Caudal analgesia reduces the sevoflurane requirement for LMA removal in anesthetized children

General versus general anaesthesia combined with caudal block in laparoscopic-assisted Soave pull-through of Hirschsprung disease: a retrospective study

BACKGROUND

Caudal block is one of the most preferred regional anesthesia for sub-umbilical region surgeries in the pediatric population. However, few studies are available on caudal block performed in laparoscopic-assisted Soave pull-through of Hirschsprung disease (HD). We aimed to compare general anesthesia (GA) and general anesthesia combined with caudal block (GA + CA) in laparoscopic-assisted Soave pull-through of HD.

METHODS

A retrospective review was performed in children with HD operated in our hospital between 2017 and 2020. Patients were divided into the GA and GA + CA group. The primary outcome was the duration of operation, and secondary outcomes included intraoperative hemodynamic changes, the Face, Legs, Activity, Cry, Consolability (FLACC) scale, dose of anesthetics, and incidence of side effects.

RESULTS

A total of 47 children with HD were included in the study, including 20 in the GA group and 27 in the GA + CA Group. The two groups were similar in age, gender, weight and type of HD (P > 0.05). The GA + CA group had significantly shorter duration of operation (especially the transanal operation time) (median 1.20 h vs. 0.83 h, P < 0.01) and recovery time (mean 18.05 min vs. 11.89 min, P < 0.01). The mean doses of sufentanil and rocuronium bromide during the procedure and FLACC scores at 1 h and 6 h after surgery were also lower in the GA + CA group (p < 0.01). The hemodynamic changes in the GA + CA group were more stable at time of t2 (during transanal operation) and t3 (10 min after transanal operation), but there was no significant difference in the incidence of postoperative side effects between the two groups (P = 1.000).

CONCLUSION

General anesthesia combined with caudal block can shorten the duration of operation, and provide more stable intraoperative hemodynamics and better postoperative analgesia.

Minimum Alveolar Concentration of Desflurane for Maintaining BIS Below 50 in Children and Effect of Caudal Analgesia on it

Context:

Neuraxial techniques have sedative properties secondary to decreased inputs from sensory and motor afferents. We hypothesized that caudal analgesia decreases the requirement of desflurane as measured by bispectral index (BIS).

Aims:

This study aims to determine the minimum alveolar concentration (MAC) of desflurane for maintaining BIS below 50 (MACBIS₅₀) in children undergoing infraumbilical surgeries with laryngeal mask airway (LMA) and study the effect of caudal analgesia on the same.

Settings and Design:

This is prospective and observational study.

Subjects and Methods:

Thirty-nine American Society of Anesthesiologists physical status Classes I and II children in between 1 and 8 years of age undergoing elective infraumbilical surgery under general anesthesia were allocated randomly into two groups (Group C and Group D) after induction with sevoflurane and LMA insertion. In Group C, caudal block was performed with 0.75 mL/kg of 0.25% bupivacaine and BIS values were recorded after 10 min for 1 min at 10 s intervals. In Group D, BIS was recorded for desflurane for 1 min at 10 s intervals followed by a caudal block with the same dose.

Statistical Analysis Used:

Dixon up-down method with a step size of 0.5%, and probit analysis were used for analysis.

Results:

A total of 39 patients were enrolled. MAC of desflurane for maintaining MACBIS₅₀ was 5.57 (95% confidence interval [CI] 5.22–5.95) in Group D and 4.31 (95% CI 3.12–5.08) in Group C. The use of caudal anesthesia lowered the MAC of desflurane for maintaining MACBIS₅₀ in children by 22.36% (P < 0.001).

Conclusions:

The use of caudal analgesia significantly reduced MAC of desflurane for maintaining MACBIS₅₀ in children undergoing infraumbilical surgeries using LMA.

A study of the effect of caudal epidural block on bispectral index targeted propofol requirement in children: A comparative study

Caudal epidural block is one of the most commonly performed neuraxial block techniques with reliable peri-operative and post-operative analgesia in pediatric patients. In our randomized, prospective, double-blinded, open level, parallel group study, we have established the effect of caudal epidural block on maintenance requirement of intravenous (IV) propofol in targeted bispectral (BIS) monitored patients.

Context:

Neuraxial anesthesia exhibits sedative properties that may reduce the requirement for general anesthesia. TIVA with propofol has been administered as an established method of maintaining general anesthesia in children. Caudal analgesia being a type of neuraxial block, also seems to reduce the requirement of sedative hypnotics in pediatric patients. Numerous studies show that for patients, administered with caudal epidural block, they require reduced intra-operative volatile inhalation anesthetics. In the present study, we have established the anesthetic sparing effect of Caudal Epidural Analgesia in children undergoing infra-umbilical surgical procedure and calculated the efficacy of propofol-infusion in maintaining adequate depth of anesthesia.

