Effects of dexmedetomidine added to caudal ropivacaine in paediatric lower abdominal surgeries

A double-blinded randomized control trial to compare the duration of analgesia using morphine, clonidine, or dexmedetomidine as adjuvants to ropivacaine in caudal anesthesia in children undergoing infraumbilical surgeries

Background and Aims

Adjuvants added to the caudal block prolong the duration of analgesia. In a developing country with economic constraints, the choice of an adjuvant will be the medication with a longer duration of analgesia, a favorable side-effect profile, and the least expensive option. We wished to study the duration of postoperative analgesia afforded by three adjuvants: morphine, clonidine, and dexmedetomidine, at doses wherein minimal or nil adverse effects would be attributed to the adjuvant. The primary objective of the current study is to compare the duration of postoperative analgesia with morphine, clonidine, or dexmedetomidine as adjuvants to 0.2% ropivacaine in a for caudal block, in children undergoing elective abdominal, urogenital, and lower limb surgeries. The secondary objectives are (a) to study the total analgesic requirement during the first 24 hours after surgery and (b) to compare the incidence of complications among the three groups.

Material and Methods

Sixty-three children aged 1-6 years, belonging to American Society of Anesthesia (ASA) physical status I, II, and scheduled to undergo elective infraumbilical surgeries, were enrolled in the study. The children were randomly assigned to one of three groups: Group D received a caudal block with dexmedetomidine 1 μg/kg, Group M received morphine 30 μg/kg, and Group C received clonidine 1.5 μg/kg. All groups also received 0.2% ropivacaine (1-1.25 ml/kg) as part of the caudal block. The duration of analgesia, total analgesic requirements during the first 24 hours after the surgery, and the incidence of complications in the three groups were monitored by a pain nurse who was blinded to the study allocation.

Results

The three groups were comparable with respect to age, sex, weight, and duration of surgery. The median time taken for the first rescue analgesic in the dexmedetomidine group was 380 minutes, in the clonidine group was 360 minutes, and in the morphine group was 405 minutes. Though the morphine group had a longer duration of analgesia, it was not statistically significant (P = 0.843). The total perioperative opioids used and side effects were similar among the three groups. There were no episodes of intraoperative bradycardia noted in Groups D, M, and C. However, one patient in Group D required treatment for bradycardia in the postanesthesia care unit. In terms of intraoperative hypotension, 10 patients (43.5%) in Group D, 5 patients (27.8%) in Group C, and 5 patients (22.7%) in Group M required treatment, but this difference was not statistically significant (P = 0.299). There was no significant difference observed in the time to awakening after the anesthesia among the three groups. Postoperative nausea and vomiting were noted in five patients (21.7%) in Group D, one patient (5.6%) in Group C, and four patients (18.2%) in Group M (P = 0.382). One patient in Group M had a sedation score of 5 and required 4 hours of supplemental oxygen via face mask in the ward. Additionally, one patient in Group D reported numbness in both feet lasting 12 hours with spontaneous resolution. While a significant number of patients in all three study groups experienced urinary retention, no patient reported pruritus in the ward.

Conclusion

Caudal administration of morphine, dexmedetomidine, and clonidine in children undergoing infraumbilical surgery resulted in an equivalent duration of analgesia.

Study of caudal ropivacaine with or without dexmedetomidine for postoperative analgesia in paediatric genitourinary infraumbilical surgery: a double-blinded randomized controlled trial

Various studies have described the use of Dexmedetomidine with local anaesthetic drugs in caudal blocks for the management of postoperative pain in children. This study was designed to determine the analgesic effect of caudal Dexmedetomidine with Ropivacaine in paediatric genitourinary infraumbilical surgeries. Postoperative analgesic effects of caudal Ropivacaine with or without Dexmedetomidine in paediatric genitourinary infraumbilical were evaluated. This study was a prospective, interventional, comparative study conducted after ethical approval from the institute. Informed expressed consent was taken from each patient's guardians. The sample size was calculated to be 31 in each group. The two groups were randomly assigned and the intervention involved caudal epidural injection with either Ropivacaine combined with Dexmedetomidine or Ropivacaine with Normal Saline. Children receiving Ropivacaine with Dexmedetomidine had a significantly prolonged duration of analgesia compared to those receiving Ropivacaine alone (840.35 ± 149.97 vs. 412.90 ± 93.46 min, P < 0.001). Postoperative rFLACC scores were consistently lower in the Dexmedetomidine group, indicating better pain control (P < 0.05 at 6, 12, and 24 h). Total analgesic consumption was lower in the Dexmedetomidine group (500.67 ± 212.92 vs. 741.75 ± 268.06 mg, P < 0.01). No significant differences in adverse effects were observed between the groups. The addition of Dexmedetomidine to Ropivacaine in caudal epidural significantly prolongs analgesia, improves pain control, and reduces analgesic consumption in paediatric genitourinary infraumbilical surgeries.

