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The rise and fall of continuous epidural infusions in children

Continuous epidural infusions have the potential to and often do provide complete postoperative analgesia. Continuous epidural analgesia for children was described in 1954 (1) and, since the mid-1980s, has enjoyed considerable popularity. However, many paediatric anaesthetists who were strong and early advocates of the technique, are more reticent in their support today. Why is this so? Despite the plethora of published literature on paediatric epidural analgesia, prospective outcome studies demonstrating the clinical benefits and cost effectiveness of continuous epidural analgesia over the simple intravenous opioid infusion in children are lacking. Furthermore, in clinical practice, continuous epidural infusions are plagued by reliability issues necessitating labour intensive troubleshooting whilst exposing the child to the risks of untreated pain and rare, potentially irreversible and disastrous complications. Audits of epidural infusions in children have shown that 17–22% of infusions are terminated prematurely (2,3) and that side-effects or complications occur in 67% of patients (2). In one study, 6% of children undergoing epidural catheterization complained of back pain after discharge (4). Should we recommend epidural analgesia, an imperfect technique with few if any proven benefits in children? Are we certain that the potential risks to the child are so rare, and the benefits so great that we can justify the choice of epidural analgesia over and above an intravenous opioid infusion for postoperative pain relief? In an era where informed consent is mandatory, it behoves the paediatric anaesthetist to provide a clear and balanced view to parents of the risk–benefits of the various postoperative analgesic techniques available and what they can expect during their child’s postoperative course. Parents naturally will want what is best for their child (optimal comfort), whilst wanting to protect their child from perceived or potential harm (unrelieved severe pain or permanent disability). Consider the situation where a child is to undergo surgery for which continuous intravenous opioid analgesia or epidural analgesia are both suitable alternatives to treat postoperative pain. With either technique, analgesia may be adequate or inadequate and children may experience common side-effects and ⁄ or rare unexpected complications that may lead to temporary or permanent sequelae. Inadequate analgesia with either technique should respond rapidly to appropriate bolus administration with or without increasing the infusion rate. However, the likelihood of achieving adequate and timely analgesia is higher with intravenous opioid analgesia; the only requirement is that the tip of the intravenous cannula be located within the lumen of a vein. Epidural analgesia, in contrast, is reliant upon optimal positioning of the catheter tip within the epidural space at the appropriate level for the surgery performed. Even with optimal positioning, analgesia may be inadequate (because of pain or discomfort remote to the surgical site from intravenous cannulae, wound or chest drains, urethral or suprapubic catheters, bladder or skeletal muscle spasm), unilateral (e.g. epidural septa) or patchy (e.g. air in epidural space). The epidural catheter tip may be misplaced, in which case the likelihood of achieving satisfactory analgesia is diminished. The tip may be located distant to the nerves supplying the dermatomes that need to be blocked, or the catheter may have been inserted into, or may have migrated into, the subdural space, an epidural vein or subcutaneous tissues. Paediatric Anaesthesia 2003 13: 91–93