Recent reports have described epidural administration of a number of other drugs to provide analgesia or decrease the side effects of epidural opioids. These include ketamine (148,149), clonidine (150,151), and butorphanol (152,153). The role of these drugs inproviding epidural anesthesia and analgesia for pediatric patients undergoing thoracic surgery remains to be defined.
For patients who are not receiving a regional anesthetic technique to provide postoperative analgesia, systemic opioids are used after thoracotomy. Although intermittent IM and subcutaneous injections have been used widely in the past, these routes of administration are painful and are associated with unpredictable and erratic uptake and distribution. Intermittent IV injections with opioids of short or moderate duration are also associated with periods of excessive sedation and inadequate analgesia. The use of methadone, which has a half-life of approximately 19 h in children over the age of 1 yr, 1 may provide more continuous analgesia than shorter-acting drugs (154). For moderate to severe pain, intermittent IV doses of methadone between 0.05 and 0.08 mg/kg as needed may be given (155).
Continuous analgesia may be achieved when opioids are administered by continuous IV infusion, with or without patient-controlled analgesia (PCA) dosing. Morphine is the drug used most often for postoperative analgesia. In neonates <1 mo old, clearance is reduced and elimination half-life is prolonged, about three times that in adults (156). For continuous infusions of morphine, an initial dose of 0.025–0.075 mg/kg followed by infusion rates of 0.005–0.015 mg · kg−1 · h−1 result in therapeutic plasma concentrations in neonates (157). Older infants and children require an initial dose of 0.05–0.10 mg/kg followed by an initial infusion rate of 0.01–0.03 mg · kg−1 · h−1. In children receiving PCA, dosing in the range of 0.01–0.03 mg/kg with a lockout interval of 6–10 min, with or without a continuous infusion, has been recommended (158). In children at risk for morphine-induced histamine release, fentanyl (0.0005–0.001 mg · kg−1 · h−1 ± 0.0005–0.001 mg/kg PCA dose) or hydromorphone (0.003–0.005 mg · kg−1 · h−1 ± 0.003–0.005 mg/kg PCA dose) may be used (158).
The side effects that may occur with IV opioid administration are similar to those described with epidural opioids and may be treated similarly (Table 3). With epidural or IV techniques, improved analgesia and a decrease in opioid dosing (and side effects) may be achieved with the concomitant administration of nonopioid analgesics. The use of these adjuvant drugs, including acetaminophen and a variety of nonsteroidal antiinflammatory drugs, has been reviewed elsewhere (159).
The anesthesiologist caring for infants and children undergoing thoracic surgery faces many challenges. An understanding of the primary underlying lesion, as well as associated anomalies that may affect perioperative management, is paramount. A working knowledge of respiratory physiology and anatomy in infants and children is required for the planning and execution of appropriate intraoperative care. Familiarity with a variety of techniques for SLV suited to the patient’s size will allow maximal surgical exposure while minimizing trauma to the lungs and airways. Finally, the use of regional anesthetic techniques, including epidural anesthesia and analgesia, facilitates optimal postoperative pain control and pulmonary function.
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