Caudal additives in children--solutions or problems?

Urethrocutaneous fistula and glans dehiscence formation of hypospadias surgery in patients receiving caudal block vs. non-caudal block: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the difference in postoperative complications as urethrocutaneous fistula or glans dehiscence, in children undergoing primary hypospadias repair with caudal block (CB) versus non-caudal block (NCB).

METHODS

Data were obtained from MEDLINE, Embase, Web of Science, and the Cochrane Library. Comparative studies of CB versus NCB were identified, with reports of complications published or presented until October 2022. Subgroup analyses were performed based on study type, meatal location (distal only), type of NCB, surgeon and technique, and concentration and dose of anesthetics.

RESULTS

Compared to the reference group of NCB, CB was not significantly associated with the development of complications following primary hypospadias repair (OR 1.40, 95 % CI 0.88-2.23). After adjusting for confounding factors, such as type of study(OR 1.51, 95%CI: 0.29-7.91), type of NCB[PB (OR 1.82, 95 % CI: 0.87-3.84), GA (OR 1.26, 95 % CI: 0.39-4.04)], meatal location (distal only) (OR 1.22, 95 % CI: 0.61-2.43), surgeon and technique (OR 1.37, 95 % CI: 0.59-3.14) and concentration and dose of anesthetics(OR 2.74, 95 % CI: 0.82-9.20), subgroup analyses revealed no significant association between CB and NCB (P > 0.05).

DISCUSSION

Previous studies have found a correlation between CB and increased incidence of postoperative complications (urethrocutaneous fistula or glans dehiscence) of hypospadias, but different literature have suggested that surgical technique, surgical duration and the severity of hypospadias, rather than CB, are closely related to the occurrence of complications. In order to reduce confounding factors, subgroup analyses were conducted. The results showed that no correlation could be found in postoperative complications and CB.

CONCLUSIONS

This meta-analysis compared the incidence of urethrocutaneous fistula or glans dehiscence in the CB and NCB groups for primary hypospadias repair in children, indicating that no clear correlation could be found in postoperative complications and CB. Subgroup analyses on study type, type of NCB, meatal location (distal only), surgeon and technique, and regional anesthetic concentration and dose supported this conclusion.

A Prospective Observational Study Analyzing the Analgesic Efficacy of Caudal Block and Nerve Stimulator-Guided Pudendal Nerve Block in Children Undergoing Hypospadias Repair

INTRODUCTION

Hypospadias repair is a common pediatric surgery. While caudal block (CB) is the most widely used procedure for analgesia, pudendal nerve block (PNB) can be utilized as an alternative. We evaluated the postoperative analgesic efficacy of CB and PNB in children undergoing hypospadias repair.

METHODS

In this prospective observational study, we evaluated 101 patients who received standard general anesthesia along with CB or PNB. Postoperative pain score (Face, Legs, Activity, Cry, and Consolability {FLACC} score) along with the total number of analgesic doses and the total amount of analgesic drugs consumed within 24 hours were noted. Time to first rescue analgesia, post-block penile length and midshaft circumference, surgeon satisfaction score, and postoperative complications were also evaluated.

RESULTS

Out of 101 patients observed, 50 received CB, and 51 received PNB. At 24-hour interval, the median FLACC score in CB was 6, while in the PNB, it was 4 (p<0.001). None of the patients who were given PNB received more than three doses (p<0.001), and the average consumption of analgesic drugs within 24 hours was significantly higher in CB (38.4±4.28) compared to PNB (21.7±6.33) (p<0.0001). The median time to first rescue analgesia in CB was four hours, while in patients receiving PNB, it was eight hours (p<0.001). The increase in penile volume was significantly higher with CB as compared to PNB (p<0.001). Surgeon satisfaction score was found to be better with PNB (p<0.002).

CONCLUSION

Patients who received PNB had significantly reduced pain scores and analgesic consumption in the first 24 hours post surgery.

Caudal block vs. transversus abdominis plane block for pediatric surgery: a systematic review and meta-analysis

Background

The caudal block and transversus abdominis plane block (TAP) are commonly used in combination with general anesthesia for pediatric lower abdominal, inguinal, and genitourinary surgeries. There is limited data directly comparing the impact of these techniques on recovery. In this meta-analysis, we compare the duration of postoperative analgesia between these two techniques.

Objective

This review examined the duration of analgesia in pediatric patients (age 0-18 years) undergoing surgery who received caudal or TAP block after induction of general anesthesia. The primary outcome was duration of analgesia, defined as the time to first rescue analgesic dose. Secondary outcomes included number of rescue analgesic doses, acetaminophen usage within 24 h postoperatively, 24 h pain score area under the curve, and postoperative nausea and vomiting.

Evidence review

We systematically searched Pubmed, Central, EMBASE, CINAHL, Google Scholar, Web of Science citation index, the US clinical trials register, and abstracts from prominent 2020-2022 anesthesia conferences for randomized controlled trials that compared these blocks and reported analgesia duration.

Findings

Twelve RCTs inclusive of 825 patients were identified. TAP block was associated with longer analgesia duration (Mean difference = 1.76 h, 95% CI: 0.70-2.81, p = 0.001) and reduced doses of rescue analgesic within 24 h (Mean difference = 0.50 doses, 95% CI: 0.02-0.98, p = 0.04). No statistically significant differences were detected in other outcomes.

Conclusion

This meta-analysis suggests that TAP block provides greater duration of analgesia than caudal block after pediatric surgeries. TAP block was also associated with fewer rescue analgesic doses in the first 24 h without increased pain scores.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=380876, identifier: CRD42022380876.

Cardiovascular Effects of Adding Epinephrine to Bupivacaine in Children Undergoing Caudal Block: A Double-blind Randomized Clinical Trial

Background: Caudal block is a common, safe, and effective anesthetic technique for lower abdominal, urological, and lower extremity surgeries in pediatrics. Objectives: This study aimed to evaluate the cardiovascular effects of adjuvant epinephrine in the caudal block on heart rate and blood pressure changes in children. Methods: This double-blind, randomized clinical trial was performed on 60 children who underwent elective infra-umbilical surgeries. They were under general anesthesia with midazolam, fentanyl, lidocaine, and propofol. The patients were ventilated through laryngeal mask airway (LMA), and anesthesia was maintained with sevoflurane in O2 and N2O mixture. The intervention group received a caudal block with 0.2% bupivacaine and 1/200000 epinephrine (1 mL/kg), while the control group received a caudal block without epinephrine. Heart rate, blood pressure, and ECG were monitored before the block and in the first, fifth, and 20th minutes after surgery. Results: The two groups showed no statistically significant differences in demographics and systolic and diastolic blood pressures. However, sinus arrhythmia was more prevalent in the study group in the first minute after the block (P < 0.001). No differences were observed in the incidence of arrhythmia in the fifth and 20th minutes after the block. Conclusions: It appears that epinephrine as an adjuvant to the caudal block does not have long-lasting effects after the block, except sinus tachycardia in the first minute. Considering that no changes in blood pressure and other hemodynamic parameters were observed, it seems that epinephrine can be used safely in the caudal block in pediatric patients.

