Caudal blocks

An Objective Evaluation of Intraoperative and Postoperative Pain in Infants Undergoing Open Inguinal Herniotomy and Laparoscopic Inguinal Hernia Repair Using the Newborn Infant Parasympathetic Evaluation (NIPE™) Monitor

PURPOSE

The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) monitor is an objective, non-invasive tool for the assessment of pain in children under 2 years of age. The aim of this study was to objectively compare pain in infants undergoing open and laparoscopic inguinal hernia surgery using the NIPE monitor.

METHOD

This prospective observational study included neonates and infants (<2 years of age) undergoing elective open inguinal herniotomy and laparoscopic inguinal hernia repair under general anaesthesia with a caudal block. The NIPE monitor was connected to the electrocardiogram monitor with continuous monitoring performed intraoperatively, and postoperatively in the Post Anaesthesia Care Unit. The NIPE index was recorded at different intraoperative steps. The median NIPE index (NIPEm) was calculated for the entire procedure and postoperative period. The NIPE index ranges from 0 to 100; lower values indicate greater levels of pain, values < 50 indicate severe pain. P values < 0.05 were considered significant.

RESULTS

There were 40 infants recruited: 27 underwent open herniotomy and 13 underwent laparoscopic repair. Intraoperatively, NIPEm was found to be significantly lower in the laparoscopic group (59.00 vs. 77.00, p = 0.0018). Postoperatively, NIPEm was also found to be significantly lower in the laparoscopic group (49.00 vs. 57.50, p = 0.0001).

CONCLUSION

This is the first study to objectively demonstrate that laparoscopic inguinal hernia repair is more painful intraoperatively and leads to greater levels of pain in the early postoperative period compared to open inguinal herniotomy. This difference might explained by painful stimuli in anatomical areas not covered by the caudal block.

TYPE OF STUDY

Treatment Study/Prospective Study.

LEVEL OF EVIDENCE

Level II.

Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS

Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.

Ultrasound-guided lumbar erector spinae plane block versus caudal block for postoperative analgesia in pediatric hip and proximal femur surgery: a randomized controlled study

BACKGROUND

According to previous research, 20% of infants experience prolonged postsurgical pain 6-12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries.

METHODS

Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia.

RESULTS

The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups.

CONCLUSIONS

The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.

Impact of caudal block on revision rates after hypospadias repair: Multi-institution review

INTRODUCTION

There is controversy surrounding the association between caudal block and complication rates after hypospadias repair. Conflicting results have been reported mostly from single-center, low volume studies and those that did not include relevant variables.

OBJECTIVES

We hypothesized that caudal block is not associated with increased rates of reoperation after primary repair and is associated with more complex hypospadias surgery.

STUDY DESIGN

The Clinical Practice Solutions Center database was queried to identify patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty, distal, one-stage proximal, or one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal block. Any revision surgery was captured between 2009 and 2019 and the types of revision surgeries were identified. Variables such as caudal block, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models.

RESULTS

The dataset query identified 3343 pediatric males who had primary hypospadias repair. The procedures were performed by 50 surgeons at 27 hospitals. Primary surgeries included meatal advancement and glanduloplasty (23%), distal (69%), proximal (6.9%), and perineal repairs (1%). Caudal block was administered to 42% of patients. Utilization of caudal block was not associated with type of primary surgery (p = 0.21). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal block (p < 0.001). Analysis did not demonstrate a statistically significant association between utilization of caudal block with rates of revision surgery.

CONCLUSIONS

This large, multi-institution study demonstrates that the use of caudal block was not associated with more complex hypospadias surgery nor statistically significantly associated with increased rates of revision surgery after primary hypospadias repair.

Laparoscopic versus Open Inguinal Hernia Repair Is Feasible in Infants with Caudal Anesthesia and Spontaneous Respiration

INTRODUCTION

 Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants.

METHODS

 Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications.

RESULTS

 A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant).

CONCLUSION

 This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration.

Review of clinical evidence of caudal block for postoperative analgesia in children with ketamine added local anesthetics

Background

Adding ketamine to local anesthetics used for caudal block in children is an emerging clinical practice. This review aims to resolve controversies related to this adjuvant for a caudal block in children who underwent sub-umbilical surgeries.

Methods

Between January 2010 and November 2021, PubMed, Cochrane Review, and Google Scholar were searched for a caudal block with ketamine added local anesthetics for children. After screening for eligibility and removing duplicates, 38,187 articles were found, 13 reviewed.

Discussion

Despite adding ketamine to local anesthetics used for a caudal block, it is a recent technique practiced worldwide. Ketamine showed equi-efficacious as other adjuvants used for the caudal block to control postoperative pain in children.

Conclusion

Ketamine with a 0.5 mg/kg dose is safe and effective to manage postoperative children's pain when used as an adjuvant to local anesthetics used for caudal block.

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Caudal additives prolong the length of analgesia than local anesthetics alone

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Ketamine is an alternative to be added for local anesthetics in a caudal block for children

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Ketamine in caudal block prolongs analgesia and reduces opioid intake.

Regional anesthesia for ambulatory pediatric penoscrotal procedures

BACKGROUND/PURPOSE

Pediatric urology procedures are amongst the most commonly performed in children. The need for proactive treatment of pain is essential for optimal patient care. Current guidelines recommend the routine use of regional anesthesia in children as appropriate unless contraindicated. Given the commonality of urologic procedures in children, it is essential to understand the indications for and the utility of regional anesthesia.

