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Karagözlü Akgül A, Canmemiş A, Eyvazov A, Hürel H, Kiyan G, Umuroğlu T, Tuğtepe H. Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair. Balkan Med J 2022; 39:239-245. [PMID: 35669925 PMCID: PMC9326942 DOI: 10.4274/balkanmedj.galenos.2022.2022-1-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial. Aims: To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias. Study Design: Retrospective cross-sectional study. Methods: Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups. Results: The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group. Conclusion: This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.
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Affiliation(s)
- Ahsen Karagözlü Akgül
- Department of Pediatric Surgery, Division of Pediatric Urology, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Arzu Canmemiş
- Clinic of Pediatric Urology Ministry of Health, Göztepe Prof Dr Süleyman Yalçın Hospital, İstanbul, Turkey
| | - Ali Eyvazov
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Hilal Hürel
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Gürsu Kiyan
- Department of Pediatric Surgery, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Tümay Umuroğlu
- Department of Anaesthesiology and Reanimation, Faculty of Medicine Marmara University, İstanbul, Turkey
| | - Halil Tuğtepe
- Department of Pediatric Surgery, Division of Pediatric Urology, Faculty of Medicine Marmara University, İstanbul, Turkey
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Xing M, Liang X, Li L, Liao L, Liang S, Jiang S, Li J, Zhang C, Zou W. Efficacy of caudal vs intravenous administration of α 2 adrenoceptor agonists to prolong analgesia in pediatric caudal block: A systematic review and meta-analysis. Paediatr Anaesth 2020; 30:1322-1330. [PMID: 32978991 DOI: 10.1111/pan.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/06/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND α2 adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α2 adrenoceptor agonists during pediatric caudal block. METHODS A systematic search, data extraction, bias risk assessment, and pooled data analysis were performed following the PRISMA guidelines. All randomized controlled trials comparing caudal with intravenous α2 adrenoceptor agonists in pediatric caudal block were included. Relative risk and weighted mean differences (the corresponding 95% confidence intervals) were calculated for dichotomous and continuous data, respectively. Trial sequential analyses were performed to evaluate the credibility of the meta-analysis. RESULTS A total of 244 patients in five trials were identified. Compared with the intravenous group (9.56 ± 4.23 hours), the time to the first rescue analgesia was prolonged in the caudal α2 adrenoceptor agonists group (12.72 ± 5.99 hours) by a weighted mean difference of 2.98 hours [95% confidence interval: 0.59-5.36 hours; P = .01]. The number of children requiring rescue analgesia in the caudal group (64, 66.67%) was lower than that in the intravenous group (80, 81.63%) [relative risk = 0.82; 95% confidence interval: 0.69-0.97; P = .02]. These findings were also verified by trial sequential analysis. There were no significant differences in the side effects. CONCLUSION Caudal α2 adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.
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Affiliation(s)
- Manyu Xing
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Xia Liang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Lin Li
- Department of Anesthesiology, The First Hospital of Changsha, Changsha, China
| | - Liping Liao
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Shuang Liang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Shasha Jiang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Jingyi Li
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wangyuan Zou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
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Kim MH, Im YJ, Kil HK, Han SW, Joe YE, Lee JH. Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study. Anaesthesia 2016; 71:773-8. [PMID: 27156500 DOI: 10.1111/anae.13463] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2016] [Indexed: 11/26/2022]
Abstract
This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty.
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Affiliation(s)
- M H Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y J Im
- Department of Urology, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - H K Kil
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S W Han
- Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y E Joe
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J H Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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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.