Effect of Combined Epidural Morphine and Midazolam on Postoperative Pain in Patients Undergoing Major Abdominal Cancer Surgery

OBJECTIVE

The objective was to compare analgesic effect of combined epidural morphine-midazolam with either drug alone on postoperative pain in patients undergoing major abdominal cancer surgery.

MATERIALS AND METHODS

Eighty-four patients were allocated in prospective randomized double-blind study to receive epidural analgesia. Patients received 5 mg morphine in morphine (Mor) group, 5 mg midazolam in midazolam (Mid) group, 5 mg morphine + 5 mg midazolam in morphine-midazolam (MM) group, 0.25% bupivacaine was added to injected solution with same volume in all groups. All groups were compared with time of first analgesic request, total analgesic consumption, number of epidural doses, postoperative Visual Analog Scale score, and adverse events.

RESULTS

Time of first analgesic request was 4 to 8 hours in Mid versus 12 to 23 and 14 to 24 hours in Mor and MM groups, respectively, with significant difference between Mid versus Mor ( P <0.001), Mid versus MM ( P <0.001), and Mor versus MM groups ( P <0.031). Analgesic consumption was more in Mid than Mor and MM groups, with significant difference between Mid versus Mor ( P <0.008), Mid versus MM ( P <0.001), with no significant difference between Mor and MM groups ( P <0.6). The number of epidural doses in Mid was 1 to 3 versus 1 to 3, and 1 to 2 in Mor and MM groups, respectively, with significant difference between Mid versus Mor ( P <0.025), Mid versus MM ( P <0.004), with no significant difference between Mor and MM groups ( P =1.0).

CONCLUSIONS

Addition of midazolam to epidural morphine prolonged time of first analgesic request and decreased total analgesic consumption.

Addition of Clonidine or Dexmedetomidine With Bupivacaine to Prolong Caudal Analgesia in Children Undergoing Infraumbilical Surgery

Introduction

Clonidine, a selective α2 adrenergic receptor agonist, combined with caudally administered bupivacaine, is frequently used in children to prolong the duration of postoperative analgesia following infraumbilical surgery. On the other hand, dexmedetomidine is highly selective and has a greater affinity toward α2 adrenergic receptors, especially toward its α2a subtype, accountable for more analgesic and hypnotic effects than clonidine.

Aims and objectives

We designed a prospective, double-blinded, randomized controlled trial to compare the analgesic efficacy and adverse effects of clonidine and dexmedetomidine when combined with bupivacaine for caudal analgesia in children undergoing infraumbilical surgeries.

Materials and methods

A total of 60 children aged one to eight years were randomly assigned into two different groups in a double-blinded manner. Following induction of general anesthesia, every patient received a single dose of caudal bupivacaine 0.25% (0.75 ml/kg) mixed with either clonidine (1 µ/kg) in normal saline or dexmedetomidine (1 µ/kg) in normal saline. We noted the hemodynamic variables and postoperative sedation scores. Duration and quality of postoperative analgesia and the number of rescue analgesic drug doses required were recorded during the first 24 hours postoperatively. We also observed the patients for any adverse effects to the study drugs.

Result

Adding dexmedetomidine to caudally administered bupivacaine significantly increased the duration of analgesia (15 ± 0.78 hours) and decreased the need for rescue drug doses than the addition of clonidine to bupivacaine (9.63 ± 1.95 hours) in children undergoing infraumbilical surgeries. Incidences of hemodynamic changes or other side effects were comparable between patients of two groups.

Conclusion

The addition of dexmedetomidine to caudally administered bupivacaine in children undergoing infraumbilical surgeries may provide a longer duration of analgesia than the addition of clonidine, with less requirement of rescue analgesic doses and without any significant differences in the hemodynamic parameters or other side effects.

The Assessment of Prolonged Inferior Alveolar Nerve Blockade for Postoperative Analgesia in Mandibular Third Molar Surgery by a Perineural Addition of Dexamethasone to 0.5% Ropivacaine: A Randomized Comparison Study

Background: Perineurally adding dexamethasone to local anesthetics could enable postoperative analgesia. Our aim was to investigate the efficacy of 4 mg dexamethasone and 0.5% ropivacaine on the prolonged duration of mandibular anesthesia for postoperative analgesia during third molar surgery. Materials and method: The patients of both sexes, and in the age range of 17 to 50 yrs of age, received the Gow-Gates anesthesia. Group I received 4 mL of plain 0.5% ropivacaine, with perineurally added 1 mL/4 mg of dexamethasone; group II received 4 mL of plain 0.5% ropivacaine with perineurally added 1 mL of 0.9% saline; group III received 4 mL of plain 0.5 bupivacaine with perineurally added 1 mL of 0.9% saline. The prime anesthesia outcome was the duration of conduction anesthesia (DCA); the secondary outcome was the duration of analgesia (DAN) and analgesia before analgesic intake. Results: In 45 randomly selected subjects (mean age 27.06 ± 8.20), DCA was statistically longest in group I (n = 15) (592.50 ± 161.75 min, p = 0.001), collated with groups II (n = 15) and III (n = 15) (307.40 ± 84.71 and 367.07 ± 170.52 min, respectively). DAN was significantly the longest in group I (mean: 654.9 ± 198.4 min, p = 0.001), compared with group II (345.4 ± 88.0 min) and group III (413.7 ± 152.3 min), with insignificant adverse reactions. One-third of the operated patients absented from the use of analgesics. Conclusion: A amount 0.5% ropivacaine with dexamethasone usefully served as an analgesic with a success rate of 93.4% of the given anesthesia.

