Mode of Anesthesia and Bladder Management Following Orthopaedic Surgery in Children With Cerebral Palsy: A System Level Analysis

Abstract

Background: Postoperative urinary retention (POUR) is a surgical complication more prevalent in children with neurodisability and associated with an increase length of hospitalization. Risk factors include pre-existing bladder dysfunction, type and duration of surgery, anesthesia medications, postoperative opioid pain management, and patient demographics. The purpose of this investigation was (1) to determine the frequency of POUR following hip/lower limb orthopaedic procedures in which epidural analgesia was used for pain management; (2) to explore factors influencing postoperative bladder management. Methods: A retrospective analysis of clinical data was performed in an orthopaedic specialty care health care system. A health outcomes network was queried for patients with a diagnoses of cerebral palsy (ICD-9/10 codes) who had one of 57 unique CPT procedure codes corresponding to hip osteotomies or tenotomies from 2011 to 2019. All surgical observations included in analysis required a discrete data element and the confirmation of a secondary proxy. The database was also queried for postoperative medications received and patient demographics of interest. Results: A total of 704 surgical procedures met inclusion criteria resulting in a patient population with a mean age of 11 years, 58% male, 53% Caucasian, and 55% classified as quadriplegia [51% Gross Motor Function Classification System (GMFCS) levels IV/V]. Three hundred and thirty-five procedures (48%) involved epidural anesthesia. Sixty-five patients required intermittent catheterization (9.2%) postoperatively following foley catheter removal, of which 23 (3.3%) required recatheterization. The rate of recatheterization was similar regardless of anesthesia mode; 1.8% for general and 1.4% for epidural and was associated with a greater number of pain medications. Epidural anesthesia resulted in significantly longer periods of catheterization. For the total group the time to urinary catheter removal differed significantly among cerebral palsy subtypes, GMFCS Level, race, and ethnicity. Factors identified as significant predictors of the length of catheterization were epidural analgesia, number of pain medications, and osteotomy. Conclusions: The number of postoperative pain medications utilized was more predictive of POUR than the mode of analgesia delivery; however, epidural analgesia and the type of surgical procedure did significantly impact the length of catheterization. Level of Evidence: Level III.

Postoperative Urinary Catheterization in Children Treated with or without Epidural Analgesia after Orthopedic Surgery: A Retrospective Review of Practice

“…These findings are consistent with recent publications regarding the overall POUR rate in children of 5% [ 11 , 12 ]. Our finding of longer UC duration postoperatively and higher incidence of UC re-insertion in the NMD population is consistent with that of Buckon’s [ 13 ] and Brenn’s [ 14 ] review of UC management in post-orthopedic surgery in children with cerebral palsy (CP). It is important to note, however, that re-insertion rates differ significantly between the studies (Buckon: 9.2%, Brenn: 70%).…”

“…While both general and regional anesthesia have previously been implicated as contributing factors in the occurrence of POUR in children [ 13 ], current literature is still sparse regarding the occurrence of POUR in children treated with epidural analgesia [ 6 , 7 ]. Furthermore, recent publications on regional anesthesia in children focus mostly on major adverse events such as neurologic, infectious, or systemic toxicity in children treated with epidural analgesia, but do not emphasize the risks of POUR and/or peri-operative UC placement.…”

Acute and Persistent Postoperative Functional Decline in Children with Severe Neurological Impairment: A Qualitative, Exploratory Study

“…The likelihood of PoPD increased by over a third in patients with complex chronic conditions (CCC) if they used eleven or more medications. A subset of children with cerebral palsy (CP) can be described as having SNI, and the recent literature indicates that children with CP often have reduced overall health, in turn making them vulnerable to perioperative complications from anesthesia and surgical intervention [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. Although there is scarce research on the impacts of anesthesia for children with CP/SNI, the Buckon study indicates that having an active health issue is a risk factor for PoPD and reinforces the need for further research that considers the unique preoperative physical, cognitive, and communication factors of children with SNI [ 42 ].…”

Urinary tract infections in pediatric orthopedic surgical patients: a Single Institution National Surgical Quality Improvement Program Study

“…That said, the use of epidural anesthesia does complicate the timing of removal of a Foley catheter. An article examining bladder management after orthopedic surgery in children with cerebral palsy showed that an epidural increases Foley catheter duration [14]. The literature also suggests that removing a Foley before the epidural may be associated with urinary retention in pediatric spinal fusion [15].…”