Improving Pain Management for Cerebral Palsy Patients Undergoing Bilateral Lower Extremity Orthopedic Surgery

Single-Event Multilevel Surgery

The Department of Orthopedic Surgery and Musculoskeletal Science at Children’s Mercy Kansas City performs approximately 100 surgeries to improve function for cerebral palsy patients each year, utilizing the single-event multilevel surgery (SEMLS) approach.

SEMLS incorporates several procedures into one surgical intervention. For example, bilateral proximal femoral varus derotational osteotomies are often combined with other lower extremity procedures. Doing so reduces the number of surgeries and hospitalizations for these patients, streamlining their postoperative care, reducing length of stay and helping patients advance to rehabilitation faster.

In pediatric hospitals where the team is highly skilled in SEMLS, outcomes have been very good and patient/family satisfaction superior.

Improving Pain Management for SEMLS Surgery

Epidural catheters are currently the gold standard when cerebral palsy patients undergo bilateral multilevel orthopedic surgery.

However, one of the challenges for those who receive an epidural is that it must remain in place postoperatively, usually for two days. This often requires the patient to be immobile, affecting the physiology of recovery, including lung function and mobility. A longer hospitalization also affects the family dynamic, requiring parents to take more time away from work or other caregiving responsibilities. Additionally, patients may have comorbidities that preclude epidural catheter placement.

This patient population also presents with additional medical challenges, including the fact that many are taking anti-spasmodics, may be on a baclofen pump, or may be on anti-epileptic medications.

To improve upon the patient’s experience, Kathryn Keeler, MD, Children’s Mercy Pediatric Orthopedic Surgeon, and Nichole Doyle, MD, Pediatric Anesthesiologist, collaborated to develop an Enhanced Recovery After Surgery (ERAS) protocol.

ERAS Protocol for SEMLS Patients

The ERAS protocol Dr. Doyle and Dr. Keeler developed is used for cerebral palsy patients undergoing bilateral lower extremity surgeries. 
Key elements of the protocol include:

• Use of peripheral nerve blocks instead of epidural catheters.
• Earlier mobilization of patients, with an earlier start to physical therapy.
• Discontinued use of the Foley catheter before arrival to the post-anesthesia care unit.
• Use of dexmedetomidine infusion for the first postoperative day as part of a multimodal pain management plan.

To determine the effectiveness of the protocol, they performed a pilot study of 10 consecutive cerebral palsy patients undergoing bilateral lower extremity surgery from May to July 2020, comparing them with 10 controls from 2017 to 2019. The groups were matched by Gross Motor Function Classification System (GMFCS) score, procedure performed and age. The biggest difference between the two groups was in the type of pain control used. The control group received epidural catheters.

The ERAS group received peripheral nerve blocks in the operating room with clonidine or dexamethasone added to prolong the blocks based on the surgical procedures planned.

Preoperatively patients were counseled about the protocol and what to expect. Some high-risk patients were started on gabapentin at this visit. On the day of surgery families were instructed to continue clear liquids until two hours before surgery. If gabapentin was not started at the preop visit, patients were given a dose preoperatively.

Intraoperatively, the ERAS patients received intravenous (IV) acetaminophen and ketorolac. They also had intraoperative dexmedetomidine and/or ketamine infusions. A short-acting narcotic was given as needed.

At completion of the surgery the Foley catheter was removed. Upon transfer to the floor, the patients continued on a dexmedetomidine infusion 0.1 mcg/kg/hr-0.2mcg/kg/hour and they were placed on scheduled acetaminophen, ketorolac, gabapentin and a bowel regimen. They received valium, narcotic, ondansetron and diphenhydramine as needed. If needed, a PCA/NCA was started.

Key Outcomes

This pilot study showed that following an ERAS protocol can help minimize the variation of care and enhance the patient and family experience with bilateral lower extremity surgery. Results showed a decreased length of stay of almost a full day and a reduction in postoperative narcotic consumption for the ERAS group. Side effects such as nausea, vomiting and pruritus also decreased in the ERAS patients.

Overall, performing single-shot peripheral nerve blocks at the beginning of the surgery has the potential to substantially increase the value of care delivered to this complex patient population, but further study in a larger patient population is needed to confirm results.

ERAS Pilot Study Highlights

• 10 ERAS protocol patients; 10 control group patients.
• GMFCS 4 for both groups.
• Decreased postoperative narcotic use in ERAS group to 0.12 morphine equivalents/kg per day compared to 0.19 morphine equivalents/kg in control group.
• Postoperative need for a PCA/NCA pump was zero in the ERAS group compared to four in the control group, two of which occurred after discontinuation of the epidural catheter.
• Time to postoperative discharge from physical therapy was 1.70 days in the ERAS group versus 2.44 days in the control group.
• Hospital length of stay was 2.20 days for the ERAS group versus 3.0 days in the control group.

Collaborate with us to study the ERAS protocol

Children’s Mercy is seeking to study the ERAS protocol in a larger patient population by collaborating with other pediatric institutions performing single-event multilevel surgeries for cerebral palsy patients. To work with our team, contact:

Kathryn Keeler, MD, Pediatric Orthopedic Surgeon 
kkeeler@cmh.edu

(816) 234-3696

Nichole Doyle, MD, Pediatric Anesthesiology 
nmdoyle@cmh.edu

(816) 234-3464

For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466-3729.

Reference:

1. Schendel DE, et al. (n.d.). Public Health Issues Related to Infection in Pregnancy and Cerebral Palsy. PubMed - NCBI. National Center for Biotechnology Information. Retrieved 9/18/2020 from: https://www.ncbi.nlm.nih.gov/pubmed/11921385.