Hemodynamic effects of high spinal anesthesia under general anesthesia in infants undergoing cardiac surgery: a retrospective cohort study
Original Article

Hemodynamic effects of high spinal anesthesia under general anesthesia in infants undergoing cardiac surgery: a retrospective cohort study

Aravinthasamy Sivamurugan1, Rakesh Sondekoppam2, Sudhakar Subramani3, Srija Manchkanti1, Srinivasan Rajagopal1, Adeeb Oweidat1, Daisuke Sugiyama1, Arun K. Singhal4, Satoshi Hanada1 ORCID logo

1Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA; 2Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA; 3Department of Anesthesiology & Perioperative Care, University of California, Irvine School of Medicine, Irvine, CA, USA; 4Department of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA

Contributions: (I) Conception and design: A Sivamurugan, R Sondekoppam, S Hanada; (II) Administrative support: S Hanada; (III) Provision of study materials or patients: AK Singhal, S Hanada; (IV) Collection and assembly of data: A Sivamurugan, R Sondekoppam, S Hanada; (V) Data analysis and interpretation: A Sivamurugan, R Sondekoppam, S Hanada; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Satoshi Hanada, MD, FASE. Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA. Email: satoshi-hanada@uiowa.edu.

Background: High spinal anesthesia (HSA), in combination with general anesthesia (GA), has been proposed as a technique to reduce the surgical stress response while minimizing opioid use in cardiac surgery. However, concerns remain regarding the potential for HSA-induced hemodynamic instability, particularly in infants with congenital heart disease. Therefore, this study aimed to evaluate the impact of HSA on hemodynamic parameters in infants undergoing cardiac surgery.

Methods: This single-center retrospective cohort study was conducted at a tertiary medical center and included pediatric patients aged 1 to 12 months who underwent non-emergent cardiac surgery between November 2010 and November 2021. Patients with a Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score greater than 3 and those who received other forms of regional anesthesia were excluded. The study compared patients who received HSA combined with GA (HSA group) to those who received GA alone (GA group). The primary outcome was the incidence of sustained hypotension and bradycardia within the first 60 minutes post-anesthesia induction, using mean arterial pressure (MAP) and heart rate (HR) as indicators. Secondary outcomes included intraoperative pressor use, as well as average MAP and HR during the 60-minute post-anesthesia induction period.

Results: A total of 202 cases were analyzed, comprising 51 in the HSA group and 151 in the GA group. The incidence of sustained hypotension did not differ significantly between the HSA and GA groups [39.2% vs. 40.4%, respectively; odds ratio (OR) 0.95, P=0.88], nor did the incidence of sustained bradycardia (11.8% vs. 6.6%, respectively; OR 1.9, P=0.24). Pressor use was also similar between the groups (9.8% vs. 11.9%, respectively; OR 0.81, P=0.70). Although the HSA group showed significantly lower average, minimum, and maximum HRs post-induction, these differences were not considered clinically significant, as the HRs remained within clinically acceptable limits.

Conclusions: Adding HSA to GA in infants undergoing non-emergent fast-track cardiac surgery appears to be as clinically safe as GA alone with respect to hemodynamic stability, as assessed by MAP and HR within the first 60 minutes after anesthesia induction.

Keywords: High spinal anesthesia (HSA); pediatric anesthesia; congenital heart surgery; cardiac surgery; hemodynamics

Submitted Feb 17, 2025. Accepted for publication Apr 16, 2025. Published online Jul 15, 2025.

doi: 10.21037/jtd-2025-329

Highlight box

Key findings

• Adding high spinal anesthesia (HSA) to general anesthesia (GA) in infants undergoing non-emergent cardiac surgery did not result in significant differences in sustained hypotension or bradycardia compared with GA alone.

What is known and what is new?

• HSA has been proposed as an adjunct to GA in pediatric cardiac surgery to reduce opioid use and facilitate fast-track recovery. However, concerns remain regarding potential hemodynamic instability due to HSA-induced sympathectomy.

• This study provides evidence that HSA does not cause clinically significant hemodynamic instability in infants undergoing cardiac surgery. These findings support its feasibility within fast-track anesthesia protocols.

What is the implication, and what should change now?