Analgesic effect of ropivacaine combined with dexmedetomidine in the postoperative period in children undergoing ultrasound-guided single-shot sacral epidural block: A systematic review and meta-analysis

Objective

This study aims to evaluate the efficacy of dexmedetomidine as an adjuvant to ropivacaine in prolonging postoperative analgesia and reducing pain scores in children undergoing surgery.

Methods

Five online databases were searched for RCTs on postoperative analgesia of pediatric patients undergoing ultrasound-guided single-shot sacral epidural block with dexmedetomidine as an adjuvant to ropivacaine up to January 2, 2023. Pain score and sedation score at 2, 4, 8, 12, and 24 h after the operation, the time of first receiving additional analgesic drugs, and the number of postoperative adverse effects were selected to compare the efficacy and safety of combined treatment with ropivacaine alone for pediatrics. The standard mean difference (SMD) or odds ratio (OR) and the corresponding 95% confidence interval (95%CI) were calculated by using a random-effects model.

Results

A total of 295 articles were retrieved, but only 20 records were included in this meta-analysis. The results showed that dexmedetomidine combined with ropivacaine for sacral epidural block in children undergoing ultrasound-guided single-shot sacral epidural block had a more prolonged analgesia effect (SMD = 3.47, 95%CI: 2.80, 4.14). There were lower analgesia scores at 2 h(T₁), 4 h(T₂), 8 h(T₃), 12 h(T₄), and 24 h(T₅) in postoperative period (T₁ : SMD = -1.02, 95%CI: -1.31, -0.72; T₂ : SMD = -1.02, 95%CI: -1.32, -0.72; T₃ : SMD = -0.84, 95%CI: -1.12, -0.56; T₄ : SMD = -0.61, 95%CI: -1.03, -0.20; T₅ : SMD = -1.03, 95%CI: -1.28, -0.78). And the incidence of adverse effects was similar between the two groups (OR = 0.84, 95%CI: 0.59, 1.18).

Conclusions

The results of this review and meta-analysis support that dexmedetomidine, as an adjuvant to ropivacaine, can improve postoperative analgesia of surgery and significantly prolong the analgesic time in children, with a similar incidence rate of adverse symptoms when compared with ropivacaine alone.

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.

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

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

Comparison between caudal epidural and ultrasound-guided ilioinguinal-iliohypogastric block with bupivacaine and dexmedetomidine for postoperative analgesia following pediatric inguinal hernia surgeries: A prospective randomized, double-blind study

Background and Aims:

Caudal epidural and ultrasound-guided ilioinguinal, iliohypogastric nerve (IL/IH) blocks are commonly used regional anesthesia techniques for postoperative analgesia in pediatric inguinal surgeries. Dexmedetomidine as an adjuvant has been proven to prolong the duration of both neuraxial and peripheral nerve blocks. We compared the duration of analgesia provided by local anesthetic (LA) and dexmedetomidine for caudal and IL/IH block for pediatric inguinal surgeries.

Material and Methods:

Forty-six children undergoing inguinal hernia repair were selected for this randomized double-blind study. After general anesthesia, children received either 0.75 mL.kg⁻¹ of 0.25% bupivacaine with 1 mcg.kg⁻¹ of dexmedetomidine in caudal epidural or 0.25 mL.kg⁻¹ of 0.25% bupivacaine with 1 mcg.kg⁻¹ of dexmedetomidine in IL/IH block. The pain was assessed up to 24 h postoperatively using face, legs, activity, cry, consolability (FLACC) score. For FLACC ≥4, rescue analgesia was provided using 1 μg/kg of intravenous fentanyl, up to 2 h postoperatively and 10 mg/kg of oral ibuprofen between 2 and 24 postoperative hours. The time for first rescue analgesia was taken as the duration of analgesia.

