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Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome?
Journal of Pediatric Surgery (2005) 40, 1118 – 1121
www.elsevier.com/locate/jpedsurg
Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome? Phillip D. Bailey a, John B. Rosea, Sundeep G. Keswanib, N. Scott Adzickb, Jeffrey L. Galinkina,* a
Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and The University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA b Department of Surgery, Children’s Hospital of Philadelphia and The University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA Index words: Congenital cystic adenomatoid malformation of the lung; Epidural analgesia; Surgical outcomes
Abstract Background/Purpose: Continuous epidural analgesia is routinely used to manage pain in infants undergoing resection of a congenital cystic adenomatoid malformation (CCAM) of the lung. Our aim was to determine if there is a difference in the length of stay (LOS), supplemental analgesic requirements, pain control, and the incidence of adverse respiratory events in infants receiving the 2 standard epidural solutions commonly used: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL. Methods: We retrospectively reviewed the charts of infants who received epidural infusions containing bupivacaine 0.1% (n = 18) and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL (n = 10) after CCAM resection during a 12-month period. LOS, rescue opioid, and nonopioid analgesic use, incidence of respiratory depression, and pain scores were recorded. Results: The LOS in patients receiving fentanyl in their epidural solution was 1 day longer than those receiving plain bupivacaine (median 4 vs 3 days, respectively). Nonopioid analgesic and rescue opioid use was greater in patients who did not have fentanyl in their epidural solutions. Pain ratings were not significantly different. The incidence of respiratory depression was greater in patients receiving epidural infusions containing fentanyl (50% vs 17%, respectively). Conclusion: The addition of fentanyl to epidural infusions of bupivacaine in infants undergoing thoracotomy for resection of CCAM may prolong recovery and increase the incidence of adverse respiratory events without providing a significant analgesic benefit. D 2005 Elsevier Inc. All rights reserved.
T Corresponding author. Department of Anesthesia, The Children’s Hospital, TCH Box B090, Denver, CO 80218, USA. Tel.: +1 303 861 6226; fax: +1 303 837 2899. E-mail address: [email protected] (J.L. Galinkin). 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.03.053
Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare condition that often requires thoracotomy in infancy for resection of the abnormal lung tissue [1]. The technique of choice at the Children’s Hospital of Philadelphia for postoperative pain management in these patients is
Epidural analgesia for CCAM resection continuous epidural analgesia. [2-6]. Patients who undergo CCAM resection usually have an epidural catheter inserted via the sacral hiatus and advanced to the thoracic level after general anesthesia is induced and before the surgical procedure commences. Two epidural solutions have been used to provide continuous epidural analgesia in these patients at the Children’s Hospital of Philadelphia: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL. It is not known whether the use of epidural fentanyl in these neonates is beneficial. We retrospectively compared length of stay (LOS), supplemental analgesic requirements, pain scores, and the incidence of adverse respiratory events in infants undergoing thoracotomy for CCAM resection with epidural solutions of either bupivacaine with fentanyl or without fentanyl.
1. Methods After obtaining institutional review board approval, a retrospective chart review was conducted on all infants who underwent CCAM resection between October 1, 2001, and September 30, 2002, had thoracic epidural catheters inserted via the sacral hiatus, and received continuous epidural analgesia with epidural solutions that contained either bupivacaine 0.1% (group B) or bupivacaine 0.1% with fentanyl 2 to 5 lg/mL (group BF) as per the preference of the attending anesthesiologist managing the postoperative pain control. The thoracic location for epidural catheters was confirmed by radiographic imaging. Patients older than 60 weeks postconceptual age at the time of thoracotomy or who received fetal surgical intervention were excluded. Moreover, patients who received epidurals placed other than via the sacral hiatus, without radiographic verification of the catheter location, or who had solutions that contained anything other than 0.1% bupivacaine or 0.1% bupivacaine with 2 to 5 lg of fentanyl were excluded from this review as well. The following information was evaluated and compared in these 28 patients: LOS, rescue opioid (morphine and/or nalbuphine) analgesic requirements, nonopioid (acetaminophen and ketorolac) analgesic use, the incidence of respiratory depression (bradypnea or apnea with oxyhemoglobin desaturation) requiring intervention (controlled ventilation with bag and mask, reintubation, and/or naloxone administration), and the maximum daily pain score assessment using the CRIES pain scale [7]. As a neonatal postoperative pain scoring system used to measure pain responses in neonates 32 to 60 weeks postconceptual age, the CRIES is an acronym of 5 physiologic and behavioral variables associated with pain: C, crying; R, requires increased oxygen administration; I, increased vital signs; E, expression; and S, sleeplessness; 0 to 2 points are assigned to each category with a maximum score of 10. A CRIES score of 4 or more is indicative of pain requiring intervention.
