733997

research-article20172017
PSH0010.1177/2010105817733997Proceedings of Singapore HealthcareWong and Lim

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Original Article OF SINGAPORE HEALTHCARE

Proceedings of Singapore Healthcare

Epidural analgesia in a paediatric 2018, Vol. 27(1) 49­–54

© The Author(s) 2017
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DOI: 10.1177/2010105817733997
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Jolin Wong1 and Serene Siu Tin Lim2

Abstract
Introduction: Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent
pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local
anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance
of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all
patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA
infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital.
Methods: Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital.
Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants
used, as well as postoperative infusion rates, were then analysed retrospectively.
Results: There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in
preference of LAs and adjuvant drugs toward safer alternatives.
Conclusion: Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety
profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be
familiar with its technical aspects and pitfalls.

Keywords
Analgesia, epidural, anaesthesia, epidural, bupivacaine, clonidine, pain, postoperative

Introduction
Epidural analgesia is a well-established method of intraopera- (APS) audit forms. These data encompassed patient demo-
tive and postoperative pain relief in the paediatric population. graphics, surgery performed, level of epidural catheter inser-
In the last two decades, a rise in the popularity and use of other tion, local anaesthetic (LA) drugs and adjuvants used, epidural
analgesic modalities have displaced it as the preferred regional infusion rates as well as any other analgesic prescriptions,
analgesic technique of choice in the postoperative period. together with daily pain scores and documentation of any
This study aims to examine the practice and trends in the adverse effects encountered.
use of epidural analgesia in a Singaporean paediatric popula- Approval for this observational study was obtained from
tion over the last 19 years. We illustrate the changes in epi- the institutional review board. A retrospective review of the
dural drugs and practices over time, and discuss their benefits above data was conducted to examine the trends and changes
and risks. Finally, we discuss the possible factors leading to the
decline of paediatric epidural anaesthesia, as well as highlight
new fields of development of alternative modalities of paedi- 1Department of Anaesthesiology, Singapore General Hospital, Singapore
atric analgesia in our Pain Service. 2Department of Anaesthesiology, KK Women’s and Children’s Hospital,
Singapore

Methods Corresponding author:

Jolin Wong, Department of Anaesthesiology, Singapore General Hospital,
Since 1997, prospectively collected data on all epidural cath- Outram Road, 169608, Singapore.
eters inserted have been recorded on our Acute Pain Service Email: [email protected]

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50 Proceedings of Singapore Healthcare 27(1)

Table 1.  Trends in level of epidurals with time.

Level Total number of Incidence of epidural

epidurals anaesthesia (%)
  Thoracic Lumbar Sacral Caudal
Year 1997 4 (13.8%) 15 (51.7%) 5 (17.2%) 5 (17.2%) 29 (100.0%) 1.05
1998 18 (22.8%) 46 (58.2%) 12 (15.2%) 3 (3.8%) 79 (100.0%) 1.39
1999 15 (22.7%) 44 (66.7%) 7 (10.6%) 0 (0.0%) 66 (100.0%) 1.02
2000 22 (33.3%) 39 (59.1%) 5 (7.6%) 0 (0.0%) 66 (100.0%) 1.04
2001 22 (28.2%) 48 (61.5%) 3 (3.8%) 5 (6.4%) 78 (100.0%) 1.15
2002 13 (27.1%) 31 (64.6%) 1 (2.1%) 3 (6.2%) 48 (100.0%) 0.71
2003 18 (48.6%) 13 (35.1%) 4 (10.8%) 2 (5.4%) 37 (100.0%) 0.63
2004 15 (34.9%) 24 (55.8%) 4 (9.3%) 0 (0.0%) 43 (100.0%) 0.61
2005 20 (62.5%) 11 (34.4%) 1 (3.1%) 0 (0.0%) 32 (100.0%) 0.47
2006 23 (46.9%) 24 (49.0%) 1 (2.0%) 1 (2.0%) 49 (100.0%) 0.70
2007 22 (59.5%) 13 (35.1%) 2 (5.4%) 0 (0.0%) 37 (100.0%) 0.52
2008 7 (29.2%) 16 (66.7%) 1 (4.2%) 0 (0.0%) 24 (100.0%) 0.31
2009 15 (50.0%) 13 (43.3%) 1 (3.3%) 1 (3.3%) 30 (100.0%) 0.38
2010 19 (67.9%) 8 (28.6%) 0 (0.0%) 1 (3.6%) 28 (100.0%) 0.36
2011 10 (52.6%) 9 (47.4%) 0 (0.0%) 0 (0.0%) 19 (100.0%) 0.23
2012 13 (32.5%) 22 (55.0%) 0 (0.0%) 5 (12.5%) 40 (100.0%) 0.46
2013 14 (41.2%) 15 (44.1%) 2 (5.9%) 3 (8.8%) 34 (100.0%) 0.42
2014 23 (53.5%) 18 (41.9%) 1 (2.3%) 1 (2.3%) 43 (100.0%) 0.51
2015 15 (46.9%) 14 (43.8%) 1 (3.1%) 2 (6.2%) 32 (100.0%) 0.39
2016 3 (20.0%) 9 (60.0%) 0 (0.0%) 3 (20.0%) 15 (100.0%) 0.47
Total 311 (37.5%) 432 (52.1%) 51 (6.2%) 35 (4.2%) 829 (100.0%) 0.60

