Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy

Review question: In preterm infants undergoing inguinal hernia repair, does the use of regional anaesthesia compared to general anaesthesia reduce postoperative complications including apnoea, bradycardia and the use of assisted ventilation? Background: babies born preterm (before 37 weeks) often have serious health problems and sometimes need surgery. Inguinal hernia (IH) (where the intestine protrudes through the abdominal wall) is the commonest condition where surgery is needed. General anaesthetics for surgery can disrupt breathing and cause other complications in preterm babies. Regional anaesthetics including spinal block (injection) might avoid complications such as pauses in breathing in the first 24 hours after surgery. Whether this improves outcomes for preterm babies having surgery is unclear because no trials have looked at the effects of anaesthetics on brain function in older children. Study characteristics: seven small trials comparing spinal with general anaesthesia in the repair of IH were identified. Results: there was no statistically significant difference in the risk of postoperative apnoea/bradycardia, postoperative oxygen desaturations, the use of postoperative analgesics, or postoperative respiratory support between infants receiving spinal or general anaesthesia. When infants who had received preoperative sedatives were excluded, the meta-analysis supported a reduction in the risk of postoperative apnoea in the spinal anaesthesia group. Infants with no history of apnoea in the preoperative period and receiving spinal anaesthesia (including a subset of infants who received sedatives) had a reduced risk of postoperative apnoea. Infants receiving spinal rather than general anaesthesia had a statistically significant increased risk of anaesthetic agent failure. Infants randomised to receive spinal anaesthesia had an increased risk of anaesthetic placement failure of borderline statistical significance. Conclusions: there is some evidence to suggest that spinal anaesthesia without the addition of sedative drugs to assist in keeping the baby still and provide additional pain relief during the procedure may be safer than general anaesthesia for a former preterm baby having surgery for inguinal hernia. A recently completed but as yet unpublished large multicentre trial comparing general anaesthesia or awake spinal anaesthesia may help give more precise answers to this question.