Tunneled epidural catheters for prolonged analgesia in pediatric patients. (Stanford University, Stanford, CA) Anesthesia and Analgesia 2001;92:1432–1438.
Authors: Aram Laleh , Krane Elliot J. , Kozloski Lori J. , Yaster Myron 
Published: March 2003

The charts of 25 patients with prolonged pain that was unresponsive to conventional opioid therapy and who received thoracic, lumbar, or caudal tunneled epidural catheters between 1995 and 1999 were reviewed for efficacy and catheter‐related complications. Tunneled epidural catheters were effective in providing extended analgesia in all subjects. In 14 patients with chronic pain, cumulative 48‐hour enteral and parenteral opioid requirements were reduced or eliminated after catheter insertion. Catheters remained in place for a median of 11 days until there was no further need for parenteral analgesia (n = 15), death because of the underlying disease (n = 6), accidental removal (n = 2), or possible infection (n = 2). No serious local or systemic complications occurred related to this technique. Five patients were discharged from the hospital with the catheter for home analgesic therapy. The use of a percutaneously inserted, subcutaneously tunneled epidural catheter is safe, effective, and provides pain relief in situations in which conventional analgesic therapy either fails or is impractical. The technique is one that may be of great value to children suffering from pain.

Comment by Alan David Kaye, M.D., Ph.D., Amr Hegazi, M.D. This retrospective study assessed the safety, efficacy, complications, indications, and duration of use of subcutaneously tunneled lumbar, thoracic and caudal epidural catheters in pediatric patients with prolonged pain.

The authors examined a total of 25 patients hospitalized for treatment of acute pain caused by trauma as well as chronic pain resulting from end‐stage cancer or cystic fibrosis. The catheters were introduced under either local anesthesia with sedation or general anesthesia after obtaining informed parental consent. Epidural catheters were inserted percutaneously, then tunneled subcutaneously away from the insertion site to bring the catheter exit site to the anterior abdominal and thoracic, posterior superior iliac crest to decrease the risk of potential infection and chance of catheter dislodgement. Tunneled catheters were effective in providing extended analgesia in all patients. None of the acutely ill patients required supplemental enteral or parenteral opioids while pediatric patients with chronic pain had dramatic decrease or elimination of opioid needs.

Two of these patients had accidental removal of the catheter. One patient had postoperative fever with possible presence of infection and another patient developed cellulites at the catheter exit site. Both the catheter and wound site were sterile on bacterial cultures. The clinical relevance of routine microbiological culturing of epidural catheters in acute pain management has been evaluated by Simpson et al. It was concluded that a significant proportion of catheter tips can be positive. This suggests that colonization of the skin at the insertion site and subsequent contamination of the tip upon removal of the catheter is a concern and strict sterile aseptic techniques should be practiced by the anesthesiologist. This is an interesting article because at most institutions, pediatric pain and certainly critically ill children are clearly undermanaged. The small size of the study group, however, enables us to appropriately define the risk of infection for long‐term catheter placement (up to 240 days in this article). Also accidental catheter dislodgement especially on patients discharged home with an epidural catheter remains a concern.