1
|
Xiong C, Han C, Lv H, Xu D, Peng W, Zhao D, Lan Z. Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis. J Clin Anesth 2022; 81:110907. [PMID: 35728381 DOI: 10.1016/j.jclinane.2022.110907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/04/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE Caudal block helps relieve pain after sub-umbilical surgery in pediatric patients; however, the duration for which it exerts its analgesic effect is limited. The addition of certain adjuvant agents to local anesthetics (LAs) that are used to administer caudal block can prolong postoperative analgesia. Therefore, we aimed to compare the efficiencies and side effects of caudal adjuvants in the settings of pediatric lower abdominal and urological surgeries. DESIGN A network meta-analysis (NMA). PATIENTS One hundred and twelve randomized controlled trials (RCTs) involving 6800 pediatric patients were included in the final analysis. INTERVENTIONS Different adjuvant agents, namely clonidine, dexamethasone, dexmedetomidine, fentanyl, ketamine, magnesium, midazolam, morphine, neostigmine, and tramadol. MEASUREMENTS The primary outcome was the duration of analgesia. The secondary outcomes included the requirement for additional analgesia, analgesic consumption, and postoperative complications. The effects and rankings were evaluated using NMA and the surface under the cumulative ranking curve scores, respectively. RESULTS Neostigmine, dexmedetomidine, and dexamethasone were found to be the three most effective adjuvants that prolong the duration of analgesia for caudal block, and these adjuvants extended this duration by 8.9 h (95% confidence interval [CI], 7.1-10.7), 7.3 h (95% CI, 6.0-8.6), and 5.9 h (95% CI, 4.0-7.7), respectively. Caudal neostigmine was associated with an increase in the incidence of postoperative nausea and vomiting, whereas dexmedetomidine and dexamethasone showed no postoperative complications. CONCLUSIONS This NMA provided evidence and suggested that dexmedetomidine and dexamethasone may be the most beneficial adjuvant pharmaceutics adding to LAs for caudal block in children. However, given the off-label status of caudal dexmedetomidine and dexamethasone, further high-quality RCTs are still warranted, especially to determine whether delayed neurological complications will occur.
Collapse
Affiliation(s)
- Chang Xiong
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Chengpeng Han
- Department of Children's Rehabilitation, Jinhua Maternal and Child Health Care Hospital, Jinhua, Zhejiang Province, People's Republic of China
| | - Huayan Lv
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Duojia Xu
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Wenyong Peng
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Dong Zhao
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
| | - Zhijian Lan
- Department of Anesthesiology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
| |
Collapse
|
2
|
Prajapati DJ, Patel M, Patel P, Vijayakumar M, Ganpule A, Mistry D. Effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the catheter-related bladder discomfort after tubeless percutaneous nephrolithotomy: A prospective randomized study. J Anaesthesiol Clin Pharmacol 2021; 36:524-530. [PMID: 33840935 PMCID: PMC8022066 DOI: 10.4103/joacp.joacp_285_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/09/2019] [Accepted: 12/20/2019] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Catheter-related bladder discomfort (CRBD) is a major cause of postoperative morbidity following urological procedures. The aim of this study was to compare the effect of caudal bupivacaine alone and with adjuvant fentanyl and nalbuphine to minimize the severity of CRBD after tubeless percutaneous nephrolithotomy (PCNL). Material and Methods: A randomized prospective study was conducted on one hundred thirty-two (American society of Anaesthesiologist physical status I to II) patients who presented for tubeless PCNL under general anesthesia. Patients were randomly divided into four groups control (C), bupivacaine (B), bupivacaine-fentanyl (BF), and bupivacaine-nalbuphine (BN) by using computer-generated codes. All patients received local infiltration at the procedure site while Groups B, BF, and BN received caudal epidural block (CEB) under ultrasound guidance after conclusion of the procedure. Groups B, BF, and BN received bupivacaine alone, bupivacaine-fentanyl, and bupivacaine-nalbuphine, respectively, for CEB. Patients were monitored 24 h for CRBD scale, visual analogue score (VAS), and duration of analgesia at 30 min, 1, 2, 4, 6, 12, 18, and 24 h intervals. The analgesics were supplemented if the CRBD score was >2 and VAS was ≥4. Student t-test, analysis of variance, and Chi-square test were applied for quantitative, within group occurrence, and qualitative analysis respectively. Results: The CRBD scores were considerably lower in the Groups BF and BN as compared to Groups C and B during the first four hours. The duration of analgesia was significantly prolonged in Group BN (475 ± 47 min) versus BF (320 ± 68 min) versus B (104 ± 40 min) versus C (26 ± 14 min). Conclusions: The severity of CRBD can be reduced with CEB. The effect of CEB can be prolonged with the addition of opioid.
