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Shah UJ, Karuppiah N, Karapetyan H, Martin J, Sehmbi H. Analgesic Efficacy of Adjuvant Medications in the Pediatric Caudal Block for Infraumbilical Surgery: A Network Meta-Analysis of Randomized Controlled Trials. Cureus 2022; 14:e28582. [PMID: 36185831 PMCID: PMC9521396 DOI: 10.7759/cureus.28582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
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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.
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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.
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Nestor CC, Ng C, Sepulveda P, Irwin MG. Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review. Anaesthesia 2021; 77:339-350. [PMID: 34904711 DOI: 10.1111/anae.15641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 12/19/2022]
Abstract
Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.
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Affiliation(s)
- C C Nestor
- Department of Anaesthesiology, University of Hong Kong, Hong Kong, China
| | - C Ng
- Department of Anaesthesiology, University of Hong Kong, Hong Kong, China
| | | | - M G Irwin
- Department of Anaesthesia and Pain Medicine, Hospital Base San Jose, Los Lagos, Chile
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Abstract
Neuraxial (spinal and epidural) anesthesia has become commonplace in the care of neonates undergoing surgical procedures. These techniques afford many benefits, and, when properly performed, are extremely safe. This article reviews the benefits, risks, and applications of neuraxial anesthesia in neonates.
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Dexamethasone versus neostigmine as an adjuvant to bupivacaine 0.25% for caudal analgesia in children undergoing open inguinal hernia repair. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Role of ketamine and tramadol as adjuncts to bupivacaine 0.5% in paravertebral block for breast surgery: A randomized double-blind study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2011.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Shirmohammadie M, Ebrahim Soltani A, Arbabi S, Nasseri K. A randomized-controlled, double-blind study to evaluate the efficacy of caudal midazolam, ketamine and neostigmine as adjuvants to bupivacaine on postoperative analgesic in children undergoing lower abdominal surgery. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 89:513-518. [PMID: 30657120 PMCID: PMC6502095 DOI: 10.23750/abm.v89i4.5775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/03/2018] [Indexed: 11/30/2022]
Abstract
Background: Caudal epidural is the most commonly used technique for the management of postoperative pain in children. The aim of the present study was to assess and compare the efficacy of caudal bupivacaine as a postoperative analgesic alone or combined with midazolam, ketamine, and neostigmine in pediatric patients undergoing lower abdominal surgery. Methods: Eighty pediatric patients categorized under the American Society of Anesthesiologists Physical Status I and II Classification System, who have been scheduled to undergo lower abdominal surgery were randomly designated into four groups to receive caudal block with either 1 ml/kg of 0.25% caudal bupivacaine for group B, 1 ml/kg of 0.25% caudal bupivacaine mixed with 2 μg/kg neostigmine for group BN, 1 ml/kg of 0.25% caudal bupivacaine mixed with 0.5 mg/kg ketamine for group BK or 1 ml/kg of 0.25% caudal bupivacaine mixed with 50 mcg/kg midazolam for group BM. Postoperative analgesia was examined by a blinded anesthetist utilizing a Revised Faces Pain Scale. Consumption of the total amount of rescue analgesic each 24 h, postoperative time to requirement of the first dose and any adverse effects were noted. Results: The four groups were comparable as regards age, sex, weight, duration of surgery, heart rate, blood pressure and the time from induction of anesthesia to response to voice. The Revised Faces Pain Scale was 2.6±1.5 in group BN, 3.1±1.8 in group BM, 4.4±2.4 in group BK, and 5.6±1.3 in group B (p=0.005). Postoperative duration of analgesia was 433±68 min, 769±118 min, 1097±126 min and 1254±176 min in groups B, BK, BM and BN respectively (P=0.001). The dose of rescue analgesic within 24 h in group B was significantly higher than those of the other three groups (P<0.05). Conclusion: Addition of either neostigmine, midazolam, or ketamine to caudal bupivacaine extended analgesia time and decreased rescue analgesic compared to bupivacaine alone in children who underwent lower abdominal surgery. (www.actabiomedica.it)
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Mokaram Dori M, Foruzin F. The Analgesic Efficacy of Intrathecal Bupivacaine and Fentanyl with Added Neostigmine or Magnesium Sulphate. Anesth Pain Med 2017; 6:e9651. [PMID: 28975069 PMCID: PMC5560647 DOI: 10.5812/aapm.9651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 08/27/2016] [Accepted: 09/10/2016] [Indexed: 11/29/2022] Open
Abstract