The number of epidural catheters inserted at each level is given in absolute numbers and as a percentage of the total number of epidurals inserted that
year. The annual incidence of epidural anaesthesia is expressed as a percentage of the total number of anaesthetics administered that year.

the use of epidural analgesia over the last 19 years; in particu-

lar, a steep drop is seen after 2001. The incidence of epidural
analgesia has remained largely unchanged in the last 10 years.
The majority of epidural catheters are inserted at thoraco-
lumbar levels (Figure 2). The first seven years saw a gradual
rise in the incidence of thoracic epidurals and a decline in
lumbar epidurals (Figure 3). Caudal catheters have also been
on the decline. Children younger than 3 years of age saw the
largest decline in trans-sacral epidurals.
Figure 4 illustrates an overall rise in the use of epidural
analgesia in infants and adolescents, and a corresponding fall in
preschoolers as well as children in the school-going age group.
The proportion of caudal catheters used was higher in neo-
Figure 1.  Incidence of epidural anaesthesia from 1997 to 2016 nates compared to the older age groups (Table 2). Conversely,
at a paediatric teaching hospital in Singapore (expressed as a the use of thoracic epidurals was less common in neonates.
percentage of total anaesthetics performed). Figures 5 and 6 illustrate trends in the drugs given via con-
tinuous epidural infusion. Levo-bupivacaine was introduced in
in practice over the last 19 years. All children who received our institution in 2012, and since then there has been a steady
epidural catheters from 1 June 1997 to 31 May 2016 were rise in the use of levo-bupivacaine instead of racemic bupiv-
included in the study. These included thoracic, lumbar, trans- acaine. The use of adjuvants has also changed over the years
sacral and caudal epidural catheters. Single-shot caudal epi- – there has been a shift away from using additives at all.
durals were not included. Patients were divided into the Opioids are used less frequently, with a fall in the use of fen-
following age groups: neonates <28 days old; infants <1 year tanyl by almost half in the last decade and the complete avoid-
old, toddlers 1–2 years of age, preschoolers 3–6 years of age, ance of morphine since 2012. Clonidine has also been used
children 7–12 years of age and adolescents >12 years of age. more frequently in the last 10 years.
Over the years, the midline approach has been favoured
over the paramedian approach, consistently accounting for
Results over 80% of all epidurals. Epidural catheters were left in situ
A total of 829 epidural catheters were inserted from 1 June for a mean of 2.3 days (95% confidence interval 2.2–2.4 days),
1997 to 31 May 2016, accounting for 0.6% of all anaesthetics with an initial rise in mean duration (from 1.7 to 2.8 days) in
(Table 1). Figures 1 and 2 illustrate an overall declining trend in the first decade and a plateau thereafter at about 2.4 days.
Wong and Lim 51

Figure 2.  Trends and approaches in paediatric epidurals from 1 June 1997 to 31 May 2016 in a paediatric teaching hospital in Singapore.

