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Literature Review

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

Birmingham P, Wheeler M, Suresh S, et al. Anesthesia & Analgesia 2003;96:686-91.

Review: The goal of the study was to examine the use of patient-controlled epidural analgesia (PCEA) in children after surgery. The medical literature available regarding the use of patient-controlled epidural analgesia in children is quite limited. On the contrary, much has been written on the use of IV patient-controlled analgesia (PCA) in children. The prospective study consisted of 128 children (132 procedures), spanning a 5-year period undergoing various procedures. The procedures included lower-extremity bony orthopedic surgery, pectus excavatum repair, renal surgery, laparotomy, thoracotomy, and a variety of other procedures. The youngest patient was 5.2 yrs old. Patients were considered for PCEA on the basis of whether the surgical procedure was felt to cause moderate-to-severe postoperative pain. Additional considerations included the child's cognitive ability and cooperation as assessed by the attending anesthesiologist and with input from the parent(s). Exclusion criteria for this study were patients' age 19 yrs old or older and those who had PCEA for nonsurgical pain.

The epidural catheters were inserted in the operating room before surgery and, in some situations, before the induction of anesthesia. Eighty-nine catheters were inserted at the lumbar level, thirty-two at the thoracic level, and eleven at the caudal level. The test dose consisted of 5mcg/mL (1:200,000) of epinephrine with lidocaine 1.5% or bupivacaine 0.125% or 0.25%. The epidural catheters were used during surgery in conjunction with general anesthesia. The continuous infusion was initiated in the OR or the PACU. Bupivacaine 0.1% with 5mcg/mL of fentanyl (range, 2 - 10mcg/mL) was most commonly used. Three patients received ropivacaine 0.2% with 3 - 5mcg/mL of fentanyl. Hydromorphone and morphine were used in one case each. Continuous infusions were initiated at 0.2mL/kg/hr or less. Demand doses ranged from 1 to 3mL, with a lockout of 15 - 30 minutes. The epidural infusion pump was programmed to maintain the maximum total hourly bupivacaine dose (continuous plus demand) at 0.4mg/kg/hr or less.

The data on the use of the demand dose option was recorded on ninety-five patients. The demand dose option was used an average of 5.8 - 42 times daily.

Side effects reported included nausea, vomiting, leg numbness/weakness, pruritus, and urinary retention. There were no reports of sedation or respiratory depression necessitating treatment. Seven patients had a change in the epidural infusion solution for the management of side effects. An additional eight patients with adequate analgesia were converted from PCEA to IV PCA for side-effect management.

Following final analysis of the data, this study demonstrated "that satisfactory analgesia for up to 103 hours could be achieved without clinical evidence of toxicity or serious side effects." It should be noted that patients as young as five years had the cognitive ability and willingness to use PCEA. These findings are the same as those noted with IV PCA.

Comments: This study is the largest to examine the use of PCEA exclusively in children. Of importance is the fact that only a small minority of patients (9.8%) necessitated conversion to IV PCA on account of unsatisfactory pain control. The results of this study are promising, and are truly worthy of consideration in one's clinical practice. The authors correctly point out that further studies are required to compare the use of IV PCA with PCEA in specific pediatric surgical populations.

Reviewed by: Cheryl K. Gooden, MD, FAAP

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