Background An appropriate anesthesia duration with minimal side effects and prolonged postoperative analgesia are the ideal characteristics of an intrathecal drug used during spinal anesthesia. Neostigmine and magnesium sulphate have been used as spinal anesthetic additives with narcotics and local anesthetics. Objectives This study aimed to assess the analgesic properties of intrathecal neostigmine and magnesium sulphate by adding them to intrathecal bupivacaine-fentanyl. Methods : In total, 210 patients undergoing tibial fracture surgery were enrolled in a double-blinded clinical trial study. Patients were randomly allocated to one of three groups: group F received 10 mg of bupivacaine and 25 µg of fentanyl as intrathecal drug for spinal anesthesia, group N received 150 µg of neostigmine added to 10 mg of bupivacaine and 25 µg of fentanyl, and group M received 50 mg of magnesium sulphate added to 10 mg of bupivacaine and 25 µg of fentanyl. Analgesia duration, motor blockade scores, postoperative pain scores 6 and 12 hours after surgery, postoperative voiding time, and the incidence of hypotension, bradycardia, respiratory depression, and nausea and vomiting were recorded. Results Group M showed significantly longer analgesia duration (330.76 ± 80.98 minutes) than group F (280.98 ± 60.33 minutes). The pain scores in group M 6 hours (NRS: 2.44 ± 0.98) and 12 hours (NRS: 4.10 ± 0.88) after surgery were significantly lower than those of the other two groups. Before discharge from recovery, motor blockade scores and voiding time were not significantly different between the three groups. Hypotension (40%), bradycardia (25%), and nausea and vomiting (70%) were more obvious among group N patients. Respiratory depression did not occur in any patients. Conclusions The addition of 50 mg of magnesium sulfate to a bupivacaine–fentanyl solution for intrathecal anesthesia improved the efficacy and duration of the analgesia without any significant side effects. The addition of 150 µg of neostigmine increased the incidence of hypotension, bradycardia, and nausea and vomiting. Moreover, neostigmine failed to prolong analgesia duration.
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Affiliation(s)
- Mehrdad Mokaram Dori
- Department of Anesthesiology and Pain Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
- Corresponding author: Mehrdad Mokaram Dori, Department of Anesthesiology and Pain Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail:
| | - Farid Foruzin
- Department of Anesthesiology and Pain Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Epidural Neostigmine versus Fentanyl to Decrease Bupivacaine Use in Patient-controlled Epidural Analgesia during Labor: A Randomized, Double-blind, Controlled Study. Anesthesiology 2017; 127:50-57. [PMID: 28475555 DOI: 10.1097/aln.0000000000001669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The addition of opioids to epidural local anesthetic reduces local anesthetic consumption by 20% but at the expense of side effects and time spent for regulatory compliance paperwork. Epidural neostigmine also reduces local anesthetic use. The authors hypothesized that epidural bupivacaine with neostigmine would decrease total hourly bupivacaine use compared with epidural bupivacaine with fentanyl for patient-controlled epidural analgesia. METHODS A total of 215 American Society of Anesthesiologists physical status II, laboring parturients requesting labor epidural analgesia consented to the study and were randomized to receive 0.125% bupivacaine with the addition of either fentanyl (2 μg/ml) or neostigmine (2, 4, or 8 μg/ml). The primary outcome was total hourly local anesthetic consumption, defined as total patient-controlled epidural analgesia use and top-ups (expressed as milliliters of 0.125% bupivacaine) divided by the infusion duration. A priori analysis determined a group size of 35 was needed to have 80% power at α = 0.05 to detect a 20% difference in the primary outcome. RESULTS Of 215 subjects consented, 151 patients were evaluable. Demographics, maternal and fetal outcomes, and labor characteristics were similar among groups. Total hourly local anesthetic consumption did not differ among groups (P = 0.55). The total median hourly bupivacaine consumption in the fentanyl group was 16.0 ml/h compared with 15.3, 14.6, and 16.2 ml/h in the 2, 4, and 8 μg/ml neostigmine groups, respectively (P = 0.55). CONCLUSIONS The data do not support any difference in bupivacaine requirements for labor patient-controlled epidural analgesia whether patients receive epidural bupivacaine with 2 to 8 μg/ml neostigmine or epidural bupivacaine with 2 μg/ml fentanyl.
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Abstract
BACKGROUND Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review. OBJECTIVES The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies. SELECTION CRITERIA We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted outcome data. MAIN RESULTS We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16). AUTHORS' CONCLUSIONS Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.