• The results suggest that HSA can be a safe adjunct to GA for infant cardiac surgery, offering potential benefits for postoperative recovery without increasing hemodynamic risk.

• Future prospective randomized trials are warranted to validate and confirm the current study’s findings.

Introduction

Pediatric cardiac surgery induces a stress response that can lead to adverse physiologic and clinical outcomes (1,2). To attenuate this stress response, high doses of opioids are traditionally used in the intra- and post-operative settings (3). However, this often leads to prolonged mechanical ventilation time and extended intensive care unit (ICU) and hospital stays, putting patients at risk for hospital-acquired illnesses (4). Additionally, neurologic and behavioral issues later in life occur at a greater rate in those who underwent cardiac surgery as infants, potentially due to prolonged intubation and extended exposure to the ICU environment (5). Therefore, to mitigate the surgical stress response and facilitate faster recovery, neuraxial blocks such as spinal, caudal, and epidural anesthesia have been used in pediatric cardiac surgery (6-10).

High spinal anesthesia (HSA) is a technique in which a high dose of local anesthetic, such as bupivacaine, is intrathecally administered along with morphine as a single shot, in combination with general anesthesia (GA) (8,11). The high dose of intrathecal local anesthetic provides a complete sensory block to a high dermatomal level, often extending up to the head. This blunts the sensation of noxious stimuli from endotracheal intubation and surgical stimulation during cardiac procedures, thereby minimizing the use of intraoperative opioids. Additionally, intrathecal morphine offers better postoperative pain control compared to conventional pain management with intravenous opioids (12-15), facilitating early extubation after surgery (11,16,17). Despite these benefits, HSA is seldom used in patients undergoing cardiac surgery, likely due to concerns about possible hemodynamic instability caused by HSA-induced sympathectomy, especially in the context of significant underlying cardiac disease and the influence of GA. Consequently, the use of HSA remains limited to a small number of centers worldwide, and few studies have investigated the precise hemodynamic changes associated with HSA in cardiac surgery. Therefore, we retrospectively investigated the impact of HSA on hemodynamic parameters in infants undergoing cardiac surgery. We hypothesized that HSA under GA would have a minimal and clinically insignificant effect on hemodynamic parameters due to the underdeveloped sympathetic nervous system in this age group (18,19). We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-329/rc).

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This single-center retrospective cohort study was conducted at the University of Iowa Health Care Medical Center and received approval from the University of Iowa Institutional Review Board (#201911151). Individual consent for this retrospective analysis was waived. We enrolled all pediatric patients who underwent non-emergent cardiac surgery between November 2010 and November 2021. The inclusion criterion was age between 1 and 12 months. Patients with a Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score greater than 3 were excluded, as these cases were not candidates for fast-tracking, and thus HSA was not indicated (20). Patients who received any other type of regional anesthesia, such as caudal or epidural anesthesia, were also excluded. Patient data, including minute-by-minute hemodynamic data 10 minutes prior to and 60 minutes after anesthesia induction, was retrieved from the electronic medical record (Epic Systems, Verona, WI, USA). The time of anesthesia induction was determined by the time marked on the Epic Anesthesia chart by the assigned anesthesia provider for each case.

The enrolled cases were divided into two groups: those with HSA in combination with GA (HSA group) and those with GA alone (GA group). In the HSA group, the intrathecal medications consisted of 0.75% hyperbaric bupivacaine (0.2 mL/kg) with preservative-free morphine (7 mcg/kg). The detailed procedure for a typical case was as follows: after standard American Society of Anesthesiologists (ASA) monitors were applied, GA was induced with sevoflurane, and the patient was endotracheally intubated after adequate muscle relaxation was achieved with rocuronium. Following the establishment of a radial arterial line and a central venous line under GA, the patient was placed in the left lateral decubitus position, and intrathecal medications were injected between L4 and S1 via a 27-gauge spinal needle. Immediately after the intrathecal injection, the patient was placed in the supine position with a 30- to 45-degree Trendelenburg tilt to facilitate the cephalad spread of spinal anesthesia. Mydriasis confirmed high spinal blockade. The typical duration of the Trendelenburg position after HSA induction was 10 minutes. GA was maintained with sevoflurane or isoflurane at 0.5–1.0 minimal alveolar concentration (MAC). Due to the high spinal block, intravenous opioids were generally unnecessary and therefore avoided intraoperatively; however, low-dose remifentanil infusion was used in selected cases at the discretion of the anesthesiologist to facilitate hemodynamic control, given its ultra-short half-life and minimal impact on recovery. In the GA group, GA was induced in a similar manner, but no regional anesthesia was provided. GA was maintained with sevoflurane or isoflurane at 0.5–1.0 MAC, with low-to-moderate doses of intravenous opioids administered intraoperatively. Typical opioids used were fentanyl, morphine, and/or remifentanil.

