Spinal anesthesia in ASA III and IV physical status pediatric patients: A retrospective review

Introduction: Spinal anesthesia (SA) may mitigate some of the risks associated with general anesthesia (GA). As an alternative to GA, SA can be used in a variety of surgical procedures and may be particularly beneficial in patients with significant comorbid conditions. We retrospectively review our experience with SA in the American Society of Anesthesiology (ASA) physical classification III and IV patients. Methods: Retrospective chart review of ASA III/IV pediatric-aged patients who received SA for surgical procedures from 2016–2023. Data included patient demographics, procedure and anesthetic characteristics, surgical procedure, additional intraoperative sedation, reasons for conversion to GA, intraoperative adverse events, and reasons for emergency department return. Results: The initial study cohort included 69 patients (median age eight months) with ASA physical status III or IV who presented for SA. SA failed in eight patients. This left a cohort of 61 patients in whom SA was successful (88%). Congenital cardiac, respiratory, genetic, and renal disorders were among the most common comorbid conditions. Thirty-six of the 61 patients (59%) received no additional sedative or analgesic medications following lumbar puncture for SA. The most common intraoperative adverse event was systolic blood pressure (sBP) less than 60 mmHg ( n = 15; 25%), but no case required the administration of a vasoactive or anticholinergic agent. Phase I recovery was bypassed in 44% ( n = 27) of cases. Six patients (9.8%) returned to the emergency department following hospital discharge, but no return was due to an anesthetic concern. Conclusion: SA offers a safe and effective alternative to GA for ASA physical class III/IV patients. The low rate of intraoperative complications highlights the safety profile of the technique even in high-risk surgical candidates.