Aims:

(1) To study and compare the dose requirements of propofol using caudal epidural analgesia. (2) To calculate the efficacy of propofol as maintenance anesthetic agent in both groups and to compare hemodynamic stability of patients in both the techniques.

Settings and Design:

In our study, after administering general anesthesia to pediatric patients, we have administered caudal analgesia and IV analgesia to monitor the requirement of intra-operative propofol infusion using BIS monitor with a target value of 40-60 in both groups.

Materials and Methods:

82 patients (aged between 3 and 6 years) have been selected undergoing infra-umbilical surgery and randomly allocated into two groups containing 41 patients in each group. Both the groups group B and group A then intubated with glycopyrrolate, 2 mg/kg injection fentanyl, propofol till loss of verbal contact and atracurium at the rate of 0.5 mg/kg and group B has been administered caudal epidural blockade with 1 ml/kg 0.2% ropivacaine. Propofol infusion at the rate of 10 mg/kg/h is given as maintenance. BIS value has been recorded throughout and propofol requirement at the end of surgery has been calculated.

Statistical Analysis Used:

Numerical variables between groups have been analyzed using the Student's t-test and the Mann-Whitney U-test as applicable. Categorical variables have been analyzed using the Pearson's Chi-square test. P < 0.05 is considered statistically significant.

Results:

Consumption of propofol at the start of operation in the group A is 2.9 ± 0.17 and group B is 2.91 ± 0.17, which is not statistically significant (P > 0.05), whereas at the end of the operation in the group A is 11.33 ± 0.17 and group B is 7.83 ± 0.63, which is statistically significant (P < 0.05). Incidence of adverse effects is statistically insignificant between the two groups. The time for administration of rescue analgesic is 2.1 ± 0.88 in group A and 6.5 ± 0.17 in group B, which is statistically significant due to caudal analgesia.

Conclusions:

We conclude that in BIS-monitored patients (3-6 years) with infra-umbilical surgeries have shown a reduction in consumption of IV propofol due to caudal epidural blockade.

The volume effect of lidocaine on thoracic epidural anesthesia in conscious Beagle dogs

OBJECTIVE

To evaluate the volume effect of local anesthetic solution on thoracic epidural analgesia in dogs.

STUDY DESIGN

Prospective, experimental trial.

ANIMALS

Five healthy adult Beagle dogs weighing 9.7 ± 1.3 kg.

METHODS

A catheter was inserted into the seventh thoracic epidural space using a lumbosacral approach, and secured with suture under total intravenous (IV) anesthesia with propofol. Each dog was administered four volume treatments (0.05, 0.10, 0.15 and 0.20 mL kg(-1)) of 2% lidocaine via the catheter at 12 hour intervals. In every treatment, dogs were re-anesthetized with propofol (6 mg kg(-1), IV) and isoflurane, and received iohexol at each volume to visualize the epidural distribution (ED) through computed tomography. Three hours after epidurography, when dogs had recovered from anesthesia, the appropriate volume of lidocaine was injected through the catheter, and sensory blockade (SB) in dermatomes was evaluated by pinching with a mosquito forceps. Results were presented as median (range), and the volume effect on ED and SB was analyzed with one-way Kruskal-Wallis anova.

RESULTS

In proportion to volumes (0.05, 0.10, 0.15 and 0.20 mL kg(-1)), there were significant increases in the extent of ED from 7.4 (5.5-9.0) to 10.4 (8.0-12.0), 13.2 (12.5-13.0), and 15.2 (13.0-18.0) vertebrae, respectively, p < 0.001, and in SB from 2.7 (1.0-5.0) to 6.8 (4.5-10.5), 9.9 (6.5-13.0), and 13.1 (11.0-15.0) dermatomes, respectively, p < 0.001. Unilateral ED and SB were observed in all treatments with various grades, and this distribution was more frequent in the low volume treatments. In the high volume treatments, temporary complications including Horner's syndrome, ataxia, paraplegia, depression, stupor, and intermittent cough occurred often.

CONCLUSIONS AND CLINICAL RELEVANCE

The increase in volume of local anesthetic solution improved SB by resulting in more consistent bilateral dermatome blockade as well as an extended blockade. However, caution should be exerted, as higher volume injections of lidocaine caused side effects in all dogs.