8 K+- 3.5
Hb- 12g/dL Hb- 11g/dL Hb- 9.5g/dL
Hct- 36 Hct- 32 Hct- 28
Glucose- 120 Glucose- 100 Glucose- 130

11. • After completion of surgery, patient was extubated
successfully when fully awake and was maintaining
saturation on room air.
9am 9:30am 10am 10:30am 11am 11:30am 12pm 12:30pm
PULSE 120 140 133 135 125 119 115 120
BP 80/50 100/60 90/53 92/52 80/45 78/48 80/50 86/55
SpO2 99% 98% 99% 100% 100% 99% 99% 99%
Temp. ◦C 36.7 36.6 36.5 36.5 36.3 36.2 36.0 35.8
1pm 1:30p
m
2pm 2:30pm 3pm 3:30pm 4pm 4:30p
m
5pm
PULSE 130 138 128 130 121 124 126 142 135
BP 101/64 94/58 85/50 80/42 82/50 80/52 88/55 95/54 88/50
SpO2 100% 100% 99% 100% 98% 99% 100% 100% 100%
Temp. ◦C 35.9 36.2 36.3 36.1 36.0 36.4 36.5 36.4 36.5

12. • Patient was observed for 15 mins and transferred to the
post operative ward with monitors attached.
• Post operative pain management was done using 0.125% to
0.0625% bupivacaine every 6-12hourly at 0.1mL to
0.3mL/kg for 3 days with proper hemodynamic monitoring.
• Epidural catheter was removed on the 4th post op day.
• Patient was monitored till 24 hours after removal of
epidural catheter.

13. • Repeated haemogram and KFT were normal.
• The patient was passing urine through the
neourethra.
• Patient was discharged on the 23rd post-
operative day and routine follow-ups were
normal.

14. From August, 2015 to June, 2016, 92 cases of
bladder exstrophy and epispadias complex
were admitted in our institute out of which
20 underwent exstrophy repair with pelvic
osteotomy and 6 of them were patients
below 6months.

15. DISCUSSION

16. • Bladder exstrophy is a rare congenital malformation
of the genitourinary system.
• There is a severe midline abdominal birth defect
causing wide separation of pubic symphysis, an
abdominal wall defect and an open bladder and
urethra.
• Failure of the cloacal membrane to be reinforced by
the ingrowth of the mesoderm.
• Subject to premature rupture depending on extent
of infraumbilical defect – bladder exstrophy, cloacal
exstrophy or epispadias results.

18. • Indirect inguinal hernia- frequent occurrence; seen in
80% boys and 10% girls.
• No association with parental age, maternal reproductive
history, exposure to drugs, alcohol, radiation or infection.
• Incidence is approx. one per 50,000 live births.
• Initial surgical reconstruction can be primary single staged
closure of the bladder and penis or a planned staged
repair.
• Pelvic osteotomies have been shown to reduce the risk of
wound dehiscence and bladder prolapse.

19. CLASSIC BLADDER EXSTROPHY

20. • Anaesthetic considerations:
– Long operating times (5-7hrs, sometimes upto 10 hours)
– Unpredictable bleeding and fluid shifts (CVP line, arterial
line may be necessary)
– Haemodynamic monitoring and measurement of blood
gases, haemoglobin, coagulation studies, electrolytes
and glucose
– Providing a bloodless surgical field (maintaining BP on
the lower side)
– Inadequate output monitoring (spillage of urine till
repair is complete)
– Intra- and post-operative pain management

21. PAEDIATRIC EPIDURAL
• Care of the child with bladder exstrophy carries high risk of morbidity
and a long hospital stay of about 4-8 weeks.
• The focus is both pain control and maintenance of immobilization.
• Epidural analgesia advantages:
– Excellent pain control
– Sedation and general anaesthesia is minimized
• Disadvantages:
– High degree of precision and patience during placement
– Local anaesthetic toxicity
– Technical difficulties
– Nerve root/ spinal cord injury
– Dural puncture

22. • Lumbar epidural in anaesthetized patients via a midline
route at L2-L3 interspace in the left lateral position.
• Caudal epidural catheters can also be placed and threaded
upto the desired vertebral level.
• In our institute, we routinely practice tunneling for proper
securing of the catheter and fentanyl as an adjuvant.
• The volume of anaesthetic solution depends on the level of
analgesia required (upto T10-T12 in bladder exstrophy).
Usual volumes range from 0.5 to 1mL/kg (upto 20mL).

