Epidural Analgesia in Infants and Children

Epidural analgesia has widespread use in infants and children for postoperative pain management and for certain chronic pain conditions such as cancer pain and complex regional pain syndrome. While epidurals can provide excellent analgesia in pediatric patients, they do require specific expertise in both the techniques of placement and in the management. Pediatric-specific protocols and guidelines can increase the success of placement, optimize efficacy of management and increase overall safety. Pediatric-specific epidural protocols are directed at how to confirm correct catheter placement, which type of age-specific infusion to use and how much is safe, and how to treat side effects. There are relatively few absolute contraindications for using epidural analgesia. Lack of parental or patient consent and infection at the insertion site are absolute contraindications. Relative contraindications are: • Coagulopathy. Usually epidural analgesia is avoided in patients who have an ongoing coagulopathy however, date suggest a relatively low complication rate in performing lumbar punctures in cancer patients with mild thrombocytopenia. Epidural analgesia may be performed in select cases with infusion of platelets, fresh frozen plasma, or other blood products just prior to placement such as in cancer pain emergencies. • Anatomic anomalies. Epidural analgesia is often avoided in patients with spina bifida and other lumbosacral anomalies due to technical difficulties with placement, disruption of the epidural space and erratic local anesthetic spread. Radiographs that confirm normal anatomy of spine and epidural space at the entry site may allow safe placement of epidural catheters. A neurologic exam should be documented prior to placement. Local anesthetic spread may be very unpredictable and careful dosing and monitoring is indicated. • Hypovolemia. Epidural analgesia should not be performed in cases of severe ongoing blood loss and hypovolemia. Mild to moderate hypovolemia should be corrected prior to placement.