of epidural analgesia. Concerns of intraoperative coagulopa-

thy, particularly where massive blood transfusion is antici-
pated or potential derangements in coagulation (e.g. with
significant hepato-biliary disease) may sway the anaesthetist
and/or surgeon to view it as a riskier rather than a beneficial
option. Further study on the perception of Asian parents as
well as anaesthetists about the safety of epidurals may shed
light on this issue. Because of our stringent and cautious
patient selection, we have encountered only one case of
postoperatively deranged coagulation requiring further labs
and delay in removal of the catheter.
The use of epidural analgesia has fallen steadily over the
last 19 years, from 1.05% in 1997 to 0.47% of all anaesthetics
Figure 3.  Trends in levels of epidurals over time. performed in 2016. This is consistent with international
data,1–3 which also showed a decline in the use of epidural
analgesia. It is also in keeping with the rise in popularity of use
Discussion of other modalities of analgesia including patient-controlled
The overall incidence of epidural analgesia is 0.6%, which is analgesia, caudal additives and peripheral regional a­ naesthesia.1
low compared to an incidence of 5.1% in the French-Language At the same time, the development of laparoscopic surgery
Society of Paediatric Anaesthesiologists (ADARPEF) study.1 has reduced analgesic requirement in many surgeries.3,4
Parental fears of potential neurological complications are not A fall in the absolute number of lumbar and trans-sacral
uncommonly encountered and preclude more frequent use epidurals was seen after 2008, when anaesthetists began

Figure 4.  Trends in age group over time.

52 Proceedings of Singapore Healthcare 27(1)

Figure 5.  Trends in local anaesthetic drugs used in epidural

Figure 6.  Trends in adjuvant drugs used in epidural infusions.
infusions.

Table 2.  Level of epidurals performed in each age group.

Age group Level Total

Thoracic Lumbar Sacral Caudal

 Neonate 1 (6.7%) 8 (53.3%) 0 (0.0%) 6 (40.0%) 15 (100.0%)
 Infant 30 (26.1%) 61 (53.0%) 12 (10.4%) 12 (10.4%) 115 (100.0%)
 Toddler 64 (33.5%) 94 (49.2%) 27 (14.1%) 6 (3.1%) 191 (100.0%)
 Preschooler 107 (46.7%) 105 (45.9%) 10 (4.4%) 7 (3.1%) 229 (100.0%)
 Child 71 (36.4%) 118 (60.5%) 2 (1.0%) 4 (2.1%) 195 (100.0%)
 Adolescent 38 (45.2%) 46 (54.8%) 0 (0.0%) 0 (0.0%) 84 (100.0%)
Total 311 (37.5%) 432 (52.1%) 51 (6.2%) 35 (4.2%) 829 (100.0%)

using additives in single-shot caudal injections. Clonidine and provide an effective analgesia,12 sparing the patient an invasive
S-ketamine were frequently used, and the prolonged dura- epidural catheter insertion. In our institution, the use of
tion of effect provided good analgesia of sufficient duration patient-controlled analgesia has tripled in the last decade
such that an indwelling epidural catheter would not be (from 0.6% in 2006 to 1.8% in 2016), and may have accounted
required.5–7 for the decline in the use of epidural catheters in school-going
Over the last decade, there has been increasing global children and preschoolers, respectively.
interest in paediatric regional anaesthesia.1–3 The ADARPEF
study in 20101 showed that peripheral nerve blocks repre-
Trends in prescription
sented 66% of all regional anaesthesia, compared to only 38%
in 1996.2 With the increase in popularity of regional anaes- (i)  LA agents. Bupivacaine has traditionally been the local
thesia since 2008, an increasing number of lower limb periph- anaesthetic of choice in continuous epidural infusions. How-
eral nerve blocks such as femoral nerve blocks have also ever, the last five years have seen the introduction and rise in
allowed anaesthetists to avoid the use of lumbar epidural use of levo-bupivacaine at our hospital. Levo-bupivacaine has
catheters and their inherent risks. This is especially so with the similar analgesic efficacy but a lower risk of toxicity (viz. neu-
increasing skill in the use of ultrasound techniques in regional rotoxicity and cardiotoxicity) when compared to racemic
anaesthesia,8 which may allow the use of a lower volume of bupivacaine. This attested superior safety profile makes it
LA and prolong the analgesic effect compared to conven- more ideal for paediatric use.13 Epidural ropivacaine remains
tional peripheral nerve block techniques.9 Peripheral catheter less popular than bupivacaine or levo-bupivacaine, a trend
techniques also allow continued postoperative analgesia10 and mirroring that of caudal analgesia, where the latter two were
have a superior safety profile compared to central neuraxial used 85% of the time,14 largely due to prevalent paediatric
blocks.1 anaesthetists’ preference.
In recent years, truncal blocks such as paravertebral blocks,
transverses abdominis plane blocks and rectus sheath blocks (ii)  Epidural opiates.  In our institution, the standard epidural
have also increased in number. These have the potential to opiate additive of choice is fentanyl at concentration of 2 mcg
decrease postoperative pain and therefore reduce the need per ml in the epidural infusate. It is entirely omitted in neo-
for thoracic epidural infusions.11 nates and younger infants. Epidural morphine has been used
Patient-controlled analgesia has been established as a safe as a substitute for hydromorphone, which is the more com-
and reliable method of postoperative analgesia in children monly used epidural opiate in the United States of America.
who are able to understand its use. Nurse-controlled analge- The hydrophilic nature of morphine produces more exten-
sia, in the presence of reliable protocols, are also safe and sive spread which results in an improvement in the quality of
Wong and Lim 53