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Affiliation(s)
- John Carlisle
- Torbay Hospital, South Devon Healthcare NHS Foundation TrustDepartment of AnaestheticsLawes BridgeTorquayDevonUKTQ2 7AA
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Lauretti GR. The evolution of spinal/epidural neostigmine in clinical application: Thoughts after two decades. Saudi J Anaesth 2015; 9:71-81. [PMID: 25558203 PMCID: PMC4279354 DOI: 10.4103/1658-354x.146319] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Since the first clinical application of analgesia following spinal anticholinesterase by 1940's, several clinical double-blind studies have been conducted to date, where intrathecal doses of neostigmine in humans ranged from 750 to 1 μg, due to side-effects. Conversely, epidural neostigmine has been evaluated in proportionally higher doses and represents an alternative, but still deserves more investigation concerning both acute and chronic pain, as it seems devoid of important side-effects.
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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, Ribeirão Preto, São Paulo, Brazil
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Derossi R, Módolo TJC, Maciel FB, Pagliosa RC. Efficacy of epidural lidocaine combined with tramadol or neostigmine on perineal analgesia in the horse. Equine Vet J 2012; 45:497-502. [DOI: 10.1111/j.2042-3306.2012.00654.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 08/19/2012] [Indexed: 11/26/2022]
Affiliation(s)
- R. Derossi
- Department of Veterinary Medicine; Surgery and Anaesthesiology; Faculty of Veterinary Medicine and Animal Science; Federal University of Mato Grosso do Sul; Campo Grande; Brazil
| | - T. J. C. Módolo
- Department of Veterinary Medicine; Federal University of Mato Grosso do Sul; Campo Grande; Brazil
| | - F. B. Maciel
- Department of Veterinary Medicine; Federal University of Mato Grosso do Sul; Campo Grande; Brazil
| | - R. C. Pagliosa
- Department of Veterinary Medicine; Federal University of Mato Grosso do Sul; Campo Grande; Brazil
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DeRossi R, Maciel FB, Módolo TJC, Pagliosa RC. Efficacy of concurrent epidural administration of neostigmine and lidocaine for perineal analgesia in geldings. Am J Vet Res 2012; 73:1356-62. [DOI: 10.2460/ajvr.73.9.1356] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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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Taheri R, Shayeghi S, Razavi SS, Sadeghi A, Ghabili K, Ghojazadeh M, Rouzrokh M. Efficacy of bupivacaine-neostigmine and bupivacaine-tramadol in caudal block in pediatric inguinal herniorrhaphy. Paediatr Anaesth 2010; 20:866-72. [PMID: 20716080 DOI: 10.1111/j.1460-9592.2010.03374.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Limited duration of analgesia is among the limitations of single caudal injection with local anesthetics. Therefore, the purpose of this study was to evaluate the effectiveness and safety of bupivacaine in combination with either neostigmine or tramadol for caudal block in children undergoing inguinal herniorrhaphy. METHODS In a double-blinded randomized trial, sixty children undergoing inguinal herniorrhaphy were enrolled to receive a caudal block with either 0.25% bupivacaine (1 ml x kg(-1)) with neostigmine (2 microg x kg(-1)) (group BN) or tramadol (1 mg x kg(-1)) (group BT). Hemodynamic variables, pain and sedation scores, additional analgesic requirements, and side effects were compared between two groups. RESULTS Duration of analgesia was longer in group BT (17.30 +/- 8.24 h) compared with group BN (13.98 +/- 10.03 h) (P = 0.03). Total consumption of rescue analgesic was significantly lower in group BT compared with group BN (P = 0.04). There were no significant differences in heart rate, mean arterial pressure, and oxygen saturation between groups. Adverse effects excluding the vomiting were not observed in any patients. CONCLUSION In conclusion, tramadol (1 mg x kg(-1)) compared with neostigmine (2 microg x kg(-1)) might provide both prolonged duration of analgesia and extended time to first analgesic in caudal block.
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Affiliation(s)
- Reza Taheri
- Department of Anesthesiology, Children's Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
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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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Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G. Postoperative pain. Paediatr Anaesth 2008; 18 Suppl 1:36-63. [PMID: 18471177 DOI: 10.1111/j.1460-9592.2008.02431.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Crellin D, Sullivan TP, Babl FE, O'Sullivan R, Hutchinson A. Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting. Paediatr Anaesth 2007; 17:720-33. [PMID: 17596217 DOI: 10.1111/j.1460-9592.2007.02218.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. METHODS We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). RESULTS Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. CONCLUSIONS There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.
