Evaluating the role for regional analgesia in children with spina bifida: a retrospective observational study comparing the efficacy of regional versus systemic analgesia protocols following major urological surgery

Abstract

IntroductionRegional techniques are a key component of multimodal analgesia and help decrease opioid use perioperatively, but some techniques may not be suitable for all patients, such as those with spina bifida. We hypothesized peripheral regional catheters would reduce postoperative opioid use compared with no regional analgesia without increasing pain scores in pediatric patients with spina bifida undergoing major urological surgery.MethodsA retrospective review of a multicenter database established for the study of enhanced recovery after surgery was performed of patients from 2009 to 2021 who underwent bladder augmentation or creation of catheterizable channels. Patients without spina bifida and those receiving epidural analgesia were excluded. Opioids were converted into morphine equivalents and normalized to patient weight.Results158 patients with pediatric spina bifida from 7 centers were included, including 87 with and 71 without regional catheters. There were no differences in baseline patient factors. Anesthesia setup increased from median 40 min (IQR 34–51) for no regional to 64 min (IQR 40–97) for regional catheters (p<0.01). The regional catheter group had lower median intraoperative opioid usage (0.24 vs 0.80 mg/kg morphine equivalents, p<0.01) as well as lower in-hospital postoperative opioid usage (0.05 vs 0.23 mg/kg/day morphine equivalents, p<0.01). Pain scores were not higher in the regional catheters group.DiscussionContinuous regional analgesia following major urological surgery in children with spina bifida was associated with a 70% intraoperative and 78% postoperative reduction in opioids without higher pain scores. This approach should be considered for similar surgical interventions in this population.Trial registration numberNCT03245242.

The role of enhanced recovery after surgery (ERAS) in promoting quality improvement and patient safety in pediatric urology

“…A study of children with VP shunts undergoing augmentation cystoplasty using bowel found no difference in the rate of shunt infections between those who did and did not undergo bowel preparation (34). Similarly, there were no VP shunt infections following introduction of an ERAS protocol for pediatric urinary tract reconstruction that included elimination of a dedicated, preoperative bowel preparation and maintenance of routine outpatient bowel regimens in those with concomitant neurogenic bowel (10). This particular example illustrates the consideration in outcomes among different patient populations when evaluating whether intended effects of ERAS elements are equally distributed.…”

“…Thus, achieving intraoperative euvolemia with the goal of maintaining adequate renal perfusion is of the utmost importance (40). This tenet is reflected in the ubiquitous adoption of minimizing excessive intraoperative fluids in both pediatric colorectal surgery and pediatric urology (4,7,10,41,42).…”

“…Similarly, drain placement has not been associated with improved outcomes in select pediatric surgeries, including upper urinary tract reconstruction (53)(54)(55). Numerous studies in pediatric urology have successfully incorporated this component into their enhanced recovery protocols without an increase in adverse events, further supporting the safety of this approach (8,10,50,56). Current evidence seems poised to obviate operative drain placement in many pediatric urologic procedures.…”

“…Time and time again, ERAS has resulted in reductions in hospital LOS for children across different surgical specialties that are both statistically and clinically significant (7,9,41,42,58). One study in children undergoing urologic reconstruction noted that the greater the number of ERAS elements implemented, the shorter the LOS (10). This suggests an additive effect of individual elements in contributing to outcomes.…”

“…Within pediatric urology, ERAS pathways have been studied in children undergoing operations ranging from pyeloplasty to complex lower urinary tract reconstructions involving augmentation cystoplasty and/or urinary diversion (8,9). Additional consideration has been given to children with comorbidities, such as spina bifida or ventriculoperitoneal shunts, to ensure that a greater proportion of patients can benefit from these interventions (10,11). In the evolving landscape of quality improvement (QI) in healthcare, ERAS is a central component to value-based care and a valuable tool that balances safety, outcomes, and surgical experiences for patients and families.…”