Comparing Wound Catheters and Epidurals in Paediatric Open Pyeloplasty. L de Neumann FRCA , BMBS, BSc/Econ (Hons); T Samuels MBBS, Bsc (Hons) FRCA , FFICM, Cert Maths , Dip Maths, Dip Stats, BA (Hons) Math Stat, AMIMA, GradStat ; A Mishra FRCA
Royal Alexandra Children’s Hospital, Brighton, UK
The majority of studies comparing wound catheters and epidurals in abdominal surgery have been done in adults (1-3) and none concern paediatric open pyeloplasties. We retrospectively compared pain scores, opiate consumption and side effect profile between these groups in our institution between 2011 and 2015.
Eighteen patients aged 18 weeks to 15 years were included in this study. Eleven had a wound catheter and seven an epidural. Epidurals were high lumbar or low thoracic. Wound catheters were placed either subcutaneously (3), above the internal oblique (3) in the transversus abdominus plane (3), or in an unrecorded location (2) by the surgeon.
Postoperatively patients received paracetamol and NSAID. 90.1% of the wound catheter group and 42.9% of the epidural group had a PCA. PRN oral morphine was given once the PCAs were stopped. All patients were cared for in the High Dependency Unit and had hourly reviews of their pain and sedation.
Patient notes were reviewed for pain scores (11 point scale), opiate consumption, antiemetic consumption, sedation scores, and respiratory depression. All opiates consumed from induction of anaesthesia to discharge were recorded and converted to the morphine equivalent, with the exception of remifentanil.
Our results suggest epidurals and wound catheters provide comparable analgesia, with no statistically significant difference in the highest pain score in the first 24 hours, in opiate consumption, anti-emetic use or length of stay. There was no difference in sedation scores or respiratory depression as measured by naloxone or O2 use. The low numbers in this study however mean that it may be underpowered to adequately detect differences.
If a post operative analgesic package using wound catheters provides comparable analgesia then their improved side effect profile may make them preferable to epidurals. Measuring markers of recovery such as time to bowel opening, micturition, mobilisation and resumption of oral intake would provide additional information.
This was a retrospective study looking at a small heterogeneous group in terms of catheter and epidural anatomical location and choice of perioperative medications. Future studies should use a larger sample size to provide adequate power, and a standardized perioperative care pathway.
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2.R. Bell, S. Pandanaboyana and K. Raj Prasad, "Epidural versus local anaesthetic infiltration via wound catheters in open liver resection: a meta-analysis," ANZ Journal of Surgery, vol. 85, pp. 16-21, 2015.
3.M. J. Hughes, E. M. Harrison, N. J. Peel, B. Stutchfield, S. McNally, C. Beattie and S. J. Wigmore, "4. Randomized clinical trial of perioperative nerve block and continuous local anaesthetic infiltration via wound catheter versus epidural analgesia in open liver resection (LIVER 2 trial)," British Journal of Surgery, vol. 102, pp. 1619-1628, 2015.