METHODS

The current literature was searched using PubMed as the primary platform. Search words included 'dorsal penile nerve block,' 'pudendal nerve block,' 'ring block,' 'spinal anesthesia,' and 'caudal,' along with 'pediatric', 'circumcision,' 'hypospadias,' 'urology', and 'urological surgery' as part of the keywords of the search.

RESULTS

The articles resulting from the literature search were reviewed for content, clarity and study design by two co-authors, and agreement determined the incorporation into the review. Additionally, a detailed description of study design, regional anesthetic technique, local anesthetic(s) used, and outcomes of each study referenced was incorporated into the supplemental table.

CONCLUSION

Given the variance in block technique and local anesthetic choice amongst the current reported studies in the literature, it is difficult to truly compare and infer superiority of the regional anesthetic choices for ambulatory penoscrotal procedures. When choosing a regional anesthetic technique, careful consideration must be placed on block coverage, severity of expected pain and surgical duration of the procedure, type and dose of local anesthetic, as well as the patient's past medical history and anatomy. Moreover, the regional block chosen should result from a thorough preoperative discussion between the surgeon and the anesthesiologist.

Inadvertent life-threatening total spinal anesthesia following caudal block in a preschool child underwent urologic surgery: A rare case report

INTRODUCTION AND IMPORTANCE

Caudal block is considered to be safe and provide optimal analgesia for pediatric patients undergoing sub-umbilical operations. It overcomes opioid-related side effects, particularly the dangers associated with respiratory depression in small children.

CASE PRESENTATION

A 5-year-old male underwent uneventful hypospadias surgery under general endotracheal anesthesia. Caudal block planned to be administered postoperatively for postoperative analgesia then performed after palpation of sacral cornu with 8 ml of 0.25% bupivacaine. A few minutes later, the patient became apneic, heart rate, blood pressure, and oxygen saturation dropped abruptly-immediate resuscitation with ventilatory support, fluid bolus, and atropine administration. After a minute patients' vital signs returned to the normal range then 2 h later patient started to breathe spontaneously and consciousness is regained. After close follow-up for 24 h in the post-anesthesia care unit patient was discharged to the pediatric ward then discharged to home without any neurologic sequelae after 3 days.

CLINICAL DISCUSSION

Total spinal anesthesia in a very infrequent incident during central neuraxial blocks, especially in the pediatrics population where a caudal block is usually performed. Manifestation of this event can be detected by loss of consciousness, cessation of respiratory effort, hemodynamic instability, and dilated pupils. Delayed treatment can result in cardiopulmonary arrest.

CONCLUSION

Unanticipated total spinal anesthesia following central neuraxial blocks can potentially cause severe adverse consequences. Preventive modalities must be employed to avoid this incident. Early recognition and instant management should be instituted to avoid dangerous complications following the total spinal blockade.

Perioperative sedation requirements of infants aged 0 to 3 months subjected to lower-body surgery under caudal blockade: a randomized controlled trial

BACKGROUND

It remains unclear how much sedation is required for subumbilical surgery under caudal blockade, and sedatives may carry a poorly understood risk of late sequelae in infants. We designed a randomized controlled study to evaluate total propofol consumption and perioperative sedation quality with the avoidance of continuous perioperative sedation in infants undergoing surgery under caudal anesthesia.

METHODS

Thirty-two infants (age: 0-3 months) were randomized to one of two groups in which perioperative administration of propofol was provided either "as needed" or by continuous infusion (5 mg kg-1 h-1). After induction of anesthesia via a facemask with sevoflurane, a venous access was established and 1 ml kg-1 of ropivacaine 0.35% was injected for caudal anesthesia. Intraoperative stress was assessed by repeated recording Comfort Behavioral Scale scores and heart rates.

RESULTS

Significantly (p = 0.0001) less propofol was administered in the as-needed group (0.7 ± 1.4 mg/kg) than in the continuous-infusion group (3.0 ± 1.6 mg/kg). This difference was not reflected in different requirements of additional intraoperative sedation (0.5 ± 0.8 mg/kg in 5 versus 0.6 ± 1.0 mg/kg in 4 cases; p = 0.76).

CONCLUSIONS

As needed propofol administration offers no disadvantage in terms of intraoperative sedation, but significant dose reductions can be achieved by avoiding continuous propofol infusion.

Primary spread of caudal blockade in children: the possible limiting role of the lumbar spinal cord enlargement (tumenescence) in combination with the cerebrospinal fluid rebound mechanism

BACKGROUND

Despite being the most frequently used pediatric nerve block, certain aspects of the initial intraspinal spread of local anesthetics when performing a caudal block need further elucidation. The fact that injected volumes of 0.7-1.3 mL kg^-1 initially only reach the thoraco-lumbar junction, with only a few vertebral segments difference despite the huge difference in injected volume, still has no apparent explanation. We hypothesize that the narrowing of the epidural space caused by the lumbar spinal enlargement may provide an anatomical barrier causing this restriction of initial spread, alone or in combination with increased intrathecal pressure caused by the "cerebrospinal fluid rebound mechanism." The aim of this observational study was to find support for or refute this hypothesis.

METHODS

Twenty nine MRI scans of the vertebral column, performed in children 0-6 years of age, was identified from the radiographic imaging computer system and analyzed for the vertebral level of the maximum of the lumbar spinal enlargement (Associated anatomical data related to the spinal canal, the dura mater, and the spinal cord were also recorded.

RESULTS

The maximum of the lumbar spinal enlargement was found at a median vertebral level of Th 11 (IQR 11-11).

