Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children?

Analgesic Efficacy of Adjuvant Medications in the Pediatric Caudal Block for Infraumbilical Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Various adjuvants are added to local anesthetics in caudal block to improve analgesia. The comparative analgesic effectiveness and relative rankings of these adjuvants are unknown. This network meta-analysis (NMA) sought to evaluate the comparative analgesic efficacy and relative ranking of caudal adjuvants added to local anesthetics (versus local anesthetics alone) in pediatric infra-umbilical surgery. We searched the United States National Library of Medicine database (MEDLINE), PubMed, and Excerpta Medica database (Embase) for randomized controlled trials (RCTs) comparing caudal adjuvants (clonidine, dexmedetomidine, ketamine, magnesium, morphine, fentanyl, tramadol, dexamethasone, and neostigmine) among themselves, or to no adjuvant (control). We performed a frequentist NMA and employed Cochrane's 'Risk of Bias' tool to evaluate study quality. We chose the duration of analgesia (defined as 'the time from caudal injection to the time of rescue analgesia') as our primary outcome. We also assessed the number of analgesic dose administrations and total dose of acetaminophen within 24 h. The duration of analgesia [87 randomized control trials (RCTs), 5285 patients] was most prolonged by neostigmine [mean difference: 513 min, (95% confidence interval, CI: 402, 625)]. Dexmedetomidine reduced the frequency of analgesic dose administrations within 24 h [29 RCTs, 1765 patients; -1.2 dose (95% CI: -1.6, -0.9)] and the total dose of acetaminophen within 24 h [18 RCTs, 1156 patients; -350 mg (95% CI: -467, -232)] the most.  Among caudal adjuvants, neostigmine (moderate certainty), tramadol (low certainty), and dexmedetomidine (low certainty) prolonged the duration of analgesia the most. Dexmedetomidine also reduced the analgesic frequency and consumption more than other caudal adjuvants (moderate certainty).

Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis

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.

Effect of Addition of Fentanyl and Clonidine to Local Anesthetic Solution in Peribulbar Block

Objective:

To compare the effect of addition of fentanyl and clonidine as adjuvants to bupivacaine and lignocaine in peribulbar block.

Methods:

The study was conducted on 105 adult patients of either sex, of ASA grade I and II undergoing ophthalmic surgeries. Patients were randomly divided into 3 groups of 35 each. All the patients were given peribulbuar block with 5ml lignocaine 2% +3 ml bupivacaine 0.5% +1 ml hyaluronidase (250 IU). In addition to this 1 ml normal saline was added to Group S, 25 μg fentanyl to Group F and 25 μg clonidine to Group C. Onset and duration of globe and lid akinesia, duration of sensory blockage and analgesia, hemodynamic parameters, number of rescue analgesic and visual analogue score were recorded.

Results:

The mean time of onset of globe and lid akinesia was significantly faster in group F and group C compared to group S, mean duration of globe and lid akinesia was longer in Group F (207.71 + 13.54 and 143.14 + 7.86 min) and group C (213.52 + 14.52 and 162.06 + 17.1 min) compared to group S (117.78 + 10.42 and 87.64 + 9.76 min). The mean duration of analgesia was significantly longer in group F (217.71 + 12.67) and C (258.82 + 14.50 min) as compared to group S (131.39 + 9.63 min).

Conclusion:

Addition of fentanyl or clonidine as adjuvant to local anaesthetic in peribulbar block provides faster onset and prolonged analgesia compared to local anaesthetic alone.

Treatment of Postoperative Pain in Pediatric Operations: Comparing the Efficiency of Bupivacaine, Bupivacaine-Dexmedetomidine and Bupivacaine-Fentanyl for Caudal Block

BACKGROUND

Caudal analgesia is a common method for postoperative pain management in pediatric patients. Additive agents such as opioids and α₂ agonists have been used to enhance the analgesic effects of local anesthetics for caudal block.

OBJECTIVES

The aim of this study was to compare the additive effects of dexmedetomidine and fentanyl on bupivacaine-induced caudal analgesia in pediatric patients who had undergone elective inguinal hernia repair.

