Chloroprocaine for epidural anesthesia in infants and children
Corresponding Author
Giorgio Veneziano
Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Correspondence
Dr. Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
Email: [email protected]
Search for more papers by this authorJoseph D. Tobias
Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
Search for more papers by this authorCorresponding Author
Giorgio Veneziano
Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Correspondence
Dr. Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
Email: [email protected]
Search for more papers by this authorJoseph D. Tobias
Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
Search for more papers by this authorSummary
Continuous epidural infusions are an effective and safe method of providing anesthesia and postoperative analgesia in infants and children with multiple advantages over systemic medications, including earlier tracheal extubation, decreased perioperative stress response, earlier return of bowel function, and decreased exposure to volatile anesthetic agents with uncertain long-term neurocognitive effects. Despite these benefits, local anesthetic toxicity remains a concern in neonates and infants because of their decreased metabolic capacity for amide local anesthetics. Chloroprocaine, an ester local anesthetic agent, which is rapidly metabolized in plasma at all ages, is an attractive alternative for this special population, particularly in the presence of superimposed liver impairment or when higher infusion rates are needed for surgical incisions stretching many dermatomes. The current manuscript reviews the literature pertaining to the use of 2-chloroprocaine for regional anesthesia in infants and children. Dosing regimens are presented and the applications of 2-chloroprocaine in this population are discussed.
Supporting Information
| Filename | Description |
|---|---|
| pan13134-sup-0001-AudioS1.mp3audio/mp3, 7.7 MB | Audio S1 Continuous chloroprocaine epidural infusions in infants: a brief overview. |
| pan13134-sup-0002-Captions.docxWord document, 11.9 KB |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
References
- 1Hall RW, Anand KJ. Pain management in newborns. Clin Perinatol 2014; 41: 895–924.
- 2Anand KJ, Hall RW. Controversies in neonatal pain: an introduction. Semin Perinatol 2007; 31: 273–274.
- 3Mather L, Mackie J. The incidence of postoperative pain in children. Pain 1983; 15: 271–282.
- 4Anand KJ, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anesthesia in preterm babies undergoing surgery: effects on the stress response. Lancet 1987; 1: 62–66.
- 5Bartocci M, Bergqvist LL, Lagercrantz H et al. Pain activates cortical areas in the preterm newborn brain. Pain 2006; 122: 109–117.
- 6Hoar PF, Stone JG, Faltas AN et al. Hemodynamic and adrenergic responses to anesthesia and operation for myocardial revascularization. J Thorac Cardiovasc Surg 1980; 80: 242–248.
- 7Scheinin B, Scheinin M, Asantila R et al. Sympatho-adrenal and pituitary hormone responses during and immediately after thoracic surgery–modulation by four different pain treatments. Acta Anaesthesiol Scand 1987; 31: 762–767.
- 8Anand KJS, Hansen DD, Hickey PR. Hormonal-stress responses in neonates undergoing cardiac surgery. Anesthesiology 1990; 73: 661–670.
- 9Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992; 32: 1–9.
- 10Peters JW, Schouw R, Anand KJ et al. Does neonatal surgery lead to increased pain sensitivity in later childhood? Pain 2005; 114: 444–454.
- 11Anand KJ, Runeson B, Jacobson B. Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life. J Pediatr 2004; 144: 449–454.
- 12Anand KJ, Palmer FB, Papanicolaou AC. Repetitive neonatal pain and neurocognitive abilities in ex-preterm children. Pain 2013; 154: 1899–1901.
- 13Akça O, Melischek M, Scheck T et al. Postoperative pain and subcutaneous oxygen tension. Lancet 1999; 354: 41–42.
- 14Llewellyn N, Moriarty A. The national pediatric epidural audit. Pediatr Anesth 2007; 17: 520–533.
- 15Polaner DM, Taenzer AH, Walker BJ et al. Pediatric regional anesthesia network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg 2012; 115: 1353–1364.
- 16Kim GS, Song JG, Gwak MS et al. Postoperative outcome in formerly premature infants undergoing herniorrhaphy: comparison of spinal and general and spinal anesthesia. J Korean Med Sci 2003; 18: 691–695.
