NM-305
Regional Anesthesia to the Rescue: A Consideration for Pediatric Oncology Patients
Nzegwu B, Ross E, Ricketts K
University of North Carolina, Chapel Hill, NC, USA
INTRODUCTION
Pain in pediatric cancer patients is prevalent, but difficult to control. Multimodal regimens are often required, but still prove inadequate in many patients. Repetitive treatments and surgeries compound acute and chronic pain making it difficult to control. They can also lead to side effects that complicate pain management. We successfully treated a patient with acute on chronic pain related to recurrent osteosarcoma using regional anesthesia and a multimodal regimen, after failed epidural placement.
CASE REPORT
Our patient is a 16 yo male with chronic pain, recurrent tibial osteosarcoma and secondary acute lymphoblastic leukemia status post limb sparing tumor resection with on-going intravenous (IV) and intrathecal (IT) chemotherapy, who presented for above knee amputation. The anesthetic plan included post-induction placement of a lumbar epidural for intra- and post-operative pain management. Using loss of resistance technique with saline, the epidural space was successfully accessed several times by two pediatric anesthesiologists; however, each time the epidural catheter was unable to be threaded. Consultation with oncology services purported that repetitive lumbar punctures (LPs) had altered the epidural space architecture. Epidural placement was aborted, and the decision made to perform sciatic and lumbar plexus catheters. The patient tolerated the procedures well, and the surgical procedure was uneventful. Post-operatively, he had a continuous 0.2% ropivacaine infusion through each catheter at 5 ml/hr with good pain control. Scheduled adjuncts included acetaminophen and gabapentin. As needed adjuncts included oxycodone, diazepam and IV hydromorphone. The peripheral nerve catheters were discontinued on POD 5.
DISCUSSION
In cancer patients, pain can be difficult to control and confounded by multiple procedures. Our patient had a history of multiple diagnostic and therapeutic LPs. The literature supports that epidural fibrosis can be caused by hematoma, infection, surgical trauma or IT contrast media (1). The invasion of fibrous connective tissue into a post-procedural hematoma can cause epidural fibrosis potentially making future catheter placement at that level challenging. While epidural fibrosis has not classically been reported in oncology patients as a result of repetitive LPs, the potential exists and may be confirmed with an epidurogram. It is also important to recognize when the risks from repetitive neuraxial anesthesia attempts outweigh the benefits, especially in a patient who is under general anesthesia and unable to report paraesthesias (2, 3). Therefore, the decision in our case to pursue another route for pain management was prudent, and multimodal alternative therapies for pain management ought to be anticipated in populations such as these.
REFERENCES
1. Manchikanti et. al. Spinal Endoscopy and Lysis of Epidural Adhesions in the Management of Chronic Low Back Pain. Pain Physician 2001:4(3):240-265
2. Bromage et. al. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med 1998:23:104-107
3. Krane et. al. The safety of epidurals placed during general anesthesia. Reg Anesth Pain Med 1998:23(5):433
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