Comparison of analgesic efficacy of caudal dexmedetomidine versus caudal tramadol with bupivacaine 0.25% in pediatric infra-umbilical surgeries

Introduction: Postoperative analgesia is very important parameter for overall management of pediatric patients. Aims: To compare the analgesic efficacy of caudal dexmedetomidine versus caudal tramadol with bupivacaine 0.25 % in paediatric Infra-umbilical surgeries. Objectives: To study hemodynamic changes. The duration of post-operative analgesia and to compare motor block and post-operative sedation in both groups, as well as the side effects associated with analgesia in both the groups. Methods: The study was carried out in 60 patients of either sex belonging to ASA Grade-I/II between age group of 1 to 8 years undergoing infra umbilical surgeries. After taking written informed consent from all the patient's care taker, pre-anaesthetic evaluation was carried out and procedure was explained to patient's care taker. Patients were randomly devided into 2 groups. Group BT: Patient received 1 ml/kg 0.25% bupivacaine with tram-adol 1 mg/kg. Group BD: Patient received 1 ml/kg 0.25% bupivacaine with dexmedetomidine 1 µg/kg. Our method of anaesthesia was G. A. with caudal block. Postoperative analgesia was assessed by FLACC score for 24 hours and If FLACC ≥ 4, Paracetamol suppository (15 mg/kg) was given as rescue analgesia. Post-operative sedation was assessed by Ramsay sedation score up to 6 hr postoperatively. Postoperatively, all the patients were monitored for any complications like Nausea, Vomiting, Shivering, Bradaycardia, Hy-potension and Respiratory depression. Results: Patients were comparable in both the groups regarding age, weight, sex distribution (P > 0.05). Mean duration of surgery in group BT was 55.3 ± 9.6 mins, in group BD was 56.7 ±12.8 mins. There was no statistically significant difference in the duration of surgery between the two groups on intergroup comparison (p > 0.05). There was no statistically significant difference in mean heart rate, mean arterial pressure and mean oxygen saturation between the groups on intergroup comparison intraoperatively and postoperatively (p > 0.05). Ramsay Sedation score was 2.0 ± 0.4 at 1 hr posto-operatively in Group BT patients. So, after 1 hr of surgery, patients of BT group remained anxious, restless and agitated. While in group BD, Sedation score was 2.0 ± 0.3 at 6 hr postoperatively. Thus all patients remained cooperative , oriented and tranquil up to 6 hr post-operatively. Group BD had significant sedation compared to Group BT for 6 hrs postoperatively (p < 0.05). We observed significant difference between the groups in terms of FLACC score. Group BT patients achieved statistically significantly higher FLACC score compared with Group BD.(P < 0.05). The mean duration of analgesia was 6.9 ± 1.2 hr in Group BT, 13.2 ± 2.8 hr in Group RD (p < 0.05). There was a statistically significant prolongation in the duration of analgesia in Group BD (p < 0.05). In present study, incidence of nausea and vomiting occurred in 5 (16.7%) of patients in Group BT and 3 (6.7%) in Group BD. None of the patients had Shivering, Brady-cardia, Hypotension, Respiratory depression, Neurological sequale in both the groups.

Sub-anesthetic intravenous ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgeries: a non-inferiority randomized single-blind controlled trial

Background

Sub-anesthetic iv ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain. Primary aim of this study was to evaluate the non-inferiority of sub-anesthetic iv ketamine vs caudal bupivacaine for postoperative analgesia in children.

Methods

Children below six years were enrolled in this single-blind study and randomized to receive either sub-anesthetic iv ketamine (0.3 mg/kg) or 1 ml/kg of caudal 0.125% bupivacaine, along with general anesthesia. Postoperative pain was assessed with the FLACC scale at 30 minutes, and at one, two, three, and six hours. Intra and postoperative opioid consumption, time to extubation, postoperative vomiting (POV), postoperative agitation, sedation, and inflammatory markers (serum IL-6 and TNF-α) were also assessed.

Results

One hundred and forty-one children completed the study, 71 in the ketamine and 70 in the caudal group. The cumulative proportion of children without significant postoperative pain (FLACC score < 4) until six hours post-surgery was 45.1% in the ketamine group vs 72.9% in the caudal group (P < 0.001). More children required an additional dose of intraoperative fentanyl (33.8% vs 5.7%; P < 0.001) and postoperative tramadol (54.9% vs. 27.1%; P < 0.001) in the ketamine group. Postoperative agitation, (4.3% vs. 9.9%; P = 0.19) and sedation (32.8% vs 22.5%; P = 0.17) were similar in the groups. Time to extubation, POV, baseline and post-surgical inflammatory markers were comparable.

Conclusions

Sub-anesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children below six years undergoing infra-umbilical surgeries but results in similar postoperative outcomes.

Clonidine as an Additive to Local Anesthetics in Caudal Block for Postoperative Analgesia in Pediatric Surgery: A Systematic Review and Meta-Analysis

Background: Clonidine is an anesthetic with favorable efficacy and safety profiles for caudal epidural block, but comparisons with other adjuvants need to be confirmed in pediatric patients. Aim: To investigate the effects of clonidine as an adjuvant in caudal epidural block to improve the intraoperative and postoperative analgesia in pediatric surgery. Methods: PubMed, Embase, and the Cochrane Library were searched for available papers published up to February 2021. The outcomes were pain score, duration of analgesia, complications, and number of analgesic requirements. The meta-analysis was performed using random-effects models. Results: Fifteen randomized controlled trials (RCTs) were included. There were no differences between clonidine and the control drug regarding the duration of analgesia (SMD = -0.71, 95%CI: -1.64, 0.23; I ² = 95.5%, P_{heterogeneity} < 0.001), pain score (SMD = 0.35, 95%CI: -0.28, 0.98; I ² = 80.8%, P_{heterogeneity} < 0.001), and requirement for additional analgesia (OR = 8.77, 95%CI: 0.70, 110.58, I ² = 81.9%, P_{heterogeneity} = 0.004), but using clonidine resulted in fewer complications than the control drugs (OR = 0.33, 95%CI: 0.20, 0.54, I ² = 21.8%, P_{heterogeneity} = 0.217). The sensitivity analysis showed that the results were robust. A publication bias was observed. Conclusion: Clonidine has the same efficacy as the other adjuvants for caudal epidural block for pediatric surgery but fewer complications. These results support clonidine as an adjuvant to local anesthetic, but additional studies should be conducted.

Day-case open reduction for developmental dysplasia of the hip

Aims

Open reduction in developmental dysplasia of the hip (DDH) is regularly performed despite screening programmes, due to failure of treatment or late presentation. A protocol for open reduction of DDH has been refined through collaboration between surgical, anaesthetic, and nursing teams to allow same day discharge. The objective of this study was to determine the safety and feasibility of performing open reduction of DDH as a day case.