1119
1.1. Surgical indications/procedure Indications for elective CCAM resection are the risks associated with CCAM including infection, pneumothorax, and malignant degeneration. CCAM resection is by either lobectomy or segmentectomy through a posterolateral thoracotomy.
1.2. Statistical analysis Parametric data were analyzed via an unpaired t test. Nonparametric data were analyzed with a Wilcoxon signed rank test. Significance was denoted by P V .05.
2. Results During this 12-month period, a total of 45 patients had thoracotomy for resection of a CCAM lesion. A total of 28 patients met the inclusion criteria and were included in this review. Of these 28 patients, 18 patients had epidural solutions that contained 0.1% bupivacaine, and 10 patients received epidural solutions containing 0.1% bupivacaine with 2 to 5 lg of fentanyl. All but 3 patients were asymptomatic for their CCAM lesion. The first 2 patients were in the bupivacaine/fentanyl group. One of these patients had a prenatally diagnosed CCAM and developed bilateral pneumothoraces shortly after birth and required supplementary oxygen to maintain oxygen saturations preoperatively. The second patient underwent a secondary CCAM resection for a lesion that involved portions of the right upper, middle, and lower lobes. The final patient was in the bupivacaine-only group. This patient had multiple comorbidities including necrotizing enterocolitis treated medically, respiratory syncytial virus, and hyperbilirubinemia. The lengths of hospital stay for these 3 patients postoperatively were 4, 5, and 2 days, respectively. Table 1 summarizes the demographic data. No significant difference was noted between groups on sex, age, weight, or duration of surgery. Table 2 summarizes the results of postoperative outcome measures. LOS in patients who received 0.1% bupivacaine was shorter ( P b .015) than that for patients in the 0.1% bupivacaine with fentanyl group (Table 2). A median LOS of 3 (mean 2.8 F 0.5, range 2-11) days was observed in the 0.1% bupivacaine group and 4 (mean 3.5 F 0.8, range 2-5) days in patients receiving 0.1% bupivacaine with fentanyl. One patient in the bupivacaineTable 1
Demographic data
Age (d) Weight (kg) Sexa (male/female)
Bupivacaine 0.1%
Bupivacaine 0.1%/fentanyl
38.5 (3-66) 4.92 (3.48-7.37) 10/8
48.3 (2-64) 5.06 (3.08-8.60) 5/5
Data are mean values (range) except where indicated. a No. of children.
1120 Table 2
P.D. Bailey et al. Postoperative measures Bupivacaine Bupivacaine 0.1% 0.1%/fentanyl
LOS (d) 2.8 F 0.5T Opioid rescues (n) 5 F 3T Ketorolac usage (no. of patients) 16/18T CRIES, median (range) 4 (0-8) Respiratory complications 3/18
3.5 F 0.8 2F2 4/10 3 (0-7) 5/10
T P b .05.
only group had a prolonged LOS (11 days) that was secondary to a pneumonia that required 1 week of intravenous antibiotic therapy. Rescue opioid use was 2 F 2 doses in patients who received bupivacaine and fentanyl in their epidural solution. The bupivacaine-only group required 5 F 3 rescue opioid doses during their hospitalization ( P b .05). The nonopioid analgesic, ketorolac, was used as needed in both groups of patients. In the bupivacaine with fentanyl group, 40% of patients received scheduled doses of ketorolac compared with 83% of patients in the bupivacaineonly group ( P b .05). The difference between the 2 groups with regard to the CRIES pain scores was not significant. In bupivacaine with fentanyl group, the median CRIES was 3 (range 0-7) compared with a CRIES of 4 (range 0-8) in bupivacaine-only group. The incidence of respiratory depression that required intervention in the bupivacaine with fentanyl group was 50% (5/10) compared with 17% (3/18) in patients in the bupivacaine-only group ( P = .09).
