Anesthesia Management for Pediatric Robotic Urological Surgeries
For pediatric robotic urological surgeries, a multimodal anesthetic approach incorporating regional anesthesia techniques, appropriate airway management, and opioid-sparing strategies is strongly recommended to minimize morbidity and mortality while optimizing quality of life.
Airway Management
- Face mask ventilation is associated with fewer perioperative respiratory adverse events in children with upper respiratory infections (URIs) when feasible for the procedure 1
- When face mask ventilation is not possible for robotic procedures, there is no clear recommendation between laryngeal mask airway (LMA) and endotracheal tube, though LMAs may be associated with less desaturation 1
- For children under 6 years with URI symptoms, administer inhaled salbutamol (2.5 mg for <20kg, 5 mg for >20kg) 30 minutes before induction to reduce perioperative respiratory complications 1
- Avoid topical lidocaine for airway management in children with URIs as it may increase risk of desaturation, laryngospasm, and bronchospasm 1, 2
Regional Anesthesia Techniques
- Regional or neuraxial anesthesia techniques are strongly recommended as part of an opioid-sparing regimen for pediatric urological surgeries 1
- Combined spinal/caudal catheter technique can be considered for complex urological procedures to minimize or eliminate general anesthesia requirements 3
- Single-injection spinal anesthesia with 0.5% plain bupivacaine can be effective for procedures lasting up to 3 hours in infants, potentially reducing exposure to general anesthetics 4, 5
- For procedures requiring general anesthesia, caudal blocks or peripheral nerve blocks should be incorporated when possible 1
Intraoperative Management
- For maintenance of anesthesia in children requiring general anesthesia, surgical levels can be maintained with 5.2-10% desflurane with or without nitrous oxide 6
- Heart rate during maintenance with desflurane is approximately 10 beats per minute faster than with halothane 6
- Excessive decreases in blood pressure during maintenance should be corrected by decreasing the inspired concentration of desflurane 6
- Monitor for physiological changes related to pneumoperitoneum and patient positioning during robotic procedures 7, 8
Multimodal Pain Management
- Implement a multimodal analgesic approach including non-opioid medications (NSAIDs, acetaminophen) and regional anesthesia to minimize opioid requirements 1
- Intravenous lidocaine (1-1.5 mg/kg) may be considered for opioid-sparing effects but requires adequate monitoring 1, 2
- Alpha-2 agonists (like dexmedetomidine) and ketamine have opioid-sparing effects and reduce the risk of respiratory depression during recovery 1
- Avoid codeine and tramadol in children younger than 12 years and in adolescents with conditions that increase risk of breathing problems per FDA guidelines 1
Special Considerations for Robotic Surgery
- Maintain lower intra-abdominal pressure settings during pneumoperitoneum to minimize cardiopulmonary effects 9, 8
- Position patients carefully to allow optimal surgical access while preventing pressure injuries 9, 7
- Be prepared for longer operative times compared to open procedures, which may require additional analgesia 9, 7
- Consider the potential neurotoxic effects of prolonged general anesthesia in young children and explore regional techniques when appropriate 6, 5
Postoperative Care
- Assess recovery carefully before discharge from post-anesthesia care unit 6
- Be prepared for postoperative agitation in children emerging from anesthesia 6
- Continue multimodal pain management into the postoperative period 1
- Monitor for respiratory complications, especially in children with recent URIs 1
By implementing this comprehensive approach to anesthesia management for pediatric robotic urological surgeries, anesthesiologists can minimize complications, reduce opioid requirements, and potentially improve outcomes for these patients.