Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience.
BACKGROUND
Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shifts and require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects. We present nine years of caudal epidural anaesthesia in delayed bladder exstrophy repair and describe its facilitation of early extubation and early feeding (within 12 h) without surgical complication.


METHODS
We retrospectively evaluated consecutive infants with classic bladder exstrophy undergoing delayed primary closure with anterior pelvic osteotomies between November 2007 and January 2016. Outcomes and complications were evaluated in terms of postoperative comfort (using the FLACC score-Face, Legs, Activity, Cry, Consolability), epidural failure rate, re-intubation rate and gastrointestinal complications.


RESULTS
Forty-four infants had average age of 5.8 months (range 1.6-17.1 months) and weight of 7.0 kg (range 3.5-11.8 kg), and their duration of surgery was 9.5 h (range 6.9-14.3 h). Forty-two of 44 (95.5%) patients received caudal epidural catheters. At 24 h, 15 of 42 (35.7%) caudal epidurals required supplementation with intravenous opioids. Fewer patients with optimally functioning epidurals required postoperative ventilation (1/27 [3.7%] compared with 3/15 [20.0%]). None of the patients with caudal epidural catheters required re-intubation. Pain scores were lower in infants with isolated caudal epidurals catheters than those with caudal epidurals supplemented by intravenous opioids (day 1 [18 vs 53; P = 0.008]; day 2 [8 vs 15; P > 0.05] and overall [32 vs 65; P = 0.014]). Infants with intravenous opioids experienced higher complications: pruritus (25% [95% confidence interval {CI}: 5%-57%] vs 0% [95% CI: 0%-13%]; P = 0.026) and nausea and vomiting (25% [95% CI: 5%-57%] vs 8% [95% CI: 1%-25%]; P = 0.30) requiring treatment. Nineteen of 44 (43.1%) infants were fed early (within 12 h of surgery). Infants who were fed early had lower pain scores than infants feeding late (day 1 [17.5 vs 31; P > 0.05]; day 2 [5.5 vs 15; P = 0.045]; overall [26 vs 55.5; P = 0.015]) without increase in complications (nausea and vomiting [6.3% vs 20.0%; P = 0.06]; ileus [0.0% vs 0.0%]; aspiration [0.0% vs 0.0%] and re-intubation aspiration [0.0% vs 0.0%]).


CONCLUSIONS
Caudal epidural analgesia facilitates postoperative extubation in infants undergoing delayed exstrophy repair. Early feeding (within the first 12 h) in delayed bladder exstrophy repair is likely to improve patient comfort and consolability without increasing the incidence of gastrointestinal complications. Intravenous opioid may be associated with increased postoperative complications that may influence peri-operative outcomes.