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Lauretti GR, de Azevedo VMS, Portes Lopes BC, de Mattos AL. Comparison between the intravenous and caudal routes of sufentanil in children undergoing orchidopexy and further evaluation of the association of caudal adrenaline and neostigmine. Saudi J Anaesth 2014; 8:345-50. [PMID: 25191184 PMCID: PMC4141382 DOI: 10.4103/1658-354x.136430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: The aim of this study was to compare the intravenous (IV) and caudal routes of administration of sufentanil for children undergoing orchidopexy and also to evaluate the effects on addition of caudal adrenaline and neostigmine. Materials and Methods: Sixty patients scheduled for orchidopexy were divided into the following groups: 1) Group IVSu received IV 0.5 μg/kg sufentanil and caudal saline; 2) Group CSu received caudal 0.5 μg/kg sufentanil and IV saline; 3) Group CSuAdr received caudal sufentanil plus adrenaline 5 μg/ml (1:200,000) and IV saline; 4) Group CSuNeo received caudal sufentanil plus neostigmine, and IV saline; and 5) Group CSuNeoAdr received caudal sufentanil plus neostigmine plus adrenaline, and IV saline. Heart rate and mean blood pressure >15% was treated with increasing isoflurane concentration. Consumption of isoflurane, side effects, quality of sleep, time to first administration of analgesic, and number of doses of 24-h rescue analgesic were recorded. Results: Groups were demographically similar. Isoflurane consumption showed the following association: Group IVSu = Group CSuNeo = Group CSuNeoAdr < Group CSu = Group CSuAdr (P < 0.02). VAS for sedation on reversal of anesthesia showed the following association: Group CSuNeo = Group CSuNeoAdr < Group CSu = Group CSuAdr = Group IVSu (P < 0.005). Time to the first administration of dipyrone showed the following association: Group IVSu = Group CSu = Group CSuAdr (3-4 h) < Group CSuNeo = Group CSuNeoAdr (10-11 h) (P < 0.05). Number of doses of rescue analgesic showed the following association: Group IVSu = Group CSu = Group CSuAdr > Group CSuNeo = Group CSuNeoAdr (P < 0.005). Incidence of adverse effects was similar among groups. Conclusion: Caudal sufentanil alone was no better than when administered in the IV route, and would just be justified by the association of neostigmine, but not adrenaline. Neostigmine association resulted in better perioperative analgesia.
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Affiliation(s)
- Gabriela Rocha Lauretti
- Department of Biomechanics, Medicine and Rehabilitation of Locomotor Members, Teaching Hospital, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil
| | | | - Bruno Carvalho Portes Lopes
- Department of Biomechanics, Medicine and Rehabilitation of Locomotor Members, Teaching Hospital, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil
| | - Anita Leocadia de Mattos
- Department of Biomechanics, Medicine and Rehabilitation of Locomotor Members, Teaching Hospital, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil
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Wang T, Xiang Q, Liu F, Wang G, Liu Y, Zhong L. Effects of caudal sufentanil supplemented with levobupivacaine on blocking spermatic cord traction response in pediatric orchidopexy. J Anesth 2013; 27:650-6. [PMID: 23608774 DOI: 10.1007/s00540-013-1613-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/07/2013] [Indexed: 11/26/2022]
Abstract
PURPOSES Caudal block is one of the most commonly used anesthetic techniques in subumbilical and genitourinary procedures. However, traditional administration of caudal levobupivacaine was inadequate on blocking peritoneal response during spermatic cord traction. The aim of this study was to evaluate whether the addition of caudal sufentanil to levobupivacaine provided better analgesia for children undergoing orchidopexy. METHODS Sixty-two patients, scheduled for right orchidopexy, received caudal block after induction. Group LS (n = 31) received levobupivacaine 0.25% 1 ml/kg plus sufentanil 0.5 μg/kg, and group L (n = 31) received levobupivacaine 0.25% 1 ml/kg only. HR or MAP fluctuation >20% or entropy increase >15% during spermatic cord traction was defined as inadequate anesthesia and was treated with increasing sevoflurane concentration. The number of children who needed sevoflurane rescue was counted, and postoperative side effects and quality of sleep were also recorded. RESULTS There were no statistically significant differences between the two groups in age, weight, and duration of surgery. Two (6.45%) children in group LS required inspired sevoflurane rescue to block hemodynamic fluctuation during spermatic cord traction, as compared with 12 (38.71%) patients in group L (P < 0.001). At the time of exerting spermatic cord traction, the median HR was, respectively, 134 and 145 (P < 0.001); the corresponding response entropy (RE) and state entropy (SE) was 65 and 54, respectively, in group LS versus 76 and 65 in group L (P < 0.001). CONCLUSION In pediatric orchidopexy, the addition of sufentanil to levobupivacaine for caudal blockade offers clinical benefit over levobupivacaine alone in blocking the spermatic cord traction response.
