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Department of Anesthesiology and Department of SurgeryUniversity of Mississippi School of Medicine Jackson, MS 39216-5939
To the Editor:
Because we frequently use regional neuraxial analgesia as an adjunct to our practice of adult cardiac surgery, it was with great interest that we read the recent articles by Peterson et al. (1) and Hammer et al. (2). The authors are to be congratulated for reporting their experience with what is a very controversial practice in pediatric cardiac surgery. We feel, however, that some issues should be amplified.
It is very difficult to interpret the data presented by Peterson et al. (1), as the demographic groups demonstrate significant variability. Should data from noncardiopulmonary bypass (CPB) procedures even be presented with that from procedures involving CPB? The non-CPB cases are more analogous to other major pediatric general surgery procedures, where regional anesthesia and analgesia are widely used. Obviously, a pacemaker placement is significantly different from a Ross procedure in so many respects that a comparison does not seem valid. Similarly, the ages studied by Peterson et al. (1) range from 0 to 36 years. Differences in neonatal and adult physiology, pain perception, and stress response again make direct comparisons problematic.
The issue of complications and risk of peridural hematoma deserve further clarification. Although Peterson et al. (1) state that theirs is merely a descriptive study, they also state no less than three times that their rate of peridural hematoma formation was zero and imply that regional anesthesia is thus safe and effective in pediatric cardiac surgery. Given an accepted incidence of between 1:150,000 and 1:220,000 for peridural hematoma after neuraxial block (3), a study consisting of only 220 patients does not have sufficient statistical power to make broad statements about safety. Although Peterson et al. (1) allude to this in their discussion of the 2% maximal risk, we feel that the overall presentation of the study implies a level of safety which does not exist. Peridural hematoma is a devastating complication with high morbidity despite prompt diagnosis and intervention. There is no shortage of case reports describing this catastrophe, even in the same issue of Anesthesia and Analgesia as the Peterson et al. (1) study (4). It may be misleading to state that thoracic epidural techniques have the lowest incidence of complications when peridural hematoma is considered an equivalent complication to emesis and pruritus, which more reasonably should be called side effects. Again, this descriptive study does not have the statistical power to draw these conclusions.
Finally, we question whether institutional bias has limited this study even more so than mentioned in the accompanying editorial (5). Although the use of neuraxial analgesia may be appropriate in children undergoing atrial septal defect repair and Tetralogy of Fallot repair, few objective practitioners would choose neuraxial analgesia as an adjunct to a Ross or Damus-Kaye-Stanzel procedure or a heart-lung transplant.
Regional anesthesia may have a role in pediatric cardiac surgery. It is impossible, however, to make a valid risk-benefit decision regarding these techniques given the data presented. As Peterson et al. (1) state, larger, prospective, randomized studies are necessary to properly address this question.
References
Pediatric Anesthesia/Critical Care Stanford University Medical Center Stanford, CA 94305
In Response:
We appreciate the interest of Drs. Mychaskiw and Heath in our recent article (1). The authors state that "the use of neuraxial analgesia may be appropriate in children undergoing atrial septal defect repair and tetralogy of Fallot repair" but not "as an adjunct to a Ross or Damus-Kaye-Stanzel procedure." The rationale for this statement is unclear. In our practice, regional anesthesia is used in infants and children for whom tracheal extubation is planned in the operating room immediately after the completion of cardiac surgery. Accordingly, we have employed these techniques in a number of pediatric patients undergoing pulmonary and/or aortic valve replacement, including the Ross procedure. However, we would not plan immediate tracheal extubation for a baby with tetralogy and a very poorly compliant right ventricle and would not, therefore, use regional anesthesia for such a patient.
In the future, regional anesthesia may be more widely used in our practice if benefits such as reduction of the stress response and preemptive analgesia are shown to have a favorable impact even in those patients not undergoing early tracheal extubation.
We agree that prospective, randomized, controlled studies are needed that compare the benefits of regional plus general anesthesia with general anesthesia alone in infants and children undergoing open heart surgery. We are currently embarking on one such study at Stanford.
Footnotes
Dr. Kristi Peterson did not wish to respond to this letter.
References
This article has been cited by other articles:
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  A. Pirat, E. Akpek, and G. Arslan Intrathecal Versus IV Fentanyl in Pediatric Cardiac Anesthesia Anesth. Analg., November 1, 2002; 95(5): 1207 - 1214. [Abstract] [Full Text] [PDF]
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