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Is fentanyl PCA really a better choice than thoracic epidural in children?
- François Semjen, Stéphanie Roullet (3 April 2007)
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François Semjen , Stéphanie Roullet
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We have read with much interest the article by Butkovic et al comparing intravenous fentanyl PCA to epidural blockade in children after the Nuss procedure. We would like to share some comments. The anaesthetists chose to place the thoracic epidural catheter before general anaesthesia. This is not commonplace in paediatric anaesthesia as the child’s movements may make the procedure unsafe. Thoracic epidural puncture under general anaesthesia is not as dangerous as it has been said, when done by experimented anaesthetists [1-4]. Moreover, having an epidural catheter placed before anaesthesia could have been a distress for the children that may have interfered with the global evaluation of the technique by the patients. Nevertheless, this last issue is maybe not a major one in the authors’ series, considering that their “children” were as old as nineteen. To assess respiratory depression the authors performed iterative arterial blood gas analyses. For doing this, did they make iterative arterial punctures? We feel that this is an ethical issue, as they could have used a non-invasive device to monitor expired carbon dioxide [5]. Or they could have placed an arterial catheter during the general anaesthesia, thus avoiding multiple arterial punctures during the hours after the procedure. As they only mention “non invasive monitoring of arterial pressure”, we doubt they did use a catheter. The authors concluded that intravenous PCA fentanyl is as efficient as epidural block to provide analgesia after thoracoscopic pectus excavatum repair. It is a conclusion hardly supported by current literature [6-8]. This may be explained by several reasons. First, they said that “analgesia after thoracic surgery is important for the patients’ respiratory function”. This means postoperative physiotherapy, coughing, and postoperative rehabilitation. But in their study, they assessed pain at rest, but not at movement or cough. Secondly, their study evaluated only short-term outcome, without evaluation of chronic postoperative pain. It is now clearly known that thoracic surgery could provide chronic neuropathic pain in up to 60% of patients, and that epidural anaesthesia prevent this pain [6]. Finally, they compared a patient-controlled technique to a nurse- or doctor-controlled technique. It is unclear that this point can be neglected… For all this reasons, even we are aware of the possible complications of the epidural technique, we can not agree with the conclusion of the authors recommending the use of fentanyl PCA instead of thoracic epidural technique for pain management following a painful thoracic surgery. Yours Sincerely Stéphanie Roullet, Dr François Semjen SAR 4 Hôpital Pellegrin-Enfants CHU Bordeaux Place Amélie Raba Léon 33076 Bordeaux Cedex France [1] Horlocker TT, Abel MD, Messick JM, Jr., Schroeder DR. Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients. Anesth Analg 2003;96(6):1547-52. [2] Grady RE, Horlocker TT, Brown RD, Maxson PM, Schroeder DR. Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Mayo Perioperative Outcomes Group. Anesth Analg 1999;88(2):388 -92. [3] Krane EJ, Dalens BJ, Murat I, Murrell D. The safety of epidurals placed during general anesthesia [Editorial]. Reg Anesth Pain Med 1998;23(5):433-8. [4] Giaufré E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French- Language Society of Pediatric Anesthesiologists. Anesth Analg 1996;83(5):904-12. [5] Biedler AE, Wilhelm W, Kreuer S, Soltesz S, Bach F, Mertzlufft FO, et al. Accuracy of portable quantitative capnometers and capnographs under prehospital conditions. Am J Emerg Med 2003;21(7):520-4. [6] Gottschalk A, Cohen SP, Yang S, Ochroch A. Preventing and treating pain after thoracic surgery. Anesthesiology 2006;104(3):594-600. [7] Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005;103(5):1079-1088. [8] Golianu B, Hammer GB. Pain management for pediatric thoracic surgery. Curr Opin Anaesthesiol 2005;18:13-21. Conflict of Interest:None declared |
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