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Evaluating the Role for Regional Analgesia in Children With Spina Bifida

3/7/2023

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Key takeaways

  • Peripheral regional catheters benefitted study participants

  • These methods reduce opioid use without increasing pain scores.

  • In study centers, regional catheter-based analgesia is now the standard of care.


Background: pain relief after urology surgery for spina bifida patients

Pediatric patients with spina bifida often require major urologic surgery, but medical literature on the optimal method of providing post-surgical pain relief to these patients is limited. Reports have shown patients with spina bifida are at higher risk for perioperative complications and decreased healthcare-related quality of life compared to children with other chronic conditions.

Reports have shown the benefits of using both thoracic epidurals and wound soaker catheters for non-opioid pain relief in pediatric patients with spina bifida, suggesting incorporating regional anesthesia techniques will be another option for multimodal pain relief in these patients.

The study authors, including , and Megan Brockel, MD, of Children’s Hospital Colorado, as well as Robert P. Moore, MD, of Stony Brook Medicine, and Nicholas E. Burjek, MD, of Lurie Children’s, sought to examine the use of perioperative analgesia and the impact of regional analgesia in children with spina bifida who underwent continent urinary diversion. They compared perioperative opioid consumption between regional and systemic analgesic protocols before and after the implementation of an Enhanced Recovery After Surgery (ERAS) protocol utilizing multimodal analgesia, including regional catheters and opioid minimization.

The authors hypothesized that peripheral regional catheters would reduce postoperative opioid use compared with no regional analgesia without increasing pain scores.

Methods

Study design and setting

A secondary, retrospective observational study was performed and included patients with neural tube defects from a prospective multicenter study designed by the Pediatric Urology Recovery after Surgery Endeavor (PURSUE) working group.

Children’s Colorado was one of seven North American study centers to analyze patients with a neural tube defect and neurogenic bladder undergoing lower urinary tract reconstructive operations between 2009 and 2021. The study included retrospective, historical controls (2009 to 2016) and prospectively enrolled ERAS patients (2017 to 2021).

Surgeries included in the study:

  • Bladder augmentation
  • Creation of catheterizable channels
  • Bladder neck surgeries

SURG_Evaluating the role for regional analgesia graphics-01.jpeg

Patients and exposure

Patients excluded from the study:

  • Did not have spina bifida
  • Received an epidural

Patients were grouped between those who did or did not receive continuous peripheral regional analgesia via catheters, as well as:

  • Regional catheters type, timing of placement and duration of treatment recorded
  • ERAS protocol emphasized the delivery of regional analgesia prior to incision and catheter-based analgesia postoperatively
  • Duration of regional catheters collected

Outcomes

Primary study outcome

  • Mean postoperative opioid requirements (milligrams intravenous morphine equivalents/kg/day) over the first three postoperative hospital days
  • PURSUE study set opioid minimization thresholds based on pilot data, with goals of:
    • <0.3 mg/kg intravenous morphine equivalents intraoperatively
    • <0.15 mg/kg/day postoperatively

Secondary study outcomes

  • Intraoperative opioid requirements
  • Opioid-free postoperative days (POD) as a fraction of the length of stay
  • Anesthesia setup time (in room to procedure start)
  • Overall room time (in room to out of room)
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Covariates

Information collected included:

  • Patient characteristics and demographics
  • Medical comorbidities
  • American Society of Anesthesiologists score
  • Preoperative, intraoperative, and postoperative non-opioid and opioid analgesics and adjuncts
  • Postoperative scheduled acetaminophen and ibuprofen recorded together within six hours of surgery end time

Results

274 patients identified in the database did or did not receive continuous regional catheters. Of those,158 patients with spina bifida were analyzed.

SURG_Evaluating the role for regional analgesia graphics-02.jpegStudy authors noted:

  • 111 (70%) had ventriculoperitoneal (VP) shunt
  • 70 (44%) had prior abdominal surgery (not including placement of a VP shunt)
  • 43 (27%) had prior lower urinary tract reconstructive surgery

Patients receiving care under ERAS protocol:

  • 13 (18%) in no regional group
  • 75 (86%) in regional group

Postoperative opioid use

  • Significantly higher in patients who did not receive continuous regional catheter-based analgesia, compared with those who did (0.23 versus 0.05 mg intravenous morphine equivalents/kg/day, p<0.01).
  • Decreased with presence of:
    • Regional catheters
    • Wheelchair-bound patients
    • Postoperative scheduled acetaminophen and non-steroidal anti-inflammatory drug (NSAID) use
  • Not associated with:
    • More functional ambulatory function status
    • Use of regional-single shot block
    • VP shunt status
    • Prior abdominal surgery
    • Use of postoperative gabapentin

SURG_Evaluating the role for regional analgesia graphics-03.jpeg

Postoperative pain scores

  • Median maximum daily pain scores significantly lower on day 2 (median maximum daily pain score 5 in the no regional arm versus 4 in the regional arm, p<0.01)
  • Regional catheters removed on median day 4; no increase in pain scores noted

Discussion

Examining opioid and non-opioid analgesics before, during and after surgery revealed significant differences between the two groups, with much greater use of non-opioid adjuncts and decreased opioid use in the group who received regional catheters. The findings demonstrated parallel application as part of multimodal analgesic strategies should be encouraged as part of the ERAS protocol.

Study authors also noted:

  • While analgesia in patients with spina bifida is needed, continuous perioperative regional therapies also play a role in pain management and benefit patients by decreasing opioid use without increasing pain scores.
  • The amount of perioperative opioid use in the no regional catheters group suggests these patients experience postoperative pain and benefit from thoughtful perioperative analgesia approaches.
  • The use of continuous regional catheters as part of a multimodal approach was associated with substantial and significant reductions in opioid consumption both intra- and postoperatively (both emphasized in the bundled ERAS protocol).
  • An important finding: The regional catheter group did not have higher pain scores despite lower opioid use, highlighting the efficacy of multimodal management. This demonstrates flexibility in applying multimodal analgesia for adequate pain control, and the approach is likely generalizable to similar settings.

Findings concerning tissue plane nerve blocks

  • General anatomic basis of fascial plane blocks supports use of bilateral catheters
  • Specific anatomic basis of ESP blocks suggests additional benefit compared with abdominal wall blocks (indirect spread of local to the paravertebral space, potential visceral analgesia)
  • Fascial plane blocks use instead of neuraxial techniques avoids risk of:
    • Dural puncture
    • Sympathectomy-induced hypotension and urinary retention
    • Neuraxial bleeding, infection, trauma
  • Fascial plane blocks useful in patients with contraindications to epidural analgesia
  • Use of these other options supported when anatomic concerns make neuraxial techniques difficult or dangerous
  • Pre-incision application of local to a fascial plane proximal to the neuraxis likely provides additional positive impacts

Findings concerning opioid use

  • Use of advanced adjuvants — mainly dexmedetomidine and gabapentin — contributed to observed reduction in intraoperative opioid use
  • Reduced opioid consumption may have impacted overall pain trajectory and recovery profile
  • Significant reduction in pain scores among regional cohort observed on POD 2, despite accelerated progression of activity in enhanced recovery patients

Conclusion

Study authors found continuous regional analgesia following major urologic surgery in children with spina bifida was associated with a 70% intraoperative and 78% postoperative reduction in opioid use without higher pain scores. This approach should be considered for similar surgical interventions in this population.