Epidural anaesthesia in paediatric surgery present status in the Hamilton general hospital

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EPIDURAL ANAESTHESIA IN PAEDIATRIC SURGERY
PRESENT STATUS IN THE HAMILTON GENERAL HOSPITAL
F (~ RUSTO~, M D
EHT ESU FO ep~dural anaesthesm m pae&atrm surgery has been described m two
prevmus reports ~ = It s~ the purpose of the ':)resent paper to report our experience
w~th th~s teehmque m the Hamdton General Hospital since these prewbus
pubheatmns, to demonstrate why we feel tlmt th,s teehmque has a defimte place
m paedmtne anaesthesm, and to endeavo~ r to erase some of the doubts whmh
have led to the statement m regard to maesthesm for pyloromyotomms that
"the use of ep~dural anaesthesia remains u lconvmelng -4
,, The anatomy and physmlogy of the ep~ tural space have been well described
by Bromage, a and will not be repeated here Techmques, drugs, dosage, comphca-
tmns, and appheatmn will be d~seussed, with reference to opera~mns handled
by the staff m anaesthesia of the Hamdton General Hospital during the permd
from 1956 to 1962 melus~ve
TECHNIQUE OF EPIDU~LL BLOCK
Epldural block may be employed m ~ehtle a single dose or a contanuous
teehmque Either may be used alone, or combined with general anaesthesia by
the inhalation or intravenous routes Premature and young infants are awake
when the block is given, as also are older infants and children, if ,they have
intestinal obstructaon These latte~ may rr a sedative d&se of thlopentone
suttlcmnt to pacify them without abohshmg the glottm reflex Large infants and
chddren are mtubated under anaesthesia wath thlopentone and a ,small dose of
sucemylchohne and are mamtalhed on n:~trous oxide, to which 0 25 per cent
halothane may be added, using a non-rebI~athlmg valve teehmque This general
anaesthesxa is reduced before the epldural b)~ek is done in order to ensure the
arway during prolonged surgery
The smg~e-dose method s~ used for premature's and neonates, ,,rod for othel
infants and chddren when the surgical time is expe'eted to be under two hours
The infants, who are awake, are held m a s~ttmg posatmn, wath the head sup-
ported and the elbows and knees grasped by the asmstant, so that the spree
s~ gently flexed Only shght wriggling movement can occur, whreg is not too
troublesome All others are held m the lateral positron ~Before the mfant s~
posltmned, the desired dose of local anaesthetm solutmn is drawn up into, a
syringe The dose m cubm centlmetres equals ~, (weight m pounds) q- i~ or 1 e c
Usually a sPan wheal is raised over the site of puncture-L2 and 8, or L8 and 4
The needle is eqmpped with procottons which md m placing and maintaining
t~ m positron while the mlectmn is bemg made A two-inch No ~ 22 gauge
Beeton, Dmkmson Ep~dural Needle with a Wagner Point 5 s~ preferred ~1 also
prefer the hanging drop ~est to ~dentffy the ep~dural space It s~ positive m 85
lg
/'
Can Anaes Soc J, ~ov 11 no ,1 januaryT1964
18
RUSTON EPIDURAL ~NAESTHESIA IN PIAEDII~.TRIC SURGERY
per cent and, in spite of an occasional false posltwe whmh sa mentmned by
Blomage, a whmh will be ewdent by the greatly increased remstance on the
plunge1 when one tries to carry out the mlectlon , tx is by far the most reliable
test However, ff the drop is not sucked in ~o does nc t fluctuate, then the loss of
resistance on the plunger of the syringe wdl ldentff, the, space Of course on~
must be sure, at this ~pomt, that the dma has not be n~ pierced If fired escapes
from the needle, ;~el a few drops fall on the bare wl tsL If these drops are cold,
the dma has been spared and it is safe to mleet th e full dose The patient is
paced on a padded board and securely wrapped with, a flannel bandage Patmnts
axe closely observed, blood pressures are taken ff it is feasible, but experience sah
shown that pulse, heart sounds, breath sounds, and eolour are pretty rehable
signs Within five minutes det}mte abdominal relaxJatlon is present, while the
