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PEDIATRIC ANESTHESIA

Patient-Controlled Epidural Analgesia in Children: Can They Do It?

Patrick K. Birmingham, MD DABA, FAAP^*, Melissa Wheeler, MD DABA, FAAP, DABPM^*, Santhanam Suresh, MD DABA, FAAP^*, Richard M. Dsida, MD DABA, FAAP^*, Bronwyn R. Rae, MBBS FANZCA, DCH (Lond), DABA^*, Jennifer Obrecht, RN MS, APN, Vicki A. Andreoni, RN MS, APN, Steven C. Hall, MD DABA, FAAP^*, and Charles J. Coté, MD DABA, FAAP^*,

Departments of *Anesthesiology, Nursing, and Pediatrics, Children’s Memorial Hospital at Northwestern University Medical School, Chicago, Illinois

Address correspondence and reprint requests to Patrick K. Birmingham, MD, Department of Pediatric Anesthesiology #19, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Address e-mail to pbirming{at}northwestern.edu

	Abstract

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Extensive clinical experience and many studies support the use of IV patient-controlled analgesia (IV PCA) and regional anesthesia techniques for the treatment of postoperative pain in children. In contrast, little has been reported about the ability of children to use patient-controlled epidural analgesia (PCEA) or about the efficacy of this technique. We report a descriptive analysis of prospectively recorded data in 128 children (132 procedures) in whom PCEA was used for acute postoperative pain control. Satisfactory analgesia was obtained in 119 patients (90.1%) for up to 103 h with no episodes of desaturation and without clinical evidence of toxicity or serious adverse effects. Analgesia was satisfactory with the initial settings in 89 patients; in 38 others, this was achieved with changes in PCEA settings or solution. Five patients were switched to IV PCA because of inadequate analgesia. Eight patients with satisfactory analgesia were converted to IV PCA because of adverse effects. Children as young as 5 yr had the cognitive ability to understand and the willingness to use PCEA, consistent with reported use of IV PCA. Careful attention should be paid to the total hourly local anesthetic dose to avoid exceeding the recommended limits. Our prospectively collected data demonstrate that PCEA provides satisfactory analgesia with a small incidence of adverse side effects in children and should be considered along with other strategies in pediatric postoperative pain management.

IMPLICATIONS: A descriptive analysis of prospectively recorded data in 132 children receiving patient-controlled epidural analgesia for postoperative pain relief demonstrates satisfactory analgesia without serious toxicity or side effects in children as young as 5 yr. This modality should be considered as another strategy in pediatric postoperative pain management.

	Introduction

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Patient-controlled analgesia using IV opioids (IV PCA) has enjoyed increasing popularity in pediatric patients since initial case reports in the late 1980s (1,2). Studies in the 1990s documented the feasibility and relative safety of this technique in children and led to the establishment of opioid dosage guidelines and younger age limits for the use of IV PCA (3–5). During the same period, regional anesthesia techniques were promoted as an additional means to improve perioperative pain relief (6–9). Intraoperative placement of an epidural catheter for postoperative delivery of analgesic solutions, usually a local anesthetic, opioid, or both, is now common. Although the use of continuous epidural infusions (CEIs) in children is an accepted technique (9,10), little has been written about the use of the patient-controlled mode. Use of a patient-controlled demand option would offer children flexibility and some control over their pain management. This might improve overall pain relief and/or patient or family satisfaction. We report our prospectively recorded experience with patient-controlled epidural analgesia (PCEA) in 128 children (132 procedures) after surgery.

	Methods

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Patients considered for PCEA were those undergoing surgical procedures anticipated to cause moderate-to-severe postoperative pain. The attending anesthesiologist made an assessment of the child’s cognitive ability and cooperation with input from the parent(s). Verbal informed consent for epidural catheter placement was obtained from the parent(s), and patient assent was obtained where appropriate.

With IRB approval, we analyzed the following prospectively collected patient data: demographics; surgical procedure; catheter insertion site; length of catheter insertion; whether the catheter was inserted under sedation or general anesthesia; initial PCEA solution and settings; number and type of changes in settings, solution, or both; number of demanded and delivered doses; changes in pain treatment modality; pain scores, by using a numeric rating scale (0–10) or Faces® scale (Wong-Baker®, 0–5); monitoring used; level of nursing care (intensive care unit [ICU], special observation unit, or regular ward); duration of catheter use; and side effects. We excluded patients 19 yr old and those who had PCEA for nonsurgical pain (e.g., sickle-cell pain crisis, cancer-related pain).