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Affiliation(s)
- Dianne Crellin
- Department of Emergency, Royal Children's Hospital, Melbourne, Victoria, Australia
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Abstract
Neostigmine is a parasympathomimetic agent that has been recently investigated for use as an adjunct analgesic agent in the perioperative and peripartum period. A number of studies have investigated the intrathecal, epidural, caudal and intra-articular routes of administration of this agent, as well as the addition of neostigmine to local anaesthetics used for brachial plexus block and intravenous regional anaesthesia. While the intrathecal administration of neostigmine produced useful analgesic effects in the postoperative period in some studies, the high incidence of adverse events, mainly nausea and vomiting, limit the clinical usefulness of this route of administration. Several studies investigated the postoperative analgesic effects of epidural neostigmine using a number of different regimens. Overall, this route of administration appeared to improve postoperative analgesia in most studies without increasing the incidence of adverse events, and merits further research. Neuraxial administration of neostigmine appears to be safe in the obstetric population, with no reported adverse effects in the mother or fetus. While intrathecal administration is limited by a high incidence of nausea and vomiting in this patient population, the epidural route appears more promising and requires further investigation. The addition of neostigmine to caudal local anaesthetics was associated with improved postoperative analgesia in a number of studies. A dose of 2 microg/kg proved to be effective in several studies but was associated with an increased incidence of vomiting in some studies. Intra-articular administration of neostigmine 500microg produced a useful analgesic effect in the postoperative period in several studies and was not associated with an increase in the incidence of adverse effects. Studies investigating the efficacy of adding neostigmine to the local anaesthetics used for brachial plexus block and intravenous regional anaesthesia reported conflicting results. Further studies are required to determine the place of the administration of neostigmine by these routes.
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Affiliation(s)
- Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
BACKGROUND Drugs can prevent postoperative nausea and vomiting, but their relative efficacies and side effects have not been compared within one systematic review. OBJECTIVES The objective of this review was to assess the prevention of postoperative nausea and vomiting by drugs and the development of any side effects. SEARCH STRATEGY We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004), CINAHL (1982 to May 2004), AMED (1985 to May 2004), SIGLE (to May 2004), ISI WOS (to May 2004), LILAC (to May 2004) and INGENTA bibliographies. SELECTION CRITERIA We included randomized controlled trials that compared a drug with placebo or another drug, or compared doses or timing of administration, that reported postoperative nausea or vomiting as an outcome. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted outcome data. MAIN RESULTS We included 737 studies involving 103,237 people. Compared to placebo, eight drugs prevented postoperative nausea and vomiting: droperidol, metoclopramide, ondansetron, tropisetron, dolasetron, dexamethasone, cyclizine and granisetron. Publication bias makes evidence for differences among these drugs unreliable. The relative risks (RR) versus placebo varied between 0.60 and 0.80, depending upon the drug and outcome. Evidence for side effects was sparse: droperidol was sedative (RR 1.32) and headache was more common after ondansetron (RR 1.16). AUTHORS' CONCLUSIONS Either nausea or vomiting is reported to affect, at most, 80 out of 100 people after surgery. If all 100 of these people are given one of the listed drugs, about 28 would benefit and 72 would not. Nausea and vomiting are usually less common and, therefore, drugs are less useful. For 100 people, of whom 30 would vomit or feel sick after surgery if given placebo, 10 people would benefit from a drug and 90 would not. Between one to five patients out of every 100 people may experience a mild side effect, such as sedation or headache, when given an antiemetic drug. Collaborative research should focus on determining whether antiemetic drugs cause more severe, probably rare, side effects. Further comparison of the antiemetic effect of one drug versus another is not a research priority.
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Affiliation(s)
- J B Carlisle
- NHS, Department of Anaesthetics, Torbay Hospital, Lawes Bridge, Torquay, Devon, UK EX6 7LU.
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Almenrader N, Passariello M. Adjuncts to caudal blockade in children. Br J Anaesth 2006; 96:401; author reply 402. [PMID: 16467437 DOI: 10.1093/bja/aei639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE OF REVIEW Caudal epidural blockade remains the cornerstone of pediatric regional anesthesia. In this article we provide a comprehensive review of the recent developments in caudal anesthesia in infants and children. RECENT FINDINGS Research has focused on prolonging the duration of single-shot caudal blocks and accurately positioning continuous caudal catheters. New local anesthetics with similar potencies but less toxicity have been introduced. Opioids prolong the duration of analgesia of local anesthetic, but have also been associated with unacceptable side effects, particularly in pediatric outpatients. Various non-opioid adjuncts with more favorable side-effect profiles may increase the duration of analgesia. New ultrasound and nerve-stimulation techniques have been developed to accurately guide epidural catheters to a specific spinal level. SUMMARY The addition of ketamine or clonidine to a caudal local anesthetic prolong the duration of the block. However, a preservative-free preparation of ketamine that is suitable for neuraxial use is not widely available. Ultrasound imaging and electrical stimulation are promising options to accurately position a caudal needle. However, because ultrasound imaging is more difficult in older children, nerve stimulation is a more-suitable technique to accurately guide caudal catheters in this patient population. Although complications associated with caudal block are rare, the risks and benefits must be carefully considered on an individual basis.
