Epidural insertion height for ureteric reimplant surgery; does location matter?

BACKGROUND: Surgical correction of vesicoureteric reflux through ureteric reimplantation is a common, highly successful treatment. Postoperative pain can be severe and may relate to somatic wound pain from the lower abdominal incision or from visceral bladder spasm pain. AIM: To conduct a prospective quality improvement audit to compare four perioperative analgesic techniques. METHODS: Observational data were collected on 217 patients following open ureteroneocystostomy over 5 days. The patients were split into four groups: (i) 'morphine' infusion; (ii) 'caudal'-single-shot caudal; (iii) 'epidural'-epidural catheter inserted at T10-L2 given a bolus, followed by an infusion of 0.125% bupivacaine with fentanyl 2 µg·ml(-1) ; (iv) 'caudal catheter'-caudal placed epidural catheter was treated similar to the epidural catheter. Data regarding postoperative analgesic interventions were recorded. Intravesical pethidine was used for bladder spasm pain and i.v. morphine for wound pain. RESULTS: Over the study period, the caudal catheter technique (mean interventions/patient = 1.8 ± 2.6) and the single-shot caudal (6.1 ± 4) needed significantly less bladder spasm interventions than morphine (9.2 ± 4) and epidural (8.0 ± 4.4) patients. For wound pain, the caudal catheter (8.8 ± 3.3) and epidural groups (11.4 ± 3.2) needed significantly less interventions than morphine (16.1 ± 3) and caudal (15.3 ± 3.3) patients. Overall, caudal catheter patients on average required about half the number of pain interventions and were associated with less high nursing workload. CONCLUSIONS: Despite some limitations in data collection and study design, the caudal catheter technique was superior at reducing pain interventions, particularly bladder spasm interventions. Overall epidural analgesia was not superior to a single-shot caudal followed by opioid infusion. The issue of bladder spasm may be similar to the phenomenon of sacral sparing in obstetric epidural anesthesia. Thus, regional techniques, such as caudal epidural, targeting a better balance between sacral and lumber nerves are required.

Postoperative pain, nausea and vomiting following adeno-tonsillectomy - a long-term follow-up.

BACKGROUND: Adenotonsillectomy is a common pediatric surgical procedure. Our knowledge of the recovery profile, parental understanding, and expectations is limited. We aimed to assess the incidence of pain, nausea, and vomiting in children undergoing adenotonsillectomy on postoperative day 3 and 7. We also wished to evaluate parental understanding regarding discharge instructions as well as parental expectations and experience of their child's recovery. METHODS: We enrolled 100 children (0-16 years) undergoing elective adenotonsillectomy. On day 3 and 7, parents were questioned about their child's level of pain, nausea/vomiting and their understanding regarding postoperative instructions. RESULTS: Hundred children (median, 6.68 years) were recruited. 52% of parents rated their child's pain as VAS ≥ 5 on day 3, dropping to 30% by day 7. Almost 33% of patients experienced nausea on day 3, dropping to 11.6% by day 7. A similar trend was observed for postoperative vomiting. Most parents, 89%, agreed that postoperative instructions were clear. However, knowledge regarding when to seek emergency medical advice was found to be lacking. On day 7, only 44% of parents reported that their child's recovery met their expectations. CONCLUSION: Adenotonsillectomy is associated with significant pain and PONV, persisting into the seventh postoperative day. Parental education and information seems inadequate and needs to be improved.