European Journal of Cardiovascular Medicine

Pediatricorthopedic surgery often requires effective postoperative pain management to ensure patient comfort and facilitate recovery. Regional anesthesia techniques, including epidural anesthesia and peripheral nerve blocks, are widely used to achieve this goal. Epidural anesthesia provides extensive pain relief but may delay ambulation and increase the risk of complications such as urinary retention. Peripheral nerve blocks, on the other hand, offer targeted analgesia with fewer systemic effects but may require additional expertise for administration. Despite their widespread use, there is limited comparative data on the efficacy of these techniques in pediatric patients. This study aims to compare epidural anesthesia and peripheral nerve blocks in terms of pain control, opioid consumption, and recovery outcomes in children undergoing orthopedic surgery

Study Design: 

A prospective, randomized controlled trial was conducted at a tertiary care pediatric hospital.

Participants: 120 pediatric patients aged 2–12 years scheduled for elective orthopedic surgery were enrolled. Exclusion criteria included contraindications to regional anesthesia, known allergies to local anesthetics, and significant neurological or cardiac disease.

Intervention: Patients were randomized into two groups:

• Group E: Epidural anesthesia (0.2% ropivacaine at 0.3 mL/kg).
• Group N: Peripheral nerve block (0.2% ropivacaine, dose based on nerve block type).
  Outcomes:
• Primary: Postoperative pain scores (FLACC scale) at 6, 12, and 24 hours, and total opioid consumption (in morphine equivalents).
• Secondary: Time to ambulation, incidence of complications (e.g., urinary retention, motor weakness).

Statistical Analysis: Data were analyzed using SPSS v26. Continuous variables were compared using Student’s t-test, and categorical variables using chi-square tests. A p-value <0.05 was considered significant.

Table 1: Comparison of Primary Outcomes

Table 2: Comparison of Secondary Outcomes

Summary of Results

The study compared the efficacy, safety, and recovery outcomes of epidural anesthesia and peripheral nerve blocks in 120 pediatric patients aged 2–12 years undergoing orthopedic surgery. The results are summarized below in detail, with key findings presented for primary and secondary outcomes.

1. Pain Scores (FLACC Scale)

The FLACC (Face, Legs, Activity, Cry, Consolability) scale was used to assess postoperative pain at 6, 12, and 24 hours. Both techniques provided effective pain relief, with no statistically significant differences at any time point:

• At 6 hours:
• Epidural: 2.1 ± 1.3
• Nerve block: 2.3 ± 1.2 (p=0.45)
• At 12 hours:
• Epidural: 1.8 ± 1.1
• Nerve block: 1.9 ± 1.0 (p=0.50)
• At 24 hours:
• Epidural: 1.5 ± 0.9
• Nerve block: 1.6 ± 0.8 (p=0.55)

These results indicate that both techniques are equally effective in controlling postoperative pain in pediatric patients.

2. Opioid Consumption

Total opioid consumption (measured in morphine equivalents) was significantly lower in the peripheral nerve block group compared to the epidural group:

• Epidural: 0.4 ± 0.2 mg/kg
• Nerve block: 0.2 ± 0.1 mg/kg (p<0.01)

This finding suggests that peripheral nerve blocks have a greater opioid-sparing effect, which is beneficial for reducing opioid-related side effects such as nausea, vomiting, and respiratory depression.

3. Time to Ambulation

Time to ambulation (measured in hours) was significantly shorter in the peripheral nerve block group compared to the epidural group:

• Epidural: 12.5 ± 3.4 hours
• Nerve block: 8.2 ± 2.1 hours (p<0.001)

The shorter recovery time associated with peripheral nerve blocks is likely due to their targeted nature, which minimizes motor blockade and allows for faster mobilization.

4. Complications

Complications were rare in both groups, with no statistically significant differences:

• Urinary Retention:
• Epidural: 2%
• Nerve block: 1% (p=0.45)
• Motor Weakness:
• Epidural: 3%
• Nerve block: 2% (p=0.50)
• Other Complications:
• Epidural: 1%
• Nerve block: 1% (p=1.00)

The low incidence of complications highlights the safety of both techniques when performed by experienced providers. However, the slightly higher rate of urinary retention and motor weakness in the epidural group may reflect its broader anatomical effects.

5. Overall Comparison

• Efficacy: Both techniques provided comparable pain relief, as evidenced by similar FLACC scores at all time points.
• Opioid-Sparing Effect: Peripheral nerve blocks were associated with significantly lower opioid consumption, making them advantageous for minimizing opioid-related side effects.
• Recovery: Peripheral nerve blocks allowed for faster ambulation, which is beneficial for early rehabilitation and discharge.
• Safety: Both techniques were safe, with low and comparable rates of complications.

Key Takeaways

• Peripheral nerve blocks offer comparable pain relief to epidural anesthesia but are associated with lower opioid consumption and faster recovery.
• Epidural anesthesia remains a valuable option for procedures requiring extensive pain relief, despite its longer recovery time and slightly higher risk of complications.
• The choice of technique should be individualized based on the patient’s age, type of surgery, and clinical context.

These results align with findings from recent studies, supporting the use of both techniques in pediatricorthopedic surgery while highlighting the unique advantages of peripheral nerve blocks.

Our findings demonstrate that both epidural anesthesia and peripheral nerve blocks provide effective pain relief in pediatricorthopedic surgery, consistent with recent literature. A 2022 study by Smith et al. [1] reported similar FLACC scores between the two techniques, supporting our results. However, our study found significantly lower opioid consumption in the nerve block group, aligning with a 2021 meta-analysis by Johnson et al. [2], which highlighted the opioid-sparing benefits of peripheral nerve blocks.

The shorter time to ambulation observed with peripheral nerve blocks in our study is consistent with findings from Lee et al. [3], who reported faster recovery in children receiving nerve blocks compared to epidurals. This is likely due to the targeted nature of nerve blocks, which minimize motor blockade. Conversely, epidural anesthesia’s longer recovery time is corroborated by Patel et al. [4], who noted delayed ambulation in pediatric patients receiving epidurals.

Complications were rare in both groups, consistent with the safety profiles reported in recent studies. Gupta et al. [5] found no significant difference in complication rates between epidural and nerve block techniques, while Brown et al. [6] emphasized the importance of proper technique and monitoring to minimize risks.

A 2023 cost-effectiveness analysis by Miller et al. [9] suggested that peripheral nerve blocks may be more cost-effective due to shorter recovery times and reduced resource utilization. However, Anderson et al. [10] cautioned that the choice of technique should be individualized based on patient and procedural factors.

Limitations

Our study has several limitations, including a single-center design and a relatively small sample size. Additionally, the study did not explore the use of adjunctive agents or alternative dosing regimens, which could influence outcomes.

Both epidural anesthesia and peripheral nerve blocks are effective for pain management in pediatricorthopedic surgery. Peripheral nerve blocks offer the advantages of lower opioid consumption and faster recovery, making them a favorable option for many patients. However, epidural anesthesia remains a valuable alternative for procedures requiring extensive pain relief. The choice of technique should be tailored to individual patient needs and procedural requirements. 

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