METHODS

This randomized, double-blind clinical trial included children aged 1 - 5 years who were divided into three groups: the bupivacaine group (Group B) received 0.25% bupivacaine (1 ml/kg), the bupivacaine-dexmedetomidine group (Group BD) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg dexmedetomidine, and the bupivacaine-fentanyl group (Group BF) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg fentanyl. The hemodynamic variables (heart rate, systolic blood pressure, respiratory rate, and peripheral arterial oxygen saturation) were measured perioperatively. Pain, sedation and motor block scores and adverse events (nausea and vomiting, pruritis, hypotension, bradycardia, urinary retention and respiratory depression) were documented at 30 and 60 minutes, and the 1st, 2nd, 4th, 6th, 12th and 24th hours after the operation. The other recordings include the duration of surgery and analgesic requirement.

RESULTS

A total of 61 patients were analyzed. The lowest pain scores were found in the BD group at all time points (P < 0.001). The sedation scores were higher in the BD group than in the other two groups at all time points (P < 0.001). No motor block was observed after the operation. Only three patients required analgesic administration 2 to 6 hours after the operation in group B. No side effects were observed in any of the groups, and there was no significant difference in the duration of surgery among the three groups.

CONCLUSIONS

The results show that the analgesic and sedative effects were better when dexmedetomidine was added to bupivacaine than when fentanyl was added or bupivacaine alone was administered in the pediatric population studied here that underwent elective inguinal hernia repair.

Postoperative analgesia in pediatric herniotomy - Comparison of caudal bupivacaine to bupivacaine infiltration with diclofenac suppository

CONTEXT

Perioperative analgesia in paediatric herniotomies demand safe, effective and less invasive strategies. Local infiltration with Bupivacaine, rectal Diclofenac and caudal Bupivacaine are widely used for pain relief.

AIMS

To compare the analgesic effects of caudal epidural using 1 mlkg(-1) of 0.25% Bupivacaine against a combination of local infiltration 0.25% Bupivacaine 0.5 mlkg(-1) with Diclofenac suppository 2 mgkg(-1) in the management of post-operative pain following paediatric inguinal herniotomy.

SETTINGS AND DESIGN

This is an observational study from a tertiary care teaching hospital.

METHODS AND MATERIAL

A total of 60 children for elective unilateral inguinal herniotomy were assigned to two groups of 30 each. Patients who received caudal block with 1 mlkg(-1) of 0.25% Bupivacaine were allocated to Group A and who received Diclofenac suppository 2 mgkg(-1) and infiltration with 0.25% Bupivacaine 0.5 mlkg(-1) were allocated to Group B. Post operative Pain was assessed using Hannallah's modified objective pain scale. At score ≥3 rescue analgesic oral Paracetamol 15 mgkg(-1) was given. Pain was assessed at 0,15,30,45,60 minutes and half hourly thereafter until 8 hours following surgery or until patient requires rescue analgesic whichever happens first.

STATISTICAL ANALYSIS USED

Employed SPSS software. Data was analysed using sample t test and P-value was calculated.

RESULTS

The demographic profile was comparable between two groups. The mean analgesic duration in group A and group B was 228.5 and 331.0 minutes respectively and is found to be statistically significant (P < 0.05).

CONCLUSIONS

Diclofenac suppository with local infiltration is a less invasive and effective alternative to caudal Bupivacaine for analgesia in paediatric herniotomy.

Comparison of caudal tramadol versus caudal fentanyl with bupivacaine for prolongation of postoperative analgesia in pediatric patients

Background and Aims:

Caudal block is a common technique for pediatric analgesia for infraumblical surgeries. Because of the short duration of analgesia with bupivacaine alone various additive have been used to prolong the action of bupivacaine. The present study was aimed to evaluate the analgesic effect of tramadol or fentanyl added to bupivacaine for infraumblical surgeries in pediatric patients.