Collapse
Affiliation(s)
- Dinesh J Prajapati
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Manoj Patel
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Pankaj Patel
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Mohankumar Vijayakumar
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Arvind Ganpule
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Deepak Mistry
- Department of Anaesthesiology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| |
Collapse
|
3
|
Nigam S, Rastogi S, Tyagi A, Bhandari R. A Comparative Study for the Analgesic Efficacy and Safety Profile of Fentanyl versus Clonidine as an Adjuvant to Epidural Ropivacaine 0.75% in Lower Abdominal Surgeries. Anesth Essays Res 2017; 11:692-696. [PMID: 28928573 PMCID: PMC5594792 DOI: 10.4103/aer.aer_254_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
CONTEXT Different adjuvants are coadministered with local anesthetics to improve the speed of onset and duration of analgesia, and to reduce the dose, the selection of which is often left to the choice of an anesthesiologist. AIM The aim of this study was to compare the analgesic efficacy and safety profile of fentanyl and clonidine as an adjuvant to epidural ropivacaine anesthesia. SETTING AND DESIGN With institutional ethical committee clearance, a prospective, randomized, placebo-controlled double-blind clinical study was conducted at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow. MATERIAL AND METHODS Two groups with thirty patients each were randomly allocated to receive 15-20 ml of 0.75% ropivacaine with 75 μg clonidine or 15-20 ml of 0.75% ropivacaine with 75 μg fentanyl, respectively. Block characteristics such as onset of analgesia, maximum level of sensory blockade, complete motor blockade, hemodynamic, time to two-segment regressions, time for rescue analgesia, time to complete motor recovery, and side effects were analyzed. RESULTS Results showed that the onset of blockade is faster when fentanyl is used as additives. Time for two-segment regression was earlier in fentanyl group but time for rescue analgesia was longer in clonidine group. STATISTICAL ANALYSIS Two groups were compared by Student's t-test and Chi-square test; ANOVA and significance of mean difference bet were done by Newman-Keuls test. CONCLUSION Addition of clonidine to epidural ropivacaine provides superior analgesia than the addition of fentanyl to epidural ropivacaine without much difference in side effect profile.
Collapse
Affiliation(s)
- Shuchi Nigam
- Department of Anesthesiology and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shivani Rastogi
- Department of Anesthesiology and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Tyagi
- Department of Anesthesiology and Critical Care, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajlakshmi Bhandari
- Department of Anesthesiology and Critical Care, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
4
|
Jarraya A, Elleuch S, Zouari J, Smaoui M, Laabidi S, Kolsi K. Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally. Pan Afr Med J 2016; 24:182. [PMID: 27795779 PMCID: PMC5072881 DOI: 10.11604/pamj.2016.24.182.6446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/25/2015] [Indexed: 11/18/2022] Open
Abstract
The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg and clonidine 1μg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.