feet can stdl be moved when stimulated (Thas mdm}tes that there is not spinal
anaesthesm ) Surgery can be started within five to ten minutes
The continuous techmque is reserved for large infants and children when the
surgmal t~me sa expected to exceed two hours The hmltmg factor s~ the size of
the needle which will go through the lnterspmom, space and still carry the
catheter For this reason I have not attempted to use the Tuohy Needle with the
Huber Point I have found that the thm-walled No 18 Becton, Dickinson Needle
with the short-bevel Crawford Point can be used m infants over three months
of age The patmnt s~ usually mtubated as mentmrled I before, and held m the
lateral positron After preparatmn, the skin is mmsed with a scalpel blade at
the sate of puncture The needle is inserted and angled as much as posmble
cephalad with the bevel m the same &rectmn When the epldural space is
entered, two cubm cent~metres of solution are m,ected m order to act as a
cushmn against the needle point and to produce a space for the cathetm to
advance and curve cephalad horn the needle point The vinyl-tubing catheter
sa advanced the length of the stalette and two eentlmetres further, wath the
tuner curve of the catheter cephalad If the catheter seems to meet an obstructmn,
the needle sa withdrawn a mllhmetre ro, two whde at the same time gentle
pressure is exerted on the catheter The needle is {hen carefully withdrawn so
that the catheter sa not &sturbed A small dressing is placed over the entry
s~te and the catheter s~ securely taped to the back w~th adheswe The &stal
end of the catheter ~sa fitted w~th a hypodermic needle and the total dose is
given at once or m &vaded doses The initial drug may be Carbocame 1 5 per cent
fotlowed by 2 per cent Nesaeame as reqmred The usual superwsmn is mare-
tamed and an attempt sa ~ade Ot antm~pate the waning of relaxatmn and anaes-
thesaa so that addmonal increments of solutmn may be mleeted
Pre anaesthetic sedatmn may or may 'not be gwen Usually nothing s~ ord,med
~oi p~emature and newborn infants, "pylorms" receive Sodmm Luminal gr 41/ z
wath atropine gr 1/600 intramuscularly 1 hour preoperatwely, others, who,
have mtravenom, cut~ runmng, receive atropine only na statable do,,age
APPLICATION
I
Table I shows wh~,t was done m Hamllton from 1949 ot 1956 and si lhom
a previous repor~ pubbshed m 1957 2 It gaves some adea of the scope of paedlatnc
14
CANADIAN ANAESTHETISTS' SOCIE~r JOUIRNAL
TABLE I
LUMBAR EPIDURAL AND CAUDAL ,A/lb'EHTSEANA 1949 TO 1956 (80 CASES)
&__._._
Condmon or operation , ,Num!)er Age
Pylorm stenosls 34 3 to 8 weeks
Volvuh 1( resect,on of 16 m small bowel) 2 3 to 5 months
Intussusceptmns (2 resectmns) 7 3 months to ~"2 years
Splenectomy (purpura) 2 5 and 7 years
Perforated appendmes (gen pentonms) 4 2 to 4 years
Agenems (exploratmn of bdiar:y system) ~o months
Meconmm pentonms, muluple volvuh (exploratory
laparotomy) 2 1 day, 1 premature (under 3 lb ,)
Duodenal atresms tanastomosls) 2 1 week and 6 months
Jejunal atreslas 2 24 hours
Bmpsy of hepatic tumour 1 6 ! months
2
Exclmon of large ovarian dermold 1 23 months
Irreduc,ble mtussusceptmn (deotransversecolostorny) 1 5 months
Colectomy (m same panent) 1 11 months
Congemtal absence of terminal portmn of deum
(anastomoms of ileum to ileum) 1 2 days
Combmed cystoscopy and exploratmn of upper ureter 1 7 years
Inguinal hermas (2 bilateral repmrs, 2 strangulated) 8 2 weeks to 2} years
Umbdmal hermas 1( large 1 omphalocele w,th exm-
stun of accessory lobe of liver) 2 60 hours and 51 months
Congemtal dislocation of hip (shelf op ) 1 ,3 yeara
Tuberculosis (hip fusmn) 2 6 and 7 years
Lumbar menmgocele postoperative (sht, nt op sub-
arachnold space to peritoneal cawty) 1 6 weeks
Caudal anaesthema
Acute retentmn, phmmsls (cwcumclsmn) 1 11 years
Anal fistula 1 01 years
Orcumclmon 1 10 years
Imperforate anus 1 42' hours
TABLE I I
PAEDIATRIC (RUOY FR~ ~'B EPIDURAL BLO( K, 1956 OT 1962
NCLUSIVE
No Comphcanons
Pylorom~ otomms 45 1 pneumonia, 1 daed