CONCLUSION

The maximum of the lumbar spinal enlargement is located at the Th 11 vertebral level. Although not entirely conclusive, the findings of the present study do support the notion that the lumbar spinal enlargement, in combination with the CSF rebound mechanism, may be the factors limiting the initial spread of a caudal block to the thoraco-lumbar junction.

Postoperative analgesic effectiveness of ultrasound-guided transmuscular quadratus lumborum block in congenital hip dislocation surgery : A randomized controlled study

BACKGROUND/OBJECTIVE

Congenital hip dysplasia (CHD) defines a spectrum of pathologies in which the acetabulum and proximal femur of babies and children abnormally develop. Open surgery in congenital hip dysplasia leads to severe postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided quadratus lumborum block (QLB) in pediatric patients undergoing surgery for congenital hip dysplasia.

MATERIAL AND METHODS

Following ethical board approval, 40 children aged between 1-5 years undergoing surgery for congenital hip dysplasia were randomized into two groups. Patients (n = 20) received ultrasound guided quadratus lumborum block (group QLB) using 0.5 mL/kg body weight 0.25% bupivacaine preoperatively. The same standard postoperative analgesia protocol was used in both groups. Pain scores, parental satisfaction, requirement for ibuprofen and opioids were recorded. Pain was measured using the face, legs, activity, crying, consolability (FLACC) scale.

RESULTS

The FLACC scores were lower at 30min and 1h, 2h, 4h, 6h, 12h and 24h in the QLB group when compared to the control group (p < 0.05). The requirement for rescue opioid analgesia was statistically significantly higher in the control group when compared to the QLB group (15/20 vs. 3/20, p < 0.001). Rate of ibuprofen usage in the ward was higher in the control group when compared to the QLB group (14/20 vs. 4/20, p = 0.004). Parental satisfaction was higher in the QLB group (p < 0.001).

CONCLUSION

Ultrasound-guided quadratus lumborum block reduces pain scores and analgesic requirements following congenital hip dysplasia surgery.

Efficacy of caudal vs intravenous administration of α2 adrenoceptor agonists to prolong analgesia in pediatric caudal block: A systematic review and meta-analysis

BACKGROUND

α₂ adrenoceptor agonists have been proposed as adjuncts to prolong analgesia in pediatric caudal block. The aim of this meta-analysis was to compare the analgesic efficacy of caudal vs intravenous α₂ adrenoceptor agonists during pediatric caudal block.

METHODS

A systematic search, data extraction, bias risk assessment, and pooled data analysis were performed following the PRISMA guidelines. All randomized controlled trials comparing caudal with intravenous α₂ adrenoceptor agonists in pediatric caudal block were included. Relative risk and weighted mean differences (the corresponding 95% confidence intervals) were calculated for dichotomous and continuous data, respectively. Trial sequential analyses were performed to evaluate the credibility of the meta-analysis.

RESULTS

A total of 244 patients in five trials were identified. Compared with the intravenous group (9.56 ± 4.23 hours), the time to the first rescue analgesia was prolonged in the caudal α₂ adrenoceptor agonists group (12.72 ± 5.99 hours) by a weighted mean difference of 2.98 hours [95% confidence interval: 0.59-5.36 hours; P = .01]. The number of children requiring rescue analgesia in the caudal group (64, 66.67%) was lower than that in the intravenous group (80, 81.63%) [relative risk = 0.82; 95% confidence interval: 0.69-0.97; P = .02]. These findings were also verified by trial sequential analysis. There were no significant differences in the side effects.

CONCLUSION

Caudal α₂ adrenoceptor agonists as adjuncts to local anesthetic during pediatric caudal block are more effective than intravenous injection. However, the results were affected by small sample size and significant heterogeneity.

Comparison of Adrenaline and Dexmedetomidine in Improving the Cutaneous Analgesia of Mexiletine in Response to Skin Pinpricks in Rats

BACKGROUND

Adrenaline (Adr) and dexmedetomidine (Dex) are commonly used adjuvants of local anesthetics; however, the difference in the improvement of analgesia of local anesthetics between the 2 adjuvants remains unclear.

OBJECTIVE

The objective of this experimental research was to evaluate the cutaneous analgesic effect of mexiletine (Mex) by coadministration with Dex or Adr.

METHODS

The effect of a nociceptive block was assessed based on the inhibition of the cutaneous trunci muscle reflex in response to skin pinpricks in rats. The analgesic activity of Mex alone and Mex coadministered with Dex or Adr was evaluated after subcutaneous injections. Subcutaneous injections of drugs or combinations include Mex 0.6, 1.8, and 6.0 μmol; Adr 13.66 nmol; Dex 1.05600 nmol; saline; and Mex 1.8 and 6.0 μmol, respectively, combined with Dex 0.01056, 0.10560, and 1.05600 nmol or Adr 0.55, 2.73, and 13.66 nmol, with each injection dose of 0.6 mL.

RESULTS

Subcutaneous injections of Mex elicited dose-related cutaneous analgesia. Compared with Mex (1.8 μmol), adding Dex or Adr to Mex (1.8 μmol) solutions for skin nociceptive block potentiated and prolonged the action. Mex (6.0 μmol) combined with Dex or Adr extended the duration of cutaneous analgesia when compared with Mex (6.0 μmol) alone. A high dose of Adr is more effective with Mex 1.8 μmol than that of Dex, whereas medium and low doses were less effective. Mex 6.0 μmol combined with any dose of Adr is superior to that of Dex.