analgesia.15 It is particularly useful in cases with inadequate than 2/10) in the majority of cases so we had little impetus to
dermatomal coverage or where its more pronounced seda- explore PCEA. An additional concern is that PCEA boluses
tive effects may be useful in postoperative care of the frac- may lead to a block level that is potentially higher than desired.
tious child. However, it is mandatory to document with This mandates more intensive assessments and monitoring,
absolute confidence that the epidural is in fact in the correct particularly when already faced with difficulties in the accu-
place (i.e. the epidural space) before utilising this prescription. rate measurement of pain in young children. With continued
It also presents a relative contraindication to the addition of a development and increased sophistication of epidural pro-
second parenteral opioid, especially as a continuous infusion gramming via the pump and cartridges used, we can currently
that is commonly utilised in younger children, in view of the explore this modality, which is already a useful tool for paedi-
unpredictable nature of delayed respiratory depression (up atric spinal surgery.23
to 17 hours after administration) associated with epidural
morphine.15
Future directions
(iii)  Epidural clonidine. Clonidine is known to prolong the The future of paediatric epidural analgesia remains uncertain
duration of epidural analgesia without significantly increasing for now. The development of liposomal local anaesthetic
the risk of adverse effects,16 and its popularity has superseded deposits which can be administered aseptically by surgeons
that of morphine. There has been an overall decline in the may herald a further decline in the number of elective epi-
use of opioid adjuvants, in keeping with international practices durals. The potential for future additives or long-acting local
on caudal additives. The addition of caudal fentanyl in particu- anaesthetic agents to extend the duration of a single shot
lar has not been shown to enhance analgesia compared to regional to the point that the need for a postoperative infu-
ropivacaine alone.17 Unlike hydrophilic morphine, its lipophilic sion is obviated, may do away with the need for an indwelling
nature may not be as useful in augmenting the analgesic catheter and its consequent associated risks. Although the
effects of incomplete blocks. use of epidural analgesia is on the decline, it still remains an
effective technique for management of acute postoperative
(iv)  Epidural ketamine. Ketamine has been reported to pain. Currently, there remain indications for the use of epi-
decrease analgesic requirements18 and prolong the dura- dural analgesia in specific instances such as open thoracic sur-
tion of caudal epidural analgesia to over six hours.19 As a gery,4 major intra-abdominal surgery24 or spinal surgery25
single-shot caudal additive at the recommended dose of 0.5 where the analgesia effected is virtually sine qua non for
mg/kg, it has provided prolonged analgesia for up to 22 those either unfamiliar with newer regional techniques or
hours with minimum behavioural anomalies and agitation.20 without the availability of ultrasound machines to guide them
Although epidural morphine has been demonstrated by in, for example, paravertebral or transversus abdominus
several authors to provide more potent analgesic and plane (TAP) blocks. Anaesthetists should maintain compe-
sedating effects than epidural ketamine, Xie et al. managed tency in the insertion of paediatric epidural catheters, but as
to show that the addition of epidural ketamine provided the overall incidence decreases, there will be fewer opportu-
superior analgesic effects.21 Adverse neurological effects nities for training and refinement of skills, sauf in vitro simula-
have been documented after neuraxially administered, tors. In our practice, due to the small numbers of infant
non-preservative-free ketamine and in our institution, only epidural catheters performed, we preferentially reserve their
preservative-free S+ ketamine can be administered in execution in this higher-risk group for paediatric specialist
neuraxial blocks. In the recent light of neurotoxicity of consultants only. Clearly, it is imprudent to allow a trainee
anaesthetic agents, we have chosen to be more conserva- who has not performed enough epidurals in older children to
tive with its use, limiting its prescription to single-shot cau- attempt this challenging and delicate task. Similarly, clinical
dals for its prolonged analgesic effect in older children, nursing skills and expertise in managing the paediatric epi-
rather than as an additive in a continuously administered dural may deteriorate with infrequent epidural patients to
epidural infusion in our younger subset. manage, giving rise to concerns regarding postoperative man-
agement of continuous epidural infusions and subsequent
(v)  Other epidural adjuvants. Neostigmine and midazolam identification and management of any adverse effects. Our
have not been employed as epidural additives in our hospital. institution has guidelines in place for the initiation and care of
Reports of their successful utilisation in the caudal/epidural epidurals, encompassing protocols on paper and electronic
space have been documented in other countries.19,22 We col- order templates to guide junior staff who may be unfamiliar
lectively chose not to try out these drugs because they are with its use. This is in addition to core training, didactic lec-
inherently not analgesics per se and more importantly tures and supervision. We also mandate ongoing accredita-
because we have not been able to procure a pharmaceutical tion for nurses in their competency skill sets in handling
preparation safe for use in the epidural space. It is possible paediatric epidurals, which embraces lectures, practical as
that their analgesic advantage is largely due to sedation and well as test/assessment aspects.
musculoskeletal relaxation, rather than manipulation of innate
opioid receptors or other established analgesic pathways.
Strengths and limitations
(vi)  Patient-controlled epidural analgesia (PCEA). In our prac- This is the first such study which has examined trends from a
tice, continuously administered epidural LA with or without single database over a period of almost two decades. It mir-
additives has provided good analgesia (with pain score less rors a global trend in paediatric anaesthetic practice
54 Proceedings of Singapore Healthcare 27(1)