Methods

A prospectively collected departmental database was visited. All consecutive surgical cases of DDH between June 2015 and March 2020 were collected. Closed reductions, bilateral cases, cases requiring corrective osteotomy, and children with comorbidities were excluded. Data collected included demographics, safety outcome measures (blood loss, complications, readmission, reduction confirmation), and feasibility for discharge according to the Face Legs Activity Cry Consolidability (FLACC) pain scale. A satisfaction questionnaire was filled by the carers. Descriptive statistics were used for analysis.

Results

Out of 168 consecutive DDH cases, 16 patients fit the inclusion criteria (age range 10 to 26 months, 13 female). Intraoperative blood loss ranged from "minimal" to 120 ml, and there were no complications or readmissions. The FLACC score was 0 for all patients. The carers satisfaction questionnaire expressed high satisfaction from the experience with adequate information and support provided.

Conclusion

Open reduction in DDH, without corrective osteotomy, is safe and feasible to be managed as a day case procedure. It requires a clear treatment pathway, analgesia, sufficient counselling, and communication with carers. It is even more important during the COVID-19 pandemic when reduced length of hospital stay is likely to be safer for both patient and their parents.

Cite this article: Bone Joint Open 2021;2(4):271–277.

Safety and efficacy of dexamethasone as an adjuvant to bupivacaine in bilateral transversus abdominis plane block in children undergoing major abdominal surgery

Background

This prospective randomized controlled double-blind clinical study was conducted on 52 patients of both genders divided into two groups (26 patients each). Local anaesthetic solution of isobaric bupivacaine 0.25% (0.3 ml/kg) was prepared. Group A received bilateral transversus abdominis plane (TAP) block with bupivacaine and dexamethasone (0.3 mg/kg) while group B received bilateral TAP block with bupivacaine and volume of saline equal to the amount of dexamethasone given in group A. Patients were observed for FLACC pain scale at the time of discharge from the post-anaesthesia care unit and then every 2 h for 36 h after the operation. This study was conducted to assess the safety and efficacy of adding dexamethasone to bupivacaine on the quality of bilateral US-guided transversus abdominis plane (TAP) block in children undergoing major abdominal surgery

Results

Dexamethasone added to local anaesthetic in ultrasound-guided TAP block significantly decreased FLACC score at 8, 10, and 12 up to 24 h postoperatively, The time to the first requested analgesia was prolonged in the dexamethasone group (P = 0.000). The total dose of acetaminophen consumption over 36 h after surgery was also reduced (P = 0.000), but no difference was found regarding the total dose of rectal diclofenac (P = 0.068).

Conclusion

Adding dexamethasone to isobaric bupivacaine TAP block reduces postoperative pain and analgesic requirements compared to isobaric bupivacaine TAP block alone in children undergoing major abdominal surgery.

Safety and efficacy of dexamethasone as an adjuvant to bupivacaine in bilateral transversus abdominis plane block in children undergoing major abdominal surgery

Background

This prospective randomized controlled double-blind clinical study was conducted on 52 patients of both genders divided into two groups (26 patients each). Local anaesthetic solution of isobaric bupivacaine 0.25% (0.3 ml/kg) was prepared. Group A received bilateral transversus abdominis plane (TAP) block with bupivacaine and dexamethasone (0.3 mg/kg) while group B received bilateral TAP block with bupivacaine and volume of saline equal to the amount of dexamethasone given in group A. Patients were observed for FLACC pain scale at the time of discharge from the post-anaesthesia care unit and then every 2 h for 36 h after the operation. This study was conducted to assess the safety and efficacy of adding dexamethasone to bupivacaine on the quality of bilateral US-guided transversus abdominis plane (TAP) block in children undergoing major abdominal surgery

Results

Dexamethasone added to local anaesthetic in ultrasound-guided TAP block significantly decreased FLACC score at 8, 10, and 12 up to 24 h postoperatively, The time to the first requested analgesia was prolonged in the dexamethasone group (P = 0.000). The total dose of acetaminophen consumption over 36 h after surgery was also reduced (P = 0.000), but no difference was found regarding the total dose of rectal diclofenac (P = 0.068).

Conclusion

Adding dexamethasone to isobaric bupivacaine TAP block reduces postoperative pain and analgesic requirements compared to isobaric bupivacaine TAP block alone in children undergoing major abdominal surgery.

Combination of clonidine–bupivacaine in caudal epidural anesthesia for hypospadias surgery in children: prospective, randomized, blind study

Background and objectives

The combination of clonidine with local anesthetic administered for epidural anesthesia via caudal route seems to improve the quality of postoperative analgesia, but with conflicting results. This study compared the postoperative analgesia of three different doses of clonidine combined with bupivacaine in caudal epidural anesthesia in children undergoing hypospadias repair.

Methods

Eighty children aged 1–10 years, candidates for surgical repair of hypospadias, were randomly divided into four groups of 20 patients to receive general anesthesia combined with caudal epidural anesthesia with bupivacaine 0.165% alone or in combination with 1, 2 or 3 μg.kg⁻¹ of clonidine. The primary outcome was morphine consumption in the first 24 h postoperatively. Mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, time to awakening, pain severity (FLACC scale), level of sedation (RAMSAY), duration of analgesia, and occurrence of adverse effects were also compared.

Results

Intraoperatively, there was no difference between groups regarding mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, and time to awakening. Postoperative morphine consumption and pain severity were similar between groups, but the group receiving clonidine (3 μg.kg⁻¹) had lower heart rate and higher sedation level than the group receiving bupivacaine alone.

Conclusions

The combination of clonidine at doses of 1, 2 or 3 μg.kg⁻¹ with bupivacaine 0.16% via caudal epidural route did not alter the consumption of morphine in the early postoperative period of children undergoing hypospadias repair.

[Combination of clonidine-bupivacaine in caudal epidural anesthesia for hypospadias surgery in children: prospective, randomized, blind study]

BACKGROUND AND OBJECTIVES

The combination of clonidine with local anesthetic administered for epidural anesthesia via caudal route seems to improve the quality of postoperative analgesia, but with conflicting results. This study compared the postoperative analgesia of three different doses of clonidine combined with bupivacaine in caudal epidural anesthesia in children undergoing hypospadias repair.

METHODS

Eighty children aged 1 to 10 years, candidates for surgical repair of hypospadias, were randomly divided into four groups of 20 patients to receive general anesthesia combined with caudal epidural anesthesia with bupivacaine 0.165% alone or in combination with 1, 2 or 3μg.kg^-1 of clonidine. The primary outcome was morphine consumption in the first 24hours postoperatively. Mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, time to awakening, pain severity (FLACC scale), level of sedation (RAMSAY), duration of analgesia, and occurrence of adverse effects were also compared.