CONCLUSIONS

Both Dex and Adr improve the sensory block and enhance the nociceptive block duration of Mex. But in most cases, Adr is superior to Dex. It may be that different mechanisms of action of the 2 adjuvants lead to the differences.

[Effects of caudal block in pediatric surgical patients: a randomized clinical trial]

BACKGROUND

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

OBJECTIVES

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

METHODS

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

RESULTS

Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

CONCLUSIONS

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Effects of caudal block in pediatric surgical patients: a randomized clinical trial

Background

Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system.

Objectives

The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods.

Methods

This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient.

Results

Children who received a caudal block had significantly lower serum glucose (p <  0.01), cortisol concentrations (p <  0.01) and pain scores 3 h (p =  0.002) and 6 h (p =  0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group.

Conclusions

The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

Ultrasound-guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex

BACKGROUND

Ultrasound-guided quadratus lumborum block is a regional anesthetic technique which can provide perioperative analgesia for all age groups, including pediatric patients undergoing abdominal surgery. We hypothesized that the quadratus lumborum block would be as efficacious as a caudal block, the gold standard of pediatric lower abdominal regional anesthesia, in providing pain control after ureteral reimplantation but also have a longer duration.

METHODS

Forty-seven pediatric patients between the ages of 1 and 17 years undergoing bilateral ureteral reimplantation surgery via a low transverse incision were enrolled and randomized into the quadratus lumborum block and caudal block groups. All blocks were performed preoperatively under general anesthesia. We analyzed the following outcomes: the requirement for narcotic analgesics, pain score, episodes of emesis, and complications at 0, 4, 24, and 48 hours postoperatively.

RESULTS

The study included 44 patients after excluding three who were ineligible. The fentanyl requirement for postoperative rescue analgesia during the first 24 hours was significantly lower in the quadratus lumborum block group than in the caudal block group (median [interquartile range]: 0 [0-1] vs 3 [0-5], P = 0.016, 95% confidence intervals: -4 to 0) but not at 30 minutes, 4, or 48 hours. No significant difference was observed in the pain scores or the incidence of interventions to treat nausea and vomiting during the entire period. No postoperative complication was observed.

CONCLUSION

The quadratus lumborum block was more effective in reducing the postoperative opioid requirement for rescue analgesia during the initial 24 hours than caudal ropivacaine/morphine.

Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit

Introduction

Caudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia.

Materials and methods

Data of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained.

Results

Data of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001).

Conclusion

Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

Evaluation of postoperative analgesia in pediatric patients after hip surgery: lumbar plexus versus caudal epidural analgesia

Background:There continues to be focus on the value of regional and neuraxial anesthetic techniques when combined with general anesthesia to improve postoperative analgesia. The reported advantages include decreased postoperative opioid requirements, decreased medication-related adverse effects, decreased hospital length of stay, and increased patient satisfaction. Orthopedic procedures of the hip may be amenable to such techniques as there is significant postoperative pain with the requirement for hospital admission and the administration of parenteral opioids. Given the surgical site, various regional anesthetic techniques may be used to provide analgesia including caudal epidural anesthesia (CEA) or lumbar plexus blockade (LPB).

Purpose: The objective of this study was to assess the effectiveness of LPB versus CEA as an analgesic thechnique for patients undergoing elective hip surgery from the opioid consumption and pain scores perspective.

Patients and methods: The current study retrospectively reviews our experience with CEA and LPB for postoperative analgesia after hip surgery in the pediatric population. Regional anesthesia technique was reviewed as well as opioid requirements and pain scores.

Results: The study cohort included 61 patients, 29 who received an LPB and 32 who received CEA. No difference was noted in the demographics between the two groups. Intraoperative opioid use was 0.7 (IQR: 0.5, 1.1) mg/kg of oral morphine equivalents (MEs) in the LPB group compared to 0.6 (IQR: 0.5, 0.9) in the CEA group (p=0.479). Postoperative opioid use over the first 48 hrs was 4 (IQR: 1, 6) mg/kg of oral ME in the LPB group, compared to 2 (interquartile range [IQR]: 1, 3) in the CEA group (p=0.103). Over the first 24 hrs after surgery, the median pain score in the LPB group was 5 (IQR: 1–6), compared to 3 (IQR: 0, 5) in the CEA group (p=0.014).Conclusion: These retrospective data suggest a modest postoperative benefit of CEA when compared to LPB following hip surgery in the pediatric population. Postoperative pain scores were lower in patients receiving CEA; however, no difference in the intraoperative or postoperative opioid requirements was noted between the two groups.

Caudal epidural blocks in paediatric patients: a review and practical considerations

Caudal epidural blockade in children is one of the most widely administered techniques of regional anaesthesia. Recent clinical studies have answered major pharmacodynamic and pharmacokinetic questions, thus providing the scientific background for safe and effective blocks in daily clinical practice and demonstrating that patient selection can be expanded to range from extreme preterm births up to 50 kg of body weight. This narrative review discusses the main findings in the current literature with regard to patient selection (sub-umbilical vs mid-abdominal indications, contraindications, low-risk patients with spinal anomalies); anatomical considerations (access problems, age and body positioning, palpation for needle insertion); technical considerations (verification of needle position by ultrasound vs landmarks vs 'whoosh' or 'swoosh' testing); training and equipment requirements (learning curve, needle types, risk of tissue spreading); complications and safety (paediatric regional anaesthesia, caudal blocks); local anaesthetics (bupivacaine vs ropivacaine, risk of toxicity in children, management of toxic events); adjuvant drugs (clonidine, dexmedetomidine, opioids, ketamine); volume dosing (dermatomal reach, cranial rebound); caudally accessed lumbar or thoracic anaesthesia (contamination risk, verifying catheter placement); and postoperative pain. Caudal blocks are an efficient way to offer perioperative analgesia for painful sub-umbilical interventions. Performed on sedated children, they enable not only early ambulation, but also periprocedural haemodynamic stability and spontaneous breathing in patient groups at maximum risk of a difficult airway. These are important advantages over general anaesthesia, notably in preterm babies and in children with cardiopulmonary co-morbidities. Compared with other techniques of regional anaesthesia, a case for caudal blocks can still be made.

