The Acute Pain Service Nurse Practitioner: A Case Study in the Postoperative Care of the Child With Bladder Exstrophy

Lori J.Kozlowski, MS, RN, CPNP

Disclosures

J Pediatr Health Care. 2008;22(6):351-359. 

In This Article

Pain and Sedation Management

Care of the child with bladder exstrophy carries a high risk of morbidity and is resource intensive with a mean hospital stay of 4 to 8 weeks (Baker and Gearhart, 1998, Nelson et al., 2005). A successful repair is dependent on a successful primary closure. Appropriate immobilization and postoperative care are important factors in this success. The focus of care for the child with bladder exstrophy is both pain control and maintenance of immobilization. Pain control generally is achieved with continuous epidural therapy or patient/parent/nurse-controlled intravenous analgesia (PCA). Epidural analgesia has advantages of giving excellent pain control, typically less postoperative nausea and vomiting, and minimal physiologic alterations, and it has special advantages in the newborn because postoperative apnea may be less likely if general anesthesia and sedation are minimized. The use of epidural analgesia commonly allows children to be alert and pain free. However, it is not without its disadvantages. It is time and resource intensive, requires a high degree of physician and nurse attention, and has the potential for toxicity from local anesthetics as well as technical difficulties and can cause nerve root and/or spinal cord injury. It is important to understand that epidural infusions containing dilute local anesthetics do not "paralyze" the child's lower extremities, so the legs can move completely normally. Epidurals do not play any part in keeping a child still. Therefore, in the exstrophy population that must remain immobilized, sedation, not just analgesia, is usually necessary (Yaster, Andresini, & Krane, 1997).

Epidural analgesia for children with bladder exstrophy is provided by using local anesthetics, either alone or in combination with opioids. Typical drug combinations that are used in our institution include lidocaine (typically used in the newborn), lidocaine and fentanyl, or bupivacaine and hydromorphone. Lidocaine may be safer to use in newborns because it is less toxic and can be measured in most hospital laboratories. Bupivacaine, usually combined with hydromorphone, typically is used in our patients who are older than 6 months. Opioids often are combined with local anesthetics to maximize pain relief (Yaster, Andresini, & Krane, 1997). Epidurals typically are left in place no longer than 5 to 7 days, but the use of an epidural in which a catheter segment has been subcutaneously tunneled allows use of the catheter for longer periods. Tunneling helps decrease the chance of accidental dislodgement and provides additional protection against infection. In a retrospective review by Aram, Krane, Kozlowski, and Yaster (2001), subcutaneous tunneled catheters were found to be effective for all 25 patients reviewed, and no serious local or systemic complications were found. This study included eight patients with bladder exstrophy with a catheter duration of 8 to 42 days.

In instances where epidural placement is contraindicated (e.g., patients with exstrophy who also have anomalies of the spine) or unsuccessful, intravenous PCA is used for pain control and to assist with sedation. Although parent/nurse-controlled analgesia is controversial in many institutions, a case series by Monitto et al. (2000) at the Johns Hopkins Children's Center showed good effectiveness and safety in a series of patients receiving either nurse and/or parent-controlled analgesia. This modality can be used in patients as young as newborns with success but not without specific protocols for parent and staff education as well as monitoring. Institutions using intravenous PCA must establish protocols that define the patient population and appropriate equipment to be used, establish consistency of drugs used and dosages, and establish a proactive program for adverse effect management. Monitoring, assessment, and documentation standards are required, as well as an organized approach for teaching patients and families before initiating therapy (Berde & Solodiuk, 2003). Typically morphine, hydromorphone, or fentanyl are used for children receiving intravenous PCA (Yaster, Kost-Byerly, & Maxwell, 2003).

The use of nonsteroidal anti-inflammatory agents and weak analgesics as opioid-sparing adjuncts can improve pain control and decrease adverse effects (Yaster, 1997). We typically use adjuncts such as acetaminophen and may add ketorolac in older patients to assist with pain control and/or to decrease bladder spasms. Ketorolac recently was shown to suppress bladder spasms after pediatric ureteral reimplantation. (Park et al., 2000).

