Epidural and Regional Anesthesia

Abstract

Children undergoing surgical procedures benefit from many improvements in pain management that have occurred over the past few decades. These enhancements are the result of changes in the attitudes of physicians, nurses, hospital administrators, and patients and their families, coupled with increased pressure from external regulatory agencies ­mandating the adequate assessment and effective treatment of pain in children. It can no longer be debated that infants and children have the capacity to feel pain, or that the experience of pain by a child potentially results in negative short- and long-term consequences. In fact, the evidence continues to mount that inadequately treated pain in children can result in harmful physiological and behavioral consequences and delay ­recovery from surgical procedures as measured by time required to return to a regular diet, activity, and hospital discharge.

Appendices

Summary Points

Inadequately treated pain in children who undergo surgical procedures can result in harmful physiological and behavioral sequelae can delays recovery from surgical procedures.

The use of an appropriate regional analgesic technique can minimize opiate consumption and reduce the incidence of opiate-related side effects.

Potential advantages of regional anesthesia/analgesia include superior site-specific analgesia, lowering of the stress response, reduced sedation, and improved patient and family satisfaction.

In children, regional analgesia is almost always used as an adjunct to general anesthesia.

In infants, the epidural space can be accessed via the sacral hiatus, which known as a “caudal block” and can be used to deliver a single dose of an analgesic or to place a catheter for infusion.

The epidural catheter needs to be positioned properly such that the affected dermatome is adequately blocked.

Complications of epidural analgesia include: inadequate analgesia due to incorrect positioning of the catheter, systemic effects of the narcotic or local anesthetic being administered, over-sedation, and, rarely, nerve root injury or epidural abscess.

Spinal anesthesia can be used in premature infants who are having a brief (<45 min) surgical procedure below the T10 dermatome as an alternative to general anesthesia with endotracheal intubation.

Regional blocks are used routinely for certain pediatric surgical procedures such as circumcision (penile block), inguinal hernia repair (ilio-inguinal block), and umbilical hernia repair (rectus sheath block) with good effect and excellent post-surgical analgesia.

Ultrasound can be used to improve the accuracy and effectiveness of some regional analgesic techniques.

Editor’s Comment

The vast majority of surgical procedures performed in children are performed under general anesthesia. Properly performed regional techniques, such as epidural analgesia and regional blocks, can very effective reduce the need for systemic narcotics, decrease the physiologic stress response, and ­provide lasting postoperative pain relief in these patients. The key ingredient, however, is accurate placement. This can be difficult to achieve, especially given that these procedures are technically demanding, therefore requiring a great deal of experience, and they are often placed when the child is already under general anesthesia, removing an element of feedback that is usually available when these are placed in adults. The use of ultrasound- and fluoroscopy-guidance seems to have greatly increased the accuracy of some of these procedures and certainly should be used more frequently.

When used as part of a post-operative fast-track protocol, epidural catheters used for postoperative pain relief after major bowel surgery have been shown to reduce the postoperative ileus and shorten hospital stay, but only when they are placed in the thoracic region and when local anesthetics are infused instead of opioids. Children with lumbar epidural catheters not only can have a prolonged ileus, but they require an indwelling Foley catheter for urinary retention, and they sometimes complain of lower extremity numbness or weakness, which delays ambulation. In addition, the failure rate of epidural analgesia can be as high as 40%. When it does occurs, it can be very painful for the child and extremely frustrating for the parents, unless there is an aggressive and rapidly instituted back-up plan, which usually includes systemic therapy with intravenous narcotics and, if necessary, adjuvant anxiolytics.