Caudal and intravenous dexmedetomidine similarly prolong the duration of caudal analgesia in children: A randomized controlled trial

BACKGROUND

Dexmedetomidine can prolong the duration of action of a local anesthetic agent, but the route of administration that is the most beneficial remains unclear. The purpose of this study was to compare the clinical effectiveness of caudal or intravenous dexmedetomidine administration on postoperative analgesia in children undergoing inguinal hernia repair given caudal levobupivacaine.

METHODS

This was a prospective, randomized, double-blinded, placebo-controlled trial. Ninety ASA I subjects, aged 2-5 year, undergoing unilateral inguinal hernia repair were enrolled. The children were randomized in a double-blind fashion to three groups. The L-Dcau group received 1 mL/kg of caudal 0.25% levobupivacaine plus 1 μg/kg dexmedetomidine and IV 20 mL saline. The L-Div group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 1 μg/kg dexmedetomidine in 20 mL saline. The L group received 1 mL/kg of caudal 0.25% levobupivacaine and IV 20 mL saline. The primary outcome was the duration of analgesia, which was defined as the time from the caudal block to a Postoperative Pain Scale (CHIPPS) score ≥4. Secondary outcomes were the number of patients requiring rescue analgesia, pain intensity, the incidence of emergence agitation, intraoperative hemodynamic variations, residual motor block, and adverse effects.

RESULTS

The median duration of analgesia in the L-Dcau group was 14.2 hour compared to 6 hour in the L group with a median difference of 8.5 hour [95% CI (6.5, 10.5), P < 0.001]. The median duration of analgesia in the L-Div group was 12.4 hour compared to 6 hour in the L group with a median difference of 6.4 hour [95% CI (4, 8.5), P < 0.001]. Fewer patients in the L-Dcau and L-Div groups required rescue analgesia in the first 24 hour postoperatively compared to the L group, although there was no significant difference between the L-Dcau and L-Div groups for these outcomes. Both dexmedetomidine routes reduced the pain and the incidence of emergence agitation. No bradycardia, hypotension, or motor block was observed in any of the three groups.

CONCLUSION

Caudal and IV dexmedetomidine similarly prolong the duration of analgesia produced by caudal levobupivacaine.

Effect of dexmedetomidine added to ropivicaine for caudal anesthesia in patients undergoing hemorrhoidectomy: A prospective randomized controlled trial

BACKGROUND

To assess the effect of dexmedetomidine added to ropivaccaine on the onset and duration of sensory block, as well as postoperative analgesia during caudal anesthesia in patients undergoing hemorrhoidectomy.

METHODS

Fifty adult patients scheduled for hemorrhoidectomy were divided into 2 groups. The group R received caudal anesthesia using 18 mL 0.3% ropivacaine plus 2 mL normal saline. The group RD received 18 mL 0.3% ropivacaine plus 2 mL 1 μg/kg dexmedetomidine. Heart rate, mean blood pressure, onset time and duration of sensory block, and duration of analgesia were observed.

RESULTS

The onset time of sensory block was shortened (9.2 ± 1.3 vs 7.2 ± 1.2), and the duration of sensory block (3.0 ± 0.7 vs 3.8 ± 0.8) and duration of analgesia (3.9 ± 0.7 vs 5.3 ± 0.8) were prolonged in group RD compared with group R (P < .05). The heart rate and the mean blood pressure were also lower in the group RD compared with group R at each observation time points, except the baseline (P < .05). No bradycardia or hypotension was reported.

CONCLUSION

Dexmedetomidine as an adjuvant to ropivacaine prolonged the duration of caudal block and improved postoperative analgesia without significant side effects in adult patients undergoing hemorrhoidectomy.

Comparison of 3 different regional block techniques in pediatric patients. A prospective randomized single-blinded study

OBJECTIVES

To compare the analgesic efficiencies of caudal blocks, ultrasound (US)-guided transversus abdominis plane (TAP) blocks, and ilio-inguinal/ilio-hypogastric (II/IH) blocks performed to provide postoperative analgesia in pediatric patients undergoing unilateral lower abdominal surgery. Methods: This prospective, randomized, single-blinded study was conducted in the Department of Pediatric Surgery, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey from July 2013 to January 2015. The doses used were as follows: 0.5 ml/kg (group T), 0.3 ml/kg (group I), and 0.7 ml/kg (group C) of a 0.25% levobupivacaine solution with 1/200,000 adrenalin for the TAP block, II/IH block, and caudal block. The primary aim was to compare postoperative analgesic consumption within the first 24 hours after surgery. The secondary aim were to compare the mCHEOPS score, first analgesic requirement time, vital signs, and undesirable effects such as nausea and vomiting, which were recorded in the surgical ward at 1, 4, 8, 16, and 24 hours after surgery. Results: Ninety patients with American Society of Anesthesiology physical status class I-II were randomized into 3 groups (group I, group T, and group C). The total amount of analgesic consumption was significantly higher in Group I compared with Groups T and C (p=0.003). Pain scores at 1, 4, and 8 hours were significantly higher in Group I compared with the other 2 groups; however, pain scores in Group I at 16 hours were significantly higher only compared with Group C (p less than 0.05). Conclusion: Caudal and TAP blocks are more effective than II/IH nerve blocks in the early postoperative period.