Results:

There were no significant differences in the pain scores or analgesic utilization between the groups. The duration of analgesia of caudal and IL/IH blocks was similar (720.3 ± 430.1 min and 808.4 ± 453.1 min, respectively). The time taken for the performance of block was significantly higher for caudal compared to IL/IH (547 ± 93 vs. 317 ± 179 s; P < 0.001).

Conclusion:

Both caudal epidural and USG-IL/IH block with dexmedetomidine as additive provide the comparable duration of postoperative analgesia with no significant side effects.

Efficacy of dexmedetomidine as an adjunct to ropivacaine in transversus abdominis plane block for paediatric laparoscopic surgeries: A double-blinded randomised trial

Background and Aims

α₂ agonists have been utilised in regional blocks, but very little data is available for their use in transversus abdominis plane (TAP) block in paediatric laparoscopic (LAP) surgeries. This study investigated the analgesic effect of ropivacaine alone versus its combination with dexmedetomidine for TAP block in children undergoing LAP surgery.

METHODS

A randomised, double-blind trial was conducted in 50 American Society of Anesthesiologists (ASA) 1 and 2 children of 2-8 years undergoing LAP abdominal surgery. Children were randomised to receive a total volume of 0.5 ml/kg of 0.2% ropivacaine (LA group) or 0.2% ropivacaine with 1 μg/kg dexmedetomidine (LAD group) for performing ultrasound-guided bilateral TAP block postoperatively (PO). Patients were monitored PO for vital signs, pain, sedation, time to first rescue analgesic and total analgesic consumption for 24 h. Time to first rescue analgesic was expressed as mean ± standard deviation (SD) and analysed using Kaplan-Meier survival analysis. Pain and sedation scores were expressed as median [interquartile range (IQR)] and analysed using Mann-Whitney U test.

Results

First rescue analgesic demand was significantly longer (P = 0.001) in LAD (474.8 min) versus LA group (240.9 min) but total analgesics consumption in first 24 h was comparable. Pain scores were significantly lower (P < 0.05) in LAD compared to LA group at all times PO. Each group had comparable but significantly lower sedation scores up to 24 h PO.

Conclusion

Addition of dexmedetomidine to ropivacaine in TAP block prolongs the time to first analgesic requirement without a difference in the total analgesic consumption.

Efficacy and safety of caudal dexmedetomidine in pediatric infra-umbilical surgery: a meta-analysis and trial-sequential analysis of randomized controlled trials

BACKGROUND

Dexmedetomidine is used as a local-anesthetics adjuvant in caudal block to prolong analgesia in pediatric infra-umbilical surgery.

OBJECTIVE

We evaluated the analgesic efficacy and safety of the addition of caudal dexmedetomidine to local anesthetics (vs local anesthetics alone) in pediatric infra-umbilical surgery.

EVIDENCE REVIEW

We searched 10 databases for randomized controlled trials (RCTs) of pediatric patients undergoing infra-umbilical surgery, comparing caudal block with and without dexmedetomidine as local anesthetic adjuvant. We performed a frequentist random-effects meta-analysis (R statistical package). We analyzed continuous outcomes as a ratio of means (ROM) and dichotomous data as relative risk (RR), along with 95% CI. We included 19 RCTs (n=1190 pediatric patients) in the meta-analysis. The primary outcome was duration of analgesia (defined as 'the time from caudal injection to the time at which the study-specific pain score was greater than a cut-off threshold').

FINDINGS

Data from 19 included RCTs (n=1190) suggested that compared with control (mean duration 346 min), the addition of caudal dexmedetomidine significantly prolonged the duration of analgesia (ratio of means 2.14, 95% CI 1.83 to 2.49, p<0.001; 'moderate' evidence). Trial-sequential analysis showed adequate 'information size' for the primary outcome. Caudal dexmedetomidine also reduced the number of analgesic administrations ('low' evidence), total acetaminophen dose ('moderate' evidence) and the risk of emergence delirium ('moderate' evidence). There were no significant differences in adverse effects such as hypotension, bradycardia, post-operative nausea and vomiting, urinary retention and respiratory depression.

CONCLUSIONS

Our results suggest that the addition of dexmedetomidine to local anesthetic in caudal block significantly improves the duration of analgesia and reduces the analgesic requirements, while maintaining a similar risk-profile compared with local anesthetic alone. Further data on neurological safety are needed.

Caudal dexmedetomidine in pediatric caudal anesthesia: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the efficacy and safety of caudal dexmedetomidine in pediatric caudal anesthesia (CA).

