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Multimodal Analgesia Approach for Scoliosis Spinal Fusion Surgery in a Pediatric Patient with Duchenne Muscular Dystrophy: A Case Report
Joshua Lee, MD; Bryant Tran, MD; Seamus Dore, MD
Virginia Commonwealth University Health System Department of Anesthesiology
Multimodal analgesia is the combination of two or more drug classes or analgesic techniques resulting in additive or synergistic analgesic effects . This method can lead to a lower incidence of opioid-related adverse effects and improved pain control which can lead to shorter hospitalization times, improved recovery, decreased healthcare costs, and decreased chronic post-surgical pain development.1 However, multimodal pain therapies have been less well studied in the pediatric population. The use of subanesthetic ketamine for analgesia has recently surged in an effort to minimize perioperative opioid use.2 Perioperative intravenous lidocaine has been shown to decrease post-operative opioid consumption and decrease chronic post-surgical pain development in several studies.3Dexmedetomidine is known to have actions on peripheral and central targets that lead to opioid-sparing effects and improved post-operative pain. 4 The risks and benefits of analgesic therapies have to be considered based on patient comorbidities. Duchenne Muscular Dystrophy is a disease known to cause a decrease in cardiopulmonary reserve which can be problematic in the perioperative period. In addition, succinylcholine and volatile anesthetics are contraindicated in these patients. 5 The goal of this case was to provide effective intraoperative multimodal analgesia to minimize post-operative pain scores, decrease post-operative opioid consumption, and decrease the risk of post-operative cardiopulmonary complications associated with opioids in a patient with an increased risk of developing significant post-operative pain and cardiopulmonary complications.
Thirteen year old 64-kg male with a history of Duchenne Muscular Dystrophy, moderate obstructive sleep apnea s/p tonsillectomy & adenoidectomy on nightly BiPAP, scoliosis, extremity contractures, diminished strength in all extremities, baseline tachycardia, and restrictive lung disease presented for T3-L5 posterior spinal fusion. TIVA required for case due to underlying Duchenne Muscular Dystrophy. Prior to case, volatile anesthetics removed from Drager anesthesia machine. The anesthesia circuit was appropriately changed and flushed with charcoal filters applied. Maintenance of anesthesia provided with the medications listed in Table 1 with rate adjustments based on patient hemodynamics. Acetaminophen IV and ondansetron IV administered. Patient extubated in OR and transported to pediatric ICU on 6 LPM nasal cannula for overnight cardiopulmonary monitoring. Patient had no cardiopulmonary complications and only required routine nightly BiPAP. Documented post-operative pain scores listed in Figure 1. Pain rated as 1/10 at two week orthopedic follow-up, 0/10 at one month follow-up, and 0/10 at four month follow-up.
This case report demonstrates an effective intra-operative multimodal analgesic regimen resulting in minimal post-operative pain after an extensive spine surgery with no postoperative complications in a patient at increased risk of developing significant postoperative pain and cardiopulmonary complications. Of note, no additional breakthrough pain medications were required for the duration of the hospitalization. Extensive research has been performed in regard to analgesic adjuncts. However, many multimodal pain medications do not have approved labeling for pediatric use with current dosing recommendations based on limited studies or individual clinical experience. Further research is needed to determine the most effective pediatric multimodal analgesic regimens and the appropriate pediatric dosing for these regimens in the perioperative setting.
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2. Cohen SP, Bhatia A, Buvanendran A, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine. 2018; 43(5):521-546. doi:10.1097/AAP.0000000000000808.
3. Dunn LK, Durieux ME. Perioperative Use of Intravenous Lidocaine. Anesthesiology. 2017; 126 (4):729-737. doi:10.1097/ALN.0000000000001527
4. Bellon M, Le Bot A, Michelet D, et al. Efficacy of Intraoperative Dexmedetomidine Compared with Placebo for Postoperative Pain Management: A Meta-Analysis of Published Studies. Pain and Therapy. 2016; 5(1): 63-80. doi:10.1007/s40122-016-0045-2.
5. Stoelting RK, Hines, RL, Marschall KE. Stoelting's Anesthesia and Co-Existing Disease. Philadelphia: Saunders/Elsevier, 2012. Internet resource.