Evisceration 1
Hem~hepatectomv 1
Volvulus 4
Close fieostomy 1
Duodenal atres~as 3
Agenes~s terminal ~leum 1
Omphalocele 2( ruptured)
Primary closure 4 I dmd 5 da~ys p o
Intestmal obstruct 1
Repair with mesh 1
-Xbdommal permeal resecnons
Hlrsehsprung's 4 1 bronchins
Redone 1
Imperforate anus 1
Pelvic turnout 1 Dmd 81 hours p o
Bl y:p elostomies 1
Hernias
tngmnal 1
Dlaphragmatm 2 Both d,ed p o
I ntussusceptlons 01
92
I:IUSTON EPIDURAL ANAESTHESIA IN CIRT!tAIDE~P YREGIIUS ~5
epldural anaesthesm Since then halothane has become an amportant agent o~
that Table II shows a more eonservatave use of slarudlp;e Table III depicts the
anaesthehe techmques used m pyloromyotomles The preponderance of epldurals
seen hole occurs throughout all abdominal surgery htll~w the exceptxon of herma
repmrs The decrease m the number of pyloromyotom~es done is due to the fact
that such pahents are now admitted also to two other hospRals m the city ~to
notI~maH Table IV shows the local anaesthehes 'used m pyloromyotom~es
TABLE III
SEIMOTOYMOROLYP TA NOTLIMAH ,LATIPsoHLARENEG
1956 OT 1962 (1953 to 1955 inclusive 1 spinal, 8
general, 26 epidural)
Year General :/~ -~pl~t~-'ra 1
1956 4 L' 1
1957 0 L i
8591% 0
1959 0
1960 0 5
1691 2 6
1%2 17 ~
I
TABLE IV
,SEIMOTOYMOROLYP 1956 OT 1962 EVISULCNI
Drug No Supplement No
'o
Xylocame 2% with 1 O~N 5
Xylocame 1 5% 1/20I),000 22 Pentothal 1
Xylocame 1% epinephrine 20 Cyclo 4
N20 and cvclo 3
N20 and fluothane 5
Nesacame 2% 5 N20 2
Carbocame 1 %, 6 "IO2N 2
45 22
Xyloeame with 1/200,000 epinephrine has been the most popular but I now
have a preference for Carbocame and Nesacmne because they can be used
without eplnephfme Nesacame is mchcated when the Ramstedt procedure is
done by a fast surgeon, fol the anaesthetm tune is oMy thirty-five minutes
~m-bocame I per cent, or Xylocame 5 per cent with epinephrine can be
depended on for two hours These anaesthetics have been adm~mstered by eight
of the eeven members of our staff, whmh explains the &verslty of supplement
My own preferencei~s mtr~us oxide with a loose llttmg mask or a mask fitted with
a Ruben s Valve, agd-su'pplement is resorted to only fl the nffant enos when
the pylorle turnout is brought up into the me,stun, tlor any exeessweerespxratory
movement will merease the dlNicuity ot the myotomy 'This provides analgesm
but does not suppress the glottm x eflex Table V..represents those patients handled
by continuous epldural block and were done b~-'yl~e The children with tutus-
16 NAIDANAC ~sTmms~rs' socmrr lo~N~x
suscepbon were gaven a small amoubt ~o Ithmpentone as a hypn~be wtule ea~t
epxdural was being mlected They cOuld|have been managed by,,a smKle-do'se
method
CONTINUOUSly_S, 1')59 OT 1962
Operatmn Age sean~A time Combined
I ntussusceptmns 8 months llhour ~ Penl~othal 2 c c I i
5 " 1~ ,, Pentothal 2 c lc
9 " (t Pentothal 3 c lc
Hem~hepatectomy 9 " 6 hours
Omphalocele repmr 2 years ~3 "
a.bd permeal resect
~11 "' ~3
Hlrschsprung's Orot,racheal ~N D
"
Redone " " and fluothal)e 0 25%
11 months ~
14 " 98(cid:1)~ 3 "
Pelvm tumour 7~ T~
The hemlhepatectomy (Figure 1) conslsted of moblhzmg the hepabc flexure
of the colon and exploration of the right I penrenal area because~of adhesmns,
but when it was found that the mahgnant tei atoma was confine d to the hver,
the abdominal mcasaon was extended thyough the chest to the right eighth
mtercostal space The diaphragm was cut, for access to the vena 9ava to check
bleedmg Resplratmns were controlled tO prevent paradoxical b~:eathmg The
right hepatm lobe and a large wedge of ~e left lobe were remo+ed while the
vena cava and the portal veto were clampedfor five minutes SuccmYlchohne was
gwen intermittently to paralyse the dmphrlagm during sta repmr P0stoperabvely
the child developed jaundme and seeme d to be on the verge ~o a hepatatm
cnsas but this did not occur
The infant wRh omphalocele (Fags 2, 13 and 4) had the prtmary repmr done
under a smile dose and the secondar wxth a combined conbnUous epldural
In v Y .
