Longer than expected-duration of caudal analgesia with two different doses of levobupivacaine in children undergoing hypospadias repair

Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: A meta-analysis

INTRODUCTION

We performed a meta-analysis of the current literature to assess the association of caudal block and postoperative complication rates following hypospadias repair.

METHODS

A Systematic literature search was conducted on October 2017. Five reviewers independently screened, identified, and evaluated comparative studies assessing postoperative outcomes following hypospadias repair with and without caudal block. The incidence of post-surgical complications from each study was extracted for caudal block and control groups to generate the odds ratio (OR) and corresponding 95% confidence intervals (CI). Effect estimates were pooled using inverse-variance method with random-effects model. Subgroup analyses were performed according to study type and hypospadias severity.

RESULTS

Nine studies (2096patients) of low- to moderate-quality were included for meta-analysis. Overall pooled effect estimates demonstrated increased occurrence of postoperative complication rates among patients with caudal block (OR 2.32; 95% CI 1.29-4.16). Subgroup analysis according to hypospadias severity revealed that a significant increased OR in complication rate was noted among proximal hypospadias (OR 3.55; 95% CI 1.80-7.01), but not distal hypospadias (OR 1.31; 95% CI 0.59-2.88).

CONCLUSIONS

Our meta-analysis of poor-quality evidence may have revealed a significant association between caudal block and postoperative complications following hypospadias repair. However, subgroup analysis demonstrated that hypospadias severity is important in determining complication rates, suggesting that confounding factors and selection bias may play a central role in characterizing the true effect of the anesthesia approach.

Use of Caudal Analgesia Supplemented with Low Dose of Morphine in Children Who Undergo Renal Surgery

INTRODUCTION

To test the efficacy and safety of caudal anesthesia (CA) supplemented by low dose morphine in children who undergo renal surgery.

MATERIALS AND METHODS

Forty patients aged 2 months-14 years were enrolled and randomly divided into two groups of 20 patients each: Group A (bupivacaine 0.2% with fentanyl); Group B (bupivacaine with morphine). The duration of surgery and hospitalization time were recorded. Postoperative pain score was measured by Face Legs Activity Cry Consolability scale and Wong-Baker Faces scale for those who are older. Overall use of rescue analgesics was calculated.

RESULTS

There was no statistical difference in the length of surgery, incidence of pruritus, postoperative nausea, vomiting and urinary retention between the two groups. However the postoperative opioid requirements were significantly higher in Group A 1.03 ± 0.9 mg/kg compared to Group B, in which only one patient required opioid therapy (p < 0.0001). Moreover the need for non-opioid rescue analgesic was higher in Group A, (36 ± 5.7 mg/kg of paracetamol) compared to morphine CA group there only 26 ± 3.6 mg/kg required during first 24 h of the postoperative period (p = 0.0312). The Face Legs Activity Cry Consolability pain score (1, 4, and 24 h after surgery) and Wong-Baker Faces scale were significantly higher in Group A. The hospitalization period was shorter in the CA morphine group, but the difference did not reach statistical significance. None developed hemodynamic instability or respiratory depression.

CONCLUSIONS

Our data show that CA supplemented with low dose morphine provides a longer duration of analgesia without significant side-effects in children undergoing renal surgery.

Pain management practice patterns for common pediatric urology procedures

OBJECTIVE

To characterize practice patterns among members of the Society for Pediatric Urology.

METHODS

A survey instrument assessing pain management was e-mailed to all members of the Society for Pediatric Urology. Five hundred fifteen invitations were sent, 134 were included, for a 26% response rate. Pain management strategies were assessed for 7 case scenarios. Surveys were included if the responder answered a minimum of 2 case scenarios. Question Pro survey engine was used to process the survey.

RESULTS

Local/regional block was the most frequent intraoperative anesthesia (54%-90%). Epidural/caudal use varied from 19% to 42%. For postop opioids, a dichotomy exists between those without age restriction and those who wait until the patient is 6 months old. Sixty three percent responded that ketorolac was prescribed only if the patient had normal renal function, 20% after confirmation of adequate urine output for bilateral procedures, 3% when postoperative creatinine was normal, and 14% did not use ketorolac at all. In regards to age limitations, most did not indicate a limit (53%), whereas a large number required the child to be older than 6 months (26%). Regarding local blocks, most urologists perform the block themselves (61%) for simple/complex penile surgery or inguinal surgery. Of this group, only 33% actually bill for the administration of the block. After a caudal block, a minority (26%) of respondents require the patient to void before discharge for ambulatory procedures.

CONCLUSION

There is no clear consensus in pain management for common pediatric urologic procedures. These disparities should be the aim of future studies.

Caudal additives do not improve the analgesia afforded by levobupivacaine after hypospadias repair

Background:

Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits.

Objectives:

This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair.

Patients and Methods:

We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used:

Primary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge.

Results:

The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation.

Conclusions:

The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.