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CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 5  |  Page : 438 Table of Contents     

Thoracic epidural analgesia as an adjunct to general anaesthesia in a case of lung cyst removal in an infant


1 MD Specialist, St. Stephen's Hospital, Delhi, India
2 DNB Senior Resident, St. Stephen's Hospital, Delhi, India

Date of Acceptance31-Aug-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Mamta Aggarwal
K-31, Plot no - 114, Indraprastha Apartments, I. P. Extension, Delhi - 110092
India
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Source of Support: None, Conflict of Interest: None


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Paediatric thoracic and lumbar epidural analgesia is an integral part in the management of pain in neonates and children. We present a case of left lower lobe lung cyst in a 2 months old infant. The infant underwent excision of the lung cyst under general anaesthesia combined with thoracic epidural analgesia using an epidural catheter inserted via the caudal route. Analgesia was provided using 0.25% bupivacaine with 10mcg of fentanyl. No muscle relaxant was used throughout the surgery. The result showed a marked decrease in the requirement of anaesthetic drugs along with epidural analgesia, reduced surgical stress, and smooth recovery.

Keywords: Thoracic epidural, Paediatric surgery, Fentanyl, Surgical stress.


How to cite this article:
Aggarwal M, Bansal R. Thoracic epidural analgesia as an adjunct to general anaesthesia in a case of lung cyst removal in an infant. Indian J Anaesth 2007;51:438

How to cite this URL:
Aggarwal M, Bansal R. Thoracic epidural analgesia as an adjunct to general anaesthesia in a case of lung cyst removal in an infant. Indian J Anaesth [serial online] 2007 [cited 2020 Nov 28];51:438. Available from: https://www.ijaweb.org/text.asp?2007/51/5/438/61179


   Introduction Top


It has been a relatively recent recognition that neo­nates and small children do feel pain; but because of the fear of overdose, they are under treated perioperatively. Pain associated with surgery, involving the major cavi­ties of abdomen or thorax, is severe, [1] and pain brings forth many deleterious physiological effects. It also gives rise to increase in stress response leading to catabolism and hampers early healing process. [2],[3],[4] So alleviating pain in children is very exciting and rewarding for anaesthesiologists.

Paediatric thoracic and lumbar epidural analgesia, [5],[6] combined with general anaesthesia is receiving its de­served attention as an excellent technique for a balanced intraoperative anaesthesia as well as for post-operative analgesia. [7] It decreases the requirement of intra-opera­tive anaesthetic agents, [8] enabling fast and smooth re­covery. However, this lumbar and thoracic epidural block may be technically difficult and hazardous for anatomi­cal reasons in infants. To achieve adequate analgesia for upper abdominal or thoracic surgery via caudal route as a single injection, requires a large volume of local anaesthetic agent with potential toxicity, morbidity, and even mortality. [9] We therefore, used the thoracic epidu­ral catheter via the caudal route.


   Case report Top


A 2-months-old female child weighing 5kg, having a left sided pneumothorax, and left lower lobe cysts was scheduled for left lower lobectomy by thoracotomy. The patient was admitted with history of fever and difficulty in breathing since 8 hours prior to admission. Preopera­tive evaluation of the baby showed decreased air entry on left side. No other detectable congenital anomalies were seen. On routine investigation, anaemia (Hb-9.2gm %) was present. Chest X-ray showed lung cysts with collapsed left lung, with mediastinal shift towards right side [Figure 1] and [Figure 2]. Patient was accepted for elective sur­gery under ASA class II.

In the preoperative evaluation, informed written consent from parents was obtained after explaining the nature of anaesthesia. The infant was allowed to be breast fed till 3 hours before surgery. Baby was pre­medicated with atropine 0.1 mg IM, and was shifted to operation theatre.

In the theatre, patient was placed on a warm mat­tress, limbs covered with cotton, and a precordial stetho­scope and pulse-oximeter probe were placed. Child was induced with halothane in increments of 0.5% up to 1% in 5 litres of oxygen, no nitrous oxide was used. Once the baby was sleepy, ECG, NIBP, and skin temperature probes were connected. Peripheral venous access was secured by 22G intravenous catheter, and intubated with 3.5 mm ID plain endotracheal tube and a pharyngeal gauze pack was inserted. Anaesthesia was maintained on IPPR with oxygen and halothane 0.5%, and no relax­ant was given. Under aseptic precautions, a 20G Portex epidural catheter was inserted through an 18G intrave­nous catheter via caudal route, placing the child in lat­eral position, and threaded up to T4 level after measur­ing the catheter from sacral hiatus to line of incision. After negative aspiration for blood and CSF, a test dose of 0.5 ml of 1% lidocaine with adrenaline was adminis­tered. A loading dose of 5 ml of bupivacaine 0.25% along with 10-mcg fentanyl (2mcg.kg -1 )[10] was adminis­tered after obtaining supine position and ascertaining that heart rate was stable. It was calculated using the Takasaki et al[11] formula (0.05ml.kg -1 per no. of der­matomes to be blocked) [Figure 2].

