Abstract
Patients with cerebral palsy (CP) experience pain through the lifespan. The hip joint is the main source of nociceptive input. Use of nonopioid adjuvant medication and regional anesthesia for hip surgeries can be an integral part of a perioperative strategy to decrease opioid use. Regional anesthesia can be delivered efficiently and safely for pediatric orthopedic patients. Objective To compare different regional anesthetic techniques used for multi-level lower limb orthopedic surgeries in children with moderate and severe CP. Material and methods A prospective randomized comparative clinical trial enrolled 101 CP patients who underwent unilateral multi-level lower limb surgery for spastic hip displacement or subluxation. According to a type of anesthesia used, patients were allocated into 3 groups: patients receiving prolonged epidural analgesia (PEA) and fentanyl for sedation (PEAF, n = 32); patients receiving PEA and benzodiazepine for sedation (PEAB, n = 37), and patients receiving a continuous femoral plus single-shot sciatic nerve block and benzodiazepines for sedation (FSNBB, n = 32). Hemodynamic findings, pain intensity, a need for opioids and additives (NSAIDs), the level of sedation and complication rate were evaluated. Results The use of NSAIDs (paracetamol) was significantly higher in PEAB and FSNBB groups as compared to PEAF patients with fentanyl administered, and there were no statistically significant differences in the level of pain recorded with the r-FLACC score among the study groups. There were no statistically significant differences in the level of sedation and agitation measured with the Ramsay Sedation Scale and Richmond Agitation-Sedation Scale (RASS) among the groups at early postoperative period. Apnoea as a complication was observed in a PEAF patient. Conclusion A continuous femoral plus single-shot sciatic nerve block and PEA added with NSAIDs (paracetamol) and benzodiazepines for sedation have shown the comparative effectiveness and safety for a perioperative analgesia of CP patients undergoing multi-level lower limb surgeries as compared to the use of PEA and fentanyl for sedation.
Highlights
Patients with cerebral palsy (CP) experience pain through the lifespan that can be associated with spasticity, visceral dysfunction and neuropathy [1, 2]
There were no significant differences in the level of pain, agitation and sedation level, postoperative depth of sedation scored at the ICU among the groups (р > 0.05) (Table 6)
Our findings indicated to the effectiveness and safety of the regional anesthesia techniques used for patients with moderate and severe CP treated with multi-level lower limb surgeries and were shown to be on par with the data reported in the large multicenter studies [15, 25]
Summary
Patients with cerebral palsy (CP) experience pain through the lifespan that can be associated with spasticity, visceral dysfunction and neuropathy [1, 2]. Pain is a disabling factor for CP children presenting with functional limitations and decrease in health-related quality of life [2, 5, 6]. Several population-based studies have calculated that the overall incidence of spastic hip displacement and dislocation is approximately 28 % across a population of children with CP and is proportional to their age and gross motor function as graded by the Gross Motor Function Classification System (GMFCS) [9–12]. Use of nonopioid adjuvant medication and regional anesthesia for hip surgeries can be an integral part of a perioperative strategy to decrease opioid use. Debate continues over the optimal approach to anesthesia and analgesia in CP patients undergoing orthopaedic procedures [15–19]
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