The HSA and GA groups were compared, with the primary outcome being the incidence of sustained hypotension, expressed as a percentage of total cases in each group. Sustained hypotension was defined as mean arterial pressure (MAP) below the threshold for 5 or more consecutive minutes during the period from 10 minutes prior to anesthesia induction to 60 minutes after induction. Similarly, instances of sustained bradycardia, defined as heart rate (HR) less than 100 for 5 or more consecutive minutes, were also compared between the groups. Thresholds for hypotension and bradycardia were derived from prior studies (21,22). We used one standard deviation below the mean as the cutoff for hypotension. For example, in a 3-month-old boy, hypotension was defined as an MAP below 35 mmHg, which is one standard deviation below the mean of 44 mmHg (21). Secondary outcomes included intraoperative pressor use, as well as the average MAP and HR during the 60-minute post-anesthesia induction. These outcomes were also compared between the groups.

Statistical analysis

Categorical primary and secondary outcomes were compared using generalized logistic regression models. The models were adjusted for covariates including weight, age, gender, RACHS-1 score, surgeon, and anesthesiologist. Odds ratios (ORs) with 95% confidence intervals (CIs) and P values were calculated for the categorical primary and secondary outcomes. Continuous outcomes, such as MAP and HR, were compared using generalized linear regression models, accounting for the same covariates. MAP and HR were also graphed as averages for each group at each time point to visualize intraoperative hemodynamics between groups. Differences in means and 95% CIs were calculated for these continuous outcomes, along with their P values. Statistical significance was determined using independent samples. The Shapiro-Wilk test was applied to assess the normality of outcomes. For normally distributed outcomes, an independent two-sample t-test was applied, while the Mann-Whitney test was used for non-normally distributed outcomes. Categorical variables were compared using the Chi-squared test. All analyses were performed using GraphPad Prism software version 9.4.1.

Results

We identified 1,188 pediatric cardiac surgeries performed between November 2010 and November 2021. November 2010 was chosen as the start of the study period due to the availability of detailed electronic patient anesthesia records. Of the 1,188 pediatric cardiac surgery cases, 393 were excluded due to the type of surgery, and an additional 155 cases involving either caudal or epidural anesthesia were excluded. Among the remaining patients, 360 were outside the age range for this study. Seventy-eight of the remaining cases had incomplete baseline data and were thus excluded from analysis (Figure 1). This left a total of 202 cases, with 51 in the HSA group and 151 in the GA group. Demographic data are shown in Table 1. None of the reported patient characteristics were significantly different between groups. Table 2 indicates the types and numbers of surgeries performed in each group.

Figure 1 Flowchart of the study. *, cases with Risk Adjustment for Congenital Heart Surgery-1 score of 4 or above were excluded. GA, general anesthesia; HSA, high spinal anesthesia.

Table 1

Patient characteristics

Characteristics HSA group (n=51) GA group (n=151) P value
Age, months 6.6±2.4 5.9±2.5 0.08
Weight, kilograms 6.5±1.3 6.6±1.6 0.68
Male sex 29 (56.9) 86 (57.0) 0.89
RACHS-1 categories† 0.30
   1 21 (41.2) 50 (33.1)
   2 17 (33.3) 69 (45.7)
   3 13 (25.5) 32 (21.2)

Data are expressed as mean ± standard deviation or n (%). †, scores range from 1 to 6, with 1 being the least risky or complex with 6 being the most risky or complex. Cases with RACHS-1 score of 4 or above were excluded from the study population. GA, general anesthesia; HSA, high spinal anesthesia; RACHS-1, Risk Adjustment for Congenital Heart Surgery-1.

