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*Service d’Anesthésie-Réanimation, Hôpital de l’Hôtel-Dieu et Debrousse, Lyon, France; and
Department of Anesthesiology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina
Address correspondence and reprint requests to Dominique Chassard, MD, PhD, Service d’Anesthésie-Réanimation, Hôpital de l’Hôtel-Dieu, 69002, Lyon, France. Address e-mail to dominique.chassard{at}chu-lyon.fr
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Abstract |
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IMPLICATIONS: We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.
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Introduction |
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Methods |
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Premedication consisted of midazolam 0.2 mg/kg by mouth or intrarectal midazolam 0.3 mg/kg given approximately 30 min before anesthesia. General anesthesia was induced with sevoflurane delivered in 100% oxygen. Once the child was anesthetized, an IV catheter was inserted, and lactated Ringer’s solution was infused at 10 mL · kg-1 · h-1. Anesthesia was maintained by remifentanil infused at 1 µg/kg during 1 min. The airway was maintained with a laryngeal mask or an orotracheal tube. Anesthesia was maintained with sevoflurane 1.5%–2% in 50% nitrous oxide in oxygen and remifentanil at a rate of 25 µg · kg-1 · h-1 until the end of the surgery.
Before the surgical procedure began, the patients were placed in the lateral position, and, under sterile conditions, an epidural catheter was inserted at the L3-4 or L4-5 interspace level by using a Tuohy 18-gauge needle and a loss-of-resistance technique with normal saline. After placement of the catheter, a test dose of lidocaine 1% with epinephrine 1:200,000 was administered.
Thirty minutes before the end of the surgical procedure, 10 mL of ropivacaine 0.2% was administered through the epidural catheter. At the end of surgery, the patient was tracheally extubated and transferred to the postanesthesia care unit. Patients allocated to the PCEA group received bolus doses of ropivacaine 0.2% 2 mL with a lockout interval of 10 min and a background infusion rate of 1.6 mL/h. Patients allocated to the CEA group received a continuous infusion of 0.4 mg · kg-1 · h-1 of ropivacaine 0.2%. Patients in the PCEA group were able to titrate their ropivacaine requirements from a minimum of 1.6 mL/h (3.2 mg) to a maximum of 13.6 mL/h (27.2 mg). After a brief observation period in the postanesthesia care unit, patients were then returned to their regular ward, and the epidural infusion was continued for 48 h.
During the 48-h study period, the quality of pain analgesia was assessed by using a VAS. Children were not awakened from sleep for assessment, and "asleep" was recorded on the chart at these times. The degree of motor block in the lower extremities was recorded with a modified Bromage scale (score: 0 = no movement; 1 = ankle only; 2 = ankle and knee; 3 = ankle, knee, and hip). Pain scores (0–10), motor block score, noninvasive arterial blood pressure, and other side effects (urinary retention, nausea, and vomiting) were recorded every 4 h for 48 h by an independent observer. The volume of ropivacaine infused was recorded hourly. Sensory level was evaluated by pinprick test twice a day. All patients received propacetamol 30 mg/kg and ketoprofen 1 mg/kg IV every 6 h. Supplemental analgesia (nalbuphine 0.2 mg/kg IV) was given if patients in either group complained of inadequate analgesia despite activating the demand button. At the end of the 48-h postoperative period, the total consumption of ropivacaine was noted. Specific problems, such as epidural catheter-related problems (disconnection, leakage, and local inflammation), were also recorded.
The proposed sample size was 18 for each group, and the study was powered to 90% to yield a statistically significant result. This computation assumes that the mean difference is 20% (corresponding to means of 0.440 versus 0.352 mg · kg-1 · h-1 of ropivacaine dosage) and that the common within-group standard deviation (SD) is 0.078. This effect was selected as the smallest effect that would be important to detect, in the sense that any smaller effect would not be of clinical or substantive significance. Data are presented as means and SD. For all statistical analyses, the StatView computer software package was used (SAS Institute, Cary, NC). Differences between groups were analyzed with a repeated-measures analysis of variance (two-way analysis of variance with repeated measures) or 
2 tests, as appropriate. The significance level was set at 0.05.
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Results |
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There were no statistical differences between the two groups with respect to side effects. The incidence of nausea and vomiting was 1 in 24 in the PCEA group versus 2 in 24 in the CEA group. Concerning urinary retention, it was present in one patient in the PCEA group and three patients in the CEA group. No block height was above T10.