RESULTS

Intraoperatively, there was no difference between groups regarding mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, and time to awakening. Postoperative morphine consumption and pain severity were similar between groups, but the group receiving clonidine (3μg.kg^-1) had lower heart rate and higher sedation level than the group receiving bupivacaine alone.

CONCLUSIONS

The combination of clonidine at doses of 1, 2 or 3μg.kg^-1 with bupivacaine 0.16% via caudal epidural route did not alter the consumption of morphine in the early postoperative period of children undergoing hypospadias repair.

The impact of caudally administrated tramadol on immune response and analgesic efficacy for pediatric patients: a comparative randomized clinical trial

Background

Immune responses appear to be affected by anesthetics and analgesics. We investigated the effects of caudal tramadol on the postoperative immune response and pain management in pediatric patients.

Methods

Sixty ASA-I pediatric patients aged 3–10 years undergoing lower abdominal surgery. Patients were randomly assigned either to a caudal bupivacaine (0.25%) group (group B), or a group that received caudal tramadol (1 mg/kg) added to the bupivacaine (0.25%) (group T). Both were diluted in a 0.9% NaCl solution to a total volume of 1ml/kg. The systemic immune response was measured by collecting blood samples preoperatively, at the end of anesthesia, and at 24 and 72 hours postoperatively, and studied for interleukin IL-6, C-reactive proteins (CRP) cortisol levels, and leucocytes with its differential count. Postoperative pain was assessed along with sedation scales.

Results

Postoperative production of IL-6 was significantly higher in group B at the end of anesthesia, than at the 24^th hour, and at the 72^nd hour in group B and group T, respectively. The immune response showed leukocytosis with increased percentages of neutrophil and monocytes, and a decreased lymphocyte response rate within both groups with no significant differences between the groups. Cortisol and CRP were significantly higher in group B.

Conclusions

Adding tramadol to a caudal bupivacaine block can attenuate the pro-inflammatory cytokine response, Cortisol, and CRP in children undergoing lower abdominal surgery.

Comparison of Analgesic Efficacy of Caudal Dexamethasone with Intravenous Dexamethasone as an Adjuvant to Caudal Block in Pediatric Patients Undergoing Urogenital Surgeries

Context:

Caudal block is one of the most common regional anesthetic techniques employed in pediatric urogenital surgeries. Adjuvants play an important role to improve postoperative analgesia.

Aims:

The aim of this study was to evaluate the analgesic effect of dexamethasone when given systemically as against caudally as an adjuvant to caudal block.

Subjects and Methods:

In this randomized controlled study, sixty American Society of Anesthesiologists Physical Status I and II patients aged 3–6 years were randomly allocated into two groups of thirty each. Group D received caudal block with local anesthetic solution and 0.1 mg/kg injection dexamethasone. Group I received a caudal block with local anesthetic solution. They received intravenous injection dexamethasone 0.1 mg/kg after the block. Both the groups were compared for the duration of postoperative analgesia and analgesic requirement.

Statistical Analysis Used:

Statistical analysis was done with unpaired t-test and Chi-square test as was appropriate.

Results:

Group D showed a significant prolongation of postoperative analgesia (626.33 ± 59.39 min) as compared to Group I (194.67 ± 27.76 min). Similarly, requirement of analgesic was reduced on 1^st postoperative day in group receiving caudal dexamethasone.

Conclusions:

Dexamethasone significantly prolongs the duration of postoperative analgesia of a caudal block when given caudally than when given intravenously.

Comparison of caudal ropivacaine-morphine and paravertebral catheter for major upper abdominal surgery in infants

BACKGROUND

The caudal epidural block is one of the most commonly used regional anesthetic techniques in children. Administration of morphine via caudal injection enables analgesia, even for upper abdominal surgery. The thoracic paravertebral block has also been successfully used to treat perioperative pain during upper abdominal procedures in pediatric patients.

AIM

In the current study, we compared the two regional techniques for upper abdominal surgery in infants to determine whether one of them was preferable to the other.

METHODS

Consecutive patients under 12 months of age who underwent upper abdominal surgery were retrospectively divided according to the chosen postoperative analgesia: Group C, caudal ropivacaine-morphine; Group P, paravertebral catheter. We analyzed the following outcomes: requirement for additional analgesics, pain scores, need for mechanical ventilation and oxygen dosage, postoperative blood pressure and heart rate, time to pass first stool, time until first full meal, and complications.

RESULTS

Twenty-one consecutive patients were included: 10 in Group C and 11 in Group P. Median age at surgery was 80 (47.5-270.0) and 84.5 (34.3-287.5) days, respectively. No difference was found between the two groups in requirement for additional analgesics at 24 h after surgery (median 1 in Group C vs 1 in Group P, P = 0.288, 95% CI: -2 to 1). BOPS pain scores were only lower in Group P when compared to Group C at 24 h after surgery (median 1 vs 2, P = 0.041, 95% CI: -2 to 0). None of the patients had perioperative complications.

CONCLUSIONS

In this small series, there was no significant difference between caudal ropivacaine-morphine and paravertebral catheter for postoperative care in infants undergoing upper abdominal surgery. Further prospective studies are needed to compare the efficacy and incidence of complications of caudal block and paravertebral catheter for postoperative analgesia.

Pudendal Versus Caudal Block in Children Undergoing Hypospadias Surgery: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Postoperative pain management after hypospadias surgery is often challenging. Caudal block is used for analgesia but has limitations. This study compares the analgesic efficiency of pudendal block with that of caudal block in pediatric patients undergoing hypospadias repair surgery.

METHODS

This prospective, double-blind, randomized, controlled study enrolled 84 patients receiving pudendal block or caudal block before hypospadias surgery. In the pudendal group, the pudendal nerve was identified using a nerve stimulator, and the block consisted of 0.25% bupivacaine 0.5 mL/kg. In the caudal group, the caudal block used 0.2% bupivacaine 1 mL/kg. Our primary outcome was pain intensity within 24 hours postoperatively. The trial was registered at ClinicalTrials.gov (number: NCT02390388).

RESULTS

For the primary outcome, patients in the pudendal group had lower postoperative pain intensity when compared with the caudal group (P < 0.001). Three patients in the pudendal group and all of the patients in the caudal group needed additional analgesia within 24 hours after the surgery (P < 0.001). The family satisfaction rate was significantly higher in the pudendal group (P < 0.001).

CONCLUSIONS

For the pudendal group, the pain scores for the first 24 hours after the surgery were significantly lower and the duration of analgesia was longer.

Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery?

BACKGROUND

Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations.

OBJECTIVE

The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block.

STUDY DESIGN

A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis).

RESULTS

Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure).