and highlights potential areas for development in paediatric prolongs caudal analgesia in children. Br J Anaesth 2009; 103:
analgesia. We acknowledge our main limitations as that of 268–274.
modest numbers and that this study examines only patients 8. Flack S and Anderson C. Ultrasound guided lower extremity
from a single institution. blocks. Paediatr Anaesth 2012; 22: 78–80.
9. Tsui BC and Pillay JJ. Evidence-based medicine: Assessment
of ultrasound imaging for regional anesthesia in infants, chil-
Conclusion dren, and adolescents. Reg Anesth Pain Med 2010; 35 (2 Suppl):
S47-S54.
Over the last 19 years, the use of epidural analgesia has been 10. Dadure C and Capdevila X. Peripheral catheter techniques.
on the decline as it is gradually replaced by alternative modali- Paediatr Anaesth 2012; 22: 93–101.
ties of analgesia with superior safety profiles. In keeping with 11. Hamill JK, Rahiri JL, Liley A, et al. Rectus sheath and transversus
global trends, we expect further growth in the area of paedi- abdominis plane blocks in children: A systematic review and
atric regional anaesthesia in the near future, specifically in the meta-analysis of randomized trials. Paediatr Anaesth 2016; 26:
fields of peripheral nerve and truncal nerve blocks. However, 363–371.
12. Howard R, Lloyd-Thomas A, Thomas M, et al. Nurse-controlled
there remain clear indications for the use of epidural analgesia
analgesia (NCA) following major surgery in 10,000 patients in a
in children, and for this reason paediatric anaesthetists must
children’s hospital. Paediatr Anaesth 2010; 20: 126–134.
retain competency and confidence in its use. 13. Ingelmo PM and Fumagalli R. Central blocks with levobupiv-
acaina in children. Minerva Anestesiol 2005; 71: 339–345.
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Declaration of Conflicting Interests 419–422.
16. Schnabel A, Poepping DM, Pogatzki-Zahn EM, et  al. Efficacy
None declared. and safety of clonidine as additive for caudal regional anesthe-
sia: A quantitative systematic review of randomized controlled
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the public, commercial, or not-for-profit sectors. blind, randomized trial of caudal block using ropivacaine 0.2%
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