Audit of Extrapleural Local Anaesthetic Infusion in Neonates following Repair of Tracheo-Oesophageal Fistulae and Oesophageal Atresia via Thoracotomy

Abstract

In order to reduce postoperative opioid requirement, extrapleural local anaesthetic infusion dosing recommendations and guidelines for extrapleural catheter insertion were developed in our institution for ‘extubatable’ neonates requiring short-gap neonatal tracheo-oesophageal fistula/oesophageal atresia repair (via thoracotomy) and audited prospectively. Data audited included patient characteristics, analgesia details and ventilation duration. We divided patients into two groups: group 1 – term patients (>36 weeks gestational age) with birth-weights >2.5 kg; group 2 – pre-term patients (<36 weeks gestational age), with birth weights <2.5 kg and those with co-morbidities. There were 26 neonates in group 1 and 11 in group 2. All received extrapleural infusions of bupivacaine or levobupivacaine: the majority (90%) <300 μg.kg−1.hour−1 (median duration 43 hours, range 1.5 to 72 hours); 36% required morphine infusion and 39% were ventilated (median duration 34 hours, range 3 to 140 hours). In group 1, 24% required morphine infusion compared with 64% in group 2. Most group 1 patients (77%) were extubated immediately postoperatively; 20% had short duration ventilation (median 15 hours, range 11 to 37 hours); one required longer-term ventilation (231 hours). 82% of group 2 were ventilated for a median of 72 hours (range 3 to 140 hours). Review of patients’ co-morbidities facilitated guideline revision. These now specify use in neonates requiring short-gap tracheo-oesophageal fistula/oesophageal atresia repair who are term at >36 weeks gestational age and >2.5 kg birth-weight, anticipated as ready for extubation either immediately or shortly after surgery.

Local anesthetic dosing and toxicity of pediatric truncal catheters: a narrative review of published practice

“…This occurred in the setting of infusions in neonates that either avoided a bolus 31 51 or used a small bolus (eg, 0.5 mg/kg). 38 TAP catheters represented a minority of catheters (48 out of 945 patients, 5%), and except for a case series of six cases, 39 all used doses below the median 24-hour dose of PVB catheters.…”