METHODS

We searched PubMed, Embased, and Cochrane Library (from inception to June 2019) for eligible studies. The primary outcomes were the time to first analgesia, time of postoperative eye opening, intraoperative endtidal sevoflurane concentration, and postoperative sedation score. We calculated pooled risk ratios (RR) and 95% CIs using random- or fixed-effects models.

RESULTS

Thirteen trials involving 793 patients were found. Meta-analysis showed that the time to first rescue pain medication and the time from the end of anesthesia to eye opening in the CA+dexmedetomidine group were significantly longer than in the CA group (P < .00001). The intraoperative end-tidal sevoflurane concentration in the CA+dexmedetomidine group was significantly decreased (P < .00001). Dexmedetomidine appeared to increase the rate of bradycardia in the CA+dexmedetomidine group (P = .04). Additionally, the sedation score in the CA+ dexmedetomidine group was significantly higher at 2 hours after the operation compared with the CA group (P < .00001 at 2 hours).

CONCLUSIONS

Caudally administered dexmedetomidine is a good alternative for prolonging postoperative analgesia with less pain, decreased intraoperative end-tidal sevoflurane concentration, and full postoperative sedation.

Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

Background

For children with cleft palates, surgeries at a young age are necessary to reduce feeding or phonation difficulties and reduce complications, especially respiratory tract infections and frequent sinusitis. We hypothesized that dexmedetomidine might prolong the postoperative analgesic duration when added to bupivacaine during nerve blocks.

Methods

Eighty patients of 1-5 years old were arbitrarily assigned to two equal groups (forty patients each) to receive bilateral suprazygomatic maxillary nerve blocks. Group A received bilateral 0.2 mL/kg bupivacaine (0.125%; maximum volume 4 mL/side). Group B received bilateral 0.2 mL/kg bupivacaine (0.125%) + 0.5 µg/kg dexmedetomidine (maximum volume 4 mL/side).

Results

The modified children's hospital of Eastern Ontario pain scale score was significantly lower in group B children after 8 hours of follow-up postoperatively (P < 0.001). Mean values of heart rate and blood pressure were significantly different between the groups, with lower mean values in group B (P < 0.001). Median time to the first analgesic demand in group A children was 10 hours (range 8-12 hr), and no patients needed analgesia in group B. The sedation score assessment was higher in children given dexmedetomidine (P = 0.03) during the first postoperative 30 minutes. Better parent satisfaction scores (5-point Likert scale) were recorded in group B and without serious adverse effects.

Conclusions

Addition of dexmedetomidine 0.5 µg/kg to bupivacaine 0.125% has accentuated the analgesic efficacy of bilateral suprazygomatic maxillary nerve block in children undergoing primary cleft palate repair with less postoperative supplemental analgesia or untoward effects.

Effects of Caudal Epidural Dexmedetomidine on Pain, Erythrocyte Sedimentation Rate and Quality of Life in Patients with Failed Back Surgery Syndrome; A Randomized Clinical Trial

Objective

To evaluate the effects of dexmedetomidine in caudal epidural on controlling pain, erythrocyte sedimentation rate (ESR) and quality of life in patients with failed back surgery syndrome (FBSS).

Methods

The study was a single-blind clinical trial. From the total of 70 patients suffering from low back pain caused by a failed back surgery syndrome were referred to Akhtar and Imam Hossein Hospitals between the ages of 25 to 75 years with a history of back pain more than 12 weeks and a visual analogue scale (VAS) score of higher than 3, and 50 people were randomly selected and divided into two groups of dexmedetomidine and control. The control group received an epidural dose of 10 cc containing triamcinolone and bupivacaine, and the dexmedetomidine group received an epidural dose of 10 cc, containing dexmedetomidine, triamcinolones and bupivacaine with diluted normal saline. Epidural caudal injections were performed in the abdomen in a laid down position. Before starting the study and at the end of the fourth week, the two test groups were measured for visual analogue scale (VAS) and ESR and were asked to complete the quality of life questionnaire.

Results

Overall, 50 patients with FBSS were enrolled. The mean age was 53.88 ± 8.9 years (range 25-75); 54% (27/50) were men. The results showed that the injection of dexmedetomidine in epidural caudal was associated with decreased pain (p=0.001) and improved quality of life (p=0.022), while showed no significant effect on ESR (p=0.110).

Conclusion

Administration of dexmedetomidine in the epidural caudal is effective in controlling pain and quality of life in patients with failed back surgery syndrome.