3. Discussion At the Children’s Hospital of Philadelphia, bupivacaine 0.1% is the most common local anesthetic and concentration used for continuous epidural infusions in infants. Fentanyl has been added to bupivacaine 0.1% in varying concentrations to increase the quality of analgesia with the assumption that the side effects would be minimal. In our review, the LOS was increased, and there were more adverse respiratory events that required intervention in those patients who received bupivacaine 0.1% with fentanyl in their epidural solution. There was also no significant reduction in postoperative pain scores with the addition of fentanyl to the epidural solution. Neonates have the neurological mechanisms at birth to experience painful stimuli and have significant morbidity associated with inadequately treated pain [8-10]. Postthoracotomy pain is intense. Frequently, the use of both opioid and nonopioid analgesics administered by various routes is required to ensure adequate analgesia and prevent perioperative morbidity. In addition to experiencing pain, neonates and infants younger than 60 weeks postconceptual age are at risk for postoperative apnea after receiving general anesthesia [11]. Systemic opioids increase the risk for apnea. Epidural analgesia, which allows for decreased consumption of opioids, is an attractive and beneficial method for managing postoperative pain in this patient population [12].
Bosenberg [13] examined the merits of epidural analgesia in neonates undergoing major surgery. In this study, a low incidence of perioperative complications and an improvement of patient outcomes were noted with the use of epidural bupivacaine. Tobias et al [4] also found that thoracic epidurals improved the management of perioperative pain associated with thoracic surgery using epidural solutions of bupivacaine and fentanyl in children. From these studies and others like them, it appears that continuous epidural infusions result in improved postoperative analgesia. What remains unclear is whether the addition of fentanyl to epidural bupivacaine infusions adds an additional benefit when compared with the bupivacaine alone. Our review suggests that bupivacaine without fentanyl may be the solution of choice for the post-CCAM resection neonatal patient population. Unfortunately, serious adverse events may occur with regional anesthetic techniques such as continuous epidural infusions, albeit a rare event 0.9 per 1000 [14]. The majority of complications are minor (eg, nausea and vomiting, motor blockade, sedation, etc) and can be easily resolved [14,15]. However, our data indicate that the addition of fentanyl to epidural infusions in this patient population may increase the risk for respiratory depression without significantly improving analgesia. There were limitations to this retrospective study, besides the retrospective design. First, the concentration of fentanyl used was not standardized and was dependent on the attending anesthesiologist who was serving as the pain service attending physician during the time of surgery. As expected, those patients who received higher concentrations of fentanyl had an increase number of side effects. The small number of patients, specifically those patients receiving fentanyl in their epidural solution, may not have been adequate to allow us to draw conclusions about the adverse effects of epidural fentanyl in the patient population being evaluated. Second, the increased use of ketorolac in the bupivacaine-only group is an additional confounding factor and may explain the outcome of earlier discharge for this group. Finally, bias by the individual pain practitioners and surgeons may have existed toward hospitalizing epidural fentanyl patients longer. From our retrospective analysis, it appears that the addition of fentanyl to epidural bupivacaine in infants younger than 60 weeks postconceptual age undergoing a thoracotomy for CCAM resection may prolong recovery without providing a significant benefit. A prospective, randomized, controlled trial examining the outcomes associated with different epidural solutions may confirm this conclusion.
References [1] Horak E, Bodner J, Gassner I, et al. Congenital cystic lung disease: diagnostic and therapeutic considerations. Clin Pediatr 2003;42: 251 - 61.