Collapse
Affiliation(s)
- Anouar Jarraya
- Service d'Anesthésie Réanimation, Hôpital Hedi Chaker, Sfax, Tunisie
| | - Sahar Elleuch
- Service d'Anesthésie Réanimation, Hôpital Hedi Chaker, Sfax, Tunisie
| | - Jawhar Zouari
- Service d'Anesthésie Réanimation, Hôpital Kremlin, Bicêtre
| | - Mohamed Smaoui
- Service d'Anesthésie Réanimation, Hôpital Hedi Chaker, Sfax, Tunisie
| | - Sofiene Laabidi
- Service d'Anesthésie Réanimation, Hôpital Hedi Chaker, Sfax, Tunisie
| | - Kamel Kolsi
- Service d'Anesthésie Réanimation, Hôpital Hedi Chaker, Sfax, Tunisie
| |
Collapse
|
5
|
Solanki NM, Engineer SR, Jansari DB, Patel RJ. Comparison of caudal tramadol versus caudal fentanyl with bupivacaine for prolongation of postoperative analgesia in pediatric patients. Saudi J Anaesth 2016; 10:154-60. [PMID: 27051365 PMCID: PMC4799606 DOI: 10.4103/1658-354x.168807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Caudal block is a common technique for pediatric analgesia for infraumblical surgeries. Because of the short duration of analgesia with bupivacaine alone various additive have been used to prolong the action of bupivacaine. The present study was aimed to evaluate the analgesic effect of tramadol or fentanyl added to bupivacaine for infraumblical surgeries in pediatric patients. Materials and Methods: We conducted a prospective, randomized, single-blind controlled trial. After written informed consent from parents, 100 patients belonging to American Society of Anesthesiologist physical status I-II, in the age group of 1-12 years, of either sex undergoing infraumblical surgery under general anesthesia were divided into two groups. Group BT received 1 ml/kg of 0.25% bupivacaine with tramadol 2 mg/kg in normal saline and Group BF received 1 ml/kg of 0.25% bupivacaine with fentanyl 2 μg/kg in normal saline with maximum volume of 12 ml in both groups. All patients were assessed intraoperatively for hemodynamic changes, the requirement of sevoflurane concentration, as well as postoperatively for pain by using FLACC (F = Face, L = Leg, A = Activity, C = Cry, C = Consolability), pain score and for sedation by using four point sedation score. Results: The mean duration of analgesia was 10–18 h in Group BT while in Group BF it was 7-11 h. The postoperatively period up to 1½ h, Group BF had higher sedation score up to two as compared to that below one on Group BT. Conclusion: Caudal tramadol significantly prolongs the duration of analgesia as compared to caudal fentanyl without any side effects.
Collapse
Affiliation(s)
- N M Solanki
- Department of Anesthesia, B. J. Medical College and Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
| | - S R Engineer
- Department of Anesthesia, B. J. Medical College and Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
| | - D B Jansari
- Department of Anesthesia, B. J. Medical College and Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
| | - R J Patel
- Department of Anesthesia, B. J. Medical College and Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
| |
Collapse
|
6
|
Abstract
Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.
Collapse
|
7
|
Doctor TP, Dalwadi DB, Abraham L, Shah N, Chadha IA, Shah BJ. Comparison of ropivacaine and bupivacaine with fentanyl for caudal epidural in pediatric surgery. Anesth Essays Res 2015; 7:212-5. [PMID: 25885835 PMCID: PMC4173527 DOI: 10.4103/0259-1162.118965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Ropivacaine, s-enantiomer of amide local anaesthetic produces differential neural blockade with less motor blockade, cardiovascular and neurological toxicity makes it suitable for day case surgery in children. AIMS To compare the effectiveness of Inj. Ropivacaine (0.2 or 0.25%) or Inj. Bupivacaine (0.25%) with fentanyl in caudal block for intra and postoperative analgesia. SETTINGS AND DESIGN Double blind retrospective randomized study. MATERIALS AND METHODS All the patients (n=112) varying from age group 3.02 ± 3.29 years belonging to ASA I-IV were randomly allocated to receive caudal analgesia Group BF inj. Bupivacaine (0.25%, 2 mg/kg) + Inj. Fentany1 μg/kg (n=70) and group RF: Inj. Ropivacaine (0.25% or 0.2%, 2 mg/kg) + inj. Fentanyl 1 μg/kg (n=42). We monitored vitals and requirement of inhalational gases inraoperatively and also observed pain by pain score (Visual Analogue Score in verbal group and Objective Pain Scale in nonverbal group) and vitals postoperatively. We used rescue analgesics (inj. Paracetamol 5 mg/kg iv) when VAS score ≥4. STATISTICAL ANALYSIS Student's t-test. RESULTS Duration of analgesia was prolonged in both group RF and BF. Time for first rescue analgesic for group RF (6.1 ± 1.1 hr) compared to group BF (5.6 ± 0.9 hr). Haemodynamic stability and less requirement of inhalation agent intraoperatively with group RF than others. CONCLUSIONS Ropivacaine with Fentanyl found to be better combination for pediatric surgeries for below umbilical surgeries as an adjuvant to general anaesthesia or sole technique with chances of less complication with high success rate.