Intraoperative parameters such as heart rate and blood pressure were noted at10-minute intervals. Inci­sion was given 20 minutes after the administration of the bolus dose. Analgesia was considered adequate in the absence of any rise in heart rate on incision. Surgery lasted 3 hours 40 minutes. One epidural top up dose of (0.25% bupivacaine 2.5 ml), was given 90 minutes after start of surgery, as wearing off of analgesia was indi­cated by rise in heart rate more than 10% of baseline. At the end of surgery, child regained consciousness within 5 minutes, and was extubated on table after ascertaining the HR, BP, RR, and colour of the child. Throughout surgery vitals were maintained. Another top up was given of 5 ml of 0.125% bupivacaine with 10mcg fenta­nyl before shifting to PICU. Next top up was required 8 hours later, and no further doses were required. Cath­eter was removed 24 hours post operatively.


   Discussion Top


Widespread acceptance of the necessity of pain relief in infants and neonates, has led to modifications of the existing modalities, chief amongst them being neuraxial block. Caudal epidural anaesthesia is the regional tech­nique of choice for surgeries below the umbilicus, and this is increasingly being used for upper abdominal and thoracic surgeries, [12],[13] in an attempt to minimize risks in term, preterm and high risk neonates. [14] To achieve ad­equate analgesia for upper abdominal or thoracic sur­gery via caudal route as a single dose would require a large volume of local anaesthetic agent with hazardous consequences. Insertion of an epidural catheter through the caudal approach is a time honored technique, and feasible as demonstrated by Ecoffey et al. [15]

In our case, we encountered no difficulty in place­ment or threading of the epidural catheter. The use of intravenous catheter for insertion of epidural catheter was similar to the technique used by Gunter et al. [16] Threading of the catheter to the required distance, (in our case being T4 level), is helped by the presence of spongy, gelatinous nature of fat in neonates as described by Gunter et al, and Bosenberg et al. [16],[17] By precise placement of the epidural catheter, the dermatomes in­volved in the surgical procedure may be selectively blocked, minimizing the dose of local anaesthetic required to provide analgesia. [18]

The use of a test dose, along with aspiration was done to prevent any in advertent intravenous injection, using 0.5 ml of 1% lidocaine with adrenaline. The bolus dose of 5 ml of 0.25% bupivacaine with 10 mcg of fentanyl, and further top up doses were effective in providing adequate analge­sia intra-operatively, and post-operatively. [19] The total dose of bupivacaine administered was within the prescribed safety limits without any adverse effects. [20],[21]

The success of the epidural block in terms of anal­gesia and motor block was assessed by comparing the cardiovascular parameters (heart rate and blood pres­sure), at incision, and at 10 min intervals intra-opera­tively. The variation in these parameters was within 10% of baseline. Only one top up dose was required 90 min after the start of surgery. These findings are consistent with the studies performed by Ecoffey et al [5] , Ruston et al [6] , and Schulte-Steinberg et al [7] .

No significant intra operative complications such as, hypotension, bradycardia, or arrhythmias were noted. [22] The requirement of anaesthetics intra opera­tively was decreased. The child was extubated on table after return of consciousness, with very little cry and pain.

Based on our experience in this case, and as cited by various studies; epidural analgesia for thoracic sur­geries via catheter threaded through the caudal route in conjunction with general anaesthesia, is feasible, effec­tive, and safe in small infants. It reduces surgical stress, leads to decreased anaesthetic requirement, and improves recovery with early ambulation. The findings in this case report are consistent with observations in several ran­domized control trials that have been cited in literature.