Epidural catheters were placed in the operating room (OR) before surgery and, in some cases, before the induction of anesthesia. Patients were monitored according to ASA standards. IV access was established before attempted catheter placement. After sterile preparation, the saline loss-of-resistance technique was used to identify the lumbar or thoracic epidural space. Anatomic landmarks and the feel of a "pop" or "give" were used to identify the caudal epidural space (10). In general, catheters were threaded 3–4 cm into the epidural space. A test dose was injected through the epidural catheter immediately after insertion. The test dose contained 5 µg/mL (1:200,000) of epinephrine with lidocaine 1.5% or bupivacaine 0.125% or 0.25%. The test dose volume was 0.1 mL/kg of body weight, to a maximum of 3 mL. Skin adhesive was applied, and a clear occlusive dressing was placed over the insertion site to secure the catheter. If the patient required a spica cast, a window was cut in the cast to allow visualization of the insertion site and aid in catheter and dressing removal (11). Standing orders were written for continuous pulse oximetry and appropriate interventions, including notification of the anesthesia service, if desaturation or depression of respiration occurred. The postoperative use of continuous cardiorespiratory monitoring was left to the discretion of the OR anesthesia staff. Standing orders were also written for the treatment of nausea, vomiting, pruritus, and urinary retention. Intraoperative antiemetic administration was left to the discretion of the anesthesia team. Side effects recorded do not include nausea or vomiting that occurred in the postanesthetic care unit (PACU) after the completion of surgery. The decision to leave an indwelling bladder catheter in for the postoperative period was left to the discretion of the surgical team. We measured pain at rest, during activity, or both and considered a Faces® score of 2 of 5 or a numeric rating scale of 5 of 10 to represent satisfactory pain relief. The threshold for evaluation and rescue maneuvers was a pain score above those values. We ensured that patients had satisfactory pain relief before PACU discharge, rounded at least twice daily on all patients, and left standing orders for the pain service to be contacted for unsatisfactory analgesia or adverse effects.

	Results

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PCEA was used for 132 procedures in 128 patients (71 boys and 57 girls) between June 1996 and December 2001. Patient demographic data are outlined in Table 1. Patients underwent lower-extremity bony orthopedic surgery (n = 42), pectus excavatum repair (n = 30), renal surgery (n = 20), laparotomy (n = 19), thoracotomy (n = 12), and a variety of other procedures (n = 9). Our youngest patient was 5.2 yr old. Eighty-nine (67.4%) catheters were inserted at the lumbar level, 32 (24.2%) at the thoracic level, and 11 (8.3%) at the caudal level.

Lumbar catheters in two patients were placed under direct vision by the surgeon: one patient was undergoing thoracolumbar spinal fusion, and another was undergoing lumbar laminectomy. Three lumbar catheters were threaded to the thoracic level. Radiography was not used to verify catheter position after catheter placement in the OR.

Bupivacaine 0.1% (range, 0.0625%–0.125%) with 5 µg/mL of fentanyl (range, 2–10 µg/mL) was the most commonly used solution. Three patients received ropivacaine 0.2% with 3–5 µg/mL of fentanyl. Hydromorphone and morphine were used in one case each. Continuous infusions were started at 0.2 mL · kg^-1 · h^-1. Demand doses ranged from 1 to 3 mL, with a lockout of 15–30 min. The epidural infusion pump was programmed to maintain the maximum total hourly bupivacaine dose (continuous plus demand) at 0.4 mg · kg^-1 · h^-1.

All patients used the demand dose option. Our database did not uniformly quantify the number of demand doses used in the earlier stages of the study period. In 95 patients in whom demand dose use was recorded, the demand option was used an average of 23.9 ± 18.1 times daily (range, 1–82).

Forty-three patients (32.6%) reported pain scores of 6 of 10 on a numeric rating scale (or 3 of 5 on a Faces® scale) at some time during treatment (Fig. 1). Thirty-three (76.7%) of these 43 patients were satisfactorily treated (i.e., pain score reduction to <3 of 5 or <6 of 10) with changes in the epidural pump settings, i.e., infusion rate, demand dose, or both. If the patient was uncomfortable primarily with activity, an increase was made in the demand dose. If the patient was uncomfortable at rest, an increase was made in the continuous infusion. An additional 5 of the 43 patients with unsatisfactory pain control obtained satisfactory analgesia with a change in the epidural infusion solution: increase in the opioid concentration (n = 2), increase in the local anesthetic (n = 2), or increase in both (n = 1). The remaining five patients with unsatisfactory pain control required conversion to IV PCA to establish adequate pain control. Two of these patients had lumbar catheters placed for thoracotomy.

View larger version (19K): [in this window] [in a new window]   Figure 1. Pain control algorithm. Total satisfactory pain control was achieved in 90.1% of children: 65.9% with the initial settings, 21.2% more with changes in patient-controlled epidural analgesia (PCEA) settings, and an additional 3.0% with a change in solution. Unsatisfactory pain control in 3.8% and side effects in 6.1% of children necessitated a change to IV patient-controlled analgesia (IV PCA).