Collapse
Affiliation(s)
- Tarlika P Doctor
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Divyang B Dalwadi
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Lissa Abraham
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Namrata Shah
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Indu A Chadha
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| | - Bharat J Shah
- Department of Anesthesia, Byramjee Jeejeebhoy Medical College, Civil Hospital, Ahmedabad, Gujarat, India
| |
Collapse
|
8
|
Immediate rescue designs in pediatric analgesic trials: a systematic review and meta-analysis. Anesthesiology 2015; 122:150-171. [PMID: 25222831 DOI: 10.1097/aln.0000000000000445] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Designing analgesic clinical trials in pediatrics requires a balance between scientific, ethical, and practical concerns. A previous consensus group recommended immediate rescue designs using opioid sparing as a surrogate measure of analgesic efficacy. The authors summarize the performance of rescue analgesic designs in pediatric trials of four commonly used classes of analgesics: opioids, nonsteroidal antiinflammatory drugs, acetaminophen, and local anesthetics. METHODS MEDLINE, Embase, CINAHL, The Cochrane Library, and Web of science were searched in April 2013. The 85 studies selected were randomized or controlled clinical trials using immediate rescue paradigms in postoperative pain settings. A random-effects meta-analysis was used to synthesize predefined outcomes using Hedges' g. Difference between the means of the treatment arms were also expressed as a percentage of the corresponding value in the placebo group (placebo-treatment/placebo). Distributions of pain scores in study and control groups and relationships between opioid sparing and pain scores were examined. RESULTS For each of the four study drug classes, significant opioid sparing was demonstrated in a majority of studies by one or more of the following endpoints: (1) total dose (milligram per kilogram per hour), (2) percentage of children requiring rescue medication, and (3) time to first rescue medication (minutes). Pain scores averaged 2.4/10 in study groups, 3.4/10 in control groups. CONCLUSIONS Opioid sparing is a feasible pragmatic endpoint for pediatric pain analgesic trials. This review serves to guide future research in pediatric analgesia trials, which could test whether some specific design features may improve assay sensitivity while minimizing the risk of unrelieved pain.
Collapse
|
9
|
Ahuja S, Yadav S, Joshi N, Chaudhary S, Madhu SV. Efficacy of caudal fentanyl and ketamine on post-operative pain and neuroendocrine stress response in children undergoing infraumbilical and perineal surgery: A pilot study. J Anaesthesiol Clin Pharmacol 2015; 31:104-9. [PMID: 25788782 PMCID: PMC4353133 DOI: 10.4103/0970-9185.150558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS It is well-known that neuroendocrine stress response (NESR) occurs in children and it can be modified by caudal block. However, there is paucity of literature comparing caudal fentanyl and ketamine on NESR. The present study was aimed to compare the analgesic efficacy of these caudal adjuvants and their effect on (NESR) in children undergoing infraumbilical and perineal surgery. MATERIALS AND METHODS A total of 60 children undergoing infraumbilical surgery were included in this randomized, double-blind study. Three groups of 20 each were assigned to receive caudal block with bupivacaine 0.25% 1 ml/kg along with either 0.9% normal saline (Group I) 1 μg/kg fentanyl (Group II) or 0.5 mg/kg ketamine (Group III). Modified visual analogue scale (VAS) was used for assessment of post-operative pain, and stress response was assessed by blood glucose, serum cortisol and insulin levels at various time intervals. RESULTS VAS scores were significantly lower in the ketamine group at all-time intervals upto 4 h (P < 0.05). Patients in ketamine group required rescue analgesia significantly later (8.23 h) when compared to fentanyl (5.95 h) and bupivacaine group (4.10 h). Caudal block led to significant decrease in cortisol and insulin levels within the groups however this significance was not achieved between groups. CONCLUSION Caudal ketamine in a dose of 0.5 mg/kg provides prolonged analgesia when compared to fentanyl 1 μg/kg. Blunting of the NESR was observed in all the groups though the indicators of the response were lowest with ketamine.
