Neuraxial anesthesia and continuous analgesia with epidural catheter in surgical correction of hip dysplasia in a 3-year-old pediatric patient.

Abstract

Introduction: Developmental dysplasia of the hip in 3-year-old children generally requires surgical management. Intravenous sedation in combination with neuraxial block for the surgical correction of hip dysplasia in pediatrics is a safe technique that reduces postoperative pain and opioid consumption.

Case presentation: Female, 3 years old with right hip dysplasia, with a surgical plan of diaphysectomy, plus open reduction, Pemberton Type acetabuloplasty to the right hip, plus psoas and adductor myotomy, on evaluation the patient had no pathological, allergic or surgical history, on physical examination she weighed 14.4 kg, height 105cm, without neurological, cardiological or pulmonary alterations, in lower extremities, with lame walking at the expense of the right pelvic limb without requiring support for movement. Laboratory tests within normal parameters for age.

Anesthetic Plan: On the surgical day, the patient was received in the operating room and with prior authorization signed by the mother, non-invasive vital sign monitoring was performed, inhalation sedation was performed with sevoflorane at 2.0 minimum alveolar concentration and FIO2 at 60% for left venous access cannulation # 22, midazolam 1.5 mg, fentanyl 30 mcg were administered intravenously, the patient was placed in recumbency. left lateral, with prior asepsis and antisepsis of the lumbosacral region and placement of a sterile field, a neuraxial space was identified at L2-L3 with a Quincke #27 spinal needle in one attempt, a flow of rock crystal-colored cerebrospinal fluid was obtained, and local anesthetic was administered with isobaric bupivacaine 5 mg in a 0.5% concentration plus dexmedetomidine 5 mcg, in space. subarachnoid, with a total volume of 1.05 ml, subsequently with a Tuohy 17 needle, a caudal epidural catheter was placed, patency was confirmed, the catheter was fixed 8cm from the skin and continuous analgesia was administered with ropivacaine at a concentration of 0.3% at 2ml/kg/hr (0.4mg/kg/hr) and maintenance of intravenous sedation with propofol infusion from 30 to 60 mcg/kg/minute and oxygen with FIO2 at 45% by pediatric circular anesthesia circuit maintaining spontaneous ventilation, he presented arterial hypotension with MAP of 38mmHg, which responded with fluid load at 10ml/kg, plus albumin 40 ml and vasopressor was started with norepinephrine at 0.04mcg/kg/min for 30 minutes, recovering MAP of 65mmHg, bleeding total of 300ml, at the end of surgery, the complete epidural catheter was removed, with prior administration of a dose of 0.3% ropivacaine plus 10mcg of dexmedetomidine by caudal catheter by fixation with a circular Hemicallot-type fiberglass device, the surgical time was 244 minutes and anesthetic time of 308 minutes, in the postoperative period the patient had no pain, no nausea or vomiting.

Conclusion: The combination of neuraxial anesthesia and continuous epidural analgesia proved to be an effective and safe strategy for the surgical correction of hip dysplasia in this 3-year-old pediatric patient. The blockade allowed adequate anesthesia and postoperative pain control, reducing the need for opioids, rapid awakening, patient comfort and less need for intravenous analgesia in the hospitalization room, favoring early hospital discharge with good functional recovery.