Materials and Methods:

We conducted a prospective, randomized, single-blind controlled trial. After written informed consent from parents, 100 patients belonging to American Society of Anesthesiologist physical status I-II, in the age group of 1-12 years, of either sex undergoing infraumblical surgery under general anesthesia were divided into two groups. Group BT received 1 ml/kg of 0.25% bupivacaine with tramadol 2 mg/kg in normal saline and Group BF received 1 ml/kg of 0.25% bupivacaine with fentanyl 2 μg/kg in normal saline with maximum volume of 12 ml in both groups. All patients were assessed intraoperatively for hemodynamic changes, the requirement of sevoflurane concentration, as well as postoperatively for pain by using FLACC (F = Face, L = Leg, A = Activity, C = Cry, C = Consolability), pain score and for sedation by using four point sedation score.

Results:

The mean duration of analgesia was 10–18 h in Group BT while in Group BF it was 7-11 h. The postoperatively period up to 1½ h, Group BF had higher sedation score up to two as compared to that below one on Group BT.

Conclusion:

Caudal tramadol significantly prolongs the duration of analgesia as compared to caudal fentanyl without any side effects.

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.

Efficacy of Caudal Clonidine and Fentanyl on Analgesia, Neuroendocrine Stress Response and Emergence Agitation in Children Undergoing Lower Abdominal Surgeries Under General Anaesthesia with Sevoflurane

INTRODUCTION

Clonidine has proved to be effective drug for postoperative analgesia but it's efficacy to alter neuroendocrine stress response and emergence agitation is unknown. This study was conducted to assess and compare the efficacy of caudal fentanyl vs. clonidine for analgesia, blunting of neuroendocrine stress responses (NESR) and emergence agitation (EA) following sevoflurane anaesthesia.

MATERIALS AND METHODS

This prospective, randomized, double blind study enrolled 60 children undergoing infraumbilical surgery. Three groups of 20 each were assigned to receive caudal block with either bupivacaine 0.25% 1 ml/kg with normal saline (group I) or bupivacaine 0.25% 1 ml/kg and 1 microgram*kg-1fentanyl (group II), or bupivacaine 0.25% 1 ml/kg and 3 μg/kg clonidine [group III]. Postoperative analgesia, sedation, NESR, emergence agitation and side effects were observed.

RESULTS

VAS score at two hours was significantly less in group III (0.60± 0.60) than in group I (1.80± 0.41) and group II (1.25± 0.44), the time to rescue analgesia was also significantly greater in group III (8.03+0.41hours) than groups I and II (4.15± 0.54 hours) and (6.18± 0.5hours) respectively. The EA scores were significantly better in Group III but patients were significantly more sedated postoperatively. Intraoperatively, NESR was blunted in all the groups and the markers of NESR were lowest in group III.

CONCLUSION

Caudal clonidine in a dose of 3 μg/kg prolongs analgesia and decreases emergence agitation as compared to bupivacaine alone or with fentanyl 1μg/kg. Modulation of the neuroendocrine stress response was observed in all the investigated groups though the indicators were lowest in clonidine group.

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.

Effects of caudal sufentanil supplemented with levobupivacaine on blocking spermatic cord traction response in pediatric orchidopexy

PURPOSES

Caudal block is one of the most commonly used anesthetic techniques in subumbilical and genitourinary procedures. However, traditional administration of caudal levobupivacaine was inadequate on blocking peritoneal response during spermatic cord traction. The aim of this study was to evaluate whether the addition of caudal sufentanil to levobupivacaine provided better analgesia for children undergoing orchidopexy.

METHODS

Sixty-two patients, scheduled for right orchidopexy, received caudal block after induction. Group LS (n = 31) received levobupivacaine 0.25% 1 ml/kg plus sufentanil 0.5 μg/kg, and group L (n = 31) received levobupivacaine 0.25% 1 ml/kg only. HR or MAP fluctuation >20% or entropy increase >15% during spermatic cord traction was defined as inadequate anesthesia and was treated with increasing sevoflurane concentration. The number of children who needed sevoflurane rescue was counted, and postoperative side effects and quality of sleep were also recorded.