T s repmr was comphcated by the presence fle the hver and a mass of gut m
the omphalocele and a large defect m ~e abdommal wall, whmh was closed
by Mersdene mesh The block was more dlfllcult because of a~ accentuated
lumbar curve The procedure was accomPhshed under excellent relaxatmn, and
most maportant, wxth constrmted, tapehke lbowel,, and spontaneou~ resptrabons
T h e abdommal permeal resectmns for Htrschsprungs d~seaseLare of some
interest One pabent had chromc bronchRls fr,om birth and the qperabon was
cancelled several tmaes because of chest~mfectmn After Operatlpn the chest
was a problem Another res~cbon (Fig 5) was a chfllcult oper~taon because
the pathologist was unable t~ find any normal ganglmmc bssue Untd sectmns
were taken from well up thelcolon, whmhlresulted m a rather stretched bowel,
wath precarious blood supply, for it was anchored by the col~stomy The
anastamosls broke down after mght days (Fag 6) The whole procedure was
repeated with the ad&tmnal transfer of the colostomy-a real surgmal problem
m a sack chddl This child recewed a minute dose of succmylcholme, t o relax spasm
of the dmphragm caused by acmdental movement of the cbaldslhead whmh
17
RUSTON EPIDUBAL ANAESTHESIA IN PAEDII_&TRIC SURGERY
GH207 1GR
NOTLn~&H CQVJC $LAlJPSOH
ANA~S~E~'~C CH&~ John G tc mos.
HGH
M It H
Sept 60
DARE19 HOSPITAL N F H
PREOPERATIVE DIAGNOSIS Malzgnant terratoma
of i lV~T
PROPOSED OPERATION He pat e c tomy( hemi- ) I
SURGEON Qameron
RECORD OF PHYSICAL EXAMINATION
DATE TIME PULSE B P 100 RESPIRA NOIFI TEMPERATURE
PHYSICAL EXAMINATION NEGATIVE EXCEPT FOR THE FOLLOWING
Chest and heart nego Abdomen dzstended, Liver at umbllleus, Had
bmopsy done a~ St Joseph~s ~ malmgnant terratomd of tr lobe of lzvero
Hb. Q~8 G Wt~ 18 Ibs 9 ozo
I
PRE OPERATIVE SEDATIVE Atrop~ gr 1/200 1 KSIR A !~ EMERGENCY
ANAESTHETIC AGENTS& TECANIQUES REMARKS
i Combined Epldural,(contlnuous) and o~otracI~eal N20 and Fluothane
2 Nesaeazne 3 % S ccs 8 15~am. N~sacal ne 2 % gces, 11,40 am,
3 ~' 2 ~ 2 " 8~20 am " 2 % 5 " 12,10 pmo
4 " 2 % 5 " 9~ am. I~00 b:ood durlng operatlon,
" 2 % 5 " 9~50 am i0 c~.s, Ca Gluconate
MIT E PO SITIO N SURGEON B1 ~ressure from it thlgh
rm)
cl
t
po
.15
OPERATION PERFORMEDRt~ & wedKe of it removed~
TOTAL OPERATING TIME8 4~ - 2 IODURATION OF ANAESTHETIC 8~DQ - 2~15
CONDITION ON LEAVING OPERATING ROOM falr
,ONED _ Q' ESmHET ST
FIGUnE 1
caused it to buck on the endotracheal tube, but abdommM ~elaxatlon remamed
excellent to the end of operatmn
Re last case of th~s group had a tumour obstmcang the pc|vie cavity ~t
was freed from above by an extraperltoneal abdommM melslon, but because
of the size and adherence to the saclum, a portion of flhe sacrum was reseeted
18 e.~q,U~AN ,~r S O ~ JO~Jt~UE,
Fm~t2 Severe omphaloeele containing hver m newborn ~rffant
FIGUrm 3 Same pain nt ready for second stage repaar-epldural cathet r m place In this
case mtubahon followed epzdural block
;NOTSU~I ra~muR~ Ar~Sa'm,-Sr~ m ~AF~Tmr YREGRUS 19
FmunE 4 The I New Look following' repaxr ' "filth Merstlene mesh
' I
to obtain room to dehver the mass Bleed,ng was excessive but blood voI,,me
was maintained by tra_nsfuslon The pat, ent 'ched suddenly eighteen hours post
operatavely Autopsy showed a s large colleetmn of blood m spate of cop
hnuous wound suchon there was also a la_n_l.mret aspLrataon The pathologist
gave some comfort t:or the turnout was a mahgnant neuroblastoma
All the operataons of thas group were done w~th electrocautery dassoctmn to
cut down on mclslonal bleeding
S N O I T A C I L P M O C
In addatldn to those already mentao~ed there were the following comphca
tons One infant developed pneumoma after five days s a Ramstedt
procedure but the paedlatrlclan thought ,t to be from a cross ~nFeetaon A new
born ms mt who had pro]eetde vomalang and who showed the typmal pmture
of pylorre stenosls after the mgestaon of L1plodol was found to have y~]no mild
pylone hypertrophy but a myotomy was done The ,nfant daed twelve syald.