Epidural analgesia for CCAM resection [2] Raghavendran S, Diwan R, Shah T, et al. Continuous caudal epidural analgesia for congenital lobar emphysema: a report of three cases. Anesth Analg 2001;93:348 - 50. [3] Rasch DK, Webster DE, Pollard TG, et al. Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children. Can J Anaesth 1990;37:359 - 62. [4] Tobias JD, Lowe S, O’Dell N, et al. Thoracic epidural anaesthesia in infants and children. Can J Anaesth 1993;40:879 - 82. [5] Tobias JD, Lowe S, O’Dell N, et al. Continuous regional anaesthesia in infants. Can J Anaesth 1993;40:1065 - 8. [6] Bosenberg AT, Bland BA, Schulte-Steinberg O, et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988; 69:265 - 9. [7] Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth 1995;5:53 - 61. [8] Truog R, Anand KJ. Management of pain in the postoperative neonate. Clin Perinatol 1989;16:61 - 78. [9] Committee American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section
1121
[10] [11]
[12]
[13] [14]
[15]
on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee: prevention and management of pain and stress in the neonate. Pediatrics 2000;105:454 - 61. Abu-Saad HH, Bours GJ, Stevens B, et al. Assessment of pain in the neonate. Semin Perinatol 1998;22:402 - 16. Cote CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. Anesthesiology 1995; 82:809 - 22. Wolf AR, Hughes D. Pain relief for infants undergoing abdominal surgery: comparison of infusions of intravenous morphine and extradural bupivacaine. Br J Anaesth 1993;70:10 - 6. Bosenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth 1998;8:479 - 83. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth Analg 1996;83:904 - 12. Wood CE, Goresky GV, Klassen KA, et al. Complications of continuous epidural infusions for postoperative analgesia in children. Can J Anaesth 1994;41:613 - 20.
www.elsevier.com/locate/jpedsurg
Does the use of fentanyl in epidural solutions for postthoracotomy pain management in neonates affect surgical outcome? Phillip D. Bailey a, John B. Rosea, Sundeep G. Keswanib, N. Scott Adzickb, Jeffrey L. Galinkina,* a
Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and The University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA b Department of Surgery, Children’s Hospital of Philadelphia and The University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA Index words: Congenital cystic adenomatoid malformation of the lung; Epidural analgesia; Surgical outcomes
Abstract Background/Purpose: Continuous epidural analgesia is routinely used to manage pain in infants undergoing resection of a congenital cystic adenomatoid malformation (CCAM) of the lung. Our aim was to determine if there is a difference in the length of stay (LOS), supplemental analgesic requirements, pain control, and the incidence of adverse respiratory events in infants receiving the 2 standard epidural solutions commonly used: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL. Methods: We retrospectively reviewed the charts of infants who received epidural infusions containing bupivacaine 0.1% (n = 18) and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL (n = 10) after CCAM resection during a 12-month period. LOS, rescue opioid, and nonopioid analgesic use, incidence of respiratory depression, and pain scores were recorded. Results: The LOS in patients receiving fentanyl in their epidural solution was 1 day longer than those receiving plain bupivacaine (median 4 vs 3 days, respectively). Nonopioid analgesic and rescue opioid use was greater in patients who did not have fentanyl in their epidural solutions. Pain ratings were not significantly different. The incidence of respiratory depression was greater in patients receiving epidural infusions containing fentanyl (50% vs 17%, respectively). Conclusion: The addition of fentanyl to epidural infusions of bupivacaine in infants undergoing thoracotomy for resection of CCAM may prolong recovery and increase the incidence of adverse respiratory events without providing a significant analgesic benefit. D 2005 Elsevier Inc. All rights reserved.