RESULTS

There were no statistically significant differences between the two groups in age, weight, and duration of surgery. Two (6.45%) children in group LS required inspired sevoflurane rescue to block hemodynamic fluctuation during spermatic cord traction, as compared with 12 (38.71%) patients in group L (P < 0.001). At the time of exerting spermatic cord traction, the median HR was, respectively, 134 and 145 (P < 0.001); the corresponding response entropy (RE) and state entropy (SE) was 65 and 54, respectively, in group LS versus 76 and 65 in group L (P < 0.001).

CONCLUSION

In pediatric orchidopexy, the addition of sufentanil to levobupivacaine for caudal blockade offers clinical benefit over levobupivacaine alone in blocking the spermatic cord traction response.

Bayesian enhanced meta-analysis of post-operative analgesic efficacy of additives for caudal analgesia in children

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.

Addition of sufentanil to bupivacaine in caudal block effect on stress responses in children

BACKGROUND

The aim of the present randomized study was to determine the effect of adding sufentanil to bupivacaine, compared with bupivacaine alone in caudal block, on the surgical stress response in children.

METHODS

The children were premedicated with midazolam 0.5 mg/kg. All children received induction with nitrous oxide and sevoflurane. Anesthesia was maintained with the same volatile agents in the both groups. The children were randomly allocated to two groups. Group I received bupivacaine alone (n = 17) and group II received bupivacaine + sufentanil (n = 16). Caudal block was performed with 0.25% bupivacaine 2 mg/kg (group I) or 0.25% bupivacaine 2 mg/kg with sufentanil 0.5 microg/kg (group II) after induction of anesthesia. Blood samples were obtained after induction of anesthesia (T(0)) to measure baseline concentrations of cortisol, prolactin, glucose and insulin. Additional samples were obtained 30 min after the start of surgery (T(1)), and 60 min after the end of surgery (T(2)).

RESULTS

All of the basal values (T(0)) were within the normal ranges of the authors' laboratory for children of this age group and there were no differences between the groups (P > 0.05). In both groups, glucose concentration increased at T(1), compared with T(0) and T(2) (P < 0.05). The glucose concentration was unchanged at T(2) compared with T(0) in both group (P > 0.05). In both groups, prolactin concentration increased at T(1), compared with T(0) and decreased at T(2), compared with T(1) (P < 0.05). Cortisol decreased at T(1) and T(2), compared with T(0) in both groups. (P < 0.05). Insulin concentration remained unchanged at T(0) and T(2), but increased slightly at T(1) in both groups (P > 0.05). There were no significant differences in plasma prolactin, cortisol, glucose and insulin levels between the two groups at T(1) and T(2) (P > 0.05).

CONCLUSION

There is no advantage in adding 0.5 microg/kg sufentanil to bupivacaine over bupivacaine alone in the caudal block, with regard to the surgical stress response in children.

A Comparison of Single-Dose Caudal Clonidine, Morphine, or Hydromorphone Combined with Ropivacaine in Pediatric Patients Undergoing Ureteral Reimplantation

BACKGROUND

Caudal blockade is a common technique for pediatric postoperative analgesia. While safe and effective, caudal opioids are associated with troublesome side effects. Caudal clonidine may offer significant analgesic benefits. We prospectively compared the analgesic, side effect, and rehabilitation profiles of caudal clonidine, hydromorphone, or morphine in a group of 60 pediatric patients undergoing ureteral reimplantation.

METHODS

Patients aged 6 mo to 6 yr were evenly and randomly enrolled in a double-blind manner. Patients received a single caudal dose of 2 mcg/kg of clonidine, 10 mcg/kg of hydromorphone, or 50 mcg/kg of morphine, combined with 1.0 mL/kg of 0.2% ropivacaine with epinephrine. After sevoflurane in oxygen/air anesthesia, all subjects received proxy nurse-controlled analgesia with morphine. Postoperative pain intensity, use of IV morphine, and side effects were assessed during the first 24 h. Oral intake and discharge home were recorded.

