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

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.

Keywords

abdominal surgery / multimodal analgesia / epidural analgesia / pediatric anesthesiology

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