Multimodal approach to perioperative protection in children in abdominal surgery: A prospective comparative study

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Abstract

OBJECTIVE: To increase the effectiveness of perioperative protection by using combined multimodal analgesia (CMA) with epidural blockade (EA) with bupivacaine in combination with low-flow anesthesia with sevoflurane in traumatic abdominal surgery in children.

MATERIALS AND METHODS: A prospective comparative study was conducted (n=102, from 1 to 17 years). Surgical planned pathology: Hirschsprung disease, Ledd and Payr syndrome, liver echinococcosis, enterocystoma, pancreatic cyst. Study period: 2018–2022. Patients were divided into two groups depending on the technique of anesthesia and management of the postoperative period. Group 1 (n=55) received CMA + EA with bupivacaine 0.5%. In the postoperative period — prolonged EA with bupivacaine 0.25% 0.5–1 mg/kg. Comparison group 2 (n=47) — traditional general anesthesia based on opioids. For the treatment of postoperative pain syndrome (PPS) — promedol 0.3 mg/kg. The effectiveness of perioperative analgesia in pediatric abdominal surgery, the time of development and intensity of postoperative pain syndrome were evaluated.

RESULTS: The data obtained as a result of the study clearly showed that the advantages lie behind the optimized method of combined multimodal analgesia CMA + EA with bupivacaine 0.5%. In general, the effectiveness of CMA in combination with epidural analgesia in the intraoperative period was quite high. Additional intraoperative administration of fentanyl was registered in 8 (14.5%) of cases. The stability of hemodynamic parameters and neuroendocrine status was noted in almost all patients of the main group. Analyzing the time of development and intensity of PPS, it can be argued that patients of group 1 had better indicators: the duration of the pain-free period was 2 times longer and the intensity of PPS was lower than in children of group 2. Motor blockade gradually resolved in patients on average, after 209±46 minutes. By this time, there was a recovery of the sensation of a pinprick and motor activity in 32 (58.1%) of patients according to the Bromage <2 scale. Analysis of the results of an oral survey of patient satisfaction with pain relief conducted 24 hours after surgery showed that in group 1 the number of cases 43 (78.1%) satisfied with the level of pain relief was 1.5 times higher compared to the control group 24 (51.1%).

CONCLUSION: Combined multimodal analgesia in combination with epidural blockade with bupivacaine in traumatic abdominal surgery in children provides sufficient perioperative stability of the hemodynamic and neuroendocrine status, significantly reduces the pharmacological burden, reduces complications, early activation of patients and rapid postoperative rehabilitation compared to the traditional method.

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ADDITIONAL INFORMATION

Funding source. This article was not supported by any external sources of funding. Competing interests. The authors declare that they have no competing interests. Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. G.Z. Ashurova — data collection and analysis, text writing; E.A. Satvaldieva - writing the text, editing the article. A.I. Fayziev - statistical processing of results, analysis of literary sources.

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About the authors

Elmira A. Satvaldieva

National Children’s Medical Center; Tashkent Pediatric Medical Institute

Author for correspondence.
Email: elsatanest@mail.ru
ORCID iD: 0000-0002-8448-2670
SPIN-code: 9896-8364