Table 2

Types and numbers of surgeries performed

Types of surgeries HSA group (n=51) GA group (n=151)
VSD repair 15 (29.4) 37 (24.5)
Tetralogy of Fallot repair 8 (15.7) 22 (14.6)
AV canal repair 6 (11.8) 22 (14.6)
Bidirectional Glenn procedure 5 (9.8) 27 (17.9)
ASD and VSD repair 4 (7.8) 12 (7.9)
ASD 4 (7.8) 4 (2.6)
Others 9 (17.6) 27 (17.9)

Data are expressed as n (%). AV, atrioventricular; ASD, atrial septal defect; GA, general anesthesia; HSA, high spinal anesthesia; VSD, ventricular septal defect.

Table 3 shows the instances of sustained hypotension, bradycardia, and pressor use between groups. The rates of sustained hypotension were not significantly different between the HSA and GA groups (39.2% vs. 40.4%, OR 0.95, 95% CI: 0.5 to 1.8, P=0.88). The rates of sustained bradycardia were also not significantly different between the groups (11.8% vs. 6.6%, OR 1.9, 95% CI: 0.7 to 5.6, P=0.24). The percentages of cases requiring pressors, such as epinephrine, norepinephrine, phenylephrine, and dopamine, were also not significantly different between the groups (9.8% vs. 11.9%, OR 0.81, 95% CI: 0.3 to 2.3, P=0.70).

Table 3

Instances of sustained hypotension, bradycardia and pressor use

Measurements HSA group (n=51) GA group (n=151) Odds ratio (95% CI) P value
Sustained hypotension 20 (39.2) 61 (40.4) 0.95 (0.5, 1.8) 0.88
Sustained bradycardia 6 (11.8) 10 (6.6) 1.9 (0.7, 5.6) 0.24
Pressor use 5 (9.8) 18 (11.9) 0.81 (0.3, 2.3) 0.70

Data are expressed as n (%). CI, confidence interval; GA, general anesthesia; HSA, high spinal anesthesia.

Table 4 presents the average, minimum, and maximum values for MAP and HR during the 60-minute post-induction period. No statistically significant difference was found for MAP. However, the average, minimum, and maximum post-induction HRs were significantly lower in the HSA group (128.8 vs. 138.0 beats per minute, P<0.001; 110.9 vs. 117.5 beats per minute, P=0.03; and 154.5 vs. 160.7 beats per minute, P=0.03, respectively). Figure 2 shows the overall trends of MAP and HR in each group over the recorded 10 minutes prior to and 60 minutes after anesthesia induction.

Table 4

Average, minimum, and maximum values for MAP and HR during the 60-minute post-induction period

Measurements HSA group GA group Difference (95% CI) P value
Average baseline pre-induction MAP (mmHg) 67.6±20.0 62.9±11.6 4.7 (−0.1, 9.5) 0.14
Average post-induction MAP (mmHg) 46.9±10.3 48.2±15.1 −1.3 (−5.8, 3.2) 0.57
Minimum post-induction MAP (mmHg) 25.0±12.5 29.4±15.0 −4.4 (−9.0, 0.2) 0.08
Maximum post-induction MAP (mmHg) 80.1±9.1 76.9±10.1 3.2 (−0.1, 6.5) 0.07
Average baseline pre-induction HR (bpm) 134.4±18.9 135.8±14.4 −1.4 (−6.4, 3.6) 0.49
Average post-induction HR (bpm) 128.8±14.4 138.0±14.7 −9.2 (−13.9, −4.5) <0.001
Minimum post-induction HR (bpm) 110.9±16.5 117.5±19.7 −6.6 (−12.7, −0.6) 0.03
Maximum post-induction HR (bpm) 154.5±20.4 160.7±17.0 −6.2 (−11.9, −0.5) 0.03

Data are expressed as mean ± standard deviation. bpm, beats per minute; CI, confidence interval; GA, general anesthesia; HR, heart rate; HSA, high spinal anesthesia; MAP, mean arterial pressure.

Figure 2 Trends of MAP and HR in the HSA and GA groups. (A) Trend of MAP during the 10 minutes before and 60 minutes after anesthesia induction. (B) Trend of HR during the 10 minutes before and 60 minutes after anesthesia induction. bpm, beats per minute; GA, general anesthesia; HR, heart rate; HSA, high spinal anesthesia; MAP, mean arterial pressure.