DISCUSSION

Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias.

CONCLUSION

The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.

Nonopioid (Dexmedetomidine, Dexamethasone, Magnesium) Adjuvant to Ropivacaine Caudal Anesthesia in Pediatric Patients Undergoing Infraumbilical Surgeries: A Comparative Study

Background:

Desirable adjuvants to caudal ropivacaine are the one which prolongs analgesia and free of side effects. We compared nonopioid drugs dexmedetomidine, dexamethasone, and magnesium as adjuvants to ropivacaine caudal analgesia in pediatric patients undergoing infraumbilical surgeries.

Materials and Methods:

This study was done on 128 pediatric patients (3–12-year olds) undergoing infraumbilical surgeries; they were randomly allocated to four groups to receive normal saline, dexmedetomidine 1 μg/kg, dexamethasone 0.1 mg/kg, and magnesium sulfate 50 mg with injection ropivacaine 0.2% in the dose 0.5 ml/kg caudally. Modified Objective Pain Score and Ramsay Sedation Score, duration of analgesia, hemodynamic changes, and side effects were assessed. ANOVA test was used for numerical values as data were expressed in mean and standard deviation. Kruskal–Wallis test was used for postoperative pain and sedation score as data were expressed as median and range.

Results:

The demographic data and hemodynamics were comparable. There was a significant prolongation of duration of analgesia in all study groups, dexmedetomidine (406.2 ± 45.5 min), dexamethasone (450.0 ± 72.6 min), and magnesium (325.0 ± 45.8 min) as compared to ropivacaine (285.9 ± 52.7 min) group. None of the adjuvants resulted in either excess or prolonged sedation. No side effects were encountered.

Conclusion:

The adjuvants dexmedetomidine, dexamethasone, and magnesium added to ropivacaine prolong caudal analgesic duration without any sedation or side effect.

Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally

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.

Dexmedetomidine as an adjuvant to bupivacaine in caudal analgesia in children

Context:

Postoperative pain management is becoming an integral part of anesthesia care. Various techniques of pediatric pain relief have been designed among which the most commonly practiced is caudal epidural block. Several adjuvants have been used to prolong the duration of caudal analgesia such as clonidine, neostigmine, ketamine, opioids, and ephedrine. We have designed the study using dexmedetomidine as an adjuvant to assess analgesic efficacy, duration of postoperative analgesia, hemodynamic stability, postoperative sedation, and any adverse effects in children.

Aims:

The aim is to study the effects of dexmedetomidine as an adjuvant to bupivacaine in caudal analgesia in pediatric patients posted for infraumbilical surgeries.

Settings and Design:

This is a randomized, double-blind study in which effect of dexmedetomidine is studied when added to bupivacaine in the caudal epidural block. The observations are made intraoperatively for hemodynamic stability and postoperatively for the duration of analgesia.

Subjects and Methods:

This study was conducted in 100 children of American Society of Anesthesiologists physical status I and II, aged 2–10 years, undergoing elective infraumbilical surgeries. They were divided into two groups as follows: Group A: (0.25%) bupivacaine 1 ml/kg + normal saline (NS) 1 ml. Group B: (0.25%) bupivacaine 1 ml/kg + 1 μg/kg dexmedetomidine in 1 ml NS. As this study was double-blind, patients were randomly assigned to receive either (bupivacaine + saline) or (bupivacaine + dexmedetomidine) in each group. The patients were observed for hemodynamic stability, respiratory depression, and postoperative pain using face, legs, activity, cry, consolability (FLACC) pain scale for 24 h postoperatively.

Statistical Analysis Used:

Unpaired Student's t-test.

Results:

The mean duration of effective analgesia in Group A patients was 4.33 ± 0.98 h versus 9.88 ± 0.90 h in Group B patients. Likewise, the difference in mean FLACC score of both the groups was also statistically significant, 7.21 ± 0.76 and 6.49 ± 1.72 in Group A and Group B, respectively.

Conclusion:

Dexmedetomidine as adjuvant to Bupivacaine increases duration of caudal analgesia and improves hemodynamic stability without an increase in adverse effects in children undergoing infraumbilical surgeries.

Evaluation of caudal dexamethasone with ropivacaine for post-operative analgesia in paediatric herniotomies: A randomised controlled study

Background and Aims:

Caudal analgesia is one of the most popular regional blocks in paediatric patients undergoing infra-umbilical surgeries but with the drawback of short duration of action after single shot local anaesthetic injection. We evaluated whether caudal dexamethasone 0.1 mg/kg as an adjuvant to the ropivacaine improved analgesic efficacy after paediatric herniotomies.

Methods:

Totally 128 patients of 1–5 years age group, American Society of Anaesthesiologists physical status I and II undergoing elective inguinal herniotomy were randomly allocated to two groups in double-blind manner. Group A received 1 ml/kg of 0.2% ropivacaine caudally and Group B received 1 ml/kg of 0.2% ropivacaine, in which 0.1 mg/kg dexamethasone was added for caudal analgesia. Post operative pain by faces, legs, activity, cry and consolability tool score, rescue analgesic requirement and adverse effects were noted for 24 h.

Results:

Results were statistically analysed using Student's t-test. Pain scores measured at 1, 2, 4, and 6 h post-operative, were lower in Group B as compared to Group A. Mean duration of analgesia in Group A was 248.4 ± 54.1 min and in Group B was 478.046 ± 104.57 min with P = 0.001. Rescue analgesic requirement was more in Group A as compared to Group B. Adverse effects after surgery were comparable between the two groups.

Conclusion:

Caudal dexamethasone added to ropivacaine is a good alternative to prolong post-operative analgesia with less pain score compared to caudal ropivacaine alone.

Efficacy of dexmedetomidine as an adjuvant to ropivacaine in pediatric caudal epidural block

Context:

Caudal analgesia is a reliable and an easy method to provide intraoperative and postoperative analgesia for infraumbilical surgeries in pediatric population but with the disadvantage of short duration of action after single injection. Many additives were used in combination with local anesthetics in the caudal block to prolong the postoperative analgesia.

Aim:

We compared the analgesic effects and side effects of dexmedetomidine added to ropivacaine in pediatric patients undergoing lower abdominal surgeries.

Settings and Design:

Double-blinded randomized controlled trial.

Materials and Methods:

Sixty patients (2-10 years) were evenly and randomly assigned into two groups in a double-blinded manner. After sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.25% (1 ml/kg) combined with either dexmedetomidine 2 μg/kg in normal saline 0.5 ml, or corresponding volume of normal saline according to group assignment. Hemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, requirement of additional analgesic, sedation, and side effects were assessed during the first 24 h.

