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LETTER TO THE EDITOR

Thoracic Epidural Anesthesia in Pediatric Liver Transplantation

Hospital Geral de Bonsucesso, Liver Transplantation Unit, Rio de Janeiro, Brazil, glaubergouvea{at}ibest.com.br

To the Editor:

Anesthesia for pediatric liver transplantation is challenging in many aspects, including pain management. Coagulopathy, which may preclude central neural-axis blockade, is very frequent at presentation (1), although it may also develop in the postoperative period—even if preoperative results are normal (2).

We describe a case of a child with diagnosis of biliary hypoplasia admitted to undergo a liver transplantation. The coagulation tests were normal, so we performed a thoracic epidural catheterization and, after injecting an anesthetic solution, the catheter was removed. We describe the perioperative and postoperative course.

A 5-yr-old, 13-kg female child was admitted to undergo a liver transplantation as a result of cholestatic disease secondary to biliary hypoplasia. Liver transplantation was indicated by frequent episodes of severe cholangitis. Preoperative laboratory results are shown on Table 1.

After arrival in the operating room, a mask induction with sevoflurane was performed and a venous line was initiated subsequently. Atracurium was given to facilitate endotracheal intubation, which was performed successfully. Thereafter, the child was positioned (left side down) and the epidural space identification was made atraumatically with a Weiss 18-gauge needle in the T8-9 interspace using the loss-of-resistance technique with normal saline. The epidural catheter was then advanced 2 cm upward. After negative aspiration, we injected the anesthetic solution, which consisted of ropivacaine 0.2% 10 mL + clonidine 45 µg and morphine 300 µg. The catheter was then removed. After arterial and central venous lines were installed, surgery was initiated.

Anesthesia was maintained with propofol, remifentanil, and atracurium infusions. A 1:1 mixture of oxygen:air was administered. Aprotinin was also infused from the beginning of surgery to the end of arterial anastomosis.

The perioperative course was uneventful, with stable hemodynamics throughout the entire procedure. The surgery lasted 5 h 40 min; the graft’s ischemia (cold + warm) lasted 5 h 30 min.

Soon after the end of the operation, the child opened her eyes spontaneously and the train-of-four showed good recovery; therefore, she was extubated while still in the operating room and then transported to the pediatric intensive care unit.

On arrival at the pediatric intensive care unit, she was in Ramsay III level of sedation. No analgesic drug was required during the first 24 h.

Diet was initiated 48 h later and the patient was discharged to the ward after 4 days.

Kim and Harbott (3) recently reported the successful use of caudal morphine for postoperative analgesia in a 3-yr-old child who underwent a liver transplantation. In their report, the child requested minimum analgesics in the first 18 h. The dose of morphine was 600 µg. However, the incisions were also infiltrated with bupivacaine at the end of the procedure, so one may not assume that the child’s comfort was entirely attributable to the caudal morphine, at least during the first 6–8 h (4).

We performed the epidural catheterization in this child because of the normal coagulation profile (Table 1). The lower thoracic T8-9 space (instead of lumbar space or upper thoracic levels) was chosen because one of the goals was to achieve segmental perioperative anesthesia, avoiding undesirable motor blockade, which may be very cumbersome for the pediatric population.

The usual dose of epidural clonidine in literature is between 4 and 6 µg/kg. We chose the smaller dose because it was added as an adjunct to morphine for postoperative analgesia. Clonidine decreases postoperative oxygen consumption and adrenergic stress response and also achieves some degree of sedation in the postoperative period, but it does not induce profound respiratory depression when used alone and only mildly potentiates opiate-induced respiratory depression. These sick children usually arrive at the pediatric intensive care unit with invasive lines, a nasoenteral feeding catheter in place, and so forth; therefore, agitation may compromise these lines, even if well-secured. Our patient remained in Ramsay III level of sedation during the first pediatric intensive care unit day. No respiratory depression was noted in 72 h clinically or by the arterial blood gas values.

The dose of epidural morphine was 300 µg. A dose between 20 and 50 µg/kg is often recommended, which would provide good analgesia with an infrequent incidence of side effects (5). Our choice of a reduced dose of morphine (23 µg/kg) was threefold: first, we were also administering clonidine; second, we positioned the catheter in the thoracic level, so a larger dose of morphine could potentially spread more rostrally, with a theoretical greater risk of respiratory depression (6); third, the liver recipient patient has decreased opioid requirements (7).

Finally, we decided to remove the catheter because of the risk of postoperative coagulopathy. The vast majority of epidural hematoma cases (at least in adults) described in the literature developed when the epidural catheter was retrieved in patients with coagulopathy (8).

In conclusion, we described the first successful use of thoracic epidural anesthesia as an adjunct for perioperative and postoperative analgesia in pediatric liver transplantation. However, close postoperative monitoring of coagulation tests is necessary, as these patients are at risk for developing postoperative coagulopathy.

Although one case does not prove a technique, we believe that epidural analgesia in these selected patients may greatly facilitate early postoperative management, which could then possibly contribute to a better outcome.

References

1. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165–77.[Free Full Text]
2. Morisaki H, Doi J, Ochiai R, et al. Epidural hematoma after epidural anesthesia in a patient with hepatic cirrhosis. Anesth Analg 1995;80:1033–5.[Web of Science][Medline]
3. Kim TW, Harbott M. The use of caudal morphine of pediatric liver transplantation. Anesth Analg 2004;99:373–4.[Abstract/Free Full Text]
4. Mayhew JF. Caudal morphine for pain relief in pediatric liver transplantation: did it help? Anesth Analg 2005;100:602–3.[Free Full Text]
5. Kim TW. Caudal morphine for pain relief in pediatric liver transplantation: did it help? Anesth Analg 2005;100:603.[Free Full Text]
6. De Negri P, Ivani G, Visconti C, et al. The dose response relationship for clonidine added to o postoperative continuous epidural infusion of ropivacaine in children. Anesth Analg 2001;93:71–6.[Abstract/Free Full Text]
7. Jamail S, Monin S, Begon C, et al. Clonidine in pediatric caudal anesthesia. Anesth Analg 1994;78:663–6.[Abstract/Free Full Text]
8. Cucchiaro G, Dagher C, Bayard C, et al. Side-effects of postoperative epidural analgesia in children a randomized study comparing morphine and clonidine. Pediatr Anaesth 2003;4:318–23.

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