ESRA19-0251 Small-dose intrathecal morphine and perioperative alpha-2 agonists with lidocaine infusions in a patient with rett syndrome undergoing scoliosis surgery: a case report

Background and aims We report the case of a girl aged 14 (1m51, 50 kg), affected by Rett syndrome, a rare genetic neurological disorder due to a mutation of MECP gene on chromosome X and complicated by a scoliosis progressing quickly in spite of wearing a corset since 2013. Our case reports the analgesia results observed with our optimised management. The surgery consisted in a posterior spinal instrumentation and fusion. Methods After inhalatory induction (sevoflurane and nitrogen oxide), anesthesia was maintained with propofol with TIVA Schnider’s model, lidocaine 2 mg/kg/h, ketamine 0.25 mg/kg/h and dexmedetomidine 1 µg/kg/h during paravertebral muscles dissection, then 0.7 µg/kg/h during the fusion, and stopped when reduction was complete. We asked the surgeon to realise a spinal anesthesia with 1mcg/kg of morphine. Results After surgery, the patient was transferred extubated to intensive care with FiO2 50% with a noradrenalin infusion to treat transient vasoplegia. We observed a moderate prolonged sedation, with a positive Naloxone test, due to spinal analgesia but she had neither respiratory nor haemodynamic complication. As no verbal communication was possible, pain was evaluated with the FLACC scale. Postoperative pain management consisted in paracetamol 60 mg/kg/d, ketorolac 0,5 mg/kg/8hs, I.V lidocaine (1.3 mg/kg/h) and clonidine (0.3 µg/kg/h) during 48h. No PCA with opioid was needed, with very good control of analgesia and comfort. Conclusions We used a smaller dose of intrathecal morphine than advised (5–10 µg/kg) but in this syndrome precaution is advisable with this technique. Perioperative alpha 2 agonist and lidocaine seem to be a good alternative to opioids for scoliosis surgery.