 
   References Top

1.McNicol LR. Paediatric Analgesia. In: Walter Nimmo and Rowbatham Smith, 2nd edition, editors. Textbook of Anaesthesiology. Blackwell Scientific Publication1989pg 1602­-1616.  Back to cited text no. 1      
2.Meakin GH, Welborn LG. Anesthesia for infants and children. In: Wylie and Churchill Davidson's 7 th edition, editors. APrac­tice of Anesthesia. Arnold Publications 2003 pg 961-981.  Back to cited text no. 2      
3.Cote, Charles J. Pediatric Anesthesia. In: Ronald D. Miller, 5th edition, editors. Anesthesia. Churchill Livingstone 2000 pg 2088-2117.  Back to cited text no. 3      
4.Charles D. Paediatric RegionalAnaesthesia. In:GeorgeA. Gre­gory, 4th edition, editor. Textbook of Paediatric Anaesthesia. Churchill Livingstone 2002 pg 267-316.  Back to cited text no. 4      
5.Ecoffey C, Dubousset AM, Samiik. Lumbar and Thoracic epi­dural anaesthesia for urologic and upper abdominal surgery in infants and children, Anesthesiology 1986; 65: 87-90.  Back to cited text no. 5      
6.Ruston FG. Epidural anesthesia in infants and children. Can Anaesth Soc J 1954; 1: 37-40.  Back to cited text no. 6      
7.Schulte-Steinberg O. Neural Blockade for paediatric surgery, neural blockadein clinical anaesthesia and management of pain. Cousins MJ, Bridenhaugh PO, editors. S. B. Lippincott Co. 1980, pg 503-523.  Back to cited text no. 7      
8.Tobias JD, Rasmussen, Walter M, et al. Continuous caudal anaesthesia with chloroprocaine as an adjunct to general anaes­thesia in neonates. Can J Anaesth 1996; 43: 1: 69-72.  Back to cited text no. 8      
9.McGown RG. Caudal analgesia in children. Anaesthesia 1982; 37: 806-818.  Back to cited text no. 9  [PUBMED]    
10.Trejakoff D, Mather LE. Pharmacokinetics of local anaesthetic agents. BJA 1975; 47: 213-217.  Back to cited text no. 10      
11.Takasaki M, Dohi S, KawabataY, et al. Dosage of lidocaine for caudal anaesthesiain infants and children. Anesthesiology1977; 47: 527-529.  Back to cited text no. 11      
12.Dalens Bernard, Tanguy Alain, Haberer Jean-Pierre. Lumbar epidural anesthesia for operative and postoperative pain relief in infants and young children. Anesth Analg 1986; 65: 1069-­73.  Back to cited text no. 12      
13.Goresky, Gerald V. Thoracic epidural anaesthesia in children - problems with retrospective data. Editorial. Can J Anaesth 1993; 40: 810-812.  Back to cited text no. 13      
14.Daftary Swati R, Jagtap SR. Caudal epidural as a sole anaes­thetic in preterm, former preterm and high risk infants. Indian J Anaesth 2005; 49:195-198.  Back to cited text no. 14    Medknow Journal  
15.Casta, Alfonso. Attempted placement of a thoracic epidural catheter via the caudal route in a newborn. Anesthesiology 1999; 91 1965-1966.  Back to cited text no. 15      
16.Gunter Joel B, Eng. Calvin. Thoracic epidural anesthesia via the caudal approach in children. Anesthesiology 1992; 76: 935-938.  Back to cited text no. 16      
17.Bosenberg Adrian T, Bland Barry AR, Schulte-Steinberg Ottheinz, Downing John W. Thoracic epidural anesthesia via caudal route in infants. Anesthesiology 1988; 69: 265-269.  Back to cited text no. 17      
18.Tobias Joseph D, Lowe Sandra, et al. Thoracic epidural anaes­thesia in infants and children. Can J Anaesth 1993; 40:879-­882.  Back to cited text no. 18      
19.Campbell FA, Yentis SM, et al. Analgesic efficacy and safety of a caudal bupivacaine-fentanyl mixture in children. Can J Anaesth 1992; 39: 661-664.  Back to cited text no. 19  [PUBMED]    
20.McCloskey John J, Huan Steven E., Deshpande Jayant K. Bupivacaine toxicity secondary to continuous caudal epidural infusion in children. Anesth Analg 1992; 75: 287-290.  Back to cited text no. 20      
21.Larsson, Lonnqvist PA, et al. Plasma concentrations of bupivacaine in neonates after continuous epidural infusion. Anesth Analg 1997;84:501-505.  Back to cited text no. 21      
22.Dalens Bernard, HasnaouiAbdou. Caudal anesthesia in pediat­ric surgery: success rate and adverse effects in 750 consecutive patients. Anesth Analg 1989;68:83-89.  Back to cited text no. 22      


    Figures

  [Figure 1], [Figure 2]



 

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