RESULTS

Caudal clonidine resulted in less postoperative nausea and vomiting (P = 0.01) and pruritus (P = 0.007) than did caudal hydromorphone or caudal morphine. Caudal morphine produced more sustained initial analgesia than did caudal clonidine (P = 0.02). No difference was observed in pain scores, total morphine use, time to first oral intake or discharge home. No postoperative respiratory depression, excessive sedation, hypotension, or bradycardia was identified.

CONCLUSIONS

Although caudal morphine may result in more sustained initial analgesia, caudal clonidine combined with nurse-controlled analgesia appears to provide comparable analgesia with fewer side effects. Based on these results, the use of caudal clonidine may be superior to caudal opioids after pediatric ureteral reimplantation.

Does adding intravenous fentanyl to caudal block in children enhance the efficacy of multimodal analgesia as reflected in the plasma level of catecholamines?

BACKGROUND AND OBJECTIVE

Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children.

METHODS

Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 microg kg(-1) (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T(0)), at the end of surgery (T(1)) and when the children were fully awake in the postanaesthesia care unit (T(2)).

RESULTS

There was a significant reduction in the catecholamine levels in the two groups when (T(1)) and (T(2)) were compared with T(0). When plasma epinephrine levels (at T(0), T(1) and T(2)) between the two groups were compared, a statistically significant reduction at T(2) was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T(0), T(1) and T(2)).

CONCLUSION

These findings suggest that the multimodal analgesic approach of adding i.v. low-dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.

A prospective, double-blind, randomized trial of caudal block using ropivacaine 0.2% with or without fentanyl 1 microg kg-1 in children

BACKGROUND

It has been reported that ropivacaine produces vasoconstriction in contrast to vasodilation produced by bupivacaine. It is possible that additives to ropivacaine can provide further analgesic advantages compared with bupivacaine. We thus evaluated whether the addition of fentanyl to ropivacaine prolonged the duration of analgesia after a single shot caudal block.

METHODS

A total of 36 children undergoing surgical procedures below the umbilicus were randomly allocated to one of two groups: Group F received ropivacaine 0.2%, 1 ml kg(-1) with fentanyl 1 microg kg(-1) and Group S received ropivacaine 0.2%, 1 ml kg(-1) with saline. The analgesic effect of the caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using the Steward score at 30 min after extubation and at 1, 2, 4, 6, 12 and 24 h. The first analgesic requirement time and side-effects in a 24 h period were also recorded.

RESULTS

There were no differences in characteristics between the groups. The end-tidal concentration of sevoflurane at extubation in Group F was significantly lower than in Group S. However, there was no significant difference in time from discontinuation of the volatile anaesthetics to tracheal extubation. No statistical differences were found in the CHEOPS and Steward score, and the time to first analgesia. The incidence of postoperative vomiting was not significantly different.

CONCLUSION

We found that the addition of fentanyl 1 mug kg(-1) to ropivacaine 0.2% for caudal analgesia provides no further analgesic advantages over ropivacaine 0.2% alone.

Physiological and catecholamine response to sympathetic stimulation in turner syndrome

OBJECTIVE

Women with Turner syndrome have increased heart rate and high blood pressure (BP), and have been described as having high tolerance for emotional stress. We hypothesized that women with Turner syndrome have reduced catecholaminergic and physiological response to sympathetic stimulation, and that changes in BP and heart rate are related to their catecholamine response to sympathetic stimulation.

DESIGN AND PATIENTS

Ten young women with Turner syndrome, age 17-34 years were the subjects of this study. Their response to sympathetic stimulation was compared to a group of 10 age-matched healthy women.

MEASUREMENTS

After a period of 30 min resting, subjects and controls were subjected to an escalating series of sympathetic stimulation: orthostatic, cold pressor and exercise, and their plasma catecholamines and haemodynamic response were monitored and compared to resting levels.

