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Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion.
J Pediatr Orthop. 2009 Sep; 29(6):588-93.JP

Abstract

BACKGROUND

Pain management remains challenging for pediatric patients after posterior spinal fusion (PSF). This study compares the effectiveness of hydromorphone and bupivacaine administered through patient-controlled epidural analgesia (PCEA) with hydromorphone patient-controlled intravenous analgesia (IV-PCA) in this population.

METHODS

Patients aged 8 to 18 years undergoing PSF for idiopathic scoliosis were randomized to receive either PCEA (0.1% bupivacaine plus hydromorphone 10 mcg/mL at 8 mL/h plus bolus dosing) or IV-PCA (hydromorphone 2 mcg/kg/h continuous infusion; 2 mcg/kg bolus dose). Pain scores, severity of muscle spasms, and analgesic doses were recorded for 3 postoperative days (PODs). Adverse events were followed until discharge.

RESULTS

Thirty-eight patients were included (19 PCEA and 19 IV-PCA). Seven in the PCEA group (37%) experienced early epidural failure, and 2 in the IV-PCA group remained intubated, sedated, and ventilated for several hours postoperatively; these patients were included in the intention-to-treat analysis. All data are presented as "per protocol" unless otherwise specified. Pain scores were significantly lower on days 2 and 3 (P < or = 0.042). Eight percent of the patients who received PCEA experienced moderate-to-severe spasms through POD 3 compared with 35% of those in the IV-PCA group (P=NS). Seven (58%) patients in the PCEA group and 17 (100%) in the IV-PCA group required diazepam (P=0.007).

CONCLUSIONS

Epidural catheters provide modestly improved analgesia in patients after PSF for idiopathic scoliosis. However, the high failure rate in this population emphasizes a need for a close assessment for adequate blockade early in the recovery period. This study provides an excellent platform on which to build future trials that could include increased baseline dosing for the epidural medications, radiographic confirmation of catheter placement, and dual catheter techniques toward the goal of improving pain control in these patients.

LEVEL OF EVIDENCE

Level 2, randomized, controlled trial.

Authors+Show Affiliations

Department of Anesthesiology, Section of Pediatrics, University of Michigan Health Systems, Ann Arbor, MI, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

19700988

Citation

Gauger, Virginia T., et al. "Epidural Analgesia Compared With Intravenous Analgesia After Pediatric Posterior Spinal Fusion." Journal of Pediatric Orthopedics, vol. 29, no. 6, 2009, pp. 588-93.
Gauger VT, Voepel-Lewis TD, Burke CN, et al. Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion. J Pediatr Orthop. 2009;29(6):588-93.
Gauger, V. T., Voepel-Lewis, T. D., Burke, C. N., Kostrzewa, A. J., Caird, M. S., Wagner, D. S., & Farley, F. A. (2009). Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion. Journal of Pediatric Orthopedics, 29(6), 588-93. https://doi.org/10.1097/BPO.0b013e3181b2ba08
Gauger VT, et al. Epidural Analgesia Compared With Intravenous Analgesia After Pediatric Posterior Spinal Fusion. J Pediatr Orthop. 2009;29(6):588-93. PubMed PMID: 19700988.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion. AU - Gauger,Virginia T, AU - Voepel-Lewis,Terri D, AU - Burke,Constance N, AU - Kostrzewa,Amy J, AU - Caird,Michelle S, AU - Wagner,Deborah S, AU - Farley,Frances A, PY - 2009/8/25/entrez PY - 2009/8/25/pubmed PY - 2009/11/18/medline SP - 588 EP - 93 JF - Journal of pediatric orthopedics JO - J Pediatr Orthop VL - 29 IS - 6 N2 - BACKGROUND: Pain management remains challenging for pediatric patients after posterior spinal fusion (PSF). This study compares the effectiveness of hydromorphone and bupivacaine administered through patient-controlled epidural analgesia (PCEA) with hydromorphone patient-controlled intravenous analgesia (IV-PCA) in this population. METHODS: Patients aged 8 to 18 years undergoing PSF for idiopathic scoliosis were randomized to receive either PCEA (0.1% bupivacaine plus hydromorphone 10 mcg/mL at 8 mL/h plus bolus dosing) or IV-PCA (hydromorphone 2 mcg/kg/h continuous infusion; 2 mcg/kg bolus dose). Pain scores, severity of muscle spasms, and analgesic doses were recorded for 3 postoperative days (PODs). Adverse events were followed until discharge. RESULTS: Thirty-eight patients were included (19 PCEA and 19 IV-PCA). Seven in the PCEA group (37%) experienced early epidural failure, and 2 in the IV-PCA group remained intubated, sedated, and ventilated for several hours postoperatively; these patients were included in the intention-to-treat analysis. All data are presented as "per protocol" unless otherwise specified. Pain scores were significantly lower on days 2 and 3 (P < or = 0.042). Eight percent of the patients who received PCEA experienced moderate-to-severe spasms through POD 3 compared with 35% of those in the IV-PCA group (P=NS). Seven (58%) patients in the PCEA group and 17 (100%) in the IV-PCA group required diazepam (P=0.007). CONCLUSIONS: Epidural catheters provide modestly improved analgesia in patients after PSF for idiopathic scoliosis. However, the high failure rate in this population emphasizes a need for a close assessment for adequate blockade early in the recovery period. This study provides an excellent platform on which to build future trials that could include increased baseline dosing for the epidural medications, radiographic confirmation of catheter placement, and dual catheter techniques toward the goal of improving pain control in these patients. LEVEL OF EVIDENCE: Level 2, randomized, controlled trial. SN - 1539-2570 UR - https://www.unboundmedicine.com/medline/citation/19700988/Epidural_analgesia_compared_with_intravenous_analgesia_after_pediatric_posterior_spinal_fusion_ L2 - https://doi.org/10.1097/BPO.0b013e3181b2ba08 DB - PRIME DP - Unbound Medicine ER -