Use of epidural analgesia falls with rise of safer analgesic modalities
The use of paediatric epidural analgesia has been declining over the years and is slowly being replaced by other analgesic modalities with superior safety profiles, according to a Singapore study.
“However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls,” researchers said.
There were 829 epidural catheters inserted from 1 June 1997 to 31 May 2016, accounting for 0.6 percent of all anaesthetics. Over the last 19 years, there had been a steady decline in the use of epidural analgesia, from 1.05 percent in 1997 to 0.47 percent in 2016, with a steep drop seen after 2001. [Proceedings of Singapore Healthcare 2018;27:49-54]
Most epidural catheters were inserted at thoraco-lumbar levels, with the first 7 years showing a gradual increase in the incidence of thoracic epidurals and a decrease in lumbar epidurals. A decline in caudal catheters had been observed as well. Furthermore, the largest drop in trans-sacral epidurals was seen in children younger than 3 years of age.
In the last 10 years, the incidence of epidural analgesia has remained mostly unchanged. In addition, there has been a shift in preference of local anaesthetics and adjuvant drugs toward safer alternatives over the study period.
The finding of a gradual decline in the use of paediatric epidural analgesia is consistent with international data. [Paediatr Anaesth 2010;20:1061-1069; Anesth Analg 1996;83:904-912; Paediatr Anaesth 2007;17:874-880]
“It is also in keeping with the rise in popularity of use of other modalities of analgesia including patient-controlled analgesia, caudal additives and peripheral regional anaesthesia,” researchers said. “At the same time, the development of laparoscopic surgery has reduced analgesic requirement in many surgeries.” [Paediatr Anaesth 2010;20:1061-1069; Paediatr Anaesth 2007;17:874-880; Paediatr Anaesth 2012;22:51-55]
Fears of potential neurological complications are common among parents, preventing more frequent use of epidural analgesia. In addition, anaesthetists and surgeons might see the procedure as a riskier than a favourable option due to concerns of intraoperative coagulopathy, particularly where massive blood transfusion is anticipated, according to researchers.
“Further study on the perception of Asian parents as well as anaesthetists about the safety of epidurals may shed light on this issue,” they said. “Because of our stringent and cautious patient selection, we have encountered only one case of postoperatively deranged coagulation requiring further labs and delay in removal of the catheter.”
The present observational study was conducted in a tertiary paediatric teaching hospital over a period of 19 years. Researchers analysed data that included patient demographics, level of epidural catheter insertion, local anaesthetic drugs and adjuvants used, as well as postoperative infusion rates.
“In keeping with global trends, we expect further growth in the area of paediatric regional anaesthesia in the near future, specifically in the fields of peripheral nerve and truncal nerve blocks. However, there remain clear indications for the use of epidural analgesia in children, and for this reason paediatric anaesthetists must retain competency and confidence in its use,” researchers said.