RESULTS

Resting heart rate was higher in Turner syndrome patients at 83 +/- 9 beats per min (bpm, mean +/- SD), as compared to controls (74 +/- 10 bpm, P < 0.05). Their supine BP was also higher at 122 +/- 9/84 +/- 6 vs. 106 +/- 11/70 +/- 9 mmHg (P < 0.02/< 0.02). The corresponding resting norepinephrine, but not epinephrine, was higher in Turner syndrome patients (2.54 +/- 1.09 nmol/l) as compared to controls (1.69 +/- 0.55 nmol/l, P < 0.02). In response to orthostatic stimulation and cold pressor test the systolic, but not the diastolic BP or heart rate, increased in Turner syndrome patients but not in the control group (P < 0.01). The change in blood catecholamine levels was comparable in both groups. Their physiological response to exercise was normal. Yet, the exercise-induced surge of norepinephrine and epinephrine in Turner syndrome patients was lower (P < 0.02).

CONCLUSIONS

Turner syndrome is associated with dysregulation of the sympathetic nervous system (SNS), leading to tachycardia and high BP, increased resting norepinephrine levels, and a greater tolerance of the cathecholamine response to exercise.

The efficacy of caudal morphine or bupivacaine combined with general anesthesia on postoperative pain and neuroendocrine stress response in children

BACKGROUND

The aim of this study was to compare the effectiveness of caudal morphine and bupivacaine usage on surgical stress response in children undergoing abdominal and genitourinary surgery while keeping anesthesia depth constant utilizing the bispectral index analysis (BIS).

METHODS

Following the approval of Institutional Review Board and informed parental consent, 28 children with ages ranging between 4 and 16 years with ASA physical status I and II , undergoing elective lower abdominal and genitourinary surgery were included in this study. Patients were randomized and separated into two subgroups. Before induction of anesthesia, patients were monitored for BIS. Epidural injection of 30 microg.kg(-1) morphine in 1 ml.kg(-1) saline for the first group (group M) and the same volume of (0.25%) bupivacaine for second group (group B) were administered via the sacral hiatus. We analyzed serum cortisol and glucose concentrations for evaluation of the stress response in the patients. Blood samples for cortisol and glucose were withdrawn at the beginning of induction (first samples), 40 min after surgical incision (second samples), and 40 min after end of the surgery (third samples). BIS scores of the patients were kept between 40 and 60 during the surgical procedure.

RESULTS

Group B had significantly lower levels of cortisol than group M in the second samples. There was a significant increase in serum glucose level in group M compared with group B during the intraoperative and postoperative periods.

CONCLUSIONS

We conclude that, caudal administration of bupivacaine is more effective than morphine for attenuating intraoperative and postoperative stress response to surgery in children.

Efficacy of caudal butorphanol

OBJECTIVE

To evaluate the efficacy of butorphanol with or without bupivacaine for caudal epidural anesthesia in children undergoing infraumbilical surgery.

METHODS

Sixty ASA physical status I and II patients of either sex aged 1-10 yr were randomized to one of three groups. Group L received 1 ml/kg of 0.25% bupivacaine; Group B received 1 ml/kg of 25 microg/kg butorphanol diluted in normal saline; and Group LB received 1 ml/kg of 25 microg/kg butorphanol in combination with 0.25% bupivacaine, in caudal epidural anesthesia. Hemodynamic variables (HR and MAP) and respiratory rate were monitored in all patients. Sedation score, pain score and requirement of rescue analgesia were recorded at preset time intervals alongwith post-operative complications.

RESULTS

There was no difference among the groups regarding sedation scores, requirement of rescue analgesia and post-operative complications. Mean duration of analgesia was maximum in group BL (14.5 +/- 3.5 hr, P<0.001), than in group L (8.8 +/- 4.8 hr) and group B (6.8 +/- 2.9 hr).

CONCLUSION

The addition of 25 microg/kg butorphanol to bupivacaine resulted in superior analgesia with a longer period compared with caudal bupivacaine and butorphanol alone, without an increase of side effects.

Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children

PURPOSE

To evaluate the analgesic efficacy and duration of varying doses of caudal neostigmine with plain bupivacaine and its side effects in children undergoing genito-urinary surgery.

