Continuous epidural infusion of bupivacaine with opioids safe, effective in children

Continuous epidural infusion of bupivacaine with either morphine or fentanyl--or both--is equally safe and effective for pain relief in children undergoing lower abdominal surgeries, according to results of a study presented at the American Pain Society's 29th Annual Scientific Meeting.

Originally published on MPR - Monthly Prescribing Reference.

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Mahesh K. Arora and M.S. Kalai Selvan of the All India Institute of Medical Sciences, New Delhi, enrolled 45 children aged 2 to 10 years scheduled for elective abdominal, urological, and major orthopedic procedures in one of three groups. Group I (n=15) received continuous epidural infusion of morphine 6 µg/kg/hr with 0.0625% bupivacaine; group II (n=15), fentanyl 0.4 µg/kg/hr with 0.0625% bupivacaine; and group 3 (n=15), morphine 3 µg/kg/hr and fentanyl 0.4 µg/kg/hr with 0.0625% bupivacaine. The catheter tip was threaded midway between the highest and lowest dermatome of surgical incision and confirmed as being in the epidural space. An epidural bolus at twice the hourly maintenance dose was then administered and continuous infusion initiated.

Postoperative pain scores were monitored via a visual analog scale if the child was older than 5 years of age and objectively if the child was younger than 5 years. If a pain score was greater than 4, epidural infusion rate was increased by 20%. After 4 hours, all pain scores were comparable. Prior to 4 hours, pain scores were slightly lower in the morphine and fentanyl groups compared to the morphine/fentanyl combined group.

Nausea, vomiting, pruritus, and sedation were higher in the group receiving morphine compared with those receiving fentanyl alone or morphine plus fentanyl with bupivacaine. The fentanyl group had good analgesia with fewer incidences of side effects. All patients were monitored in a high-dependency unit, and no episodes of desaturation or respiratory depression were reported.

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