Evaluation of prolonged epidural chloroprocaine for postoperative analgesia in infants

• Published in: Journal of clinical anesthesia 2015-09, Vol.27 (6), p.463-469
• Main Authors: Ross, Emma L., PharmD, Reiter, Pamela D., PharmD, Murphy, Michael E., PharmD, Bielsky, Alan R., MD
• Format: Article
• Language: English
• Subjects: Analgesia; Analgesia, Epidural - methods; Analgesics, Opioid - therapeutic use; Anesthesia & Perioperative Care; Anesthesia, Epidural; Anesthetics, Local - administration & dosage; Anesthetics, Local - adverse effects; Anesthetics, Local - therapeutic use; Child, Preschool; Chloroprocaine; Cohort Studies; Epidural; Female; Humans; Infant; Infant, Newborn; Intensive Care Units, Neonatal; Male; Pain; Pain Medicine; Pain, Postoperative - drug therapy; Postoperative; Pregnancy; Procaine - administration & dosage; Procaine - adverse effects; Procaine - analogs & derivatives; Procaine - therapeutic use; Respiration, Artificial; Retrospective Studies; Tachyphylaxis
• ISSN: 0952-8180; 1873-4529
• DOI: 10.1016/j.jclinane.2015.05.022

Abstract Study Objective To describe the use and adverse effects of chloroprocaine for epidural analgesia in young infants for infusion durations greater than 3.5 hours. Design A retrospective cohort review of the electronic medical record over a 14-month period. Setting The level IV neonatal intensive care unit of a 414-bed free-standing children's hospital. Patients Eighteen infants (mean age, 1.7 ± 1.8 months [0.03-6.3]; mean weight, 3.8 ± 1.3 kg [1.56-6.9]; n = 10 [55%] males) received 1% chloroprocaine for epidural analgesia postoperatively for up to 96-hour duration and met criteria for inclusion. Measurements Dosing requirements, placement of epidural catheter, supplementary analgesic therapy, respiratory support, vital signs, and incidence of adverse events associated with local anesthetics were collected. Main Results Epidural catheter placement was caudal (n = 8), lumbar (n = 6), or thoracic (n = 4). Mean operative time was 2.48 ± 1 hour (1-5). Initial chloroprocaine dose was 1.3 ± 0.5 mL/h (0.4-2.5) (3.5 ± 1 mg/kg per hour [1.4-5]) with a maximum dose of 1.5 ± 0.6 mL/h (0.4-3) (4.2 ± 1.1 mg/kg per hour [2.2-6.1]). Duration of epidural analgesia was 48.3 ± 21.5 hours (10-96). Duration of epidural infusion did not influence dosing requirement, suggesting the absence of drug tachyphylaxis. All patients received intermittent doses of opioid and nonopioid pain medications while receiving chloroprocaine. Two mechanically ventilated patients required continuous infusion of opioids. No adverse events were directly attributed to chloroprocaine use. Conclusion Epidural 1% chloroprocaine, in doses of 0.4-3 mL/h (1.5-6.1 mg/kg per hour), was well tolerated in both mechanically ventilated and spontaneously breathing infants for up to 96 hours with no identified adverse effects or tachyphylaxis.