METHODS

In a randomized double-blind prospective study 80 boys aged two to eight years scheduled for surgical repair of hypospadias were allocated randomly to one of four groups (n = 20 each) and received either only caudal 0.25% plain bupivacaine 0.5 mL.kg(-1) (Group I) or 0.25% plain bupivacaine 0.5 mL.kg(-1) with neostigmine (Groups II-IV) in doses of 2, 3 and 4 microg.kg(-1) respectively. Postoperative pain was assessed for 24 hr using an objective pain score. Blood pressure, heart rate, oxygen saturation, total amount of analgesic consumed and adverse effects were also recorded.

RESULTS

The duration of postoperative analgesia in Group I (5.1 +/- 2.3 hr) was significantly shorter than in the other three groups (II -16.6 +/- 4.9 hr; III - 17.2 +/- 5.5 hr; IV - 17.0 +/- 5.8 hr; P < 0.05). Total analgesic (paracetamol) consumption was significantly more in Group I (697.6 +/- 240.7 mg) than in the groups receiving caudal neostigmine (II - 248.0 +/- 178.4; III - 270.2 +/- 180.8 and IV -230.6 +/- 166.9 mg; P < 0.05). Groups II, III and IV were comparable with regards to duration of postoperative analgesia and total analgesic consumption (P > 0.05). Incidence of nausea and vomiting were comparable in all four groups. No significant alteration in vital signs or any other adverse effects were observed.

CONCLUSIONS

Caudal neostigmine (2, 3 and 4 microg.kg(-1)) with bupivacaine produces a dose-independent analgesic effect ( approximately 16-17 hr) in children as compared to those receiving caudal bupivacaine alone (approximately five hours) and a reduction in postoperative rescue analgesic consumption without increasing the incidence of adverse effects.

Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block

BACKGROUND

Both caudal epidural and ilioinguinal/iliohypogastric nerve blocks have been used to provide effective intra- and postoperative analgesia. Stress response hormone levels can be used as an objective method to assess the analgesic efficacy of the anaesthetic techniques used in infraumbilical surgery in children. In this study, we compared catecholamine blood levels in children undergoing these two different supplementary analgesic/anaesthetic techniques.

METHODS

Thirty male paediatric patients undergoing orchidopexy, ASA I, received inhalation general anaesthesia, and were randomly allocated to one of two groups: a caudal group (n = 15) and an ilioinguinal/iliohypogastric nerve block group (n = 15). Plasma epinephrine and norepinephrine concentrations were measured at the induction time, at the end of surgery, and in the postanaesthesia care unit. Postoperative pain score was also assessed in the postanaesthesia care unit.

RESULTS

In both groups, there was a substantial decrease in the catecholamine blood levels; however, there were significantly higher levels of epinephrine in the ilioinguinal group at the end of surgery (P = 0.008) and in the recovery room (P = 0.02) and a significant higher level of norpinephrine in the recovery room (P = 0.008).

CONCLUSIONS

The result of this study revealed that caudal epidural block was more effective than ilioinguinal block in suppressing the stress response as reflected in epinephrine and norepinephrine blood levels in orchidopexy patients.

The caudal catheter in neonates: where are the restrictions?

PURPOSE OF REVIEW

In neonates, epidural catheters inserted at the sacral hiatus can easily be advanced to a lumbar or thoracic level. These 'caudal catheters' are popular because they allow the neonate to benefit from epidural analgesia without the concerns of spinal cord injury potentially associated with primary thoracic placement in an asleep neonate. This review looks at use and benefits, and risks and complications of caudal epidural catheters in neonates.

RECENT FINDINGS

Restrictions of neonatal caudal catheters are related to risks associated with placement and advancement of the catheters, infectious risks of caudal catheters, and toxicity risks related to the higher free fraction and lower clearance of bupivacaine in neonates. Caudal catheters in neonates are popular, but evidence that they improve outcome is lacking.

SUMMARY

Epidural anesthesia and analgesia for neonates should be performed and managed by pediatric anesthesiologists. Potential risks and complications must be appreciated and all steps to maximize safety of the technique must be taken. In particular, close postoperative observation and pain service management are indispensable. Future research should investigate the risks of caudal and segmentally placed catheters in neonates, study the role of epidural analgesia in outcome improvement for neonates, and guide us to safer use of local anesthetics suitable for neonates with their pharmacologic immaturity.