T Corresponding author. Department of Anesthesia, The Children’s Hospital, TCH Box B090, Denver, CO 80218, USA. Tel.: +1 303 861 6226; fax: +1 303 837 2899. E-mail address: [email protected] (J.L. Galinkin). 0022-3468/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2005.03.053
Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare condition that often requires thoracotomy in infancy for resection of the abnormal lung tissue [1]. The technique of choice at the Children’s Hospital of Philadelphia for postoperative pain management in these patients is
Epidural analgesia for CCAM resection continuous epidural analgesia. [2-6]. Patients who undergo CCAM resection usually have an epidural catheter inserted via the sacral hiatus and advanced to the thoracic level after general anesthesia is induced and before the surgical procedure commences. Two epidural solutions have been used to provide continuous epidural analgesia in these patients at the Children’s Hospital of Philadelphia: bupivacaine 0.1% and bupivacaine 0.1% with fentanyl 2 to 5 lg/mL. It is not known whether the use of epidural fentanyl in these neonates is beneficial. We retrospectively compared length of stay (LOS), supplemental analgesic requirements, pain scores, and the incidence of adverse respiratory events in infants undergoing thoracotomy for CCAM resection with epidural solutions of either bupivacaine with fentanyl or without fentanyl.
1. Methods After obtaining institutional review board approval, a retrospective chart review was conducted on all infants who underwent CCAM resection between October 1, 2001, and September 30, 2002, had thoracic epidural catheters inserted via the sacral hiatus, and received continuous epidural analgesia with epidural solutions that contained either bupivacaine 0.1% (group B) or bupivacaine 0.1% with fentanyl 2 to 5 lg/mL (group BF) as per the preference of the attending anesthesiologist managing the postoperative pain control. The thoracic location for epidural catheters was confirmed by radiographic imaging. Patients older than 60 weeks postconceptual age at the time of thoracotomy or who received fetal surgical intervention were excluded. Moreover, patients who received epidurals placed other than via the sacral hiatus, without radiographic verification of the catheter location, or who had solutions that contained anything other than 0.1% bupivacaine or 0.1% bupivacaine with 2 to 5 lg of fentanyl were excluded from this review as well. The following information was evaluated and compared in these 28 patients: LOS, rescue opioid (morphine and/or nalbuphine) analgesic requirements, nonopioid (acetaminophen and ketorolac) analgesic use, the incidence of respiratory depression (bradypnea or apnea with oxyhemoglobin desaturation) requiring intervention (controlled ventilation with bag and mask, reintubation, and/or naloxone administration), and the maximum daily pain score assessment using the CRIES pain scale [7]. As a neonatal postoperative pain scoring system used to measure pain responses in neonates 32 to 60 weeks postconceptual age, the CRIES is an acronym of 5 physiologic and behavioral variables associated with pain: C, crying; R, requires increased oxygen administration; I, increased vital signs; E, expression; and S, sleeplessness; 0 to 2 points are assigned to each category with a maximum score of 10. A CRIES score of 4 or more is indicative of pain requiring intervention.
1119
1.1. Surgical indications/procedure Indications for elective CCAM resection are the risks associated with CCAM including infection, pneumothorax, and malignant degeneration. CCAM resection is by either lobectomy or segmentectomy through a posterolateral thoracotomy.
1.2. Statistical analysis Parametric data were analyzed via an unpaired t test. Nonparametric data were analyzed with a Wilcoxon signed rank test. Significance was denoted by P V .05.