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Affiliation(s)
- Tingting Wang
- Department of Anesthesia, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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ENGELMAN E, MARSALA C. Bayesian enhanced meta-analysis of post-operative analgesic efficacy of additives for caudal analgesia in children. Acta Anaesthesiol Scand 2012; 56:817-32. [PMID: 22313028 DOI: 10.1111/j.1399-6576.2012.02651.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND The authors calculated the effect size for post-operative analgesia of three additives, clonidine, neostigmine, and tramadol to bupivacaine, ropivacaine, or levobupivacaine used for single-dose caudal extradural blockade in children. METHODS A meta-analysis was performed for three end points of efficacy: the increase of time until administration of analgesic drugs, the proportion of patients requiring analgesic drugs during the initial 24 post-operative hours, and the amounts of post-operative analgesic drugs. A Bayesian inference supporting direct statements about the probability of the magnitude of an effect was used to compare the effects size. RESULTS Neostigmine increased the duration of analgesia by 9.96 h (95% confidence interval: 7.75 to 12.16), as compared with 3.68 h (2.65 to 4.7) with clonidine and 4.45 (2.84 to 6.07) with tramadol. There is a 95% probability that neostigmine increases the duration of post-operative analgesia by more than 8 h, clonidine by more than 2.8 h, and tramadol by more than 3.25 h, as compared with local anesthetics alone. The odds ratios for the proportion of patients requiring analgesic drugs were 0.22 [0.13 to 0.37] for clonidine and 0.28 [0.10 to 0.75] for neostigmine. With tramadol, there was no statistically significant difference. All three additives reduced the amounts of post-operative analgesic drugs. Neostigmine and tramadol increase the probability for post-operative nausea or vomiting (PONV). CONCLUSIONS Neostigmine provides the longest post-operative analgesia. With clonidine, the duration of analgesia is shorter and sedation is increased, but the probability for PONV could be decreased.
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Affiliation(s)
- E. ENGELMAN
- Department of Anaesthesia; CUB Hopital Erasme; Brussels; Belgium
| | - C. MARSALA
- Department of Anaesthesia; CUB Hopital Erasme; Brussels; Belgium
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Walker SM, Yaksh TL. Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data. Anesth Analg 2012; 115:638-62. [PMID: 22798528 DOI: 10.1213/ane.0b013e31826253f2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.
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Affiliation(s)
- Suellen M Walker
- Portex Unit: Pain Research, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, London, UK.
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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).
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Affiliation(s)
- Martin Jöhr
- Pediatric Anesthesia, Department of Anesthesia, Kantonsspital, Luzern, Switzerland.
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Yildiz TS, Ozdamar D, Bagus F, Solak M, Toker K. Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study. Paediatr Anaesth 2010; 20:524-9. [PMID: 20412459 DOI: 10.1111/j.1460-9592.2010.03296.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg.kg(-1) and mixture of both in children undergoing day-case surgery. METHODS Sixty-three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg.kg(-1) (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml.kg(-1)). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children's and Infants' Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was > or =4. RESULTS No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 +/- 160 min vs 322 +/- 183 min and 248 +/- 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. CONCLUSION Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.
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Affiliation(s)
- Tulay S Yildiz
- Department of Anesthesiology, Medical Faculty, University of Kocaeli, Kocaeli, Turkey.
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Karaaslan K, Gulcu N, Ozturk H, Sarpkaya A, Colak C, Kocoglu H. Two different doses of caudal neostigmine co-administered with levobupivacaine produces analgesia in children. Paediatr Anaesth 2009; 19:487-493. [PMID: 19565667 DOI: 10.1111/j.1460-9592.2009.02969.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY BACKGROUND This study was aimed to evaluate the analgesic efficacy duration of analgesia, and side effects of two different doses of caudal neostigmine used with levobupivacaine in children. METHODS Sixty boys, between 5 months and 5 years, undergoing genitourinary surgery were allocated randomly to one of three groups (n =20 each). Group I patients received caudal 0.25% levobupivacaine (1 ml.kg(-1)) alone. Groups II and III patients received neostigmine (2 and 4 microg.kg(-1) respectively) together with levobupivacaine used in the same does as Group I. Pain scores were assessed using Children's and Infant's Postoperative Pain Scale (CHIPPS) at 15th (t(1)) min after arrival to postanesthetic care unit, and 1st (t(2)), 2nd (t(3)), 3rd (t(4)), 4th (t(5)), 8th (t(6)), 16th (t(7)), and 24th (t(8)) hour postoperatively. Duration of analgesia, amount of additional analgesic (paracetamol), score of motor blockade and complications were recorded for 24 h postoperatively, and compared between groups. RESULTS CHIPPS scores were higher during t(2), t(3), t(6), t(7), and t(8) periods, duration of analgesia was shorter, and total analgesic consumption was higher in Group I compare to neostigmine groups (P < 0.05). Duration of postoperative analgesia and total analgesic consumption were similar in Groups II and III (P > 0.05). Adverse effects were not different between three groups. CONCLUSIONS Caudal neostigmine in doses of 2 and 4 microg.kg(-1) with levobupivacaine extends the duration of analgesia without increasing the incidence of adverse effects, and 2 microg.kg(-1) seems to be the optimal dose, as higher dose has no further advantages.
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Affiliation(s)
- Kazim Karaaslan
- Department of Anesthesiology, Abant Izzet Baysal University, Faculty of Medicine, Bolu, Turkey
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