Pediatric Anesthesiology Section Editor: Peter J. Davis The Transesophageal Doppler and Hemodynamic Effects of Epidural Anesthesia in Infants Anesthetized with Sevoflurane and Sufentanil Antoine Monsel, MD* Amelie Salvat-Toussaint, MD* Philippe Durand, MD† Vincent Haas, MD† Catherine Baujard, MD* Philippe Rouleau, MD* Souad El Aouadi, MD* Dan Benhamou, MD* Karin Asehnoune, MD, PhD*† BACKGROUND: It is thought that pediatric epidural anesthesia (EA) provides hemo- dynamic stability in children. However, when compared with information relating to adults, little is known about the hemodynamic effects of epidural EA on cardiac output (CO) in infants. METHODS: Using transesophageal Doppler to monitor CO, we prospectively studied 14 infants 10 kg who were scheduled for abdominal surgery. During sevoflurane general anesthesia, CO transesophageal Doppler monitoring was performed before and after lumbar EA with 0.75 mL/kg of 0.25% bupivacaine and 1:200,000 adrenaline. CO, arterial blood pressure, and heart rate were measured before and 5, 15, and 20 min after performance of EA. RESULTS: In patients anesthetized with sevoflurane and sufentanil, EA resulted in an increase in stroke volume by 29% (P  0.0001) and a decrease in heart rate by 13% (P  0.0001). EA also induced a significant decrease in systolic, diastolic, mean arterial blood pressure, and systemic vascular resistance by 11%, 18%, 15%, and 25%, respectively. Conversely, CO remained unchanged. CONCLUSIONS: The increase in stroke volume observed is probably explained by optimization of afterload because of the sympathetic blockade induced by EA. These results confirm that EA provides hemodynamic stability in infants weighing 10 kg and supports the use of EA in this pediatric population. (Anesth Analg 2007;105:46 –50) It is generally recognized that epidural anesthesia (EA) does not cause significant hemodynamic alter- ation in children. This technique has been increasingly used in recent years, especially in patients undergoing abdominal surgery (1– 4). EA is reliable and safe, even when combined with general anesthesia (5–9). Never- theless, little is known about its hemodynamic effects in infants and children. Two major concepts may explain the pediatric specificity regarding central block-induced hemodynamic changes. 1) Children have lower basal sympathetic tone as compared to adults (5,10 –12). 2) The lower-limb blood volume in children might explain a slower rate of blood pooling in the denervated lower extremities (5,10,11). These concepts have been challenged. Payen et al. suggested that caudal anesthesia induces blood pooling in the denervated lower extremities (blocked areas) and a reflex vasoconstriction in the innervated areas (13). Moreover, Larousse et al. suggested that hemody- namic alterations observed after caudal anesthesia were induced by sympathetic block (8). At present, the effects of EA on cardiac output (CO) in infants is not known. The recent introduction into clinical practice of a noninvasive measurement of CO for infants, has allowed us to examine the hemody- namic alterations caused by EA in a group of infants weighing 10 kg undergoing abdominal or urologic surgery. METHODS After approval by our Human Studies Committee, and parental written informed consent were obtained, 14 consecutive ASA I–II children weighing 10 kg, were enrolled. Patients with known cardiovascular or esophageal abnormalities, and those with conditions contraindicating EA were excluded from the study. Fasting time was 6 h for solids and all infants received an oral intake of 15 mL/kg of 15% glucose 2 h before surgery. Midazolam 0.5 mg/kg per os was adminis- tered 45 min before surgery. On arrival in the operat- ing room, heart rate (HR) was continuously recorded, and noninvasive arterial blood pressure was mea- sured by an automated blood pressure cuff every 5 min. After denitrogenation, general anesthesia was induced by inhalation of 100% oxygen and 8% From the *Service d’Anesthe ´sie-Re ´animation et Unite ´ Propre de Recherche de l’Enseignement Supe ´rieur-Equipe d’Accueil (UPRES-EA 392); and †Service de Re ´animation Pe ´diatrique, Centre Hospitalo- Universitaire de Bice ˆtre, Assistance Publique-Ho ˆ pitaux de Paris (AH- HP), Le Kremlin Bice ˆtre, France. Accepted for publication March 19, 2007. Address correspondence and reprint requests to Karim Aseh- noune, MD, PhD, Service d’Anesthe ´sie-Re ´animation, Ho ˆpital de Bice ˆtre 94275 Le Kremlin Bice ˆtre, France. Address e-mail to asehnounekarim@hotmail.com. Copyright © 2007 International Anesthesia Research Society DOI: 10.1213/01.ane.0000265554.76665.92 Vol. 105, No. 1, July 2007 46