Serenity after surgery

When seven-year-old Bayleigh arrived at the MUSC Shawn Jenkins Children’s Hospital for reconstructive urologic surgery, she was already a seasoned patient, like many other children with complex medical conditions. Armed with her iPad, hot pink unicorn and cozy blanket, she knew the routine. But like many similar children, she also remembered the fear and distress she experienced after poorly managed pain from former procedures at other institutions. So she was willing to cooperate, but only up to a point.

This time was different, everyone assured her. With a dedicated pediatric pain management team at the Children’s Hospital, she would be more comfortable and stress-free both during and after her procedures. This time her doctors would start regional anesthesia during surgery and continue that pain control after surgery to keep her pain-free. They would plan a strategy with her parents ahead of surgery and then follow up regularly to monitor her comfort afterwards. And they would keep her epidural in place for as long as her body needed, anywhere from 3-7 days, and then transition her care to oral or IV pain medication as she continued to recover.

Tracy Wester, M.D., codirector of the MUSC Pediatric Anesthesiology Care Team, explained that the team optimizes pain control for kids having surgeries by using regional nerve blocks and neuraxial techniques (things like spinal and epidural anesthesia). This makes patients more comfortable and eliminates or minimizes the need for narcotics.

She recently placed an epidural in an eight-month-old baby with a Wilms tumor while the baby was asleep for surgery. “The epidural was in place for surgery as well as part of the postoperative recovery,” she said. “And the surgeon was really satisfied with it, the kid was super comfy, and the family was really happy.”

This type of surgery can be very painful and normally requires a lot of narcotics, but instead the child was able to be awake and interactive with the family after surgery and start their recovery quickly — without reliance on narcotic medicine alone.

Natalie Barnett, M.D., a pediatric anesthesiologist on the MUSC Pediatric Anesthesiology Care Team, is an advocate of regional pain management for pediatric surgical procedures. She and her former colleagues at New York’s Icahn School of Medicine recently published a review in the Journal of Pediatric Urology in which they examined this approach specifically for urologic procedures, some of the most commonly performed procedures in children.

In their most recent guidelines, the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists revealed that less than half of surgical patients reported adequate pain control after surgery. And since many children, especially very young ones, cannot communicate their pain effectively — and because physicians are reluctant to risk adverse side effects from opioid medications — the historic tendency leaned toward an overall undertreatment of pain in children.

Wester concurred that the common practice up to about 15 years ago was to use IV medications such as morphine or fentanyl and possibly oral acetaminophen as the mainstays of surgical pain control. But with the risks of both side effects and narcotic tolerance, finding the right balance between effective pain control and safety was a challenge.

And while caudal nerve blocks administered near the tailbone have been used for decades for urologic procedures in kids, it has been far less common to use things like pudendal nerve blocks that target the perineum or other peripheral nerve blocks in children.

In their review article, Barnett and her coauthors examined the safety and efficacy of regional anesthesia options in children, and while there was no consensus around specific techniques or the choice and dosage of anesthetic, the results showed that regional anesthesia is a safe option for pediatric patients.

“The one common conclusion is simply that regional anesthesia works,” Barnett said. “And it decreases the amount of narcotic pain medication that kids get afterwards as well as lessens side effects, which in the time of the opioid epidemic is a huge bonus.”

Barnett concluded that at the end of the day, regional anesthesia should be a part of the pediatric anesthetic plan when possible. She stresses that there are benefits and contraindications to each of the many available options for this type of care. Therefore, she believes that the anesthesiologist, surgeon and parents should decide on the exact type of block, choice of anesthetic and medication dosage for their unique situation.

In Bayleigh’s case, Barnett and Wester — along with the surgeon, Shumyle Alam, M.D., and her parents — decided that an epidural would be the best approach to pain management. Bayleigh would be in surgery for a full day to repair multiple complex urologic needs, so she and her parents met with Barnett and Alam beforehand to chat and prepare. When it was time for the day to begin, Bayleigh received general anesthesia for surgery, and Barnett placed the epidural and administered a neuraxial anesthetic perioperatively.

After a successful surgery, the epidural remained in place for about a week while Bayleigh recovered, until she was comfortable without it. Barnett visited her during her postoperative stay, and the pediatric anesthesia team made daily clinical rounds to make sure that she was not in pain. Soon Bayleigh was able to move forward with the business of playing games, watching cartoons and snuggling with her unicorn.

Barnett and Wester are part of a full roster of fellowship-trained pediatric anesthesiologists that serve on the pediatric anesthesia team at MUSC. These attending physicians manage regional and general anesthesia for surgical procedures, but they also lend support in other ways: discussing options with patients and their families, providing care to patients who need sedation for nonsurgical procedures like MRIs, and advising other physicians on pain management strategies for their patients.

Many children with complex conditions have an ongoing relationship with their surgeon, but access to the pain team as well can be a game changer. The anesthesiologists on the team understand that with chronic medical conditions come situations where the child may respond differently to some medications, and they work with the family and the surgeon to come up with a customized pain control strategy.

“These families aren't new customers to a hospital system,” said Barnett. “They’ve landed in the hospital for procedure after procedure, and they really appreciate being seen every day by someone from the anesthesia team.”

Wester has seen the same impact, where patients and families say that their experiences with and without regional anesthesia have been like night and day, with a new level of comfort when pain is under control. “I’ve had young patients tell me that they’ve never been this comfortable after surgery,” she said. “And it's always lovely to hear that, when people are that satisfied.”