2011 - ISBTS 2011 Symposium

Oral Communications 5: Long Term TPN and Rehab

7.142 - Epidural analgesia following intestinal lengthening procedures - serial transverse enteroplasty (STEP) and bianchi procedures

Presenter: Clarivet, Torres, Washington, United States
Authors: Clarivet Torres1, Sarah Reece-Stremtan1, Ira Cohen1, Alla Alla Tauber1, Anthony Sandler1, Yewande Johnson1

Epidural analgesia following intestinal lengthening procedures - serial transverse enteroplasty (STEP) and bianchi procedures

Clarivet Torres, Sarah Reece-Stremtan, Ira Cohen, Alla Alla Tauber, Anthony Sandler, Yewande Johnson

Division of Anesthesiology and Pain Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Division of General Surgery, Children’s National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States

Mu-opioid agonists decrease peristalsis and increase transit time through the intestine, which may be especially deleterious in patients with baseline decreased gut function. Epidural analgesia inhibits afferent pain signals and efferent sympathetic reflex arcs when used intra- and postoperatively which potentially has a beneficial effect on gut motility. This is especially important in intestinal failure parenteral nutrition dependent patients with severe reduced baseline intestinal motility. Intestinal lengthening (IL) procedures have shown improved enteral tolerance in children with SBS. Although long-term bowel motility is preserved with the STEP procedure, an early complication is possible bowel obstruction. Thus, the concern remains for use of parenteral opioids postoperatively in patients undergoing these procedures. Here we report a series of patients that have undergone IL procedure with epidural analgesia.

Methods: From 2009-2011, seven children, ages 7-35 months, underwent IL procedures for SBS with epidural (thoracic or lumbar) placement for intra-operative and postoperative analgesia. Patients received epidural ropivacaine with or without fentanyl as well as general inhalation anesthesia during surgery; the infusions were changed to a ropivacaine 0.1%/fentanyl 2mcg/mL mixture postoperatively. Epidural analgesia was continued at the rate of 0.4cc/kg/hr until post-operative day 4-5. Intravenous opioids for breakthrough pain were available while the epidural catheter was in place

Results: All children tolerated well epidural analgesia. Only one patient required supplemental intravenous opioids while the epidural catheter was infusing. No patients required IV opioids after discontinuation of the epidural catheter. Enteral feeding was begun between postoperative days 7-11. All patient families expressed satisfaction with the pain control their children received. There were no complications secondary to epidural placement and no patients incurred postoperative bowel obstruction.

Conclusions: Epidural analgesia should be considered as a modality for analgesia children undergoing bowel lengthening surgery, it reduces the need of Mu-opioid agonists and its secondary effects.

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