Epidural analgesia for tracheo‐oesophageal fistula repair

Abstract

Introduction: Traditionally neonates undergoing surgical repair of tracheo‐oesophageal fistula (TOF) would receive opioid analgesia and be returned ventilated to a neonatal intensive care unit (ICU). It has been shown that the use of epidural analgesia can reduce the need for postoperative ventilation (1). In recent years it has been the practice in our institution to use epidural analgesia for these neonates where possible. This is an audit of our recent experience.Methods: We retrospectively identified cases of TOF repair at our institution from January 2002 to September 2005. The notes of these neonates were reviewed for the following information: birth weight, gestational age, co‐existing congenital anomalies, preoperative respiratory function, operation duration, postoperative analgesia, ICU admission and duration of stay in ICU.Results: Thirty‐five TOF repairs were identified. One neonate was excluded as he had concomitant abdominal surgery. Of the 34 remaining, 30 sets of notes were reviewed. The outcome for these neonates is shown in the diagram. Of the 10 neonates who did not receive an epidural, a reason was found in eight cases: three were already ventilated, two had abnormal coagulation, two had coexisting congenital heart disease and one had recurrent apnoeas. Only three of the 20 neonates with an epidural required postoperative ventilation, one for metabolic acidosis, one for lung collapse and one for inadequate respiratory effort. All three remained on ICU for <24 h. The median PICU stay for those neonates who did not receive an epidural was 4 days (range 2–11 days). The group who received epidural analgesia was more mature (38.7 weeks c.f. 35.3 weeks gestational age) and heavier (2.9 kg c.f. 2.3 kg) than the group who did not. The mean operative time (including bronchoscopy and surgery) was 2.8 h in the epidural group and 3.3 h in the nonepidural group. Conclusion: Mature neonates presenting for TOF repair can be managed with epidural analgesia, usually removing the need for postoperative ventilation and an ICU bed. There is a group of smaller, less mature neonates that did not receive epidural analgesia, we cannot determine from this audit whether any of these would have benefited from epidural analgesia.Reference 1 Bosenberg AT, Wiersma R, Hadley GP. Esophageal atresia: caudo‐thoracic epidural anesthesia reduces the need for post‐operative ventilatory support. Pediatr Surg Int 1992; 7: 289–291.