20 CANADIAN ANAESTHETI~;TS' SOC'IETY JOURNAL
GH207 R61
HAMILTON CIVIC HOSPITALS
AHAESTHETIC CHART
HGH P, .S l~ ~lsry
~HH lS--l
DATE 7 Aug. 62 tlOSPITAL N F H
PREOPERATIVE SISONGAID Hlrsehsprung' s Dis |
PROPOSED OPERATION Abdomznal
f
perlneal pull throush. NOEGRUS G. Cameron
DROCER FO .~ACISYLFP NOITANIMAXE
/
DATE El%IT~ PULSE B P ~O RESPIRATION TEMPERATURE
PHYSICAL EXAMINATION NEGATIVE EXCEPT FOR THE FIOLLOWIJ ~ and heart ineg.
Adm2tted two t~mes but operation cancelled because of resp~ra!tory
(cid:12)9 nfectlons. Transverse colostomy a~ 1 week. Weight 24 lbs.
PRE OPERATIVE SEDATIVE ktropo gr. 1"~300 1 RISK A B C D EMERGENCY
ANAESTFIETIC AGENTS & TECHNIQUES ~ REMARKS
Combined contlnuous epldural
i
ces 2(cid:1)89 % Pentothal + (cid:1)89 cc. Anectlne + orotracheal N20 + 0,2g %
.~ Fluothane wlth # 4 Por~ex tube and Lelgh - Slatdr Valve,
E_~idural lnltlal dose :arbocaxne 1 1 ccs t 8 20 am
MIT E POSITION US RGEON
lO ~ ~ COMMENTS
280 '
Addltlonal doses
60
Nesaealne 2 %
22O 8.25 2cos.
20O Inl nmmnmmninnmn i~ii lO.1Q lOccs.
180 .IiBnm n . unulnm.inmunmn.inmmnmu.imlml.nmmm . . . . . . . nn 10.45 lOces.
mmul (cid:12)9 mum(cid:12)9149 mi
|60
I am nmmnaimmnmlnm in ,ll.14 ~cCs.
INN iaii~aillimmil in ui
140 II(cid:12)9 limaiaimmnmln(cid:12)9 mm
Bleedlng ~ncreased at
mmin i mm (cid:12)9149 lai
Inn unnaiai(cid:12)9 el i0,45 , cut down glvlng
100 tam(cid:12)9 laiiminii(cid:12)9 pai
lin linnnianinln&, ~ai trouble. Blood by
8O ill flnmiimnBnmlnn in
60 syrxnge. Patzent to
40 recovery room 12.0~ r-
20, satlsfactory.
F
0
1 hr 2 Nrs ~ hrl~
'~ OPERA3~ION PERFORMED ~ ~ "
TOTAL OPERATING TIME 3~- hrs. DURATION O~ANAE~THETIC ~ ~krs.
