EPIDURAL ANALGESIA IN NEWBORNS AFTER CONGENITAL DIAPHRAGMATIC HERNIA REPAIR FACILITATES PULMONARY PRESERVATION STRATEGY

• Published in: Pediatrics (Evanston) 1999-09, Vol.104 (3), p.679-679
• Main Authors: Goobie, S.M, Houck, C.S, Seefelder, C
• Format: Article
• Language: English
• Subjects: Pediatrics
• ISSN: 0031-4005; 1098-4275

Background: Although the early perioperative survival after congenital diaphragmatic hernia (CDH) repair improved markedly with the availability of extracorporeal membrane oxygenation (ECMO) in the 1980's, long term survival remained unchanged at approximately 50%. (1) Autopsy studies showed that in the absence of other congenital anomalies, the leading causes of death were pulmonary hypoplasia and iatrogenic barotrauma. A strategy aimed at pulmonary preservation was instituted at this hospital in the early 1990's, which allowed permissive hypercapnia and promoted spontaneous ventilation with neonatal pressure support ventilation. (2) As a part of this, perioperative analgesia was provided with thoracic epidural analgesia in an effort to avoid the respiratory depression associated with opioid analgesics and the ineffective ventilation noted with inadequate pain relief. Methods: After approval from the Committee on Clinical Investigation, we retrospectively reviewed the hospital records of all infants undergoing CDH repair between August 1995 and January 1998. Demographic data such as age, weight, estimated gestational age, associated diagnoses, and need for preoperative ECMO were recorded. The epidural insertion site, tip location by radiographic study, type and infusion rates of local anesthetics administered, duration of epidural infusion and need for additional analgesics or anxiolytics were recorded. Time to return of spontaneous ventilation and duration of mechanical ventilation were noted. Results: During the study period a total of 38 infants with congenital diaphragmatic hernia were identified. Thirteen infants (34%) required ECMO preoperatively and were removed from further analysis. Of the remaining 25 infants, 21 infants had an epidural catheter placed just prior to surgical repair, 2 had a catheter placed at the conclusion of surgery and 2 did not have a catheter placed due to technical difficulties with placement. Epidural infusions consisted of 0.05% bupivacaine with 1 mcg/cc fentanyl at rates between 0.1 and 0.3 ml/kg/hour. With the exception of one infant who developed profound hypoxia and shunting at the end of surgery and required emergent ECMO support, all infants who received epidural analgesia were breathing spontaneously on neonatal pressure support on the day of surgery. There were no episodes of apnea recorded during epidural use. Five infants were given either fentanyl or midazolam while the catheter was in place; 3 infants were gi