Collapse
Affiliation(s)
- Sharmila Ahuja
- Department of Anaesthesiology and Critical Care, and Medicine, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sangeeta Yadav
- Department of Anaesthesiology and Critical Care, and Medicine, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| | - Nandita Joshi
- Department of Anaesthesiology and Critical Care, and Medicine, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| | - Sujata Chaudhary
- Department of Anaesthesiology and Critical Care, and Medicine, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| | - S V Madhu
- Department of Anaesthesiology and Critical Care, and Medicine, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| |
Collapse
|
10
|
Abstract
SUMMARY Local anesthetics have a limited duration of action. Adjuvants are used to prolong the duration of action and to augment analgesia allowing lower concentrations of local anesthetic to be used. Adjuvants have been used more extensively with neuraxial blocks, particularly caudal epidural blocks, but more recently to supplement peripheral nerve blocks. Intrathecal adjuvants are not covered in this review since spinal anesthesia is not widely used in children except in ex-premature infants. Morphine is the historical gold-standard with which other adjuvants are compared. Clonidine is most useful and is becoming increasingly popular, while the side-effect profile of other agents reduces their utility. Concerns with regard to the neurotoxicity of ketamine in animal models has led to its withdrawal in some countries.
Collapse
Affiliation(s)
- Adrian Bosenberg
- Department of Anesthesiology & Pain Management, Faculty of Health Sciences, University of Washington, Seattle, USA and Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105, USA.
| |
Collapse
|
11
|
Shukla U, Prabhakar T, Malhotra K. Postoperative analgesia in children when using clonidine or fentanyl with ropivacaine given caudally. J Anaesthesiol Clin Pharmacol 2013; 27:205-10. [PMID: 21772681 PMCID: PMC3127300 DOI: 10.4103/0970-9185.81842] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The aim of the study was to compare the efficacy of clonidine and fentanyl as an additive to ropivacaine given via single shot caudal epidural in pediatric patients for postoperative pain relief. Materials and Methods: In the present double blind study, 90 children of ASA-I-II aged 3-8 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either ropivacaine 0.25% 1 ml/kg + clonidine 2 μg/kg (group I) or ropivacaine 0.25% 1 μl/kg + fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamics, and side effects/complications. Results: Both the groups were similar with respect to patient and various block characteristics. The analgesic properties and hemodynamics were also comparable in both groups (P > 0.05). Side effects such as respiratory depression, vomiting bradycardia were significantly less in group I than group II (P < 0.05) ensuing more patient comfort. Conclusions: The analgesic properties of clonidine and fentanyl as additives to ropivacaine in single shot caudal epidural in children are comparable but clonidine offers a more favorable side effect profile. The use of clonidine as additive to ropivacaine in caudal epidural is superior choice to fentanyl because of lack of unwanted side effects and increased patient comfort.
Collapse
Affiliation(s)
- Usha Shukla
- Department of Anaesthesiology and Critical Care, U.P Rural Institute of Medical Sciences and Research, Saifai, Etawah, India
| | | | | |
Collapse
|
12
|
Abstract
Paediatric anaesthesia and paediatric regional anaesthesia are intertwined. Almost all surgeries unless contradicted could be and should be supplemented with a regional block. The main objective of this review is to elaborate on the recent advances of the central neuraxial blocks, such as application of ultrasound guidance and electrical stimulation in the pursuit of safety and an objective end point. This review also takes account of the traditional technique and understand the benefits as well the risk of each as compared with the recent technique. The recent trends in choosing the most appropriate peripheral block for a given surgery thereby sparing the central neuroaxis is considered. A penile block for circumcision or a sciatic block for unilateral foot surgery, rather than caudal epidural would have a better risk benefit equation. Readers will find a special mention on the recent thoughts on continuous epidural analgesia in paediatrics, especially its rise and fall, yet its unique importance. Lastly, the issue of block placements under sedation or general anaesthesia with its implication in this special population is dealt with. We conducted searches in MEDLINE (PubMed) and assessed the relevance of the abstracts of citations identified from literature searches. The search was carried out in English, for last 10 years, with the following key words: Recent advances in paediatric regional anaesthesia; ultrasound guidance for central neuraxial blocks in children; role of electrical stimulation in neuraxial blocks in children; complications in neuraxial block. Full-text articles of potentially relevant abstracts were retrieved for further review.
