Subcutaneous tunnelling of an epidural catheter in a child with epidermolysis bullosa

Abstract

Sir,Epidermolysis bullosa (EB) is a rare inherited disorder characterized by excessive susceptibility of the skin and mucosae to separate from the underlying tissues after trivial mechanical trauma). Insufficient post-operative analgesia in a child with EB will result in an unsettled child who will pull at his/her dressing and be more prone to new bullae formation (1). Patient-controlled analgesia is difficult for a patient with EB because of limited finger function or syndactyly from skin lesions.We present the successful management with continuous epidural block of a 13-year-old girl with EB using subcutaneous tunnelling of the epidural catheter.A 124-cm, 20-kg, 13-year-old girl with dystrophic EB underwent splenectomy and cholecystectomy. She had been suffering from anaemia and chronic cholelithiasis with gallstones as a result of hereditary spherocytosis. She was induced with fentanyl 30 mg, propofol 40 mg and vecuronium 3 mg. Induction, monitoring and maintenance of anaesthesia were handled to avoid skin lesions. Epidural anaesthesia was performed under general anaesthesia. A 20-gauge Touhy needle was inserted from the Th 7-8 intervertebral space to a depth of 2.5 cm using the loss of resistance technique. A 22-gauge epidural catheter was advanced 6.0 cm cephalad and fixed by subcutaneous tunnelling (Fig. 1). The epidural catheter was then covered with gauze. Twelve millilitres of epidurally administered 0.5% ropivacaine with 2.0 mg of morphine and a total of 100 mg of intravenous fentanyl produced excellent anaesthesia during the operation for a total of 3.5 h. Continuous epidural analgesia was accomplished by 0.2% ropivacaine at 3 ml/h with morphine at 5 mg/kg/h over 20 h, followed by a continuous epidural infusion of 0.2% ropivacaine at 3 ml/h until the third post-operative day. No bullae, skin lesions or infections occurred at the insertion point of the epidural catheter or around the subcutaneous tunnel. The patient was discharged at the eighth post-operative day without any sequelae.Adhesive tape should be avoided. Chronic epidermal infection may cause an epidural abscess. Subcutaneous tunnelling with direct suturing without adhesive tape has been reported (4, 5). Our experience confirms this to be an alternative for decreasing the risk of migration and local infection. bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth 2002; 12 (5): 388-97. 2. Carl P, Crawford ME, Ravlo O. Fixation of extradural catheters by means of subcutaneous tissue tunnelling. Br J Anaesth 1984; 56 (12): 1369-71. 3. Aram L, Krane EJ, Kozloski LJ, Yaster M. Tunneled epidural catheters for prolonged analgesia in pediatric patients. Direct Suturing Catheter Insertion Site Subcutaneous Tunnel Fig. 1. The tunnel was made by inserting an 18-gauge intravenous catheter from the puncture site to 3 cm away from the site for use as a guide. The hub of the intravenous catheter was removed leaving only part of the catheter. The epidural catheter was then threaded in and the guide was removed. The epidural ...

Pain care for patients with epidermolysis bullosa: best care practice guidelines

“…Ultrasound guidance can be used for peripheral nerve blocks with generous use of gel to minimize skin abrasion when moving the probe. When a catheter is placed (epidural or peripheral nerve), it may be tunnelled subcutaneously if desired [ 53 ] then secured to the skin using silicone-based tapes and dressings (Mepitac®, Mepitel®, Mepilex®) or other soft non-adhesive dressings. Adhesive dressings and adhesive adjuncts should be avoided.…”

“… Basic perioperative assessment and pain treatments should be used as for non-EB patients, with modification A All Goldschneider 2010 [ 41 ] (5a), Goldschneider 2010b [ 42 ] (5a) Transmucosal (including intranasal fentanyl and transbuccal opioids) should be considered for short procedures and pain of brief duration when intravenous and enteral routes are unavailable B All Manjushree et al ., 2002 [ 45 ] (2b); Borland et al ., 2007 [ 46 ] (2b); Desjardins et al ., 2000 [ 47 ] (2a) Perioperative opioid use must account for preoperative exposure, with appropriate dose increases to account for tolerance B All Hartrick 2008 [ 56 ] (1a), Mhuircheartaigh 2009 [ 55 ] (1a), Viscusi 2005 [ 54 ] (2a) Regional anesthesia is appropriate for pain resulting from a number of major surgeries. Dressing of catheters must be non-adhesive and monitored carefully C All Diwan 2001 [ 51 ] (5a), Doi 2006 [ 53 ] (5b), Englbrecht 2010 [ 52 ] (5a), Kelly 1988 [ 48 ] (5b), Sopchak 1993 [ 49 ] (5a), Yee 1989 [ 50 ] (5a) C. Skin wounds and related pain are the hallmark of EB of most subtypes. Prevention and rapid healing of wounds through activity pacing, optimal nutrition and infection control are important.…”

Anesthetic management and outcomes of patients with Steven-Johnson Syndrome—A retrospective review study

“…[ 23 ] Splenectomy and cholecystectomy performed under general anesthesia and continued epidural blockade have also been described. [ 24 ] In our study, peribulbar block was given in 56 (11.4%) cases using lignocaine, bupivacaine, and ropivacaine without any adverse events. Thus, all the anesthetic agents (local and general) used in our study were observed to be safe without encountering any adverse effects.…”

Anesthetic Management of Adults With Epidermolysis Bullosa

“…Alternatively, catheters may be tunneled under the skin. 31,52 In EB patients, catheters are commonly removed on the first postoperative day, but use of a peripheral catheter for as long as 5 days without complication has been reported. 21,53,54 Catheters should be removed as soon as feasible, balancing the benefits of analgesia with the risk of infection, which will vary depending on the location of catheter and proximity to chronic wounds.…”