Results:

The duration of postoperative analgesia was significantly longer (P = 0.001) and total consumption of rescue analgesic was significantly lower in Group RD compared with Group R (P < 0.05). Group RD have better quality of sleep and prolonged duration of sedation (P = 0.001). No significant difference was observed in the incidence of hemodynamic changes or side effects.

Conclusion:

Addition of dexmedetomidine to caudal ropivacaine significantly prolongs analgesia in children undergoing lower abdominal surgeries without an increase in the incidence of side effects.

A comparison of dexamethasone and clonidine as an adjuvant for caudal blocks in pediatric urogenital surgeries

Background:

Caudal block is a reliable regional analgesic technique for pediatric urogenital surgeries. Various adjuvants have been tried to enhance the duration of action of bupivicaine. Though clonidine is extensively used as an adjuvant in caudal anaesthesia, it can have troublesome adverse effects like bradycardia, hypotension and sedation. Lately dexamethasone has become popular as an adjuvant in paediatric caudals due to its safety profile.

Aim:

The aim of this study was to compare dexamethasone and clonidine coadministered with bupivicaine caudally in paediatric patients undergoing urogenital surgeries in terms of analgesia and adverse effects.

Settings and Design:

Prospective, double blinded randomised study.

Subjects and Method:

Sixty American Society of Anesthesiologists physical status I and II children, aged 1-6 years undergoing urogenital surgeries were allocated in 2 groups: Group I: 0.5 mL.kg⁻¹ of 0.25% bupivicaine with dexamethasone 0.1 mg.kg⁻¹ in 1 ml normal saline (NS) Group II: 0.5 mL.kg⁻¹ of 0.25% bupivicaine with clonidine 1 μg.kg⁻¹ diluted in 1 ml normal saline. The parameters studied included duration of analgesia, intraoperative and postoperative hemodynamics, sedation scores and incidence of adverse effects like wound dehiscence, bleeding, vomiting and respiratory depression.

Statistical Analysis Used:

Statistical analysis was carried out using Stata Version 10. After checking for the normality assumption, t-test for comparing means of two independent samples was used for comparing baseline continuous variables. P values <0.05 were considered significant.

Results:

Patients in Group II had longer duration of analgesia postoperatively. Patients in this group also had lower heart rate and more sedation scores.

Conclusion:

Our study shows that caudal dexamethasone is a good alternative to clonidine with more stable hemodynamics and lesser sedation scores in the immediate postoperative period. Both the drugs offer good analgesia postoperatively with the duration of analgesia more in clonidine.

A comparison of ropivacaine, ropivacaine with tramadol and ropivacaine with midazolam for post-operative caudal epidural analgesia

BACKGROUND AND AIMS

Caudal epidural analgesia is the most commonly used method of post-operative analgesia in children undergoing subumbilical surgeries. Many additive drugs have been used to prolong the post-operative analgesia. The aim of this study was to compare the efficacy of tramadol or midazolam addition to caudal ropivacaine for post-operative analgesia in children undergoing subumbilical surgeries.

METHODS

In this prospective, randomised, double-blinded comparative study, sixty children of either gender, in the age group of 1-5 years and scheduled for elective subumbilical surgeries were randomly divided into three groups of twenty each. Children in Group R received an epidural injection of 1 mL/kg of 0.2% plain ropivacaine whereas children in Group RT received an epidural injection of 2 mg/kg of tramadol plus 1 mL/kg of 0.2% ropivacaine and Group RM received an epidural injection of 50 μg/kg midazolam plus 1 mL/kg of 0.2% ropivacaine. The primary outcome variable was the duration of time to rescue analgesia. The secondary outcome variables were motor block, sedation score and urinary retention. Statistical comparison among the three groups was performed using one-way ANOVA with post hoc analysis using Bonferroni. For qualitative variables, Chi-square test was used. Statistical significance was defined as P < 0.05.

RESULTS

The mean duration of time to rescue analgesia was significantly longer (P < 0.001) in Group RT (913 ± 315.5 min) and Group RM (769.2 ± 331.9 min) compared to Group R (437.75 ± 75.68 min). However, there was no significant difference in the duration of time to rescue analgesia between RT and RM groups. Motor block and sedation scores were comparable between groups.

CONCLUSIONS

The addition of tramadol or midazolam to caudal epidural ropivacaine prolongs the duration of analgesia without causing significant side effects.

Comparison of ropivacaine and bupivacaine with fentanyl for caudal epidural in pediatric surgery

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.

Efficacy of caudal fentanyl and ketamine on post-operative pain and neuroendocrine stress response in children undergoing infraumbilical and perineal surgery: A pilot study

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.

Adjuncts should always be used in pediatric regional anesthesia

A number of different adjuncts to local anesthetics can be used to prolong and optimize postoperative pain relief following regional anesthesia in children. The present text provides a slightly opinionated but evidence-based argument in favor of this practice.

A dose-response study of caudal dexmedetomidine with ropivacaine in pediatric day care patients undergoing lower abdominal and perineal surgeries: a randomized controlled trial

OBJECTIVES

This randomized double-blind study was conducted to evaluate the analgesic efficacy and safety of addition of three different doses of dexmedetomidine in caudal ropivacaine compared with plain ropivacaine for postoperative analgesia in pediatric day care patients.

METHODS

Eighty children of American Society of Anesthesiologists grade I-II, aged 1-8 years, undergoing lower abdominal and perineal surgery were included. Children were randomly allocated into four groups. Group 1 received 0.2% plain ropivacaine 0.75 ml·kg(-1), while group 2, 3, and 4 received dexmedetomidine 0.5, 1.0, and 1.5 μg·kg(-1), respectively, along with 0.2% ropivacaine 0.75 ml·kg(-1). Anesthesia was induced and maintained with sevoflurane and 50% N2O in oxygen. Children were observed for postoperative pain, nausea-vomiting, agitation, sedation, and adverse effects. Rescue analgesia was provided with oral paracetamol.

RESULTS

Postoperative analgesia was significantly prolonged in all dexmedetomidine groups as compared to plain ropivacaine group (P < 0.001). All patients in the plain ropivacaine group required rescue analgesia within first 6 postoperative hours, while none in the other three groups. None of the patients showed delayed anesthetic emergence. Four patients in the plain ropivacaine group developed agitation, while none in the dexmedetomidine groups. Patients receiving dexmedetomidine 1.5 μg·kg(-1) were more sedated as compared to the other groups (P < 0.01), but it did not delay discharge of the patients.