Caudal and intravenous dexamethasone as an adjuvant to pediatric caudal block: A systematic review and meta-analysis

BACKGROUND

Dexamethasone has become a popular additive for regional anesthesia. The aim of this meta-analysis was to assess the effectiveness of this additive on the duration of postoperative analgesia, postoperative vomiting, and possible adverse events in pediatrics.

METHODS

We searched databases, conference records, and registered trials for randomized controlled trials. The databases included the Cochrane Library, JBI Database of Systematic Reviews, PubMed, ISI Web of Knowledge, Science-Direct, and Embase. Odds ratio, weighted mean difference, and the corresponding 95% confidence intervals were calculated using the REVMAN software, version 5.3, for data synthesis and statistical analysis, which following the PRISMA statement. The main outcomes were duration of postoperative analgesia (time from the end of surgery to first administration of analgesics as evidenced by a pain score) and postoperative vomiting.

RESULTS

Seven studies were selected for this meta-analysis, involving 647 pediatric patients. All the patients were randomized to receive caudal or intravenous dexamethasone with caudal block (experimental group) or plain caudal block (control group). There was significantly longer duration of postoperative analgesia in the experimental group compared with control group (weighted mean difference: 238.40 minutes; 95% CI: 193.41-283.40; P < .00001). The experimental group had fewer patients who needed analgesics after surgery (odds ratio: 0.18 minutes; 95% CI: 0.05-0.66; P = .009). Additionally, the number of subjects who remained pain-free to 2, 6, 24, and 48 hours after operation was significantly greater in the experimental group than control group. Side effects in these 2 groups were comparable (odds ratio: 0.94; 95% CI: 0.34-2.56; P = .90). The incidence of postoperative vomiting was significantly decreased in the experimental group compared with control group (odds ratio: 0.29; 95% CI: 0.13-0.63; P = .002).

CONCLUSION

Caudal and intravenous dexamethasone could provide longer duration of postoperative analgesia and reduced the incidence of postoperative vomiting with comparable adverse effects than plain caudal block. However, any additive to the caudal space carries with it the potential for neurotoxicity and that caution should always be exercised when weighting the risks and benefits of any additive. The result was influenced by small numbers of participants and significant heterogeneity.

Ultrasound-guided bilateral superficial cervical plexus block for thyroid surgery: The effect of dexmedetomidine addition to bupivacaine-epinephrine

Background:

The thyroid gland surgery is a common and painful procedure demanding analgesia. Many regional techniques are applied for anterior neck surgeries mostly assigned in relation to the involved cervical fascia. Dexmedetomidine (Precedex) is a selective alpha 2 adrenoceptor agonist which prolongs the sensory blockade duration of local anesthetics. Our study hypothesis is that ultrasound (US)-guided bilateral superficial cervical plexus block (BSCPB) may provide longer analgesia when adding dexmedetomidine to bupivacaine-epinephrine.

Purpose:

The aim of this study is to evaluate the analgesic efficacy and possible side effects of US-guided BSCPB and the effect of dexmedetomidine addition to bupivacaine-epinephrine in patients undergoing thyroid surgery.

Methods:

This prospective, double-blind, randomized study was performed on 42 patients randomized into two equal groups each of 21; bupivacaine Group B and dexmedetomidine Group D. Patients with contraindications to regional anesthesia or uncontrolled comorbidities were excluded from the study. Total pethidine consumption in 24 h is the primary outcome. The visual analog scale, timing of the first opioid request, and hemodynamics are the secondary outcomes.

Results:

In Group D, there was a longer time to the first request of opioid postoperatively, a lower total pethidine consumption and pain score postoperatively, and lower fentanyl requirements intraoperatively.

Conclusions:

Sonographic-guided bilateral SCPB using a combination of bupivacaine, dexmedetomidine, and epinephrine was superior to bupivacaine for prolonged analgesia with less intra- and postoperative opioid consumption and lower side effect profile during thyroid surgery.

Ultrasound-guided versus conventional injection for caudal block in children: A prospective randomized clinical study

STUDY OBJECTIVE

The aim of this study was to compare the efficacies of ultrasound guided sacral hiatus injection and conventional sacral canal injection performed for caudal block in children.

DESIGN

Randomized controlled clinical trial.

SETTING

Operating rooms of university hospital of Erzurum, Turkey.

PATIENTS

One hundred-thirty four children, American Society of Anesthesiologists I-II, between the ages of 5 and 12, scheduled for elective phimosis and circumcision surgery.

INTERVENTIONS

Patients assigned to two groups for ultrasound guided caudal block (Group U, n=68) or conventional caudal block (Group C, n=66). Caudal solution was prepared as 0.125% levobupivacaine plus 10mcg/kg morphine (total volume: 0.5ml/kg), and was administered to both groups.

MEASUREMENTS

The block performing time, the block success rate, the number of needle puncture, the success at first puncture and the complications were recorded.

