Perioperative epidural analgesia in children undergoing major abdominal tumor surgery--a single center experience

Epidural Analgesia Is Associated With Reduced Inpatient Opioid Consumption and Length of Stay After Wilms Tumor Resection

INTRODUCTION

Wilms' tumor (WT) is the most common renal malignancy in children and requires an extensive laparotomy for resection. Epidural analgesia (EA) is commonly used in postoperative pain management, but previous literature suggests it may prolong length of stay (LOS). We hypothesized that EA is associated with prolonged LOS but decreased postoperative opioid use in children undergoing WT resection.

MATERIALS AND METHODS

A retrospective chart review was performed for all WT patients who underwent nephrectomy between January 1, 1998, and December 31, 2018, at a tertiary children's hospital. Patients with incomplete records, bilateral WT, caval or cardiac tumor extension, or intubation postoperatively were excluded. Outcomes included postoperative opioid consumption measured in oral morphine equivalents per kilogram, receipt of opioid prescription at discharge, and postoperative LOS. Mann-Whitney and multivariable regression analyses were performed.

RESULTS

Overall, 46/77 children undergoing WT resection received EA. Children with EA used significantly less inpatient opioids than children without EA (median 1.0 vs. 3.3 oral morphine equivalents per kilogram; P < 0.001). Comparing patients with EA to patients without, there was no significant difference in opioid discharge prescriptions (57% vs. 39%; P = 0.13) or postoperative LOS (median 5 d vs. 6 d; P = 0.10). Controlling for age and disease stage, EA was associated with shorter LOS by multivariable regression (coefficient -0.73, 95% confidence interval: -1.4, -0.05; P = 0.04).

CONCLUSIONS

EA is associated with decreased opioid use in children without an associated increase in postoperative LOS following WT resection. EA should be considered as part of multimodal pain management for children undergoing WT resection.

Incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years

Background and Aims

Postoperative pain in pediatric patients is one of most inadequately treated conditions. This study aimed to investigate the incidence of and modifiable risk factors for inadequate epidural analgesia in pediatric patients aged up to 8 years at Siriraj Hospital-Thailand's largest national tertiary referral center.

Material and Methods

This retrospective study included pediatric patients aged 0-8 years who underwent surgery with epidural catheter during January 2015 to January 2020. Patients with missing data were excluded. Records from both the ward staff and the acute pain service were reviewed. All relevant data were extracted until the epidural catheters were removed.

Results

One hundred and fifty pediatric patients were included. The median age was 29 months and the range varied from 12 days to 98 months on the day of surgery, and 86 (57.3%) were male. The incidence of inadequate epidural analgesia was 32%. Most patients (95.8%) had an unacceptably high pain score within 4 hours after arriving at the ward. Univariate analysis revealed direct epidural placement, the length in epidural space less than 5 cm, and postoperative leakage to be substantially higher in the inadequate pain epidural analgesia group. When those factors were included in multivariate analysis, only length in epidural space less than 5 cm was identified as an independent risk factor.

Conclusion

The incidence of inadequate epidural analgesia in this pediatric study was 32%. Multivariate analysis showed length of catheter in epidural space less than 5 cm to be the only factor independently associated with inadequate epidural analgesia.

Development of a Structured Regional Analgesia Program for Postoperative Pain Management

OBJECTIVES

We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019.

METHODS

A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time.

RESULTS

There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups.

CONCLUSIONS

We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

Epidural analgesia in a paediatric teaching hospital: Trends, developments, and a brief review of literature

Introduction:

Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital.

Methods:

Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital. Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants used, as well as postoperative infusion rates, were then analysed retrospectively.

Results:

There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in preference of LAs and adjuvant drugs toward safer alternatives.

Conclusion:

Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls.

Pain after surgery in children: clinical recommendations

PURPOSE OF REVIEW

This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations.

RECENT FINDINGS

Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions.

SUMMARY

Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.

Postoperative pain control with paravertebral catheters after pediatric total pancreatectomy and islet autotransplantation: a retrospective cohort study

BACKGROUND

Total pancreatectomy and islet autotransplantation (TPIAT) has been used to treat pediatric patients with chronic pancreatitis. The primary symptom of this disease is extreme poorly controlled pain. This results in significant alterations in the quality of life of the patient. We sought to determine if the addition of bilateral thoracic paravertebral catheters with continuous ropivacaine infusion would improve postoperative opioid use and pain control.

METHODS

The medical records of 32 patients who underwent TPIAT from March 2011 to July 2014 were analyzed retrospectively (15 without paravertebral catheters and 17 with paravertebral catheters). Maximum and minimum pain scores, opioid use (mg · kg(-1) · day(-1)), percent opioid use above baseline, length of stay, and complications were recorded.

RESULTS

Those patients who had bilateral thoracic paravertebral catheters had decreased total opioid use in the first 7 days postoperatively when compared to those who did not (612 (95% CI: 432-792) vs 943.7 (95% CI: 650-1237) mg of morphine equivalents; P = 0.043). The total opioid use remained significantly decreased when corrected for weight (12.53 (95% CI: 9.19-15.44) vs 18.85 (95% CI: 13.69-24.03) mg · kg(-1) of morphine equivalents; P = 0.03). In addition, those on preoperative opioids had less percent opioid use above baseline on postoperative days 1, 2, and 7 as well as decreased opioid use (mg · kg(-1) · day(-1)) on postoperative days 1, 2, 3, and 7. There were no differences in complications or length of stay.

CONCLUSIONS

Bilateral paravertebral catheters may provide decreased opioid use and improved postoperative pain control after TPIAT.

Fluoroscopically guided tunneled trans-caudal epidural catheter technique for opioid-free neonatal epidural analgesia

Epidural analgesia confers significant perioperative advantages to neonates undergoing surgical procedures but may be very technically challenging to place using a standard interlaminar loss-of-resistance to saline technique given the shallow depth of the epidural space. Thoracic epidural catheters placed via the caudal route may reduce the risk of direct neural injury from needle placement, but often pose higher risks of infection and/or improper positioning if placed without radiographic guidance. We present a detailed method of placing a fluoroscopically guided, tunneled transcaudal epidural catheter, which may reduce both of these risks. The accuracy and precision of this technique often provides adequate analgesia to allow for opioid-free epidural infusions as well as significant reductions in systemic opioids through the perioperative period. Opioid-free analgesia using a regional anesthetic technique allows for earlier extubation and reduced perioperative sedation, which may have a less deleterious neurocognitive effect on the developing brain of the neonate.

Endogenous opiates and behavior: 2014

This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).