title: Continuous chloroprocaine infusion for thoracic and caudal epidurals as a postoperative analgesia modality in neonates, infants, and children.
abstract: BACKGROUND
  Neonates and infants have decreased metabolic capacity for amide local anesthetics and increased risk of local anesthetic toxicity compared to the general population. Chloroprocaine is an ester local anesthetic that has an extremely short plasma half-life in infants as well as adults. Existing reports support the safety and efficacy of continuous chloroprocaine epidural infusions in neonates and young infants during the intraoperative period. Despite this, continuous chloroprocaine epidural infusion may be an under-utilized method of postoperative analgesia for this patient population. In particular, it may improve pain control in neonates and infants with incisions stretching many dermatomes or those with hepatic impairment.
  
  
  METHODS
  We retrospectively reviewed our experience over 4 years with continuous chloroprocaine epidural infusions in neonates, infants, and children with a focus on the postoperative management of pain.
  
  
  RESULTS
  Twenty-one pediatric patients received continuous 2-chloroprocaine epidural infusions for postoperative pain management from January 2010 to April 2014 for thoracic, abdominal, and limb procedures. The epidural infusion consisted of 1.5% chloroprocaine or 1.5% chloroprocaine with fentanyl. Tabulating the morphine and hydromorphone used for rescue analgesia, the median (interquartile range) opioid consumption (mg·kg(-1) ·day(-1) of intravenous morphine equivalents) for the first, second, and third 24-h postoperative periods were 0.02 (0-0.48), 0.30 (0-0.44), and 0.14 (0-0.29), respectively. Examining the total fentanyl usage, the median (interquartile range) fentanyl consumption (μg·kg(-1) ·day(-1)) for first, second, and third 24-h postoperative periods were 3.89 (0.41-7.24), 0 (0.00-4.06), and 0 (0.00-0.51), respectively. The median N-PASS score assessed every 6 h from 0 to 72 h postoperatively was 0, 1, 2, 0, 0, 1, 0, 0, 0, 0, 1, 0, and 0, respectively. The median FLACC score assessed every 6 h from 0 to 72 h postoperatively was 0, 0, 2, 0, 0, 0, 0, 0, 0, 0, 0, 0, and 0, respectively.
  
  
  CONCLUSIONS
  The results suggest that chloroprocaine offers an efficacious alternative to the amide local anesthetics for postoperative epidural analgesia in the pediatric population.
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Veneziano
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Iliev
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tripi
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: David
authors.initials: D
authors.lastname: Martin
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Aldrink
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Tarun
authors.initials: T
authors.lastname: Bhalla
authors.affiliation: Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.|Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Tobias
mesh_terms: D015360:Analgesia, Epidural / Q000379:methods*; D000767:Anesthesia, Epidural / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007262:Infusions, Intravenous; D008297:Male; D010149:Postoperative Pain / Q000188:drug therapy*; D011343:Procaine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000779:Anesthetics, Local; D011343:Procaine; C004616:chloroprocaine
keywords: analgesia; anesthetics; chloroprocaine; epidural; infant; local; newborn; pain; pain management; postoperative