The utilization of caudal hydromorphone for fast-tracking in congenital cardiac surgery in a tertiary-care Children's hospital: An audit

Study objective: Our study sought to audit our institutional practice of routine single-shot caudal epidural hydromorphone injection in children undergoing congenital cardiothoracic surgery to assess perioperative pain control and evaluate for any caudal complications. Design: Retrospective observational study of all patients that received a caudal hydromorphone injection as part of the anesthetic for their cardiac surgical operation between January 2017 and July 2019. Setting: Pediatric Cardiothoracic Operating Room (OR), Cardiac Intensive Care Unit. Patients: One hundred and twenty-seven patients that received caudal hydromorphone as part of their anesthetic for a cardiac surgical operation. Interventions: Caudal epidural injection performed immediately following induction of anesthesia utilizing only hydromorphone. Measurements: The primary outcome was well-controlled pain, defined as a score of <4/10 on rFLACC or verbal pain scoring. Secondary outcome measures included in-OR extubation, pain service duration (from first assessment to “sign-off”), complications related to the caudal block, intensive care unit (ICU) length of stay (LOS), and Hospital LOS. Main results: One hundred and nine patients were included in the final analysis. Pain was “well-controlled” on average in 96.3% of patients (105/109). Average pain in the 24-h post-block period was 1.67 (SD = 2.37), with median pain score of 0 [0–3]. Peak pain score remained <4/10 for the entire 24-h post-block period in 22% of patients. 77.1% of caudal hydromorphone patients were extubated in the operating room. The median time to heparinization post-block was 108 min, beyond the ASRA recommendation of 60 min for neuraxial procedures. There were two caudal-related complications: one subcutaneous injection, and one instance of a time to heparinization of less than 60 min (56 min). Neither caudal complication led to patient harm. Conclusion: Caudal hydromorphone injection can safely contribute to achieving “well-controlled” pain in the pediatric cardiac surgical population when used as a component of a perioperative pain control plan.