Continuous thoracic epidural infusions for postoperative analgesia after pectus deformity repair

To determine whether continuous epidural analgesia after repair of a pectus deformity is a viable and safe alternative to high-dose narcotics in children.

Data were collected prospectively for 19 children (4 to 17 years of age; 15 boys, 4 girls) who underwent pectus excavatum (14) or carinatum (5) repair between June 1, 1991 and July 1, 1994. Seventeen had a thoracic epidural catheter placed for postoperative pain control and two did not. The epidural catheter was routinely plead preoperatively by the anesthesiologist at the T3-T8 level, after induction of general anesthesia. Epidural catheters were test-dosed with local anesthesia alone or in combination with fentanyl, and afterward a continuous epidural infusion was maintained on the floor. Postoperative pain was assessed by nursing and house staff on the Wong-Baker scale, with adjustment of the dose rate or analgesic medication as appropriate.

All patients had extubation before leaving the operating room and were sent to the general pediatrics ward after leaving the recovery room. The average duration of the epidural was 69 hours (range, 20 to 116 hours). Sixteen patients received their test epidural dose preoperatively, and one patient had his in the recovery room. Fifteen epidural initially were dosed with bupivicaine (1 to 2 mg/kg) alone or in combination with fentanyl (1 to 2 micrograms/kg). Two patients received initial doses of lidocaine (1 to 1.5 micrograms/kg). Ten of 17 patients received fentanyl (1 microgram/kg/h) with bupivicaine (0.5 to 1.0 mg/kg/h) in the epidural as their maintenance medication, and the remainder received bupivicaine alone at the same dosage rate. Eight of 17 patients required additional intermittent supplemental narcotics, with an average of two doses of intravenous morphine per day (0.1 mg/kg) over the first 3 postoperative days. In contrast, the two patients who did not have an epidural catheter for pain control required high-dose intravenous morphine (0.2 mg/kg) every 2 to 3 hours for the first 3 to 4 postoperative days. No catheter-related complications occurred.

Thoracic epidural analgesia was completely successful in nine (53%) children who underwent repair of pectus deformity, and effectively reduced the intravenous narcotic demand in the other eight. Pain control was excellent, and no catheter-related complications were encountered. The data show that this method of analgesia in children is a safe and attractive alternative to intravenous narcotics, and eliminates the potential disadvantages of sedation and respiratory compromise.