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Discussion |
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On the basis of previous studies, the dosage regimen used in our CEA group was set at 0.4 mg · kg-1 · h-1. This dose regimen has been successfully used for postoperative analgesia in children by the caudal route (4–6). Hansen et al. (7) showed that CEA of 0.4 mg · kg-1 · h-1 provided good analgesia with few side effects. Total and free ropivacaine concentrations with this dose regimen were within the range reported to be "safe" in previous studies in adults (100–3189 µg/L and 10–56 µg/L respectively) (8).
There are no studies on the use of PCEA with ropivacaine 0.2% for postoperative analgesia in children. We chose ropivacaine because it has the potential to produce differential neural blockade with less motor block and less systemic toxicity than bupivacaine (9). Ropivacaine 0.2% has been used in younger children, and several studies have reported its clinical efficacy and safety when administered for caudal epidural anesthesia and as a CEA for postoperative analgesia (4–7). We did not observe significant motor block, as assessed by the Bromage score, in this study. However, all patients underwent orthopedic procedures on the lower limbs and could not walk in the first 48 postoperative hours; the preservation of motor function is a less important element in orthopedic surgery.
Our study demonstrates that the PCEA method is effective for pain relief and is safe over 48 hours. In an elderly population, PCEA showed several advantages over patient controlled-analgesia (PCA), particularly concerning the side effects associated with systemic opioids (10). Thus, compared with morphine PCA, PCEA with a local anesthetic may also result in fewer opioid toxicity reactions in a pediatric population. Concerning the side effects, there were no differences between our two groups.
PCEA provided similar analgesia to CEA with a smaller dose of ropivacaine. A major finding of our study is that analgesia with PCEA was obtained at half the dose of ropivacaine. The hourly dose requirement for ropivacaine 0.2% has also been reported to be smaller during PCEA than during CEA (11). The differences in the sparing effect observed with PCEA among previous studies are probably linked to the amount of the background infusion during PCEA and to the solution used for the PCEA method. PCEA may help to reduce local anesthetic doses by adjusting analgesia.
We chose a PCEA method that used a bolus injection plus a continuous, fixed-rate infusion because this method has shown that the use of PCA with morphine with background infusion is associated with a better sleep pattern than PCA without background infusion (12). In adults, the effect of the use of a background infusion rate during PCEA is still controversial. A decrease of the physician-administered supplemental bupivacaine dose has been reported by Ferrante et al. (13). But a background infusion in PCEA with sufentanil does not offer major advantages in terms of sleep quality or sufentanil consumption (14). Side effects may be more pronounced because of increased drug administration. Thus, further studies are required before a background infusion rate during PCEA in children is recommended.
The demand to delivery ratio (D/D ratio) has been used as an indirect indicator of pain relief during PCA or PCEA. Adequate analgesia is usually provided with a D/D ratio less than 2 (15). This study reported a mean D/D ratio of 3.11 for the first day and 2.9 for the second day. However, we observed that two children pressed the demand button because of anxiety while their VAS scores were <3. When these two patients were omitted, the D/D ratio was of 2.34 and 1.43 at Day 1 and Day 2, respectively. Thus, the D/D ratio must be used with caution for analyzing the efficacy of PCEA in children.
In summary, this study suggests that the use of PCEA with lumbar epidural placement for postoperative analgesia after orthopedic surgery has an analgesic-sparing effect in children. The PCEA is an attractive method for postoperative pain treatment in children, and various dose regimens may be developed for this purpose.
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This article has been cited by other articles:
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  F. Duflo, V. Sautou-Miranda, A. Pouyau, P. Taylor, S. Combet, F. Chotel, N. Bleyzac, and D. Chassard Efficacy and plasma levels of ropivacaine for children: controlled regional analgesia following lower limb surgery Br. J. Anaesth., August 1, 2006; 97(2): 250 - 254. [Abstract] [Full Text] [PDF]
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 C. Dadure, S. Bringuier, F. Nicolas, L. Bromilow, O. Raux, A. Rochette, and X. Capdevila Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study. Anesth. Analg., March 1, 2006; 102(3): 744 - 749. [Abstract] [Full Text] [PDF]
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