Collapse
|
13
|
Abstract
Caudal anesthesia is the single most important pediatric regional anesthetic technique. The technique is relatively easy to learn (1), has a remarkable safety record (2), and can be used for a large variety of procedures. The technique has been reviewed in the English (3) and French (4) literature, as well as in German guidelines (5) and in pediatric anesthesia textbooks (6).
Collapse
Affiliation(s)
- Martin Jöhr
- Pediatric Anesthesia, Department of Anesthesia, Kantonsspital, Luzern, Switzerland.
| | | |
Collapse
|
14
|
Cho JE, Kim JY, Hong JY, Kil HK. The addition of fentanyl to 1.5 mg/ml ropivacaine has no advantage for paediatric epidural analgesia. Acta Anaesthesiol Scand 2009; 53:1084-7. [PMID: 19572930 DOI: 10.1111/j.1399-6576.2009.02046.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Epidural opioids are frequently combined with local anaesthetics for an additive antinociceptive effect. We investigated the efficacy of epidural fentanyl to 1.25 or 1.5 mg/ml ropivacaine for post-operative epidural analgesia in children. METHODS One hundred and eight children undergoing hypospadias repair were randomized to receive 1.25 mg/ml ropivacaine (R1.25 group), 1.25 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.25F group), 1.5 mg/ml ropivacaine (R1.5 group) or 1.5 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.5F group) for post-operative epidural analgesia. The epidural catheter was threaded caudally through the L4-5 interspace. The face, legs, activity, cry, consolability (FLACC) score was assessed at every hour and at FLACC score >4, an epidural bolus of 0.5 ml/kg of ropivacaine 1.5 mg/ml was given as the rescue analgesia. The incidence of side effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was recorded. RESULTS The need for rescue analgesia was higher in the R1.25 group compared with that in the other three groups (all P<0.05). The incidence of side effects was higher in the R1.5F group compared with that in the R1.25 and R1.5 groups (both P=0.010). CONCLUSION The addition of 0.2 mcg/kg/h fentanyl to 1.5 mg/ml ropivacaine increased the incidence of side effects without improvement of analgesia in infants and children undergoing hypospadias repair. The use of plain 1.25 mg/ml ropivacaine increased the need for rescue analgesia and this could be compensated by addition of fentanyl.
Collapse
Affiliation(s)
- J E Cho
- Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
15
|
Erol A, Tavlan A, Tuncer S, Topal A, Yurtcu M, Reisli R, Otelcioglu S. Caudal anesthesia for minor subumbilical pediatric surgery: a comparison of levobupivacaine alone and levobupivacaine plus sufentanil. J Clin Anesth 2008; 20:442-6. [PMID: 18929285 DOI: 10.1016/j.jclinane.2008.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Revised: 04/16/2008] [Accepted: 04/22/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Atilla Erol
- Department of Anaesthesiology and Intensive Care, University of Selcuk of Meram Medicine Faculty, Konya, Turkey.