- 17Somri M, Gaitini L, Vaida S et al. Postoperative outcome in high-risk infants undergoing herniorraphy: comparison between spinal and general anesthesia. Anesthesia 1998; 53: 762–766.
- 18Tobias JD, Rasmussen GE, Holcomb GW III et al. Continuous caudal anaesthesia with chloroprocaine as an adjunct to general anaesthesia in neonates. Can J Anaesth 1996; 43: 69–72.
- 19Bosenberg AT. Epidural analgesia for major neonatal surgery. Paediatr Anaesth 1998; 8: 479–483.
- 20Olney JW, Wozniak DF, Jevtovic-Todorovic V et al. Drug-induced apoptotic neurodegeneration in the developing brain. Brain Pathol 2002; 12: 488–498.
- 21Scallet A, Schmued L, Slikker W et al. Developmental neurotoxicity of ketamine: morphometric conformation, exposure parameters, and multiple fluorescent labeling of apoptotic neuron. Toxicol Sci 2004; 81: 364–370.
- 22Wolf AR, Hughes D. Pain relief for infants undergoing abdominal surgery: comparison of infusions of IV morphine and extradural bupivacaine. Br J Anaesth 1993; 70: 10–16.
- 23Gomez-Chacon J, Encarnacion J, Couselo M et al. Benefits of epidural analgesia in major neonatal surgery. Cir Pediatr 2012; 24: 149–154.
- 24Di Pede A, Morini F, Lombardi MH. Comparison of regional vs systemic analgesia for post-thoracotomy care in infants. Pediatr Anesth 2014; 24: 569–573.
- 25Bozza P, Morrini F, Conforti A et al. Stress and ano-colorectal surgery in newborn/infant: role of anesthesia. Pediatr Surg Int 2012; 28: 821–824.
- 26Peutrell JM, Holder K, Gregory M. Plasma bupivacaine concentrations associated with continuous extradural infusions in babies. Br J Anaesth 1997; 78: 160–162.
- 27Agarwal R, Gutlove DP, Lockhart CH. Seizures occurring in pediatric patients receiving continuous infusion of bupivacaine. Anesth Analg 1992; 72: 284–286.
- 28McCloskey JJ, Haun SE, Deshpande JK. Bupivacaine toxicity secondary to continuous caudal epidural infusion in children. Anesth Analg 1992; 75: 287–290.
- 29Berde CB. Convulsions associated with pediatric regional anesthesia. Anesth Analg 1992; 75: 164–166.
- 30Larsson BA, Lönnqvist PA, Olsson GL. Plasma concentrations of bupivacaine in neonates after continuous epidural infusion. Anesth Analg 1997; 84: 501–505.
- 31Bosenberg AT, Thomas J, Cronje L et al. Pharmacokinetics and efficacy of ropivacaine for continuous epidural infusion in neonates and infants. Pediatr Anesth 2005; 15: 739–749.
- 32Mazoit J, Dalens B. Ropivacaine in infants and children. Curr Opin Anaesthesiol 2003; 16: 305–307.
- 33Luz G, Innerhofer P, Haussler B et al. Comparison of ropivacaine 0.1% and 0.2% with bupivacaine 0.2% for single-shot caudal anesthesia in children. Paediatr Anaesth 2000; 10: 499–504.
- 34Bosenberg A, Thomas J, Lopez T et al. The efficacy of caudal ropivacaine 1, 2 and 3 mg·ml−1 for postoperative analgesia in children. Paediatr Anaesth 2002; 12: 53–58.
- 35Kuhnert BR, Kuhnert PM, Philipson EH et al. The half-life of 2-chloroprocaine. Anesth Analg 1986; 65: 273–278.
- 36Foldes FF, McNall PG. 2-chloroprocaine: a new local anesthetic agent. Anesthesiology 1952; 13: 287–296.
- 37Covino BG. Toxicity of local anesthetic agents. Acta Anaesthesiol Belg 1988; 39: 15–164.
- 38Ford DJ, Raj PP. Peripheral neurotoxicity of 2-chloroprocaine and bisulfite in the cat. Anesth Analg 1987; 66: 719–722.
- 39Wang BC, Hillman DE, Spielholz NI et al. Chronic neurologic deficits and Nesacaine-CE – an effect of the anesthetic, 2-chloroprocaine, or the antioxidant, sodium bisulfite? Anesth Analg 1984; 63: 445–447.