MD, Dr. Sci. (Med.), Professor

Uzbekistan, Tashkent; Tashkent

Otabek Ya. Faiziev

Tashkent Pediatric Medical Institute

Email: fayziev.otabek@mail.ru
ORCID iD: 0000-0003-0847-3585
SPIN-code: 1925-0828

anesthesiologist-resuscitator

Uzbekistan, Tashkent

References

  1. Lugovoy AV, Panteleeva MV, Nadkina ED, Ovezov AM Intraoperative prevention of cognitive impairment in total intravenous anesthesia in school-age children: randomized clinical trial. Annals of Critical Care. 2018;4:57–64. (In Russ). doi: 10.21320/1818-474X-2018-4-57-64
  2. Debono B, Wainwright TW, Wang MY, et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J. 2021;21(5):729–752. doi: 10.1016/j.spinee.2021.01.001
  3. Aleksandrovich YS, Gorkovaya IA, Miklyaeva AV. Effect of Anesthesia in the Ante- and Intranatal Periods of Development on the Cognitive Status of Children Aged from 0 to 3 Years. Annals of the Russian Academy of Medical Sciences. 2020;75(5):532–540. (In Russ). doi: 10.15690/vramn1391
  4. Ishchenko AI, Aleksandrov LS, Ishchenko AA, Khudoley EP. Multimodal Strategy For The Management Of Surgical Patients (Fast Track Surgery). V.F. Snegirev Archives of Obstetrics and Gynecology. 2017;4(4):172–177. (In Russ). doi: 10.18821/2313-8726-2017-4-4-172-177
  5. Gorobets ES. Kontseptsiya mul’timodal’noi kombinirovannoi anestezii — podkhod k obespecheniyu bezopasnosti travmatichnykh operatsii. Annals of Critical Care. 2009;2:51–57. (In Russ).
  6. Gorobets ES, Shin AR. Sevofluran ili propofol v kachestve komponenta mul’timodal’noi kombinirovannoi anestezii pri operatsiyakh po povodu opukholei biliopankreatoduodenal’noi zony? Annals of Critical Care. 2012;1:37–40. (In Russ).
  7. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–641. doi: 10.1016/s0002-9610(02)00866-8
  8. Man JY, Gurnaney HG, Dubow SR, et al. A retrospective comparison of thoracic epidural infusion and multimodal analgesia protocol for pain management following the minimally invasive repair of pectus excavatum. Paediatr Anaesth. 2017;27(12):1227–1234. doi: 10.1111/pan.13264
  9. Avis G, Gricourt Y, Vialatte PB, et al Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial. Reg Anesth Pain Med. 2022:rapm-2022-103737. Epub ahead of print. doi: 10.1136/rapm-2022-103737
  10. Polushin YuS, editor. Rukovodstvo po anesteziologii i reanimatologii. St. Petersburg: Elbi-SPb; 2004. (In Russ).
  11. Hicks CL, von Baeyer CL, Spafford PA, et al. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173–183. doi: 10.1016/S0304-3959(01)00314-1
  12. Costi D, Cyna AM, Ahmed S, et al. Effects of sevoflurane versus other general anaesthesia on emergence agitation in children. Cochrane Database Syst Rev. 2014;9:CD007084. doi: 10.1002/14651858.CD007084.pub2
  13. Ovechkin AM, Politov ME, Sokologorsky SV, Evsyukova MA. Propofol vs inhalation anesthetics: can we talk about the renaissance of total intravenous anesthesia? Russian Journal of Anaesthesiology and Reanimatology = Anesteziologiya i Reanimatologiya. 2021;5:71–79. (In Russ). doi: 10.17116/anaesthesiology202105171
  14. Ovezov AM, Mashkov AE, Lugovoi AV, Lodatko IM, Gus’kov IE. Primenenie sevoflurana dlya ingalyatsionnoi induktsii i podderzhaniya anestezii u detei raznogo vozrasta. Poliklinika. 2013;2–1:47–50. (In Russ).
  15. Devroe S, Lemiere J, Van Hese L. The effect of xenon-augmented sevoflurane anesthesia on intraoperative hemodynamics and early postoperative neurocognitive function in children undergoing cardiac catheterization: A randomized controlled pilot trial. Paediatr Anaesth. 2018;28(8):726–738. doi: 10.1111/pan.13444
  16. Zabolotskiy DV, Koryachkin VA. Child and regional anesthesia — What for? Where? And how? Regional Anesthesia and Acute Pain Management. 2016;10(4):243–253. (In Russ). doi: 10.17816/RA42815
  17. Bryskin RB, Londergan B, Wheatley R, et al. Transversus Abdominis Plane Block Versus Caudal Epidural for Lower Abdominal Surgery in Children: A Double-Blinded Randomized Controlled Trial. Anesth Analg. 2015;121(2):471–478. doi: 10.1213/ANE.0000000000000779