Appropriate pelvic and patient immobilization may be difficult to achieve even once pain has been appropriately addressed. In this patient population, it often requires multimodal therapy. Reassurance, distraction, and parental presence may be helpful, but pharmacologic intervention frequently is required. A child's level of cognitive development determines how they are able to understand pain and the experience of immobilization. The challenges of postoperative care of patients with exstrophy are very different depending on the age and cognitive level of the child. Primary repair or re-repair generally occur, however, during the first 2 years of life. When attempting to achieve long-term immobilization in these patients, temperament plays into the equation, as does a child's previous activity level (i.e., always on the go vs. complacent). A newborn may not find being in traction objectionable if he or she knows nothing different. A more difficult challenge may be the parental challenge of attempting to bond with the infant who is immobilized and requires sedation. In contrast, a toddler may have a very difficult time with the loss of control caused by immobilization. This loss of control only serves to heighten his or her distress and may exacerbate pain. It is very difficult to keep an active toddler in traction for 6 weeks! Children who receive multiple invasive procedures throughout a prolonged hospitalization, as occurs with patients with exstrophy, are at risk for the development of anxiety (Gaffney et al., 2003, McGrath and Hillier, 2003).

Depending on the child's age and pre-admission activity level, sedatives, anxiolytics, and muscle relaxants such as diazepam also may be required to ensure the child is immobilized. These agents will help provide sleep and calmness and relieve spasticity. It must be remembered that medications such as diazepam and midazolam have no intrinsic analgesic activity, and caution must be used when combining epidural and/or intravenous opiates with these adjuvant medications because synergistic sedation or respiratory depression can occur. These agents can potentiate the respiratory depression produced by opioids regardless of their route of administration. Some children have a paradoxical excitement with some benzodiazepines, which increases the challenge of sedation in this population. Some medications are used because their adverse effect profiles are of benefit to the patient. Butorphanol is a medication that belongs to a class of drugs known as mixed agonist-antagonist opioids. This drug has pain control properties but also has sedation as a side effect, which is useful in this population (Yaster et al., 2003). It often takes a period of trial and error to determine which drug combinations will produce the desired effects. When the usual combinations of benzodiazepines and opioids are not effective for sedation of a child with exstrophy, barbiturates may provide an alternative. Because of the potentially profound central nervous system effects of these drugs, especially when used in combination with other drugs, children receiving these medications usually require monitoring in an intensive care unit (Yaster & Cote, 1997). Transition from intravenous or epidural analgesia to oral or transdermal medication typically occurs once the child is able to drink and/or eat and once the pain is less severe, because severe pain is more difficult to control with oral analgesics alone (Krane & Yaster, 1997).

As noted, patients with exstrophy usually are treated with multiple opioids, benzodiazepines, and sedatives in an attempt to provide comfort and sleep. With a typical hospital stay of more than 20 days and opioid and benzodiazepine therapy throughout their stay, physical dependence will occur. Patients who have received more than 5 to 10 days of therapy should be considered to be dependent on opioids and benzodiazepines and require a weaning regimen to prevent symptoms of withdrawal. Sudden cessation of these medications after continued therapy will lead to the development of withdrawal. Withdrawal should be anticipated and can be prevented easily by weaning patients rather than abruptly stopping medications. Most parents are concerned about the long-term effects of these medications. It is important to tell parents that physical dependence is not the same as addiction, which involves psychological dependence on drugs (Golianu et al., 2000, Tobias, 2003).

As the time for discharge draws near, all pain and sedation drugs should be reviewed and converted to a single member of that drug family using equianalgesic dosing. Dosing should be converted to at least every 6-hour dosing to make care of the patient easier at home and allow continuation of the wean as an outpatient. The baseline dose of each drug is decreased by 10% to 20% per day. When a more prolonged wean is anticipated, switching to a longer-acting oral agent, such as methadone, should be considered. Methadone is useful in the weaning of patients in whom opioid dependence has developed. It is important to explain the rationale of this medication choice to families because often a stigma is attached to methadone. Scoring symptoms can be helpful to assist with identification and grading of the signs and symptoms of withdrawal, which include neurologic, gastrointestinal, and autonomic alterations. In our practice, clonidine sometimes is added early on in therapy because the central nervous system effects can produce mild sedation and a sense of calmness. It also is added as an assistant to weaning because it ameliorates the symptoms of withdrawal for both opioids and benzodiazepines (Golianu et al., 2000, Krane and Yaster, 1997).

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