- 40Hersh EV, Condouris GA, Havelin D. Actions of intrathecal chloroprocaine and sodium bisulfite on rat spinal reflex function utilizing a noninvasive technique. Anesthesiology 1990; 72: 1077–1082.
- 41Taniguchi M, Bollen AW, Drasner K. Sodium bisulfite: scapegoat for chloroprocaine neurotoxicity? Anesthesiology 2004; 100: 85–91.
- 42Stevens RA, Urmey WF, Urquhart BL et al. Back pain after epidural anesthesia with chloroprocaine. Anesthesiology 1993; 78: 492–497.
- 43Hejtmanek MR, Pollock JE. Chloroprocaine for spinal anesthesia: a retrospective analysis. Acta Anaesthesiol Scand 2011; 55: 267–272.
- 44Kouri ME, Kopacz DJ. Spinal 2-chloroprocaine: a comparison with lidocaine in volunteers. Anesth Analg 2004; 98: 75–80.
- 45Coda B, Bausch S, Haas M et al. The hypothesis that antagonism of fentanyl analgesia by 2-chloroprocaine is mediated by direct action on opioid receptors. Reg Anesth 1997; 22: 43–52.
- 46Toledo P, McCarthy RJ, Ebarvia MJ et al. The interaction between epidural 2-chloroprocaine and morphine: a randomized controlled trial of the effect of drug administration timing on the efficacy of morphine analgesia. Anesth Analg 2009; 109: 168–173.
- 47Kuhnert BR, Philipson EH, Pimental R et al. A prolonged chloroprocaine epidural block in a postpartum patient with abnormal pseudocholinesterase. Anesthesiology 1982; 56: 477–478.
- 48Smith AR, Hur D, Resano F. Grand mal seizures after 2-chloroprocaine epidural anesthesia in a patient with plasma cholinesterase deficiency. Anesth Analg 1987; 66: 677–678.
- 49Henderson K, Sethna NF, Berde CB. Continuous caudal anesthesia for inguinal hernia repair in former preterm infants. J Clin Anesth 1993; 5: 129–133.
- 50Tobias JD, Hersey S. Continuous caudal anesthesia during inguinal hernia repair in an awake, 1440 gram infant. Paediatr Anaesth 1994; 4: 187–189.
10.1111/j.1460-9592.1994.tb00158.x Google Scholar
- 51Tobias JD. Anaesthic management of the child with myotonic dystrophy: epidural anaesthesia as an alternative to general anesthesia. Paediatr Anaesth 1995; 5: 335–338.
- 52Ross EL, Reiter PD, Murphy ME et al. Evaluation of prolonged epidural chloroprocaine for postoperative analgesia in infants. J Clin Anesth 2015; 27: 463–469.
- 53Veneziano G, Iliev P, Tripi J et al. Continuous chloroprocaine infusion for thoracic and caudal epidurals as a postoperative analgesia modality in neonates, infants, and children. Pediatr Anesth 2015; 26: 84–91.
- 54Muhly WT, Gurnaney HG, Kraemer FW et al. A retrospective comparison of ropivacaine and 2-chloroprocaine continuous thoracic epidural analgesia for management of post-thoracotomy pain in infants. Pediatr Anesth 2015; 25: 1162–1167.
- 55Kamata M, Corridore M, Tobias JD. Thoracic epidural infusion with chloroprocaine for postoperative analgesia following epicardial pacemaker placement in an infant. J Pain Res 2014; 7: 609–613.
- 56Bardain S, Dodson B, Zurakowski D et al. Paravertebral nerve block catheters using chloroprocaine in infants with prolonged mechanical ventilation for treatment of long-gap esophageal atresia. Pediatr Anesth 2015; 25: 1151–1157.
- 57Cladis FP, Litman RS. Transient cardiovascular toxicity with unintended intravascular injection of 3% 2-chloroprocaine in a 2-month-old infant. Anesthesiology 2004; 100: 181–183.
- 58Hernandez M, Boretsky K. Chloroprocaine: local anesthetic systemic toxicity in a 9-month infant with paravertebral catheter. Pediatr Anesth 2016; 26: 665–666.
Citing Literature