  18. Singhal NR, Jones J, Semenova J, et al. Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: A retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure. J Pediatr Surg. 2016;51(4):612–616. doi: 10.1016/j.jpedsurg.2015.10.084
  19. Tornero Tornero C, Fernández Rodríguez LE, Orduña Valls J. Multimodal analgesia and regional anaesthesia. Rev Esp Anestesiol Reanim. 2017;64(7):401–405. doi: 10.1016/j.redar.2017.01.008
  20. Gautam SKS, Das PK, Agarwal A, et al. Comparative Evaluation of Continuous Thoracic Paravertebral Block and Thoracic Epidural Analgesia Techniques for Post-operative Pain Relief in Patients Undergoing Open Nephrectomy: A Prospective, Randomized, Single-blind Study. Anesth Essays Res. 2017;11(2):359–364. doi: 10.4103/0259-1162.194559
  21. Svetlov VA, Zaitsev AYu, Kozlov SP. Sbalansirovannaya anesteziya na osnove regionarnykh blokad: strategiya i taktika. Russian Journal of Anaesthesiology and Reanimatology = Anesteziologiya i Reanimatologiya. 2006;4:4–12. (In Russ).
  22. Matinyan NV, Kuznetsov DA, Kovaleva EA, et al. Perioperative anesthesia in children with oncological diseases: prospective single-center continuous cohort study of a 6-year clinical experience. Regional Anesthesia and Acute Pain Management. 2022;16(4):255–266. (In Russ). doi: 10.17816/RA110736
  23. Sichkar SYu, Afukov II, Stepanenko SM. Epidural analgesia for intraoperative and postoperative care in newborns. Anaesthesiology and Reanimatology = Anesteziologiya i Reanimatologiya. 2015;60(3):65–70. (In Russ).
  24. Gupta A, Jay MA, Williams G. Evolving pediatric epidural practice: An institution’s clinical experience over 20 years — A retrospective observational cohort study. Paediatr Anaesth. 2020;30(1):25–33. doi: 10.1111/pan.13767
  25. Ulrikh GE, Zabolotskii DV, Aleksandrovich YS, et al. Levobupivacaine for regional blockades in orthopedics and traumatology in children: recent evidence and future directions. Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(4):77–83. (In Russ). doi: 10.17816/PTORS6477-83
  26. Praveen P, Remadevi R, Pratheeba N. Caudal Epidural Analgesia in Pediatric Patients: Comparison of 0.25 % Levobupivacaine and 0.25 % Ropivacaine in Terms of Motor Blockade and Postoperative Analgesia. Anesth Essays Res. 2017;11(1):223–227. doi: 10.4103/0259-1162.200231
  27. Casati A, Santorsola R, Aldegheri G, et al. Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine in major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine. J Clean Anesth. 2003;15(2):126–131. doi: 10.1016/s0952-8180(02)00513-5
  28. Ivani G, DeNegri P, Conio A, et al. Comparison of racemic bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal anesthesia: effects on postoperative analgesia and motor block. Reg Anesth Pain Med. 2002;27(2):157–161. doi: 10.1053/rapm.2002.30706
  29. Frawley G, Smith KR, Ingelmo P. Relative potencies of bupivacaine, levobupivacaine, and ropivacaine for neonatal spinal anaesthesia. Br J Anaesth. 2009;103(5):731–738. doi: 10.1093/bja/aep259

Supplementary files

Supplementary Files
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1. Fig. 1. Changes in hemodynamics at the stages of anesthesia in patients of the 1st group.Note. Here and in Fig. 2: * — significance of differences at p <0.05, ** — significance of differences at p <0.01 compared with outcome. Here and in Fig. 2–5: УПС — specific peripheral resistance, ЧСС — heart rate, УО — stroke volume, СрАД — mean arterial pressure.

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2. Fig. 2. Changes in hemodynamics at the stages of anesthesia in patients of the 2nd group.

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3. Fig. 3. Comparative dynamics of cortisol in the blood at different sites of anesthesiaNote (here and in Fig. 4, 5). * — significance of differences at p <0.05 compared with the outcome.

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4. Fig. 4. Comparative dynamics adrenaline in the blood at different sites of anesthesia.

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5. Fig. 5. Changes in blood glucose levels at the stages of the study in children of both groups.

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