Commentary: Thoracic epidural anesthesia for pediatric cardiac surgery and enhanced recovery: Still lessons yet to be learned.

Barry D. Kussman, MBBCh, FFA(SA)

Fluoroscopy-guided placement of a thoracic epidural catheter for pediatric heart surgery has a high success rate, but any benefit is constrained by the risk of epidural hematoma and paraplegia.

See Article page 64.

Neuraxial anesthesia may be used as an effective perioperative opioid-sparing modality for enhanced recovery in pediatric cardiac surgery. Correct anatomical placement of an epidural catheter is obligatory and advanced techniques, including fluoroscopy and ultrasonography, have been developed to facilitate or confirm accurate catheter placement., In this issue of the Journal, Schmehil and colleagues report their experience with fluoroscopy-guided thoracic epidural catheter placement in a cohort of 120 patients (median age 24 months [range, 3 days-27 years] and weight 11 kg [range, 2.1-113 kg]) undergoing congenital heart surgery. The intention of this retrospective study was to evaluate the potential benefits of fluoroscopy-guided thoracic epidural catheter placement as part of an enhanced recovery protocol. The primary outcome was successful fluoroscopy-guided thoracic epidural catheter placement, which was achieved in 119 patients (99%). Although there were no complications and limited outcomes are presented, important limitations of the report are the absence of a control group and the lack of data (e.g., pain scores, opioid consumption, etc.) demonstrating the success of the epidural in providing the intended analgesia.

This brief report calls to attention 2 important factors to consider before choosing epidural anesthesia for congenital heart surgery. The first is the risk of paraplegia from epidural bleeding. In adult cardiac surgery, the risk of a catheter-related epidural hematoma is about 1 in 5493 (95% confidence interval, 1/970-1/3114). In pediatric cardiac surgery with placement of an epidural catheter about 60 minutes before heparinization, the 95% confidence limit for the maximal risk of spinal cord injury is about 2%. With this high risk and the lack of comparative studies showing an extraordinary benefit of thoracic epidural analgesia over systemic intravenous analgesia and other regional anesthetic techniques, the choice of thoracic epidural anesthesia in pediatric cardiac surgery with anticoagulation is perhaps unwise. With placement of the catheter at the end of surgery, when hemostasis is restored clinically and can be verified by coagulation testing, plus the ability to perform a neurologic examination shortly thereafter, it is possible that the risk of epidural hematoma and paraplegia may be reduced. However, factors such as the need for postoperative anticoagulation, the timing of catheter removal, and the risk of bleeding associated with congenital heart disease need to be considered.,

The second factor is the relatively recent development of ultrasound-guided peripheral nerve blocks, which can be opioid-sparing. Bilateral erector spinae plane block has been shown in adult cardiac surgery to be a suitable alternative to thoracic epidural anesthesia for pain management and fast tracking and also to be opioid-sparing when compared with systemic analgesia. In a small cohort (n = 10) of children undergoing cardiac surgery with bypass and matched to historical controls, pain scores were low in both groups, and although postoperative opioid use at 48 hours was statistically less in the block group, this was clinically insignificant. Bilateral transverse thoracic muscle plane block with or without rectus sheath block is an alternative opioid-sparing regional block., Larger prospective comparative studies are required to demonstrate the safety and effectiveness of regional techniques and their contribution to enhanced recovery in pediatric cardiac surgery.