A Randomized Controlled Trial Study on the Effect of Adding Dexmedetomidine to Bupivacaine in Supraclavicular Block Using Ultrasound Guidance

Background

The benefits of regional anesthetic techniques are well established. Use of additives to local anesthetics can prolong these benefits. The aim of this study was to find out the effect of adding dexmedetomidine to bupivacaine for supraclavicular block.

Methods

In this randomized, double-blind study, 70 ASA I & II patients of either sex undergoing elective surgeries on the upper limb were given supraclavicular block under ultrasound guidance. Group C (n=35) received 38 mL 0.25% bupivacaine + 2mL normal saline and group D received 38 mL 0.25% bupivacaine + 1 µg/kg dexmedetomidine (2mL). Patients were observed for, onset of motor and sensory block, duration of motor and sensory block, duration of analgesia, sedation score, hemodynamic changes and any adverse events.

Results

In group D, the onset was faster (P< 0.001), durations of sensory and motor block duration of and analgesia were prolonged as compared to group C (P < 0.0001).There was a significant drop in heart rate (HR) from the baseline in group D (P < 0.05) at 30, 60, 90 and 120 min. However, none of the patients dropped HR below 50/min. Mean Arterial Pressure (MAP) remained unaffected. The patients in group D were more effectively sedated than those in group C (P < 0.05). No adverse event was reported in either group.

Conclusion

Dexmedetomidine as adjuvant to bupivacaine in supraclavicular block resulted in faster action, prolonged motor and sensory block, prolonged analgesia with hemodynamic stability and adequate sedation.

Caudal Analgesia for Hypospadias in Pediatrics: Comparative Evaluation of Adjuvants Dexamethasone and Dexmedetomidine Combination versus Dexamethasone or Dexmedetomidine to Bupivacaine: A Prospective, Double-Blinded, Randomized Comparative Study

Background:

Caudal block is the most commonly used regional anesthetic technique in pediatric surgeries; different additives have been used for better and safer outcome.

Aim:

The aim of this study is to compare the combination of dexamethasone and dexmedetomidine as adjuvants to bupivacaine versus using each agent solely with bupivacaine in pediatric caudal block as regards their efficiency in pain relief (the duration of postoperative analgesia, first time to request analgesia, and modified objective pain score [MOPS]).

Study Design:

This was a prospective, double-blinded, randomized study.

Patients and Methods:

Patients and Methods: Sixty-three children scheduled for hypospadias surgery wererandomized into three groupsaccording to the adjuvant drug added to caudal bupivacaine : Group I (n = 21): dexamethasone 0.1 mg/kg + 0.5 mg/kg bupivacaine 0.25%, Group II (n = 21): dexmedetomidine0.01 μg/kg + 0.5 mg/kg bupivacaine 0.25% and Group III (n = 21): dexamethasone 0.1 mg/kg + dexmedetomidine 0.01 μg/kg + 0.5 mg/kgbupivacaine 0.25%. Intraoperative and postoperative hemodynamics were recorded. In postoperative anesthesia care unit and then the ward, MOPS and sedation score were recorded at 30 min and 1, 2, 3, 6 and 12 h. Further, the time of first analgesic request and side effects were recorded.

Statistical Analysis:

Categorical data were presented as frequencies (%) and analyzed using Chi-square test. Continuous data were presented as mean (standard deviation) and median (quartiles). Continuous data were analyzed using one-way analysis of variance for single measures and two-way mixed model for repeated measures. Kaplan–Meier analysis was performed for the duration of analgesia.

Results:

In Group III, MOPS was lower than Groups I and II at the study times. Further, Group III had prolonged time for first request of analgesic. Sedation scores were prolonged in Group III and Group II than in Group I. There was a reduction in heart rates in Group III more than Group I and Group II but with no significant difference. However, there was a significant reduction in mean arterial blood pressure 30 min intraoperatively and postoperatively in Group III as compared to Groups I and II.

Conclusion:

The addition of combined dexmedetomidine at a dose of 1 μg/kg and dexamethasone 0.1 mg/kg to caudal bupivacaine seemed to be an attractive alternative to each drug if used alone with more prolonged analgesia and almost no adverse effects.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Comparison of analgesic efficacy of caudal dexmedetomidine versus caudal tramadol with ropivacaine in paediatric infraumbilical surgeries: A prospective, randomised, double-blinded clinical study

Background and Aims:

Caudal epidural analgesia is commonly practised regional block technique in children undergoing infraumbilical surgeries but has a short duration of action after single shot local anaesthetic injection. The aim of this study was to compare ropivacaine 0.25% with dexmedetomidine and tramadol in caudal anaesthesia in paediatric infraumbilical surgeries.

