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

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. 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. Pediatric Cardiothoracic Operating Room (OR), Cardiac Intensive Care Unit. One hundred and twenty-seven patients that received caudal hydromorphone as part of their anesthetic for a cardiac surgical operation. Caudal epidural injection performed immediately following induction of anesthesia utilizing only hydromorphone. 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. 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. 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. • Caudal hydromorphone injection was used safely in cardiac surgical patients on- and off-bypass. • Caudal hydromorphone achieved well-controlled pain as part of a multimodal anesthetic plan. • Delayed respiratory depression was not seen in any patient that received caudal hydromorphone. • No complications of caudal injection led to patient morbidity or mortality or delayed surgery.