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Affiliation(s)
- Ban C H Tsui
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Almenrader N, Passariello M, D'Amico G, Haiberger R, Pietropaoli P. Caudal additives for postoperative pain management in children: S(+)-ketamine and neostigmine. Paediatr Anaesth 2005; 15:143-7. [PMID: 15675932 DOI: 10.1111/j.1460-9592.2004.01396.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of the present pilot study was to compare the analgesic efficacy of S(+)-ketamine either alone or in combination with neostigmine for caudal blockade in pediatric surgery. METHODS A total of 40 children were randomly assigned to receive after induction of general anesthesia either caudal S(+)-ketamine 1 mg.kg(-1) (group K, n = 20) or caudal S (+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1) (group KN, n = 20). Anesthesia was maintained with sevoflurane and a laryngeal mask airway (LMA), no additional analgesics were administered. Postoperative pain and sedation were assessed by the Children's Hospital of Eastern Ontario Pain Score and Ramsay scale for 24 h. RESULTS No statistical difference in duration of analgesia and sedation was found. Mean duration of postoperative analgesia was 18 +/- 9.4 h in group K and 21.8 +/- 6.7 h in group KN. There was a significantly higher incidence of postoperative vomiting after administration of caudal ketamine with neostigmine (30% group KN Vs 0% group K; P < 0.05). CONCLUSIONS This pilot study demonstrates equianalgesic effects on postoperative pain relief in children with both caudal S(+)-ketamine 1 mg.kg(-1) and caudal S(+)-ketamine 0.5 mg.kg(-1) plus neostigmine 10 microg.kg(-1). Further studies are required to confirm adoption of caudal neostigmine into routine clinical practice.
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Affiliation(s)
- N Almenrader
- Department of Anesthesia and Intensive Care Medicine, University of Rome, La Sapienza, Rome, Italy.
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Passariello M, Almenrader N, Canneti A, Rubeo L, Haiberger R, Pietropaoli P. Caudal analgesia in children: S(+)-ketamine vs S(+)-ketamine plus clonidine. Paediatr Anaesth 2004; 14:851-5. [PMID: 15385014 DOI: 10.1111/j.1460-9592.2004.01306.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to evaluate postoperative analgesia provided by caudal S(+)-ketamine and S(+)-ketamine plus clonidine without local anesthetic. METHODS Forty-four children aged 1-5 years consecutively scheduled for inguinal hernia repair, hydrocele repair or orchidopexy were randomly assigned to receive a caudal injection of either S(+)-ketamine 1 mg x kg(-1) (group K) or S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) (group KC). Postoperative analgesia and sedation were evaluated by CHEOPS and Ramsay scale from emergence from general anesthesia for 24 h. RESULTS No statistical difference was observed between study groups with respect to pain and sedation assessment. A slight trend toward a reduced requirement for rescue analgesia in group KC was observed, although not statistically significant. CONCLUSIONS Caudal S(+)-ketamine 1 mg x kg(-1) and S(+)-ketamine 0.5 mg x kg(-1) plus clonidine 1 microg x kg(-1) are safe and provide effective postoperative analgesia in children without adverse effects.
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Affiliation(s)
- M Passariello
- Department of Anaesthesia and Intensive Care Medicine, Univerity of Rome La Sapienza, Rome, Italy.
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Abstract
PURPOSE OF REVIEW This review will focus on recently published data concerning side effects and complications of paediatric regional anaesthesia, putting into perspective the currently used techniques. RECENT FINDINGS Penile block is clearly a technique with a very large benefit and minimal side effects. Ilioinguinal nerve block, on the other hand, quite commonly leads to complications. Single-shot caudal anaesthesia is considered a safe and effective technique; however, even with this widely used block, complications such as sacral osteomyelitis can occur. Recent review articles have focussed on the role of additives for prolonging the duration of paediatric caudal anaesthesia. The use of ketamine or s-ketamine as an additive appears to be most promising for the future. SUMMARY Paediatric regional anaesthesia is now widely used for postoperative pain relief in children. However, a careful risk-benefit analysis is always mandatory before such medical interventions are undertaken.
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Affiliation(s)
- Martin Jöhr
- Paediatric Anaesthesia, Department of Anaesthesia, Kantonsspital, Luzern, Switzerland.
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