In addition to the five patients converted to IV PCA use for inadequate analgesia, eight patients with satisfactory analgesia were converted from PCEA to IV PCA for side-effect management (Table 3). Only 1 of 11 patients who had a temperature of 38.5°C had the catheter removed and was placed on IV PCA. An additional patient, who underwent small-bowel transplantation, received preoperative IV PCA for chronic pain management. He received satisfactory postoperative pain control during 70 h of PCEA, after which IV PCA was resumed.

	Discussion

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Our experience with PCEA in 132 procedures over a 5-year period shows that satisfactory analgesia for up to 103 hours can be achieved without clinical evidence of toxicity or serious side effects. Children as young as five years had the cognitive ability to understand and a willingness to use PCEA, consistent with our and other authors’ experience with standard IV PCA (12).

Our study is the largest reported series of PCEA use exclusively in children. A large prospective experience with PCEA in 1799 patients, primarily adults, also included 163 pediatric patients 16 years (13). Although PCEA was used in all the adult patients, 23% of children were not given a demand option because of age considerations, and the overall pediatric experience was not further described.

Of our patients, 13 (9.8%) of 132 required conversion to IV PCA, but only 5 patients (3.8%) were converted because of inadequate pain control. One patient had the catheter removed for an oral temperature of 38.8°C. Although a 35% colonization rate with epidural catheters in children has been reported, epidural abscess is rare (14). Strafford et al. (15) reported no epidural abscesses in 1620 pediatric patients. Catheters in that study were left in for an average of two days and for as long as eight days. Our standing orders state that the pain service is to be notified if the patient’s temperature is 38.5°C. The decision to remove a catheter on the basis of fever depends on our assessment of the patient and is made in consultation with the surgeons. There are many reasons for postoperative fever or temperature increases that are unrelated to the epidural catheter. Removing a well functioning catheter for any temperature increase in the postoperative period may prematurely deprive patients of an excellent means of postoperative pain control. We left catheters in most patients with temperatures 38.5°C with no adverse effect.

During the study period, we also placed an additional 444 patients on CEI without a demand option. We did not compare PCEA with CEI alone. A comparative study of PCEA with CEI in adults demonstrated effective and comparable analgesia with smaller doses of fentanyl in the PCEA group (16). The only comparative study between PCEA and CEI in children is an abstract (17). Antok et al. (17) used ropivacaine 0.2% without an opioid in children undergoing orthopedic surgery. The PCEA group consumed less local anesthetic to achieve comparable pain scores to the CEI group.

Additional studies are also needed to compare the use of this more invasive technique with IV PCA in select pediatric surgical populations. Lin et al. (18) recently reported, in abstract form, a prospective comparison of IV PCA with PCEA in 25 pediatric patients who had idiopathic scoliosis repair. Despite maximized epidural medication dosage with bupivacaine 0.1% with 25 µg/mL of hydromorphone, 2 (15%) of 13 patients in the epidural group did not complete the study because of inadequate pain control within 24 hours after surgery. The remaining PCEA patients had better pain relief at rest and with cough compared with the IV PCA group. In a retrospective review of PCEA versus IV PCA in adolescents undergoing spinal fusion, 13.3% of PCEA patients were converted to IV PCA for reasons unknown to the authors (19). Comparable pain control was demonstrated in the remaining patients, but the PCEA group had a significantly earlier return to full diet and a 0.5-day-earlier hospital discharge.

The solution most often used in our cohort was bupivacaine 0.1% with 5 µg/mL of fentanyl because our experience suggested that this combination provides adequate pain relief with acceptable side effects. Caudle et al. (20) reported a retrospective review of PCEA with epidural fentanyl without local anesthetic in 31 children. Good-to-excellent pain relief was achieved in 78% of patients. Our incidence of minor side effects such as pruritus and nausea/vomiting was less frequent than reported by Caudle et al. and was comparable to that reported in a review of adult patients with epidural analgesia (21). We did not compare the safety or efficacy of our solution with those of others containing different local anesthetics, opioids, or medications such as clonidine.

Although we practice some flexibility in dosing to ensure satisfactory analgesia, we are careful to ensure that the total hourly bupivacaine dose is 0.4 mg · kg^-1 · h^-1, including the theoretical maximum number of demand doses that could be given per hour. This limit is advocated because CNS toxicity, most notably seizures, has not been shown to occur at or less than this hourly infusion rate (22). Although this limit is unlikely to be reached by the usual rates used in the adolescent or adult patient, it is approachable in the smaller pediatric patient. For example, a 20-kg patient receiving our most common concentration, bupivacaine 0.1% with 5 µg/mL of fentanyl, who is placed on a continuous infusion of 4 mL/h (0.2 mL · kg^-1 · h^-1), would be limited to a 1-mL demand dose and 15-minute lockout. This would allow a maximum of 8 mL/h, which is 0.4 mg · kg^-1 · h^-1.