Methods:

In a randomised, prospective, double-blinded study, sixty children (1–8 years) belonging to American Society of Anesthesiologists’ physical status I or II scheduled for infraumbilical surgeries were included. They were randomly assigned into two groups: Group ropivacaine with tramadol (RT) (n = 30) received 0.25% ropivacaine 1 mL/kg with 2 mg/kg of tramadol, and Group ropivacaine with dexmedetomidine (RD) (n = 30) received 0.25% ropivacaine 1 mL/kg with dexmedetomidine 2 μg/kg. The primary outcome variable was the duration of analgesia, and the secondary outcome variables included motor block, sedation score, time from caudal block to skin incision, emergence time and adverse effects.

Results:

The mean duration of analgesia was 654.20 ± 78.38 min in Group RT, while in Group RD, it was 780.29 ± 71.21 min (P = 0.0001). The difference between the mean sedation score and mean emergence time between the two groups were statistically significant (P = 0.0001 and 0.0411, respectively). No significant difference was observed in the incidence of haemodynamic changes or side effects.

Conclusion:

Caudal dexmedetomidine with ropivacaine prolongs post-operative analgesia compared to caudal tramadol with ropivacaine.

The Effect of Dexmedetomidine on Lumbar Epidural Injection for Failed Back Surgery Syndrome

Purpose. Failed back surgery syndrome is a chronic pain condition requiring rapid, effective, and efficient management. This study evaluates the effect of adding dexmedetomidine to lumbar epidural steroids in patients with failed back surgery syndrome. Methods. Fifty patients suffering from failed back surgery syndrome were randomly assigned to one of two groups, receiving an epidural injection of 20 mL of either a mixture of betamethasone (14 mg) and bupivacaine 0.5 mg (group C) or a mixture of betamethasone (14 mg), bupivacaine 0.5 mg, and dexmedetomidine (0.5 μg/kg) (group D) adjusted to the volume with normal saline. The effect was evaluated using visual analogue scale (VAS), analgesic requirement, and Oswestry disability index 2 weeks, 4 weeks, 8 weeks, and 12 weeks after injection. Results. VAS and ibuprofen consumption showed a significant reduction in group D. The Oswestry disability index was significantly improved in group D. There were no records of hypotension, bradycardia, sedation, or hypoxemia in both groups. Conclusion. The present study demonstrated potential safe and effective usage of adding dexmedetomidine to epidural steroid to control pain in patients with failed back surgery syndrome.

Effect of addition of dexmedetomidine to ropivacaine 0.2% for femoral nerve block in patients undergoing unilateral total knee replacement: A randomised double-blind study

BACKGROUND AND AIMS

Total knee replacement (TKR) patients experience considerable post-operative pain. We evaluated whether addition of perineural dexmedetomidine to ropivacaine 0.2% in the femoral nerve block would enhance post-operative analgesia in patients undergoing unilateral TKR under spinal anaesthesia.

METHODS

Fifty patients were allocated randomly to two groups of 25 each. Group D received ropivacaine (0.2%) with dexmedetomidine (1.5 μg/kg), and Group C received ropivacaine (0.2%) with normal saline. Pain scores, time to the first request for analgesia and total consumption of ropivacaine in 48 h, along with haemodynamic parameters and sedation scores, were recorded. Quantitative data were compared using t-test, categorical data using Chi-square or Fisher's exact test and time variables using ANOVA.

RESULTS

The mean pain scores were significantly low till 2 h post-operatively in Group D. Time to the first demand for analgesia after initial loading dose was statistically prolonged in Group D, with mean duration of 346.8 ± 240 min, compared to 150 ± 115.2 min in Group C (P = 0.001). Total local anaesthetic consumption was also decreased over 24 and 48 h in Group D (P = 0.001). Haemodynamically, there was no significant variation in heart rate from their baseline mean values in either group (P > 0.05). However, the drop in systolic and mean blood pressure post-surgery was significant till 4 (P = 0.002) and 8 h (P = 0.02), respectively, in Group D. Group D patients were also significantly more sedated till 4 h post-operatively (P < 0.005).