23. • Drugs used:
– Bupivacaine 0.25%/0.125%
– Levobupivacaine 0.25%
– Ropivacaine 0.2%
– lidocaine
– Adjuvants: Adr 1:2,00,000, fentanyl,
clonidine, morphine, hydromorphine
• It is better to avoid adjuvants in paediatric patients below
6months of age but no adverse outcome was encountered
on administration of fentanyl in the epidural catheter in our
patients intra-operatively.

24. • In all the operated cases an epidural was placed and
fentanyl was given as an adjuvant in a dose of 1µg/kg
intra-operatively.
• Care was taken to keep at 2hours in between last
administered dose of epidural fentanyl and the end of
surgery.
• Patients were monitored post operatively upto 24 hours
after the removal of the catheter for any haemodynamic
or respiratory complications.

25. • Complications:
– Local anaesthetic toxicity (bupivacaine is most used
and most feared)
– Bacterial colonization
– Accidental removal
• Subcutaneous tunneling decreases chance of accidental
dislodgement, longer catheter times and additional
protection against infection.
• The use of NSAIDs, sedatives etc can improve pain
control and decrease adverse effects and ensure that
the child is immobilized.

26. Approximation after pelvic osteotomy and the picture
after complete repair

27. • In a risk of hypoglycemia, 5% dextrose in 0.45% normal
saline should be administered as an infusion at
maintenance rates to minimize chance of a bolus
infusion.
• Since urine output monitoring is inadequate and third
space losses are inevitable in bladder exstrophy repair,
the fluid status monitoring is done depending on clinical
signs.
• With the use of the above formulas and constant
vigilance on our part, no major fluid deficits or overload
has been encountered.

28. EXTUBATION
• Timing of the removal of the endotracheal tube after surgery
depends on the age of the infant, length and complexity of the
surgery, and amount of fluid and blood the patient received
during surgery.
• Routine post-operative ventilator support is not practised in
our setup unless required.
• In awake extubation, patient should be extubated when :
– purposeful movements
– coughing or gagging on the tracheal tube
– spontaneous eye opening
– normal respiratory pattern.

29. CONCLUSION

30. • Lumbar epidural catheters provide safe analgesia upto 3-
4days post-op with switching over to i.v. and oral
analgesics later.
• Interdisciplinary approach required.
• Due to the complexity of the procedure and the long
surgical hours, one must be prepared for any type of
complications during induction, intubation, blood losses,
blood transfusion, extubation and the post operative
period.
• Proper communication between the surgeons and
anaesthetists is required throughout with contributions
from the nursing staff in the post operative period.

31. REFERENCES
1. Miller’s Anaethesia, 8th edition
2. Clinical Anaesthesia, Paul G. Barash, 7th edition
3. Massanyi EZ, gearhart JP, Kost-Byerly S. perioperative
management of classic bladder exstrophy. Res Rep Urol 2013; 5:
67-75
4. S. Kost-Byerly et al, perioperative anaesthetic and analgesic
management of newborn bladder exstrophy repair, J Pediatric
Urol, 4 (2008)
5. Sethi N et al, J Anaesth Clin Pharmacol 2012; 28: 4-5
6. Lori J. Kozlowski MS et al, the acute pain nurse practitioner: a
case study in the postoperative care of the child with bladder
exstrophy, J Pediatric health Care, 2008
7. Ibrahim S. Farid et al, perioperative analgesic managemnet of
newborn bladder exstrophy repair using a directly placed
tunneled epidural catheter with 0.1% ropivacaine, a & a case
reports

32. THANK YOU