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Ponde VC, Chan V, Singh N, Johari AN, Lee J, Gursale A, Chavan D. Regional anesthesia and analgesia in patients with spastic cerebral palsy undergoing orthopedic surgery: a historical cohort study. Can J Anaesth 2024; 71:826-833. [PMID: 37919631 DOI: 10.1007/s12630-023-02617-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE We sought to examine the incidence of severe postoperative pain in patients with cerebral palsy (CP) in the first 48 hr after surgery performed under combined regional and general anesthesia and its association with patient and surgical factors. METHODS In a historical cohort study, we reviewed the electronic records of 452 patients with spastic CP who underwent orthopedic surgeries of the upper and lower extremities from April 2016 to February 2020. Collected data included patient characteristics, American Society of Anesthesiologists Physical Status, details of anesthesia and surgery, types of regional anesthesia applied, success rate of anesthesia, incidence of severe pain, and adverse events. RESULTS We analyzed data from 440 patients; 404 patients underwent lower extremity surgery, 20 upper extremity surgery, and 15 both, and one patient required stem cell injection. All patients received general anesthesia before block performance. Single-injection neuraxial anesthesia was performed in 241 (54.8%) patients, brachial plexus block in 27 (6.1%) patients, and femoral/sciatic nerve blocks in 17 (3.9%) patients. Continuous neuraxial, brachial plexus, and femoral/sciatic nerve blocks were performed in 149 (33.9%), four (0.9%), and seven (1.6%) of the patients, respectively. Major and complex major surgeries were performed in 161 (36.6%) and 72 (16.4%) patients, respectively and continuous catheters were inserted in 50.3% of patients undergoing major surgery and in 91.7% of patients undergoing complex major surgery. Severe pain was reported by the caregivers of 68 (15.5%) patients who received nonopioid analgesic interventions. CONCLUSION Despite the use of regional anesthesia, approximately 15% of patients with spastic CP undergoing orthopedic surgery for spastic cerebral palsy experienced severe pain that responded to treatment adjustments. STUDY REGISTRATION CTRI.nic.in (027002); registered 5 August 2020.
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Affiliation(s)
- Vrushali C Ponde
- Children Anesthesia Services, Surya Children Hospital, Mumbai, Maharashtra, India.
| | - Vincent Chan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Neha Singh
- Department of Anesthesiology and Critical Care, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
| | - Ashok N Johari
- Department of Pediatric Orthopedic Surgery, Children Orthopedic Centre and Surya Children Hospital, Mumbai, Maharashtra, India
| | - Jolene Lee
- Nanyang Technological University, Singapore, Singapore
| | - Anuya Gursale
- Children Anesthesia Services, Surya Children Hospital, Mumbai, Maharashtra, India
| | - Dilip Chavan
- Children Anesthesia Services, Surya Children Hospital, Mumbai, Maharashtra, India
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Kulkarni VA, Kephart DT, Ball MA, Tumber S, Davidson LT, Davids JR. Neuraxial anesthesia for post-operative pain control after hip surgery in children with cerebral palsy and pre-existing intrathecal baclofen pumps. J Pediatr Rehabil Med 2022; 15:3-11. [PMID: 35275572 DOI: 10.3233/prm-210027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The purpose of this study is to describe the efficacy and adverse events of neuraxial anesthesia for post-operative pain control in non-ambulatory children with cerebral palsy with pre-existing intrathecal baclofen (ITB) pumps undergoing hip reconstructive or palliative surgery. METHODS Twelve children (mean age 11.25 years) were included in the study with the following neuraxial anesthesia methods: indwelling epidural catheter (8 patients), neuraxial opioids administered through the side port of the ITB pump (3 patients), and single injection spinal anesthetic (1 patient). Observational pain scores and opioid requirements were quantified for all patients. RESULTS There were no ITB pump or surgical complications at a mean follow-up of 2.2 years. The average length of stay was 6 days. Patients had good post-operative pain control with a mean observational pain score of 0.7 and mean morphine equivalent use of 0.26mg/kg/day. Four patients required anti-emetics to control nausea and three patients had urinary retention requiring repeat catheterization, but all medical complications resolved prior to discharge. CONCLUSION Neuraxial anesthesia can effectively control post-operative pain in children with a pre-existing ITB pump. Utilizing the side port of the ITB pump for administration of neuraxial opioids is an option when epidural or spinal anesthesia is not possible.