Discussion

This retrospective study aimed to investigate the hemodynamic effects of HSA under GA in infants undergoing cardiac surgery. Instances of sustained hypotension and bradycardia were not found to be significantly different between the HSA and GA groups. Analysis of post-induction MAP and HR did not reveal clinically significant differences between the groups. Our results suggest that HSA may be safely performed in conjunction with GA in infants undergoing cardiac surgery without the risk of HSA-induced intractable hemodynamic collapse.

The use of central neuraxial blocks such as spinal, caudal, and epidural anesthesia has increased for a range of pediatric surgeries due to the potential benefits they provide in recovery (23,24). The use of spinal anesthesia in pediatric open-heart surgery significantly attenuates the stress response through reduced plasma norepinephrine, epinephrine, and lactate concentrations (25). Further, a recent study from our group shows the use of HSA facilitates early extubation (16), allowing for faster patient recovery in children undergoing congenital heart surgery (26). Despite these benefits in patient recovery and more efficient hospital resource utilization (27), the use of HSA in pediatric cardiac surgery remains limited to a few institutions, possibly due to concerns about HSA-induced hemodynamic collapse.

Spinal anesthesia has been used in infants undergoing non-cardiac surgeries with minimal hemodynamic disturbances (28); however, studies investigating its effects in patients undergoing cardiac surgery are limited. Even in cardiac surgery patients, due to the immature sympathetic nervous system in infants, the effects of HSA-induced sympathectomy during the procedure could theoretically be minimal. The current study results showed that adding HSA to GA had a clinically negligible impact on hemodynamic parameters such as MAP and HR. We found that the rates of sustained hypotension were equivalent between the HSA and GA groups, at approximately 40%. Since the true incidence of HSA-induced hypotension could have been masked by pressor use, we also investigated postinduction pressor use and found no difference between groups. In terms of HR, the average, minimum, and maximum post-induction HRs were significantly lower in the HSA group, which we speculated was due to the total sensory blockade and an attenuated stress response. Further statistical analysis using logistic regression revealed that the primary contributor to intraoperative bradycardia was the anesthesiologist assigned to the case, suggesting that individual providers may differ in their likelihood to intervene when HR decreases. Nevertheless, these differences are clinically insignificant, as the HR in both groups remained within acceptable limits. These findings highlight the safety and potential advantages of incorporating HSA in pediatric cardiac surgery, providing valuable insights and contributing to the existing body of knowledge in a field where evidence is scarce.

This study has several limitations. Due to its retrospective nature, confounding and selection biases were likely present. Patient selection may have been influenced by unaccounted factors, with healthier patients potentially being preferentially chosen for HSA. Additionally, the hemodynamic data were retrieved on a minute-by-minute basis, which may have overlooked brief but clinically significant disturbances. Furthermore, data artifacts may have been captured on the electronic anesthesia chart, and such data could have been inadvertently included in the analysis. Furthermore, the current study focused on hemodynamic data within 60 minutes after anesthesia induction, which may have excluded any lingering effects of HSA, if any, beyond this period. Lastly, the results may not be generalizable to patients with higher RACHS-1 scores, as this study excluded patients with RACHS-1 scores greater than 3, limiting its applicability to patients with more complex cardiac conditions.

Conclusions

The results of this study suggest that combining HSA with GA in infants undergoing non-emergent fast-track cardiac surgery can be as clinically safe as GA alone in terms of hemodynamic stability, using MAP and HR as indicators, within the first 60 minutes after anesthesia induction. Future prospective randomized trials are necessary to validate these findings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-329/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-329/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-329/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-329/coif). R.S., MD, is a consultant for CIVCO Medical Solutions (https://www.civco.com/). The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the University of Iowa Institutional Review Board (#201911151) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Sivamurugan A, Sondekoppam R, Subramani S, Manchkanti S, Rajagopal S, Oweidat A, Sugiyama D, Singhal AK, Hanada S. Hemodynamic effects of high spinal anesthesia under general anesthesia in infants undergoing cardiac surgery: a retrospective cohort study. J Thorac Dis 2025;17(7):4940-4947. doi: 10.21037/jtd-2025-329

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