Abstract
Purpose
Two modalities of epidural analgesia in children with two types of cerebral palsy (CP) were compared for differences in the incidence of common complications (inadequate analgesia, hypopnea, hypoxaemia, sedation, vomiting, pruritus, urinary retention, and seizures).
Methods
Demographic, procedural and postoperative complication data were collected on children with CP receiving epidural analgesia. Information was recorded contemporaneously with the child’s care by one of the authors on 92 consecutive children with CP (age, 107 ± 50.1 mo; weight, 26 ± 14.2 kg) who had undergone infraumbilical orthopaedic or Nissen fundoplication procedures between December 1994 and December 1996. The first 44 patients received intermittent bolus (IB) epidural morphine and the next 48 received continuous infusion (CI) bupivacaine and fentanyl. Two forms of CP (spastic diplegia and quadriplegia) and the two modalities of analgesia were compared.
Results
Excellent analgesia was obtained in 91/92 patients. Excessive sedation occurred in six patients (6.5%) but only in IB patients, (P < 0.02 vs CI). Emesis occurred in 52% of patients, and was more common in diplegic than in quadriplegic patients (68% vs 38%,P < 0.01). Pruritus was observed in 29% of patients and was more common in diplegia than quadriplegia (48% vs 12.5%,P < 0.001). The incidences of hypopnea, hypoxaemia, urinary retention and seizures were not affected by the types of CP or analgesia and no difference in sedation was observed between spastic diplegic and quadriplegic patients.
Conclusions
Continuous infusion of epidural bupivacaine and fentanyl provided excellent analgesia for children with CP without serious complications. Intermittent bolus epidural morphine was associated with a high incidence of excessive sedation and should be avoided in this population.
Résumé
Objectif
Comparer deux modes d’analgésie péridurale, chez des enfants atteints de deux types d’infirmité motrice cérébrale (IMC), selon l’incidence des complications courantes (analgésie insuffisante, hypopnée, hypoxémie, sédation, vomissements, prurit, rétention urinaire et convulsions).
Méthode
On a rassemblé les caractéristiques démographiques, opératoires et postopératoires des complications survenues pendant les interventions auprès des enfants atteints d’IMC qui ont reçu une analgésie péridurale. Ces informations ont été recueillies par l’un des auteurs au moment du traitement auprès de 92 enfants atteints d’IMC (âge : 107 ± 50,1 mois; poids : 26 ± 14,2 kg), qui se sont successivement présentés pour subir une intervention orthopédique sous-ombilicale ou une fundoplicature de Nissen, entre décembre 1994 et décembre 1996. Les 44 premiers patients ont reçu de la morphine péridurale en bolus intermittents (BI) et les 48 autres ont reçu une perfusion continue (PC) de bupivacaine et de fentanyl, Deux formes d’IMC (la maladie de Little et la quadriplégie) ainsi que deux modes d’analgésie ont été comparés.
Résultats
Une excellente analgésie a été obtenue chez 91 des 92 patients. Une sédation excessive a été notée chez six patients (6,5 %) mais dans le groupe BI seulement, (P < 0,02 vs CP). Chez 52 % des patients, il y a eu des vomissements qui étaient plus fréquents chez les enfants diplégiques que chez les quadriplégiques (68 % vs 38 %,P < 0,01). On a observé du prurit chez 29 % des enfants et surtout chez les diplégiques par rapport aux quadriplégiques (48 % vs 12,5 %,P < 0,001). L’incidence de l’hypopnée, de l’hypoxémie, de la rétention urinaire et des convulsions n’était pas influencée par le type d’IMC ou d’analgésie et aucune différence de sédation n’a été observée entre les patients diplégiques et les patients quadriplégiques.
Conclusion
La perfusion continue de bupivacaïne et de fentanyl périduraux a fourni une excellente analgésie, sans complications importantes, à des enfants atteints d’IMC. Les bolus intermittents de morphine péridurale ont été associés à une plus forte incidence de sédation excessive et on devrait éviter de les utiliser auprès de cette population.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Ecoffey C, Dubousset A-M, Samii K. Lumbar and thoracic epidural anesthesia for urologic and upper abdominal surgery for infants and children. Anesthesiology 1986; 65: 87–90.
Desparmet J, Meistleman C, Barre J, Saint-Maurice C. Continuous epidural infusion of bupivacaine for post-operative pain relief in children. Anesthesiology 1987; 67: 108–10.
Dalens B, Tanguy A, Haberer J-P. Lumbar epidural anesthesia for operative and postoperative pain relief in infants and young children. Anesth Analg 1986; 65: 1069–73.
Murat I, Delleur MM, Esteve C, Egu JF, Raynaud P, Saint-Maurice C. Continuous extradural anaesthesia in children. Br J Anaesth 1987; 69: 1441–50.
Eicher PS, Batshaw ML. Cerebral palsy. Paediatr Clin North Am 1993; 40: 537–51.
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82: 1474–506.
Chaney MA. Side effects of intrathecal and epidural opioids. Can J Anaesth 1995; 42: 891–903.
Scott DA, Beilby DSN, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients. Anesthesiology 1995; 83: 727–37.
Wood CE, Goresky GV, Klassen KA, Kuwahara B, Neil SG. Complications of continuous epidural infusions for postoperative analgesia in children. Can J Anaesth 1994; 41: 613–20.
Dalens B. Caudal anesthesia and lumbar epidural anesthesia.In: Dalens B (Ed.). Regional Anesthesia in Infants, Children, and Adolescents. Baltimore: Williams & Wilkins, 1995: 171–248.
McGrath PJ, Johnson G, Goodman J, et al. The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS): a behavioral scale for rating pain in children.In: Fields H, Dubner R, Cervero F (Eds.). Advances in Pain Research and Therapy, Vol. 9. New York: Raven Press, 1985: 395–402.
Ohta K, Katsuno M, Kawana S, Namiki A. Epidural opioids for postoperative pain control in pediatric patients with cerebral palsy. Masui 1993; 42: 664–8.
Sparkes ML, Klein AS, Duhaime A-C, Mickle JP. Use of epidural morphine for control of postoperative pain in selective dorsal rhizotomy for spasticity. Pediatric Neuroscience 1989; 15: 229–32.
Lawhorn CD, Boop F, Brown R, Andelman P. Epidural pain management in the postrhizotomy patient. Pediatr Neurosurg 1994; 20: 198–202.
Reid CJD, Borzyskowski M. Lower urinary tract dysfunction in cerebral palsy. Arch Dis Child 1993; 68: 739–42.
Mayo ME. Lower urinary tract dysfunction in cerebral palsy. J Urol 1992; 147: 419–20.
McCloskey JJ, Haun SE, Deshpande JK. Bupivacaine toxicity secondary to continuous caudal epidural infusion in children. Anesth Analg 1992; 75: 287–90.
Agarwal R, Gutlove DP, Lockhart CH. Seizures occurring in pediatric patients receiving continuous infusion of bupivacaine. Anesth Analg 1992; 75: 284–6.
Berde CB. Convulsions associated with pediatric regional anesthesia. Anesth Analg 1992; 75: 164–6.
Author information
Authors and Affiliations
Corresponding author
Additional information
Study completed at the Alfred I. duPont Hospital for Children
Rights and permissions
About this article
Cite this article
Brenn, B.R., Brislin, R.P. & Rose, J.B. Epidural analgesia in children with cerebral palsy. Can J Anaesth 45, 1156–1161 (1998). https://doi.org/10.1007/BF03012456
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03012456