Epidural analgesia compared with intravenous analgesia after pediatric posterior spinal fusion.
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.


METHODS
Level 2, randomized, controlled trial.
Gauger
Virginia T
VT
Department of Anesthesiology, Section of Pediatrics, University of Michigan Health Systems, Ann Arbor, MI, USA.
Voepel-Lewis
Terri D
TD
Burke
Constance N
CN
Kostrzewa
Amy J
AJ
Caird
Michelle S
MS
Wagner
Deborah S
DS
Farley
Frances A
FA
D000293:Adolescent; D015360:Analgesia, Epidural / Q000009:adverse effects / Q000379:methods; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects / Q000379:methods; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D002045:Bupivacaine / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D002404:Catheterization / Q000379:methods; D002648:Child; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D007262:Infusions, Intravenous; D008297:Male; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy* / Q000209:etiology; D011446:Prospective Studies; D012600:Scoliosis / Q000601:surgery; D012720:Severity of Illness Index; D013035:Spasm / Q000188:drug therapy / Q000209:etiology; D013123:Spinal Fusion / Q000009:adverse effects* / Q000379:methods
D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D004091:Hydromorphone; D002045:Bupivacaine