Single‐shot thoracic epidural: an aid to earlier discharge for pediatric laparoscopic cholecystectomy

SIR—Laparoscopic surgery has become the standard of care for many operations and has been associated with decreased pain, shortened hospital stays, and faster recovery (1). Ambulatory laparoscopic cholecystectomy has become an accepted practice in adults, but is not yet widely practiced in pediatric medicine. Two recent studies have demonstrated that the use of appropriate clinical pathways, utilizing regional anesthesia, can allow for safe same-day discharge (SDD) following laparoscopic cholecystectomy in pediatric patients (2,3). Epidural anesthesia, for pain management, has been used effectively in adult laparoscopic cholecystectomy but currently there are limited data for its use in pediatric laparoscopic cholecystectomy. We retrospectively studied elective pediatric laparoscopic cholecystectomies from 2007 to 2012. All patients were offered a single shot thoracic epidural (SSTE) vs narcotics for pain control and the option of SDD. SSTE use was based on parental preference. Our purpose was to better understand if SSTE for pediatric laparoscopic cholecystectomies could reduce length of stay, facilitate SDD, and improve postoperative pain control. Statistical analysis was conducted using SAS Software (version 9.3, SAS Institute Inc., Cary, NC, USA) and JMP (Version 11. SAS Institute Inc., Cary, NC, 1989-2007). All statistical tests were two-tailed tests. We identified 26 patients receiving SSTE and compared age-matched controls that only received standard intravenous opioid analgesia. SSTE was administered at T6–T8 spinal level after induction of general anesthesia in a lateral position with a standard loss of resistance technique to confirm placement. Approximately, 7–10 ml of 0.25% bupivicaine clonidine (1 lg/kg) was used based on the anesthesiologist assessment. No epidural catheters were placed. All analgesic dosing, for purpose of analysis, were reported as morphine equivalents. We found that SDD was more common in SSTE patients (65% vs 35%, P = 0.027) along with decreased length of stay (14.3 vs 22 h, P = 0.03) when compared to age-matched controls receiving only standard intravenous opioid analgesia. Intraoperative and postoperative intravenous analgesic use was greater in the non-SSTE group (both total intraoperative morphine equivalents [27 vs 9 mg, P = 0.001], and weight-based morphine equivalents [0.39 vs 0.14 mg kg , P < 0.001]). There was no significant difference in postoperative nausea or postoperative opiate use within 2 h of surgery between the two groups. There was a decreased time to first PO intake in the SSTE compared to the non-SSTE. There were no reported complications related to SSTE (Table 1). Our goal was to show that SDD for pediatric laparoscopic cholecystectomy can be safely achieved in adolescents. SSTE showed decreased intraoperative opiate usage suggesting improved pain control and a significant increase in successful SDD. With proper patient selection, SSTE can be used to aid SDD. There are inherent limitations due to the small population and retrospective study. This illustrates the need for future prospective studies that could be directed at minimizing the biases of small retrospective studies and further delineating the role of regional anesthetic