MAIN RESULTS

The block performing time and the success rate of block were similar between Group U and Group C (109.96±49.73s vs 103.17±45.12s, and 97% vs 93%, respectively p>0.05). The first puncture success rate was higher in Group U than in Group C (80% vs 63%, respectively p=0.026). No significant difference was observed between the groups with regard to the number of needle punctures (p=0.060). The rates of vascular puncture and subcutaneus bulging were higher in Group C than in Group U (8/66 vs 1/68, and 8/66 vs 0/68, respectively p<0.05).

CONCLUSIONS

Despite the limitations in central neuroaxial anesthesia we recommend the use of ultrasound since it reduces the complications and increases the success rate of first puncture in pediatric caudal injection.

Epidural analgesia in a paediatric teaching hospital: Trends, developments, and a brief review of literature

Introduction:

Continuous epidural analgesia has proven to be a good tool in the anaesthetist’s quest to provide excellent pain relief for an extended perioperative period. Pharmaceutical advances provide us with a larger array of both local anaesthetic (LA) drugs and additives that can prolong the duration or enhance the quality of analgesia, or both. The avoidance of LA toxicity is of paramount importance for safe prescription, especially in the high-risk neonatal and infant cohort, and all patients stand to benefit from ‘safer’ LA agents and adjuvants that promote the use of a lowered concentration of epidural LA infusions. We present a descriptive review of trends in epidural prescription and technique in our hospital.

Methods:

Our observational study was conducted over a period of 19 years in a tertiary paediatric teaching hospital. Prospectively collected data that included patient demographics, level of epidural catheter insertion, LA drugs and adjuvants used, as well as postoperative infusion rates, were then analysed retrospectively.

Results:

There was a decline in the use of paediatric epidural analgesia. Over the study period, we also observed a shift in preference of LAs and adjuvant drugs toward safer alternatives.

Conclusion:

Paediatric epidural analgesia is gradually being superseded by other analgesic modalities with superior safety profiles (e.g. peripheral neural blockade). However, indications remain for its continued use, and anaesthetists should be familiar with its technical aspects and pitfalls.

Adjuvants to local anesthetics: Current understanding and future trends

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids (dexamethasone), anti-inflammatory agents (parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action (tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability (liposomal, microspheres and cyclodextrin systems) and further studies with other drugs (adenosine, neuromuscular blockers, dextrans).

The effect of adjunct caudal block on postoperative analgesia in robot-assisted laparoscopic radical prostatectomy: A prospective randomized controlled, single blinded pilot study in a tertiary centre

Objective

Caudal block provides satisfactory postoperative pain relief in lower abdominal operations. This pilot study explores its safety and effect on postoperative pain control in patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP).

Methods

From 2013 to 2014, 40 consecutive patients were randomized into two groups - one received caudal block using ropivacaine immediately after operation, the other received standard analgesia. Primary outcome measure was pain score based on 11-point Likert scale (0-10) recorded at recovery room, and at 6, 12, 24, 48, and 72 h after operation. All analgesic requirements, opioid-related adverse events and time to passage of flatus were examined.

Results

Mean age of the two groups was similar (60.4 vs. 62.3 years, p = 0.33), as was American Society of Anaesthesiologists (ASA) class, body mass index (BMI) and operation times. No significant difference in median pain scores was reported in recovery room (2 vs. 3, p = 0.34), and at 6 h (2 vs. 2, p = 0.94), 12 h (0 vs. 0, p = 0.62), 24 h (1 vs. 0, p = 0.58), 48 h (1 vs. 0, p = 0.36) and 72 h (0 vs. 0, p = 0.78) postoperatively between control and caudal block groups, respectively. There was a higher mean opioid usage in the caudal block group which was not statistically significant. Although this was statistically insignificant while no significant difference in mean paracetamol usage was observed postoperatively. Median time to passage of flatus was similar (2.0 vs. 2.0 days, p = 0.97). There was one case of superficial wound infection and no opioid-related adverse events observed. Hospital stay was similar in both groups (2.5 vs. 2.5 days, p = 0.96).

Conclusion

Although a safe modality, caudal block in post RARP patients does not seem to improve pain control nor reduce analgesia requirements.

Awake caudal anaesthesia in neonates/young infants for improved patient safety

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.

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.

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates

PURPOSE

The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants.

METHODS

A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter.

RESULTS

Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day.

CONCLUSION

Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

A review of perioperative anesthesia and analgesia for infants: updates and trends to watch

This review focuses on pharmacokinetics and pharmacodynamics of opioid and non-opioid analgesics in neonates and infants. The unique physiology of this population differs from that of adults and impacts drug handling. Morphine and remifentanil are described as examples of older versus recently developed opiates to compare and contrast pharmacokinetics and pharmacodynamics in infants. Exploration of genetics affecting both pharmacokinetics and pharmacodynamics of opiates is an area of active research, as is the investigation of a new class of mu-opiate-binding agents which seem selective for analgesic pathways while having less activity in pathways linked to side effects. The kinetics of acetaminophen and of ketorolac as examples of parenteral non-steroidal analgesics in infants are also discussed. The growth in regional anesthesia for peri-operative analgesia in infants can fill an important role minimizing intra-operative anesthetic exposure to opioids and transitioning to post-operative care. Use of multi-modal techniques is recommended to decrease undesirable opiate-related side effects in this vulnerable population.

Topical versus caudal ketamine/bupivacaine combination for postoperative analgesia in children undergoing inguinal herniotomy

Background:

Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy.

Patients and Methods:

This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topical group). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative.

Results:

Kaplan–Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P = 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6^th till 48^th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia.

Conclusion:

Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair.

Caudal anesthesia in a patient with peritonitis: Is it safe??

Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented.

Fluoroscopically guided tunneled trans-caudal epidural catheter technique for opioid-free neonatal epidural analgesia

Epidural analgesia confers significant perioperative advantages to neonates undergoing surgical procedures but may be very technically challenging to place using a standard interlaminar loss-of-resistance to saline technique given the shallow depth of the epidural space. Thoracic epidural catheters placed via the caudal route may reduce the risk of direct neural injury from needle placement, but often pose higher risks of infection and/or improper positioning if placed without radiographic guidance. We present a detailed method of placing a fluoroscopically guided, tunneled transcaudal epidural catheter, which may reduce both of these risks. The accuracy and precision of this technique often provides adequate analgesia to allow for opioid-free epidural infusions as well as significant reductions in systemic opioids through the perioperative period. Opioid-free analgesia using a regional anesthetic technique allows for earlier extubation and reduced perioperative sedation, which may have a less deleterious neurocognitive effect on the developing brain of the neonate.

The role of ultrasound guidance in pediatric caudal block

Objectives:

To compare the time interval of the procedure, possible complications, post-operative pain levels, additional analgesics, and nurse satisfaction in ultrasonography-guided and standard caudal block applications.

Methods:

This retrospective study was conducted in Celal Bayar University Hospital, Manisa, Turkey, between January and December 2014, included 78 pediatric patients. Caudal block was applied to 2 different groups; one with ultrasound guide, and the other using the standard method.

Results:

The time interval of the procedure was significantly shorter in the standard application group compared with ultrasound-guided group (p=0.020). Wong-Baker FACES Pain Rating Scale values obtained at the 90th minute was statistically lower in the standard application group compared with ultrasound-guided group (p=0.035). No statistically significant difference was found on the other parameters between the 2 groups. The shorter time interval of the procedure at standard application group should not be considered as a distinctive mark by the pediatric anesthesiologists, because this time difference was as short as seconds.

Conclusion:

Ultrasound guidance for caudal block applications would neither increase nor decrease the success of the treatment. However, ultrasound guidance should be needed in cases where the detection of sacral anatomy is difficult, especially by palpations.

Regional anaesthesia in neonates, infants and children: an educational review

Prophylactic analgesia with local anaesthesia is widely used in children and has a good safety record. Performing regional blocks in anaesthetised children is a safe and generally accepted practice. When compared with adults, lower concentrations of local anaesthetics are sufficient in children; the onset of a block occurs more rapidly but the duration is usually shorter. Local anaesthetics have a greater volume of distribution, a lower clearance and a higher free (non-protein-bound) fraction. The recommended maximum dose has to be calculated for every individual. Peripheral blocks provide analgesia restricted to the site of surgery, and some of them have a very long duration of action. Abdominal wall blocks, such as transverse abdominis plane or ilio-inguinal nerve block, should be performed with the aid of ultrasound. Caudal anaesthesia is the single most important technique. Ropivacaine 0.2% or levobupivacaine 0.125 to 0.175% at roughly 1 ml  kg⁻¹ is adequate for most indications. Clonidine and morphine can be used to prolong the duration of analgesia. Ultrasound is not essential for performing caudal blocks, but it may be helpful in case of anomalies suspected at palpation and for teaching purposes. The use of paediatric epidural catheters will probably decline in the future because of the potential complications.

The Use of Epinephrine in Caudal Anesthesia Increases Stroke Volume and Cardiac Output in Children

BACKGROUND AND OBJECTIVES

Caudal anesthesia is a common and effective regional anesthesia technique in pediatric patients. The addition of epinephrine to local anesthetics in caudal anesthesia is a frequent practice; however, changes in hemodynamic and cardiac parameters produced by epinephrine in caudal anesthesia are not well studied. Using data collected with the ICON noninvasive cardiac output monitor, we examined the hemodynamic changes associated with the administration of epinephrine containing local anesthetics during caudal anesthesia in children.

METHODS

We performed a retrospective analysis of 40 patients who received caudal anesthesia among 402 patients from whom we prospectively collected continuous noninvasive cardiac output data using the ICON monitor, which estimates cardiac output by measuring changes in thoracic bioimpedance during the cardiac cycle. Twenty-three children received epinephrine with local anesthetic (ELA), and 17 children received only local anesthetic (OLA) in their caudal blocks. We compared heart rate (HR), stroke volume (SV), cardiac output (CO), and cardiac index (CI) changes from baseline before caudal injection to 1-minute intervals over 15 minutes after caudal injection for both ELA and OLA groups (Table, Supplemental Digital Content 1, http://links.lww.com/AAP/A179). We also performed subgroup analysis of the same parameters comparing both ELA and OLA groups in infants younger than 6 months and in children 6 months or older.

RESULTS

Stroke volume, CO, and CI are significantly increased after caudal injection in the ELA group compared with baseline values at caudal injection time. Conversely, there were no statistically significant changes in SV, CO, and CI in the OLA group. There were no significant HR or blood pressure changes observed in either the ELA or OLA group within 15 minutes compared with baseline caudal injection time. In infants younger than 6 months, no significant differences were found in HR, SV, and CI in children in the ELA group compared with the OLA group. In children 6 months or older, SV and CI increased significantly in the ELA group compared with the OLA group.

CONCLUSIONS

Epinephrine added to local anesthetic injected for caudal anesthesia produces significant increases in SV, CO, and CI in children. Stroke volume and CI changes from epinephrine added to local anesthetic for caudal anesthesia seem to take place only in children 6 months or older.