Epidural analgesia in children with cerebral palsy

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. I 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 ( (21) 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 91192 patients. Excessive sedation occurred in six patients (6.5%) but only in IB patients, (P < 0.02 vs Cl). Emesis occurred in 52% of patients, and was more common in diplegic than in quadriplegic patients (68% v~ 38%, P < 0.01). Pruritus was observed in 29% of patients and was more common in diplegia than quadriplegia (48% vs 12.5%, P < 0.00 I). 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. Cx)nck~ions: 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. l~]t~ts: Une excellente analg&ie a ~t~ obtenue chez 91 des 92 patients. Une s~dation excessive a ~t~ not& chez six patients (6,S %) mais clans le groupe BI seulement, (P < 0,02 vs CP). Chez 52 % des patients, il y a eu des vomissements qui ~taient plus frequents chez les enfants dipl~giques que chez les quadriplEgiques (68 % vs 38 %, P < 0,01). On a observ~ du prurit chez 29 % des enfants et surtout chez les diplEgiques par rapport aux quadripl~giques (48 % vs 12,5 %, P < 0,00 I). l'incidence de l'hypopn~e, de l'hypox~mie, de la r&ention urinaire et des convulsions n'~tait pas influenc~e par le type d'IMC ou d'analg&ie et aucune diff&ence de s~dation n'a ~t~ observ~e entre les patients dipl~giques et les patients quadripl~giques. C~nd~sion : La perfusion continue de bupivacaine et de fentanyl p&iduraux a fourni une excellente analg&ie, sans complications importantes, ~ des enfants atteints d'IHC. Les bolus intermittents de morphine p&idurale ont ~t~ associ& ~ une plus forte incidence de s~dation excessive et on devrait ~viter de les utiliser aupr& de cette population.From the

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

“…28 The reasons for this are multifactorial and include a combination of altered upper airway tone, difficulties clearing secretions and swallowing, potential sleepdisordered breathing, and reactive airway disease secondary to often silent aspiration. 5,17,[29][30][31][32] Sedation scores were similar between the groups, in keeping with the study by Cucchiaro et al 9 that demonstrated (using a lower clonidine dose) similar sedation scores in children receiving fentanyl and clonidine.…”

“…17 Adding epidural fentanyl to bupivacaine resulted in better analgesia after unilateral femoral osteotomy in healthy children 18 but has been associated with oxygen desaturation and pruritis in children with CP. 5 Adding clonidine to epidural local anaesthetic has theoretical advantages. It is used in the treatment of spasticity 19,20 and epidural clonidine has been shown in itself to be analgesic.…”

“…• Adding fentanyl results in more vomiting and oxygen desaturation. recovery room until the epidural was removed or for 72 hours: (1) heart rate, arterial oxygen saturation, respiratory rate; (2) pain score, sedation score, muscle spasm score: highest score attained for that hour; (3) epidural interventions (boluses or rate change or withdrawal of catheter), administrations of diazepam or paracetamol; (4) vomited (yes/no) and administration of anti-emetics; (5) blood pressure and temperature.…”

“…Continuous epidural infusion with bupivacaine and fentanyl is advantageous over intermittent epidural morphine boluses, but using fentanyl is associated with a high incidence of pruritus (23%) and emesis (55%). 5 Clonidine is an a-2-adrenroreceptor agonist that is widely used in paediatric anaesthesia as a pre-medication, to reduce emergence delirium and as an adjunct in regional anaesthesia. 6 The use of epidural clonidine has several potential benefits.…”

Postoperative pain

“…Epidural opioids are effective, reduce the dose requirements of local anesthetic and rescue i.v. opioids but increase the incidence of side effects: Grade B (182,189,190).…”