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Epidural analgesia in children. A Survey of Current Opinions and Practices amongst UK Paediatric Anaesthetists.Williams DG and Howard RF. Paediatric Anaesthesia 2003;13:769-776
Reviewed by: Hoshang J. Khambatta, MD
The authors state that despite the widespread use of epidural analgesia in children, its place in pediatric pain management has not been clearly established. The authors surveyed pediatric anesthetists and pediatric pain management teams in the UK in order to investigate current practices. An initial questionnaire was sent to all members of the Association of Paediatric Anaesthetists of Great Britain and Ireland working within the UK (n = 254). A subgroup of anesthetists was identified as lead clinicians for acute pain in the major centers for pediatric surgery (n = 26). Each member of this subgroup was sent an expanded questionnaire. This expanded version was also sent to the clinical nurse specialist in pain management at each of the pediatric surgical centers, one of which had two hospitals but a single specialist nurse. Replies from pediatric anesthetists totaled 185 (73%), lead pain clinicians 23 (89%), and clinical nurse specialists 17 (68%). When calculating the overall percentage response to each question the denominator was the actual number of responders for that question.
Overall, epidural analgesia appears to be increasing in popularity. Half of the respondents from the initial questionnaire performed between two and five epidurals per month, a fifth did more then five, and a third did one or less per month. As for the pediatric surgical centers, half performed over 100 epidurals per year, a fifth did between 50 and 100, and a third less then 50 a year. Postoperative epidural analgesia was routinely considered for all age groups, including neonates, by half of the anesthetists. It was offered as a treatment for chronic pain in seven of the 26 main pediatric centers.
A consultant was present in 71% of the surgical centers during insertion of epidural catheter. Neonates and infants up to six months age had 100% supervision by a consultant. The procedure was discussed with parents and/or patient by 99% of the responders, of which only 5% obtained written consent. Adverse reactions were discussed, such as failure of technique, dural tap, neurological sequelae, infection, and if opioids were used - itching, urinary retention, and respiratory depression, but there was considerable variation as to what was discussed on each occasion. Abnormal coagulation and local infection was considered to be a contraindication by all responders, systemic infection was considered a contraindication by 70%. Neurological disease and bony deformity of the spine were evaluated on an individual basis, and some felt that in diseases such as cerebral palsy, epidural anesthesia may even be beneficial. Written protocols for management of epidurals were present in 88% of the centers and 43% had protocols for the technique itself. All epidurals were performed under general anesthesia. Aseptic technique using sterile gloves and towels were used by all, 79% also used sterile gowns, and 50% a face mask. Loss of resistance to injection was used by all to find the epidural space, followed by saline 79%, or by air 17%, and either by 4%. Application of continuous pressure to the syringe was used by 67%, intermittent pressure by 15%, and either by 18%. An 18 g or 19 g needle was normally used, 48% had a hospital policy specifying this choice. Of the anesthetists, 57% used a test dose, of which 74% used a local anesthetic, 1% used epinephrine, and 25% used a combination of these drugs. Nine percent gave local anesthetic through the needle before insertion of the catheter. The amount of catheter left in the space was variable, averaging 3 - 5 cm, depending on the level of insertion, site of surgery, age, weight, and size of the patient, and anesthetic drug usage. There was little consensus on the selection of the local anesthetic or the concentration used (most common was 0.25% bupivicaine), nor of the use of other drugs (most common fentanyl, morphine, and diamorphine) either during surgery or in the postoperative period. During surgery, half the responders used repeated boluses and the remainder used a continuous infusion after the initial dose. In the postoperative period, over half used an infusion alone and a third used an infusion plus extra doses as needed. Concurrent nonsteroidal analgesics were prescribed by most of the anesthetists. Post operative epidural management was shared between several groups within each hospital. Of the responders, 5% of the inserting anesthetist had the sole responsibility during the day and night. In 19%, there was supervision during the day by the inserting anesthetist, but outside of normal working hours, the responsibility fell on the on-call anesthetist. Over half of the responders felt the general ward to be the appropriate location for the child. Special designated areas were used by 32% of the responders, and 16% stipulated intensive care, where the nursing staff was specially trained in the care of epidurals, but the mandatory nurse patient ratio was not reported. A common minimum acceptable standard for monitoring was not identified. All responders agreed that some basic monitoring was required, but there was little consistency regarding the actual vital signs, or frequency and duration of monitoring. Pain score, sedation score, heart rate, and respiratory rate were advocated by the majority of the responders; and then in reducing frequency, blood pressure, oxygen saturation, nausea/vomiting, pruritis, motor function, and apnea monitor. Nasal oxygen was routinely given by 17% of the responders, and urinary catheter was routinely inserted by 31%. Most epidural catheters were removed on postoperative day two or three, with the maximum time being five to seven days. The removal of the epidural catheter was undertaken by the ward staff in 81% cases, the pain team was involved in 56%, and the anesthetist alone in 38% of the cases. A majority used a transparent dressing so that the insertion site could be inspected. The dressings were not changed, as it was considered a risk factor for accidentally displacing the catheter.
The practice of epidural analgesia was not audited by over a third of the pediatric surgical centers. In many centers, the audit system is still in its early stage. The data reported showed large variations in the incidence of complications among different hospitals, and it is difficult to draw any conclusions about this factor. A total of 30 serious events were reported, half were neurological, with foot drop and convulsions accounting for the majority of the problems. High blocks, total spinal, and Horner's syndrome were reported. Technical errors such as infusion pump programming and malfunctioning and drug doses formed the next largest group. No attributable mortalities were reported.
Of the 26 UK pediatric surgical centers, 23 had an acute pain team, of which 20% had been operating for less then a year. The composition of the teams differed between hospitals. In two hospitals, the pain team was run by a consultant anesthetist alone, in three hospitals a single specialist nurse dealt with acute pain, in the remainder both the anesthetist and the nurse were involved. An educational program for the management of epidurals was operating in all institutions.
Comments: The use of epidural analgesia in children in the UK appears to be increasing in popularity. This is despite any conclusive evidence for any benefit over other methods of analgesia and little data in terms of efficacy and outcome. Evidence is accumulating in the adult literature as to the benefits of epidural analgesia in major surgery. However, these findings need to be confirmed in children. Well constructed prospective, randomized, controlled trials are needed in all aspects of the technique. Because of the low numbers of epidurals performed, a multicenter approach will be needed. An ongoing audit is a potential tool for obtaining useful outcome data and should be undertaken by all centers. Adequate financial support and resources are vital for the operation of an acute pain service. Education of all staff in pain management is of great importance. The data reported in this study gives statistics related to the procedure of pediatric epidural anesthesia. No statistics were presented with regards to number or relative frequency of this procedure compared to others. Such information is sorely lacking. The true place of epidural analgesia in pediatric practice will not be fully elucidated until we have gathered an extensive body of thorough and extensive data concerning all aspects of the technique as compared to other methods. It is high time, that a major pediatric center in the US, either on its own or in conjunction with other centers, give us a definitive answer to the very important questions posed by our British colleagues.
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