| | | | | | | | | | | | | |
Collapse
|
16
|
Affiliation(s)
- D A H de Beer
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JN, UK
| | | |
Collapse
|
17
|
Baris S, Karakaya D, Kelsaka E, Güldogus F, Ariturk E, Tür A. Comparison of fentanyl-bupivacaine or midazolam-bupivacaine mixtures with plain bupivacaine for caudal anaesthesia in children. Paediatr Anaesth 2003; 13:126-31. [PMID: 12562485 DOI: 10.1046/j.1460-9592.2003.00979.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the intensity and effectiveness of 0.75 ml.kg-1 bupivacaine 0.25% with the addition of fentanyl or midazolam for caudal block in children undergoing inguinal herniorrhaphy. METHODS Seventy-five children were allocated randomly to three groups to receive a caudal block with either 0.25% bupivacaine with fentanyl 1 microg.kg(-1) (group BF) or with midazolam 50 microg.kg(-1) (group BM) or bupivacaine alone (group B) after induction of anaesthesia. Haemodynamic parameters, degree of pain, additional analgesic requirements and side-effects were evaluated. RESULTS The mean systolic arterial pressure at 10, 20, 30 min after caudal block was higher in group B compared with groups BF and BM. Mean intraoperative heart rate was lower in group BF than the other groups. Adequate analgesia was obtained in all patients (100%) in group BF, 23 patients (92%) in group BM and 21 patients (84%) in group B (P > 0.05). The time to recovery to an Aldrete score of 10 was significantly shorter in group B than group BM (P < 0.05). Although not significant, it was also shorter in group B than group BF. There was no difference in additional analgesic requirements between the groups in the first 24 h. Sedation score was higher in the midazolam group at 60 and 90 min postoperatively than the other groups. CONCLUSIONS Caudal block with 0.75 ml.kg(-1) 0.25% bupivacaine and 50 microg.kg(-1) midazolam or 1 microg.kg(-1) fentanyl provides no further analgesic advantages to bupivacaine alone when administered immediately after induction of anaesthesia in children undergoing unilateral inguinal herniorrhaphy.
Collapse
Affiliation(s)
- Sibel Baris
- Departments of Anaesthesiology and Paediatric Surgery, Faculty of Medicine, Ondokuz Mayis University, Kurupelit, Samsun, Turkey.
| | | | | | | | | | | |
Collapse
|
18
|
Ozcengiz D, Güneş Y, Ozalevli M, Işik G. Postoperative analgesia in children: comparison of bupivacaine with a mixture of bupivacaine and alfentanil. Eur J Anaesthesiol 2001; 18:695-6. [PMID: 11553247 DOI: 10.1046/j.1365-2346.2001.0903a.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- D Ozcengiz
- Cukurova University Faculty of Medicine, Department of Anaesthesiology, Adana, Turkey
| | | | | | | |
Collapse
|
19
|
The influence of sufentanil and/or clonidine on the duration of analgesia after a caudal block for hypospadias repair surgery in children. Eur J Anaesthesiol 2000. [DOI: 10.1097/00003643-200006000-00007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
20
|
Gaitini LA, Somri M, Vaida SJ, Yanovski B, Mogilner G, Sabo E, Lischinsky S, Greenberg A, Levy N, Zinder O. Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children? Anesth Analg 2000; 90:1029-33. [PMID: 10781448 DOI: 10.1097/00000539-200005000-00006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1-8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 microg/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H(0)), at the end of surgery (H(1)), and in the postanesthesia care unit (H(2)). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H(1) and H(2) with H(0) within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H(0), H(1), and H(2) (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children's Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0. 19). This study suggests that adding fentanyl 1 microg/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block.
Collapse
Affiliation(s)
- L A Gaitini
- Department of Anesthesiology, B'nai Zion Medical Center, Rambam Medical Center, Haifa, Israel.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Joshi W, Connelly NR, Dwyer M, Schwartz D, Kilaru PR, Reuben SS. A comparison of two concentrations of bupivacaine and adrenaline with and without fentanyl in paediatric inguinal herniorrhaphy. Paediatr Anaesth 1999; 9:317-20. [PMID: 10411767 DOI: 10.1046/j.1460-9592.1999.00368.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study was designed to determine whether administration of caudal bupivacaine with fentanyl would have any effect on analgesia in paediatric patients undergoing inguinal herniorrhaphy repair. Fifty-six outpatient paediatric patients undergoing inguinal hernia repair were evaluated. Patients received, in a randomized manner, 1 ml.kg-1 of either bupivacaine 0.25% or 0.125% with or without fentanyl 1 microg.kg-1. There was no difference in pain scores in the hospital, the night of surgery, or 24 h postoperatively nor was there a difference in the oral analgesics administered between any of the groups. There was a higher incidence of vomiting at home in both 0.25% bupivacaine groups irrespective of the use of fentanyl. The 0.125% bupivacaine group had significantly more patients who received intravenous fentanyl in the PACU than did the other three groups (P<0.001). Increasing the concentration of bupivacaine from 0. 125% to 0.25% increased the incidence of postoperative vomiting. We recommend that clinicians utilize bupivacaine 0.125% with 1 microg. kg-1 fentanyl as the caudal injectate in paediatric patients undergoing inguinal hernia repair.