2. Results During this 12-month period, a total of 45 patients had thoracotomy for resection of a CCAM lesion. A total of 28 patients met the inclusion criteria and were included in this review. Of these 28 patients, 18 patients had epidural solutions that contained 0.1% bupivacaine, and 10 patients received epidural solutions containing 0.1% bupivacaine with 2 to 5 lg of fentanyl. All but 3 patients were asymptomatic for their CCAM lesion. The first 2 patients were in the bupivacaine/fentanyl group. One of these patients had a prenatally diagnosed CCAM and developed bilateral pneumothoraces shortly after birth and required supplementary oxygen to maintain oxygen saturations preoperatively. The second patient underwent a secondary CCAM resection for a lesion that involved portions of the right upper, middle, and lower lobes. The final patient was in the bupivacaine-only group. This patient had multiple comorbidities including necrotizing enterocolitis treated medically, respiratory syncytial virus, and hyperbilirubinemia. The lengths of hospital stay for these 3 patients postoperatively were 4, 5, and 2 days, respectively. Table 1 summarizes the demographic data. No significant difference was noted between groups on sex, age, weight, or duration of surgery. Table 2 summarizes the results of postoperative outcome measures. LOS in patients who received 0.1% bupivacaine was shorter ( P b .015) than that for patients in the 0.1% bupivacaine with fentanyl group (Table 2). A median LOS of 3 (mean 2.8 F 0.5, range 2-11) days was observed in the 0.1% bupivacaine group and 4 (mean 3.5 F 0.8, range 2-5) days in patients receiving 0.1% bupivacaine with fentanyl. One patient in the bupivacaineTable 1
Demographic data
Age (d) Weight (kg) Sexa (male/female)
Bupivacaine 0.1%
Bupivacaine 0.1%/fentanyl
38.5 (3-66) 4.92 (3.48-7.37) 10/8
48.3 (2-64) 5.06 (3.08-8.60) 5/5
Data are mean values (range) except where indicated. a No. of children.
1120 Table 2
P.D. Bailey et al. Postoperative measures Bupivacaine Bupivacaine 0.1% 0.1%/fentanyl
LOS (d) 2.8 F 0.5T Opioid rescues (n) 5 F 3T Ketorolac usage (no. of patients) 16/18T CRIES, median (range) 4 (0-8) Respiratory complications 3/18
3.5 F 0.8 2F2 4/10 3 (0-7) 5/10
T P b .05.
only group had a prolonged LOS (11 days) that was secondary to a pneumonia that required 1 week of intravenous antibiotic therapy. Rescue opioid use was 2 F 2 doses in patients who received bupivacaine and fentanyl in their epidural solution. The bupivacaine-only group required 5 F 3 rescue opioid doses during their hospitalization ( P b .05). The nonopioid analgesic, ketorolac, was used as needed in both groups of patients. In the bupivacaine with fentanyl group, 40% of patients received scheduled doses of ketorolac compared with 83% of patients in the bupivacaineonly group ( P b .05). The difference between the 2 groups with regard to the CRIES pain scores was not significant. In bupivacaine with fentanyl group, the median CRIES was 3 (range 0-7) compared with a CRIES of 4 (range 0-8) in bupivacaine-only group. The incidence of respiratory depression that required intervention in the bupivacaine with fentanyl group was 50% (5/10) compared with 17% (3/18) in patients in the bupivacaine-only group ( P = .09).
3. Discussion At the Children’s Hospital of Philadelphia, bupivacaine 0.1% is the most common local anesthetic and concentration used for continuous epidural infusions in infants. Fentanyl has been added to bupivacaine 0.1% in varying concentrations to increase the quality of analgesia with the assumption that the side effects would be minimal. In our review, the LOS was increased, and there were more adverse respiratory events that required intervention in those patients who received bupivacaine 0.1% with fentanyl in their epidural solution. There was also no significant reduction in postoperative pain scores with the addition of fentanyl to the epidural solution. Neonates have the neurological mechanisms at birth to experience painful stimuli and have significant morbidity associated with inadequately treated pain [8-10]. Postthoracotomy pain is intense. Frequently, the use of both opioid and nonopioid analgesics administered by various routes is required to ensure adequate analgesia and prevent perioperative morbidity. In addition to experiencing pain, neonates and infants younger than 60 weeks postconceptual age are at risk for postoperative apnea after receiving general anesthesia [11]. Systemic opioids increase the risk for apnea. Epidural analgesia, which allows for decreased consumption of opioids, is an attractive and beneficial method for managing postoperative pain in this patient population [12].
