A retrospective study examined whether caudal analgesia enhanced pain management during pediatric burn surgery.

 

INTRODUCTION

Every 100,000 hospital admissions, 15-20 people have paediatric burns. As methods for managing outpatients have improved over time, the incidence has declined. Even yet, some of these burns necessitate hospitalization and surgical treatment. The youngest age group, those under one, made up 29.6% of patients, the largest percentage of any age group, and scald burns were the most frequent type of burn in this age group, according to the most recent Healthcare Cost and Utilization Project (HCUP) statistics from 2013.

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Complex pain management is required while treating young burn victims. The burns themselves and the corresponding operations are excruciatingly unpleasant and painful, but regrettably there is little information on the development of persistent neuropathic pain after burn injury as well as on the best methods for controlling acute pain. Using regional anaesthetic treatments to manage postoperative pain is becoming more popular. A study of 19 patients who underwent donor graft harvest from the thigh and assessed the efficacy of local infiltration, lateral femoral cutaneous nerve block, or fascia iliaca, as well as a study evaluating caudal morphine, are the two studies in the paediatric burn literature that come closest to what is being reported.

One of the most often used regional anaesthetic methods for paediatric patients is caudal epidural block with local anaesthetics, but little is known about how it affects burn children.  Using landmarks or ultrasound guidance, the epidural space is accessed through the sacrococcygeal ligament during the surgery. Delivery methods include single injection and continuous infusion. Block failure, systemic toxicity, infection, and dural puncture are risks related to this procedure; however, the frequency of complications related to caudal epidurals continues to be minimal.

METHODS

Study participants

Due to the retrospective nature of the study, our Institutional Review Board (Human Research Protections Program) decided to waive the need for permission. In this retrospective cohort observational analysis, patients under the age of 7 who underwent in-patient burn surgery between October 28, 2013, and December 27, 2021, presented to a regional burn hospital accredited by the American Burn Association. 408 cases were found when the electronic medical record was searched for all burn surgeries that met the criteria.

Data collection

The use of intraoperative caudal analgesia was the main independent variable (defined as a binary variable indicating whether a caudal was performed or not). 24-hour opioid consumption was the main outcome of interest. It was evaluated in morphine equivalents (MEQ), and then corrected for patient weight (kg).

Statistic evaluation

The statistical analysis was done with R (version 4.2.0). Comparing the primary outcome of postoperative analgesia involved translating opioid use into morphine equivalents and making weight-based adjustments. First, we conducted a comparison of the patient characteristics and outcomes across the two groups using an unadjusted approach (caudal vs. no caudal). On each data subset, Shapiro-Wilk tests were run to check for a normal distribution. 

RESULTS 

Caudal analgesia and patient demographics

A total of 164 (40.2%) of the 408 patients that were identified underwent surgery for a lower extremity burn, lower extremity graft donor harvest, or both lower extremity burn surgery and lower extremity graft donor harvest. A caudal block was administered to 62 (37.2%) of these patients using a single injection of 0.5–1 ml/kg of either 0.2% ropivacaine or 0.25% bupivacaine. Surprisingly, there was little to no documentation of additions. Age in months (24.0 vs. 20.5, p = 0.346), weight in kg (14.2 vs. 13.2, p = 0.214), sex (52/102 vs. 25/62, p = 0.185), percent total body surface area of burn (4.00 vs. 3.39, p = 0.778), or burn mechanism were not statistically different between the no caudal and caudal cohorts.

DISCUSSION

The study's findings showed that caudal analgesia was not linked to a reduction in postoperative opioid intake after 24 hours when comparing propensity-score matched groups.

For paediatric patients undergoing infraumbilical procedures, caudal analgesia is a tried-and-true method for reducing pain. But nothing is known about how caudal analgesia affects burn surgery. This retrospective observational study's objective was to ascertain if patients who had single-shot caudal blocks had better pain management in the post-operative period, as shown by fewer opioid needs.

Intriguingly, the results from the unmatched cohorts revealed that patients who had a caudal block needed more analgesics during and after surgery. When matching cohorts were created using propensity-score analysis, those discrepancies vanished. This shows that the discrepancy between the two cohorts was probably caused by an imbalance of variables and confounders.

CONCLUSION

According to our knowledge, this is the first study to examine the impact of caudal analgesia on postoperative pain management in pediatric burn patients. When the data were adjusted using propensity-score matching, the difference between the groups that got caudal blocks and those who did not no longer reached statistical significance. The initial assumption that patients with caudal analgesia would need less postoperative pain medication was refuted by this unexpected discovery. This observation might be explained by the fact that the paediatric anesthesiologist was more likely to administer caudal analgesia to patients who were thought to be in more pain. Propensity-score matching also serves as a stand-in for randomised patient cohorts, the gold standard for confounder control. Last but not least, the process of examining how paediatric burn patients manage their pain has uncovered further potential to raise the standard of care and postoperative pain control for our paediatric burn patients.

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