Collapse
MESH Headings
- Administration, Oral
- Ambulatory Surgical Procedures
- Analgesics/administration & dosage
- Analgesics/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Analysis of Variance
- Anesthesia Recovery Period
- Anesthesia, Spinal
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Bupivacaine/administration & dosage
- Bupivacaine/adverse effects
- Chi-Square Distribution
- Child
- Child, Preschool
- Epinephrine/administration & dosage
- Epinephrine/adverse effects
- Fentanyl/administration & dosage
- Fentanyl/therapeutic use
- Follow-Up Studies
- Hernia, Inguinal/surgery
- Humans
- Incidence
- Infant
- Injections, Intravenous
- Injections, Spinal
- Pain, Postoperative/prevention & control
- Postoperative Nausea and Vomiting/chemically induced
- Vasoconstrictor Agents/administration & dosage
- Vasoconstrictor Agents/adverse effects
Collapse
Affiliation(s)
- W Joshi
- Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
Laboratory data, economic pressures, and the wish for humane treatment have been some of the driving forces behind improvements in paediatric pain management. Within the space of 10 years, there have been dramatic changes in the quality of treatment received by children undergoing surgical operations. Moreover, those receiving medical treatment, for example, sickle cell disease, have also benefited from increased experience in pain management. Children receiving care in specialised centres can now expect to benefit from up-to-date techniques of pain management, such as patient-controlled analgesia, nurse-controlled analgesia, and epidural infusions. They will be managed by ward nurses experienced and trained in paediatric pain relief, they will be attended by nurses whose special interest and training is the management of children's pain, and they will be provided with the techniques of analgesia by competent, trained anaesthetic staff. Improved care, with close attention to pain relief, is not only humane, but improves the patient turnaround by enhancing rapid discharge. Further education is required to spread these benefits to children being managed outside highly specialised centres. Not only education, but investment, is needed also to ensure that all children receive a standard of care second to none.
Collapse
Affiliation(s)
- A R Lloyd-Thomas
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| |
Collapse
|
23
|
|
24
|
|
25
|
Tobias JD, Holcomb GW, Lowe S, Hersey S, Brock JW. Caudal epidural block for analgesia following herniorrhaphy with laparoscopy in children. JOURNAL OF LAPAROENDOSCOPIC SURGERY 1994; 4:117-20. [PMID: 8043919 DOI: 10.1089/lps.1994.4.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study prospectively evaluated the efficacy of caudal epidural block in providing analgesia following inguinal herniorrhaphy and laparoscopy. Laparoscopy was used only to inspect the contralateral side to determine if a second hernia was present. No surgical manipulation was performed through the telescope. Following mask induction with halothane in nitrous oxide and oxygen, a caudal epidural block was performed with 1.2 mL/kg of 0.25% bupivacaine. Pain scores were obtained at four points during the in-hospital postoperative course, and the need for supplemental analgesic agents was assessed. A total of 45 patients were studied. Caudal epidural block could not be performed in 1 patient, and this patient was excluded from further consideration. There were 34 boys and 10 girls, ranging in age from 2 to 84 months (mean +/- SD 37.4 +/- 18.2 months) and weighing from 3.4 to 34 kg (mean +/- SD 14.2 +/- 5.8 kg). Thirty-six of 44 patients (82%) did not require supplemental analgesic agents during their in-hospital postoperative course and had pain scores of 2 or less at all four evaluation points. Six of 8 patients required a single dose of intravenous fentanyl (0.5 microgram/kg) to maintain scores of 2 or less. No significant complications related to caudal epidural block were noted in any patient. Caudal epidural block provides effective analgesia following inguinal herniorrhaphy and laparoscopy in children.
Collapse
Affiliation(s)
- J D Tobias
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | | | | | | | | |
Collapse
|