Bosenberg [13] examined the merits of epidural analgesia in neonates undergoing major surgery. In this study, a low incidence of perioperative complications and an improvement of patient outcomes were noted with the use of epidural bupivacaine. Tobias et al [4] also found that thoracic epidurals improved the management of perioperative pain associated with thoracic surgery using epidural solutions of bupivacaine and fentanyl in children. From these studies and others like them, it appears that continuous epidural infusions result in improved postoperative analgesia. What remains unclear is whether the addition of fentanyl to epidural bupivacaine infusions adds an additional benefit when compared with the bupivacaine alone. Our review suggests that bupivacaine without fentanyl may be the solution of choice for the post-CCAM resection neonatal patient population. Unfortunately, serious adverse events may occur with regional anesthetic techniques such as continuous epidural infusions, albeit a rare event 0.9 per 1000 [14]. The majority of complications are minor (eg, nausea and vomiting, motor blockade, sedation, etc) and can be easily resolved [14,15]. However, our data indicate that the addition of fentanyl to epidural infusions in this patient population may increase the risk for respiratory depression without significantly improving analgesia. There were limitations to this retrospective study, besides the retrospective design. First, the concentration of fentanyl used was not standardized and was dependent on the attending anesthesiologist who was serving as the pain service attending physician during the time of surgery. As expected, those patients who received higher concentrations of fentanyl had an increase number of side effects. The small number of patients, specifically those patients receiving fentanyl in their epidural solution, may not have been adequate to allow us to draw conclusions about the adverse effects of epidural fentanyl in the patient population being evaluated. Second, the increased use of ketorolac in the bupivacaine-only group is an additional confounding factor and may explain the outcome of earlier discharge for this group. Finally, bias by the individual pain practitioners and surgeons may have existed toward hospitalizing epidural fentanyl patients longer. From our retrospective analysis, it appears that the addition of fentanyl to epidural bupivacaine in infants younger than 60 weeks postconceptual age undergoing a thoracotomy for CCAM resection may prolong recovery without providing a significant benefit. A prospective, randomized, controlled trial examining the outcomes associated with different epidural solutions may confirm this conclusion.
References [1] Horak E, Bodner J, Gassner I, et al. Congenital cystic lung disease: diagnostic and therapeutic considerations. Clin Pediatr 2003;42: 251 - 61.
Epidural analgesia for CCAM resection [2] Raghavendran S, Diwan R, Shah T, et al. Continuous caudal epidural analgesia for congenital lobar emphysema: a report of three cases. Anesth Analg 2001;93:348 - 50. [3] Rasch DK, Webster DE, Pollard TG, et al. Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children. Can J Anaesth 1990;37:359 - 62. [4] Tobias JD, Lowe S, O’Dell N, et al. Thoracic epidural anaesthesia in infants and children. Can J Anaesth 1993;40:879 - 82. [5] Tobias JD, Lowe S, O’Dell N, et al. Continuous regional anaesthesia in infants. Can J Anaesth 1993;40:1065 - 8. [6] Bosenberg AT, Bland BA, Schulte-Steinberg O, et al. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988; 69:265 - 9. [7] Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth 1995;5:53 - 61. [8] Truog R, Anand KJ. Management of pain in the postoperative neonate. Clin Perinatol 1989;16:61 - 78. [9] Committee American Academy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthesiology. Section
1121
[10] [11]
[12]
[13] [14]
[15]
on Surgery. Canadian Paediatric Society. Fetus and Newborn Committee: prevention and management of pain and stress in the neonate. Pediatrics 2000;105:454 - 61. Abu-Saad HH, Bours GJ, Stevens B, et al. Assessment of pain in the neonate. Semin Perinatol 1998;22:402 - 16. Cote CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. Anesthesiology 1995; 82:809 - 22. Wolf AR, Hughes D. Pain relief for infants undergoing abdominal surgery: comparison of infusions of intravenous morphine and extradural bupivacaine. Br J Anaesth 1993;70:10 - 6. Bosenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth 1998;8:479 - 83. Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesth Analg 1996;83:904 - 12. Wood CE, Goresky GV, Klassen KA, et al. Complications of continuous epidural infusions for postoperative analgesia in children. Can J Anaesth 1994;41:613 - 20.