One issue in pediatric regional analgesia is the appropriate site for catheter insertion. Insertion of catheters at the thoracic level may result in direct damage to the spinal cord (10). Catheters inserted below the first or second lumbar vertebral level may offer a safety feature by being below the termination of the spinal cord. However, delivery of the epidural solution below the desired dermatome(s) may result in inadequate analgesia. Caudle et al. (20) showed that patients with thoracic epidural catheters placed for thoracic or upper-abdominal procedures seemed to enjoy better pain relief, although they also reported a more frequent incidence of sedation in the thoracic catheter group. In adult patients undergoing thoracotomy, delivery of epidural fentanyl or sufentanil by the lumbar route resulted in comparable analgesia to thoracic delivery (23,24). In our cohort, two of three thoracotomy patients with inadequate pain control had lumbar epidural catheters in place. Although the numbers are too small for statistical analysis, this observation may support Berde’s (22) recommendation that satisfactory analgesia is more likely with a catheter tip close to or at the surgical dermatome. It is possible that a more hydrophilic opioid, such as hydromorphone, might have resulted in a more cephalad spread, with better analgesia in these patients; however, the potential for respiratory depression would also have increased. In infants and small children, it is possible to successfully thread catheters from lower vertebral levels to the thoracic level (25). This is more successful with the caudal than the lumbar route (26). The likelihood of successfully threading a caudal catheter to the thoracic level diminishes in children 10 kg in weight (27).

Another area of some controversy is whether the epidural catheter should be inserted with the patient awake or sedated or after the induction of general anesthesia. Some authors emphasize the importance of attempting neuraxial anesthesia in patients before the induction of general anesthesia to minimize the likelihood of nerve injury (10). The awake or lightly sedated patient is more able to report the presence of a paresthesia during needle insertion, catheter threading, or injection of epidural solution. Others point out the difficulty of attempting neuraxial anesthesia in an awake or sedated child and suggest that general anesthesia may actually be safer for epidural catheter placement, because it ensures immobility in an otherwise uncooperative patient (10,28). More than 80% of our patients had catheters placed after anesthetic induction; however, patients having catheters placed at the thoracic level were more likely to have the catheter placed before induction. Caudle et al. (20) placed catheters before induction in 39% of cases.

The use of PCEA in a younger population distinguishes this analysis from other published studies, both in terms of average overall age (11.9 years) and youngest patient age (5.2 years). Patients younger than nine years of age had demand dose use similar to that in older patients and achieved a similar rate of satisfactory analgesia. Although our youngest patient was 5.2 years old, age <5 years was not an exclusion criterion. Indeed, successful IV PCA use has been reported in children as young as two or three years of age (29).

The decision to admit children to the ICU, a regular ward, or an intermediate special care unit for postoperative care was based on the surgical procedure and the patient’s medical condition, not on the presence of an epidural catheter or the use of PCEA. Seventy-eight percent of our patients were safely cared for on the regular ward. We used continuous pulse oximetry in all patients and allowed the OR anesthesia team and the pain service attending to decide whether continuous cardiorespiratory monitoring was also indicated. This decision was also based on the procedure and the patient’s medical condition rather than on the use of PCEA.

The patients in our study self-administered their epidural demand doses. Nurse administration of epidural fentanyl in adults achieves pain relief and side effects comparable to patient-administered epidural fentanyl (30). Nurse- or parent-assisted analgesia has been reported in children receiving IV PCA (31,32). Operation of the demand option by someone other than the patient has been a source of concern because of the possibility of increased serious adverse side effects, most notably respiratory depression. There may be select circumstances in which an appropriately trained nurse or appropriately counseled parent would be able to safely provide pain relief with an epidural demand option in children unable or unwilling to do so, yet in whom epidural analgesia may offer the possibility of excellent analgesia.

PCEA can provide satisfactory analgesia without serious side effects in children and should be considered along with other strategies in pediatric postoperative pain management. Additional comparative studies with other means of pain control are needed to clarify whether PCEA offers advantages such as superior analgesia, less overall drug consumption, or better patient and/or parental satisfaction and to offer insight into factors such as choice of solution, catheter insertion site and tip position, and optimal patient subpopulations.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (11) Citing Articles via Google Scholar Google Scholar Articles by Birmingham, P. K. Articles by Coté, C. J. Search for Related Content PubMed PubMed Citation Articles by Birmingham, P. K. Articles by Coté, C. J. Related Collections Postanesthetic Care Unit Pediatrics Regional Anesthesia