EPIDURAL ANALGESIA IN THE MANAGEMENT OF SEVERE VASOOCCLUSIVE SICKLE-CELL CRISIS

Objectives. To determine whether continuous epidural analgesia could e ffectively decrease pain and thereby improve the management of severe vaso-occlusive crisis in children with sickle cell disease who were un responsive to conventional analgesic therapy. Design. Retrospective ob servational study. Setting. A tertiary care hospital with a large pedi atric sickle cell patient referral population. Patients. The study des cribes nine children in 11 painful vaso-occlusive crises, unresponsive to high-dose systemic opioids, nonsteroidal anti-inflammatory drugs, and adjunctive measures, who underwent continuous epidural analgesia t o control pain. Outcome Measures. Subjective pain scores, arterial oxy gen saturation monitoring, and plasma lidocaine levels. Methods. Place ment of an epidural catheter for the administration of a continuous in fusion of local anesthetic, alone, or in combination with fentanyl, in the management of vaso-occlusive crisis. Results. At initiation of ep idural analgesic therapy, 8 of 9 patients reported severe pain (8 to 1 0 on a scale of 0 to 10, 0 = no pain, 10 = the worst pain they ever ex perienced). Analgesia was immediate (pain score 0 to 2) in 8 of 9 pati ents, and continuously effective in 9 of 11 crises. Five patients requ ired either the addition of fentanyl or changing the local anesthetic from lidocaine to bupivacaine to maintain analgesia for 2 to 5 days. I n 7 of 9 patients, oxygen saturation dramatically increased from 87 to 95% to 99 to 100% after epidural analgesia was initiated. In all pati ents, plasma lidocaine levels ranged from 1.1 to 4.6 mg/L and dose-rel ated toxicity did not occur. One patient developed hypotension seconda ry to high sympathetic blockade (T-4), one had an inadvertent dural pu ncture during insertion of the catheter, one had the epidural catheter removed for fever, and one achieved analgesia only transiently. There were no other complications, and epidural analgesia was not associate d with sedation, respiratory depression, or limitation of movement. Al l epidural catheters were cultured on removal, and colonization did no t occur. Conclusions. Epidural analgesia with local anesthetics admini stered alone or in combination with fentanyl effectively and safely tr eats the pain of sickle cell vaso-occlusive crisis unresponsive to con ventional pain management and does so without causing sedation, respir atory depression, or significant limitation on ambulation. Furthermore , early treatment of painful crisis with this technique may improve ox ygenation, a critical factor in the evolution of further sickling.