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Affiliation(s)
- Vedant A Kulkarni
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Donald T Kephart
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Madeleine A Ball
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Sundeep Tumber
- Department of Anesthesia, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Loren T Davidson
- Department of Physical Medicine and Rehabilitation, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
| | - Jon R Davids
- Department of Orthopaedic Surgery, Shriners Hospitals for Children - Northern California, Sacramento, CA, USA
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Wong JSH, Kuong EE, So NLW, Ali A, To MKT, Chow W. Quality of Surgery and Patient Selection Are Keys to Success in Hip Stabilization Surgery in Cerebral Palsy. J Pediatr Orthop 2022; 42:e72-e77. [PMID: 34608041 DOI: 10.1097/bpo.0000000000001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral palsy patients are at risk of hip instability, to which various soft tissue and bony surgeries are performed should conservative management fail. We aim to identify factors associated with treatment failure to guide surgical management. METHODS Cerebral palsy patients treated at 2 university-affiliated tertiary pediatric orthopaedic referral centers with hip stabilization surgery performed for subluxation in 1998 to 2015 with minimum of 5 years follow-up were reviewed. Failure was defined as reoperation to the same hip because of recurrent subluxation. Age, sex, Gross Motor Function Classification System level, tone abnormality, operation type, Reimer's migration index (RMI), and acetabular index (AI) were assessed. Cut-off values were identified through Youden index on receiver operating characteristic curve. RESULTS Eighty-nine hips from 55 patients with mean follow-up of 12.4 years were analyzed. Revision surgery was performed in 14 hips. Postoperative hip subluxation (P<0.001) and acetabular dysplasia (P=0.001) were predictive of failure, with postoperative RMI conferring an adjusted hazard ratio of 1.13 (95% confidence interval: 1.08-1.19, P<0.001) on multivariable survival analysis. Achieving a postoperative RMI of <27.5% predicts success with 92.9% sensitivity and 72% specificity with area under curve of 0.916 (P<0.001), while postoperative AI of <23.1 degrees predicts success with 92.3% sensitivity and 62.2% specificity with area under curve of 0.796 (P=0.001). In subgroup analysis of soft-tissue-only procedures, RMI >44% preoperative and >32% postoperative were associated with reoperation. In femur-only osteotomies, preoperative RMI >48% and postoperative RMI >28% were associated with failure. In pelvic and combined osteotomies, postoperative RMI >32% and AI >30 degrees were associated with failure. Other factors analyzed were not associated with reoperation. CONCLUSIONS Patient selection and quality of surgery in terms of residual postoperative hip subluxation and acetabular dysplasia are associated with need for remedial surgery. Soft-tissue-only procedures should aim to correct RMI to <32%. Bony surgery should be considered when preoperative RMI >44%, and pelvic osteotomies if RMI >48%. Pelvic osteotomies should target postoperative RMI <32% and AI <30 degrees. LEVEL OF EVIDENCE Level II-prognostic study.
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Affiliation(s)
- Janus S H Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam
| | - Evelyn E Kuong
- Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, Sandy Bay, Hong Kong SAR
| | - Noah L W So
- Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, Sandy Bay, Hong Kong SAR
| | - Abbas Ali
- Khyber Teaching Hospital Peshawar, Peshawar, Pakistan
| | - Michael K T To
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pok Fu Lam
| | - Wang Chow
- Department of Orthopaedics and Traumatology, Duchess of Kent Children's Hospital, Sandy Bay, Hong Kong SAR
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End C, Propst EJ, Cushing SL, McKinnon NK, Narang I, Amin R, Chiang J, Al-Saleh S, Matava C, Wolter NE. Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review. Laryngoscope 2021; 132:687-694. [PMID: 34032299 DOI: 10.1002/lary.29625] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/24/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP). STUDY DESIGN Systematic review. METHODS We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included. RESULTS Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA. CONCLUSIONS Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 2021.