CONCLUSIONS

All three doses of caudal dexmedetomidine appear to be effective for preventing postoperative pain in pediatric day care patients. Caudal dexmedetomidine used in these doses seems to be safe for day care surgery.

Assessing Caudal Block Concentrations of Bupivacaine With and Without the Addition of Intravenous Fentanyl on Postoperative Outcomes in Pediatric Patients: A Retrospective Review

Caudal blocks are a significant and efficacious aspect of pediatric anesthesia, especially in urologic and many general surgery cases. This type of regional anesthesia is common because it has a high success rate and provides between 6 and 8 hours of postoperative pain control. The aim of this study was to determine whether the concentration of bupivacaine or the addition of intravascular (i.v.) fentanyl affected the postanesthesia care unit (PACU) discharge time. A retrospective cohort study comparing the outcomes in pediatric patients who have received varying caudal concentrations with and without the addition of i.v. fentanyl was performed. A total of 849 consecutive patients undergoing hypospadias repairs or circumcisions were reviewed and placed in one of the following 3 groups: 0.125% bupivacaine (group 1), 0.25% bupivacaine (group 2), or one of these concentrations of bupivacaine + i.v. fentanyl intraoperatively (group 3). Total PACU time for each group was 46.1 minutes (group 1), 48.9 minutes (group 2), and 49.7 minutes (group 3). Our results revealed that there is no statistically significant difference between concentrations of bupivacaine administered in a caudal block with or without i.v. fentanyl with regard to the outcome of PACU duration (P = 0.16). Overall, based on the retrospective cohort design, there is no difference in primary and secondary outcomes based on the concentration of bupivacaine, when administered at a volume of 1 mL/kg.

Adjuvants in pediatric regional anesthesia

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.

Analgesic efficacy of caudal dexamethasone combined with ropivacaine in children undergoing orchiopexy

BACKGROUND

Epidural administration of dexamethasone might reduce postoperative pain in adults. We evaluated whether a caudal block of 0.1 mg kg(-1) dexamethasone combined with ropivacaine improves analgesic efficacy in children undergoing day-case orchiopexy.

METHODS

This randomized, double-blind study included 80 children aged 6 months to 5 yr who underwent day-case, unilateral orchiopexy. Patients received either 1.5 ml kg(-1) of 0.15% ropivacaine (Group C) or 1.5 ml kg(-1) of 0.15% ropivacaine in which dexamethasone of 0.1 mg kg(-1) was mixed (Group D) for caudal analgesia. Postoperative pain scores, rescue analgesic consumption, and side-effects were evaluated 48 h after operation.

RESULTS

Postoperative pain scores at 6 and 24 h post-surgery were significantly lower in Group D than in Group C. Furthermore, the number of subjects who remained pain free up to 48 h after operation was significantly greater in Group D [19 of 38 (50%)] than in Group C [four of 37 (10.8%); P<0.001]. The number of subjects who received oral analgesic was significantly lower in Group D [11 of 38 (28.9%)] than in Group C [20 of 37 (54.1%); P=0.027]. Time to first oral analgesic administration after surgery was also significantly longer in Group D than in Group C (P=0.014). Adverse events after surgery including vomiting, fever, wound infection, and wound dehiscence were comparable between the two groups.

CONCLUSIONS

The addition of dexamethasone 0.1 mg kg(-1) to ropivacaine for caudal block can significantly improve analgesic efficacy in children undergoing orchiopexy. Clinical trial registration NCT01604915.

The effectiveness of pudendal nerve block versus caudal block anesthesia for hypospadias in children

BACKGROUND

Caudal block (CB) has some disadvantages, one of which is its short duration of action after a single injection. For hypospadias repair, pudendal nerve block (PNB) might be a suitable alternative since it has been successfully used for analgesia for circumcision. We evaluated PNB compared with CB as measured by total analgesic consumption 24 hours postoperatively.

METHODS

In this prospective, double-blinded study, patients were randomized into 2 groups, either receiving CB or nerve stimulator-guided PNB. In the PNB group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. In the CB group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. Analgesic consumption was assessed during the first 24 hours postoperatively. The "objective pain scale" developed by Hannalah and Broadman was used to assess postoperative pain.

RESULTS

Eighty patients participated in the study, 40 in each group. The mean age in the PNB group was 3.1 (1.1) years and in the CB group was 3.2 (1.1) years. The mean weights in the PNB and CB groups were 15.3 (2.8) kg and 15.3 (2.2) kg, respectively. The percentage of patients who received analgesics during the first 24 hours were significantly higher in the CB (70%) compared with the PNB group (20%, P < 0.0001). The average amount of analgesics consumed per patient within 24 hours postoperatively was higher in the CB group (paracetamol P < 0.0001, Tramal P =0.003).

CONCLUSION

Patients who received PNB had reduced analgesic consumption and pain within the first 24 hours postoperatively compared with CB.

Postoperative analgesia in children when using clonidine or fentanyl with ropivacaine given caudally

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.

Ketamine: use in anesthesia

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

Efficacy of clonidine as an adjuvant to ropivacaine for caudal analgesia in children undergoing subumbilical surgery

Context:

The use of clonidine as an adjuvant to ropivacaine in different concentrations through the caudal space has been shown to improve the analgesic efficacy of local anesthetics.

Aims:

The purpose of our study was to compare the efficacy of ropivacaine 0.1% with clonidine 1 mcg/kg to that of plain 0.1% and 0.2% ropivacaine for caudal analgesia in children.

Settings and Design:

Prospective, double blind, randomized controlled trial.

Materials and Methods:

Sixty children in the age group of 1–6 years undergoing subumbilical surgeries were included in the study. Group A received 1 ml/kg of 0.1% ropivacaine, group B received 1 ml/kg of 0.1% ropivacaine with clonidine 1 mcg/kg, and group C received 1 ml/kg of 0.2% ropivacaine.

Results:

The mean duration of analgesia was 243.7 ± 99.29 min in group A, 590.25 ± 83.93 min in group B, and 388.25 ± 82.35 min in group C. The duration of analgesia was significantly prolonged in group B compared to groups A and C with the P value of 0.001. At 8 h, all the 20 children in group A had received the first rescue analgesic compared to 18 children in group C and 3 children in group B. The duration of motor blockade after extubation was 30.6 ± 7.8 min and was noted only in group C. Only 1 child in group B received two rescue medications compared to 15 (75%) children in group A and 8 (40%) children in group C. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted.

Conclusions:

Clonidine 1 mcg/kg with ropivacaine 0.1% prolongs the duration and quality of analgesia compared to plain ropivacaine 0.1% and 0.2% without any significant sedation.

Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data

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.