Effect of Extradural Analgesia on Stress Responses to Abdominal Surgery in Infant

Abstract

We studied 40 children younger than 4 yr having elective abdominal surgery under general anaesthesia supplemented with either systemic opioids or extradural bupivacaine. Venous blood samples were obtained before tracheal intubation to measure baseline concentrations of adrenaline, noradrenaline, glucose, ACTH and cortisol. Additional samples were obtained 45 min after the start of surgery, at the end of surgery, 1 h and 24 h after the end of surgery. Plasma concentrations of bupivacaine were measured also in the extradural group at each sampling time. Both techniques provided acceptable analgesia, but the perioperative increases in adrenaline, glucose and ACTH were significantly greater in the opioid group. Noradrenaline concentrations decreased to less than baseline values in the extradural group and were significantly less than in the opioid group. The perioperative increase in cortisol was similar in the two groups, despite the differences in ACTH responses. Most responses returned to the baseline values within 24 h. Plasma bupivacaine concentrations remained within safe limits during the study, but systemic concentrations increased in some of the patients during postoperative infusion with 0.125% bupivacaine.

Current Status of Pain Management in Children

“…59,60 Although newer local anesthetic drugs are now available, bupivacaine remains frequently used; however, either L-bupivacaine or ropivacaine may be a more sensible choice when toxicity is a particular concern. 61 Agents new to acute pain treatment and with novel mechanisms of action, such as ketamine and clonidine, are being used systemically and epidurally.…”

Epidural and subarachnoid blockade in children

“…In recent years, single-shot, intermittent bolus and infusion epidural analgesia at the thoracic and lumbar levels have become more popular, often permitting light anaesthesia, minimal opioid use, early extubation and the avoidance of postoperative ventilation. The catabolic stress response to surgery is modified by epidural anaesthesia and analgesia [50][51][52] and in certain circumstances there is evidence that the postoperative outcome in high-risk cases is favourably influenced by epidural analgesia. Groups in which this appears to be the case include patients with gastro-oesophageal reflux undergoing fundoplication [53], children with respiratory disabilities undergoing abdominal surgery [54] and neonates undergoing repair of oesophageal atresia [55].…”

Respiratory complications due to inadequate analgesia following thoracotomy in a neonate

“…Extradural analgesia is known to attenuate the stress response in adults and has been shown to improve operative outcome in certain classes of adult patient [7]. In a recent comparison in infants, pen-operative extradural bupivacaine was demonstrated to attenuate the stress response more effectively than systemic opioids [8]. In addition, intra-operative extradural analgesia allows the use of low concentrations of potent volatile agents, avoidance of systemic opioids, early extubation and rapid return to normal activity.…”