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Affiliation(s)
- Christopher End
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Cushing
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Cung S, Ritz ML, Masaracchia MM. Regional anesthesia in pediatric patients with preexisting neurological disease. Paediatr Anaesth 2021; 31:522-530. [PMID: 33590927 DOI: 10.1111/pan.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 12/01/2022]
Abstract
Preexisting neurological disease in pediatric patients presents unique challenges to the anesthesiologist. In-depth knowledge of the disease processes and awareness of sequalae that uniquely influence the risks and benefits of anesthetics are needed to make informed decisions. Because these vulnerable populations are often susceptible to perioperative airway or cardiopulmonary complications, the use of regional anesthesia can be advantageous. However, these clinical conditions already involve compromised neural tissue and, as such, create additional concern that regional anesthesia may result in new or worsened deficits. The following discussion is not intended to be a full review of each disease process, but rather provides a concise, yet thorough, discussion of the available literature on regional anesthesia in the more common, but still rare, pediatric neurological disorders. We aim to provide a framework for pediatric anesthesiologists to reengage in a healthy discussion about the risks and benefits of utilizing regional anesthesia in this vulnerable population.
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Affiliation(s)
- Stephanie Cung
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew L Ritz
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Melissa M Masaracchia
- University of Colorado School of Medicine, Aurora, CO, USA.,Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Xu N, Matsumoto H, Roye D, Hyman J. Post-Operative Pain Assessment and Management in Cerebral Palsy (CP): A Two-Pronged Comparative Study on the Experience of Surgical Patients. J Pediatr Nurs 2019; 46:e10-e14. [PMID: 30850174 DOI: 10.1016/j.pedn.2019.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION This study compares the current practice patterns of pain assessment and management between children with and without CP following either posterior spinal instrumentation and fusion (PSIF) or hip osteotomy (HO). METHODS Two cohorts of CP patients were retrospectively identified and matched with non-CP patients based on age, surgical procedure, and approach to post-operative pain management. Sixteen CP patients undergoing PSIF and twenty-two undergoing HO were respectively matched with the same numbers of non-CP patients receiving the same procedures. The frequency of assessments conducted, highest pain scores recorded on each post-operative day (POD), and the amount of adjuvant analgesics administered were collected for POD 0-4. RESULTS Patients with CP were significantly more frequently evaluated for pain post-operatively, tended to have lower pain scores as measured by current scales, and received slightly fewer analgesics. Patients with CP differed from their non-CP counterparts in both frequency and method of post-operative pain assessment. CONCLUSIONS The purpose of this study is to elucidate the current state of post-operative pain assessment and management in children with CP undergoing major orthopaedic surgeries, to improve CP patient/caregiver understanding and expectation of the post-operative experience regarding pain, and to provide recommendations for improving the post-operative care for these patients.
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Affiliation(s)
- Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.
| | - Hiroko Matsumoto
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, United States of America
| | - David Roye
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, United States of America
| | - Joshua Hyman
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY, United States of America.
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Abstract
Cerebral palsy is a rare condition following injury of the developing brain and including nonprogressive neurological disorders, spasticity, intellectual impairment and others. Boys with cerebral palsy have a high incidence of undescended testis. Although the motives for treatment (infertility, cancer prevention, psychological aspects, testicular torsion) are not different in boys without neurological impairment, the decision-making process in boys with cerebral palsy is very difficult. Besides medical and surgical arguments the discussion involves challenging ethical issues.
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