Epidural Analgesia Versus Intravenous Fentanyl Infusion in Children with Cerebral Palsy Undergo Major Orthopedic Surgery: Randomized Controlled Trial
Keywords:Epidural analgesia, Intravenous fentanyl infusion, Postoperative pain control, Cerebral palsy, Major orthopedic surgery
Background : Pelvic varus derotation osteotomy and Dega osteotomy are major orthopedic procedures aim to correct hip subluxation in cerebral palsy patients. These procedures can cause severe postoperative pain which is difficult to manage especially in CP patients who have limited communication ability.
Objective : This study aimed to compare the effectiveness between intravenous fentanyl infusion and epidural analgesia for postoperative pain control.
Methods : A randomized controlled trial was conducted after institutional ethics committee’s approval. 34 patients were enrolled, all received general anesthesia for pelvic varus derotation osteotomy or Dega osteotomy. Then 17 patients were randomized to intravenous fentanyl infusion group (caudal block with intravenous fentanyl infusion) and 17 patients were randomized to epidural analgesia group (epidural block with continuous epidural infusion). The study drugs were continued for 24 hours postoperatively. Postoperative pain were assessed using the Noncommunicative Children’s Pain Checklist Postoperative version. Studied outcomes were: incidence of postoperative pain (NCCPC-PV >10), fentanyl rescue dose, postoperative pain score at PACU, 8, 16, 24 hours and peri-anesthetic complications. Data were analyzed using SPSS version 16.0. Statistics used were Mann–Whitney U-test, Pearson ChiSquare, and Fisher’s Exact Test. P < 0.05 was considered significant.
Results : Baseline characteristics were similar in both groups. The overall incidence of postoperative pain was 67% and the incidence of pain was not statistically different in each group (70.6 % in group IV fentanyl VS. 64.7 % in group epidural, p = 0.71.) Mean postoperative pain scores were not different except for 24 hours postoperatively (4 in IV fentanyl group VS. 1 in epidural group, p = 0.032). The most common complication is postoperative nausea and vomiting (29.4% in IV fentanyl group VS. 35.3% in epidural group, p = 0.714). There were no serious complications in both groups in this study.
Conclusion : Continuous epidural analgesia and intravenous fentanyl infusion for postoperative pain control in children with cerebral palsy undergo major orthopedic surgery resulted in similar pain control in first 24 hours after surgery.
Muthusamy K, Recktenwall SM, Friesen RM, Zuk J, Gralla J, Miller NH, et al. Effectiveness of an anesthetic continuous-infusiondevice in children with cerebral palsy undergoing orthopaedic surgery. J Pediatr Orthop 2010; 30:840-5.
Shrader MW, Jones J, Falk MN, White GR, Burk DR, Segal LS. Hip reconstruction is more painful than spine fusion in children with cerebral palsy. J Child Orthop 2015; 9:221-5.
Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth 2001; 87:62-72.
Moore RP, Wester T, Sunder R, Schrock C, Park TS. Perioperative pain management in children with cerebral palsy: comparative efficacy of epidural vs systemic analgesia protocols. Pediatr Anesth 2013; 23:720-5.
Kjeldgaard Pedersen L, Nikolajsen L, Rahbek O, Uldall Duch B, Møller-Madsen B. Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction. Acta Orthop. 2015; 87:176-82.
Løvstad RZ, Støen R. Postoperative epidural analgesia in children after major orthopaedic surgery. A randomised study of the effect on PONV of two anaesthetic techniques: low and high dose i.v. fentanyl and epidural infusions with and without fentanyl. Acta Anaesthesiol Scand 2001; 45:482-8.
Nolan J, Chalkiadis GA, Low J, Olesch CA, Brown TC.Anaesthesia and pain management in cerebral palsy.Anaesthesia 2000; 55:32-41.
Ohta K, Katsuno M, Kawana S, Namiki A. [Epidural opioids for post-operative pain control in pediatric patients with cerebral palsy]. Masui 1993; 42:664-8.
Peter JD, Franklyn PC, Etsuro KM. Smith’s anesthesia for infants and children. 8th ed. Mosby: Elsevier; 2011.
Kabara S, Kagawa T, Ikejima N, Takatsuji S, Sueda A. [Side Effects of Continuous Fentanyl Infusion for Postoperative Pain Relief in Children]. Masui 2015; 64:799-803.
Bernard R. Fundamentals of biostatistics (5th ed.). Duxbery: Thomson learning, 2000; 384-5.
Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions (3rd ed.). John Wiley & Sons; 2003.
Ngamjarus C, Chongsuvivatwong V. n4Studies: Sample size and power calculations for iOS. The Royal Golden Jubilee Ph.D. Program - The Thailand Research Fund & Prince of Songkla University; 2014.
Liabsirinon S, Tantilipikorn P, Mahasup N. Interrater reliability Thai version of gross moter function classification system (GMFCS) in Thai children with cerebral palsy 2008; 1: 26-36
Breau LM, Finley GA, McGrath PJ, Camfield CS. Validation of the Non-communicating Children’s Pain ChecklistPostoperativeVersion. Anesthesiology 2002; 96:528-35.
Montalee S, Samerduen K, Wimonrat S, Duenpen H.Reliability and validity of the Thai version of noncommunicating childrens pain checklist-postoperative version (NCCPC-PV).
Johansen A, Romundstad L, Nielsen CS, Schirmer H, Stubhaug A. Persistent postsurgical pain in a general population: prevalence and predictors in the Tromsø study. Pain 2012; 153:1390-6.
Lynn MB, G. AF,Patrick JM, Carol SC.Validation of the Non-communicating Children’s Pain Checklist–Postoperative Version. Anesthesiology 2002; 96:528–35.
Heyland K, Dangel P, Gerber AC. Postoperative nausea and vomiting (PONV) in children. Eur J Pediatr Surg 1997; 7:230-3.
Naja Z, Kanawati S, Al Khatib R, Ziade F, Naja ZZ, Naja AS, et al. The effect of IV dexamethasone versus local anesthetic infiltration technique in postoperative nausea and vomiting after tonsillectomy in children: A randomized double-blind clinical trial. Int J Pediatr Otorhinolaryngol 2017; 92:21-6.
Kozek-Langenecker SA, Marhofer P, Jonas K, Macik T, Urak G, Semsroth M. Cardiovascular criteria for epidural test dosing in sevoflurane- and halothane-anesthetized children. Anesth Analg 2000; 90:579-83.
Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, et al. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:862-75.
How to Cite
ข้อความและข้อคิดเห็นต่างๆ เป็นของผู้เขียนบทความ ไม่ใช่ความเห็นของกองบรรณาธิการหรือของวารสารกรมการแพทย์