CONDITION NO LEAVING OPERATING ROOM Sat~i sJ~aeto,ry
Ficta~ 5
later and autopsy estabhshed that death resulted from congemtal bdateral
hydronephrosls and hydroureters and a too(cid:12)9 pneumonms, the latter thought
to have arisen from "either vagmlhs of 'the mother or anhblohe therapy gwen
the mfant"
tiUSTON EPIDUtlAL ANAESTHESIA IN PAEDIIATBIC SURGERY 21
CH207 R61
ttAIIILII)It CIVIC IiOSl'Olll$
AIIAISI'HfTIC CNA~
P S l(cid:1)89 yrs~
tt O H I~
M H H I----1
61 guA 62
DATE tlOSPITAL N F H ----1
PREOPERATIVE DIAGNOSIS Wound dehzscence
and oreakdoMn of anastlmosls
PROPOSED OPERATION
I
Exploratzon~ transfer of colostomy
SURGEON G Cameron
and re-anastzmos~s at rectum
RECORD OF PHYSICAL EXAMINAIlON
DATF ~ME PULSE B P RESPIRATION TEMPERATURE
PHYSICAL EXAMINATION NEGATIVE EXCEPT FOR THE FOLLOWING
Abdomznal per~neal pull through for Hirschsprungls on 7 aug~ 62~
Eruptlon of abdominal wound Rectal examznatzonlshowed breakdown of
anastzmOs~s. Weight 24 lbs|
1/300
PRE OPERATIVESEDATIVE Atropo gr. RISK AB~ D iMERGENCY
ANAESTHETIC AGENTS&TECHNIQUES Como~ned contznuous epi~ura~ EMARKS
and orotraCheal N20 + 0,25 % Fluothane ,
2
3 Epidural 12 ccso I~5 % Carboca~ne at l~l.~'pm
4
s (cid:1)89 cc Anect~ne at 2.~0 as patient bucked when endotracheal tube
MIT E POSITION SURGEON acc~denty moved~
2
COMMENTS
: s ~ I I I l I I i I I I I I I ~ . A
H~II I I I,",', I~II I l J I I , ~ l I I I l I l I l+tHJcH:t::fJdd~::B
Blood started 1o45
II ~ 1 I I I I I 1 ~
~l)r-l~/-i i i ! I I I 1 I I I ~il I 11 I I I I 1 1 1 Ill I LI_I_s
ok3._k_! ! t I ~ ! tl II ii1~11111 tl iiitl I_L_J__ _L:22
~ -/11 i 1 i i I i i ii i i i 1 1 111 i i I I 1 1 |1 1 1 i i i i i i II Anectzne ~ CCo 2~
U 1 11 11 l 1 I I I I I ~ I I 11 I 1 | I '_l_J_
kl II ~ .I t II 1 _l_J_
AopHIIIIotl , I ,I,I II I ,ll~tll, I ,, II I,Il it I HI~ ,
/ I 16 0J_l I I I I I I | I I I I I I I111A t*'l 1 I I I11 1 iil I
~,1 I J I t'l I I llA I t I I I g I~r I I I 1 11 I I LLL
'..E . . . . i I I I i 1 I_LJ_LLI_J_I~ To recovery room
t 0~ I t I I I rl?l 111-1 1 111 It/I TI ILLLJ_~I 11 I I ~
!11 I ) I I 1 I~ IJ I I~1~ ~ ~1 t I l I I I I III I I 11 I I I I I I 3,33 pro.
,ot-H--t-411 I r llll I I I I-H-Ft-H+H-H4~~K~
I-H I~ IIII I IIII llll I I H-HIIIIII~,, lll
ao
t--H-..t.:t::to,., I ' I~ 14-I
i IIiI!tLLLLLIil il ill li,_LIJ_J..Si, lt
I I i',,, I II II111111 I I I IIlI_I_L.LL_LIiL_LL.t
,oLLI./t I I I I I I I I I I ~ I I Ill I 1 i I 1 I I I I I ! I-1 1 LI_J_LJ_JLJ_LJ
L'LIlIIII 1 1 -I 1 1 1 I I I I li II _L.L.LLI_Lk_I . 1 1 I I I II I t I I I I..J_L.LJ.1..I_~ ; ~
oLIAttI,,, ,,ll Ill
oU,,._l I I I I I 1 I I I I I I 1 I I 11 I I I I I I I 1 I I III I I 1 I I I I 1 It'| ~
I hr 2 hrs. 3 hrs 4 hra
OPERATION PERFORMED
2~ ~rs
TOTAL OPFRATING TIME 2 hrso DURATION OF ANAESTHETIC
CONDITION NO LEAVING OPERATING ROOM Satisfactory
SIGNED
TSITE~'TS~A
FIGURE 6
A newborn who underwent surgery for an omphalocele &ed five days post-
operahvely morf" a cerebra hemorrhage and a congemtal heart defect
Both infants with &aphragmaue hernias d, ed, one from pneumoma and the
other from a tear m the lung bud I do beheve that combined epldural bh)ek
aids m the operation