CONCLUSION

Adding dexmedetomidine to ropivacaine 0.2% in the femoral nerve block in patients undergoing unilateral TKR improves the quality and prolongs the duration of post-operative analgesia.

Comparison between two doses of dexmedetomidine added to bupivacaine for caudal analgesia in paediatric infraumbilical surgeries

Background and Aims:

Caudal block (CB) with adjuvants is routinely used in children for anaesthesia. We evaluated the efficacy of the α2 adrenergic agonist, dexmedetomidine at two different doses as an adjuvant to bupivacaine in CB.

Methods:

This study was conducted on ninety children. Control group BD0 received 0.25% bupivacaine 1 ml/kg, whereas, the study groups BD1 and BD2 received 1 μg/kg and 2 μg/kg dexmedetomidine, respectively, with 0.25% bupivacaine 1 ml/kg as a single shot CB. Adequacy of the block, haemodynamic changes, duration of analgesia and side effects were compared. Analysis of Variance was used for between-group comparisons of numerical variables. Student's t-test and Mann–Whitney U-test were used for quantitative data.

Results:

The demography was comparable. Anal sphincter 5 min after administration of the CB was relaxed in 89.3%, 82.1% and 75% of cases in BD0, BD1 and BD2 groups, respectively. The sphincter was relaxed at the end of surgery in all the cases. Comparable haemodynamics was noted with significantly prolonged duration of analgesia in the groups BD1 (964.2 ± 309 min) and BD2 (1152.6 ± 380.4 min) compared to control (444.6 ± 179.4 min). While no complications were encountered in groups BD0 and BD1, bradycardia was observed in four cases of BD2 group with accompanied hypotension in one of them.

Conclusion:

Dexmedetomidine as an adjuvant to bupivacaine improves the quality of CB, provides good operating conditions and increases the duration of post-operative analgesia. We conclude that 1 μg/kg is as effective as 2 μg/kg of dexmedetomidine and with a better safety profile.

Comparative study for better adjuvant with ropivacaine in epidural anesthesia

BACKGROUND

Better adjuvants for epidural analgesia are still evolving. Dexmedetomidine that is alpha-2 agonist can be used as an adjuvant in epidural analgesia and anesthesia.

AIMS

The aim of this study was to compare the effect of dexmedetomidine versus clonidine in combination with ropivacaine in epidural anesthesia on intraoperative and postoperative analgesia, to find out the better adjuvant for regional anesthesia.

SETTINGS AND DESIGN

Randomized control trial.

MATERIALS AND METHODS

Sixty adult patients (18-60 years) with American Society of Anesthesiologists (ASA) 1/ASA 2 grade and undergoing lower abdominal and lower limbs surgeries were included and randomized into three groups of 20 patients each. Group 1 - received ropivacaine with normal saline. Group 2 - received ropivacaine with dexmedetomidine. Group 3 - received ropivacaine with clonidine.

STATISTICAL ANALYSIS

Mean and Standard deviation were calculated. All the data were analyzed using analysis of variance and Chi-square test. The value of P< 0.05 was considered significant.

RESULTS

All the three groups were comparable with respect to age, sex, and ASA grade. There was statistically significant mean time to reach T10 sensory block level (15.8, 5.7, 9.6 min in Groups 1, 2, and 3, respectively). The maximum duration of analgesia was statistically higher in Group 2 patients (383.7 vs. 365.3 and 280.5 min in Group 3 and Group 1, respectively). The mean time to reach motor block was significantly shorter in Group 2. Side effects were comparable in all groups with statistically insignificant fall in mean arterial pressure and hypotension was noted with Group 2.

CONCLUSION

We concluded that the patients receiving the addition of dexmedetomidine to ropivacaine in epidural anesthesia had a faster onset and longer duration of sensory and motor blockade. Dexmedetomidine in comparison to clonidine had acceptable sedation and hemodynamic stability and minimal dose requirement make very effective adjuvant in epidural anesthesia with comparable side effects.

Dexmedetomidine as an adjuvant to bupivacaine in caudal analgesia in children

Context:

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

Aims:

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

Settings and Design:

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

Subjects and Methods:

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

Statistical Analysis Used:

Unpaired Student's t-test.

Results:

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

Conclusion:

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

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

Context:

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

Aim:

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

Settings and Design:

Double-blinded randomized controlled trial.

Materials and Methods:

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

Results:

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

Conclusion:

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

A comparative study of dexmedetomidine and fentanyl as adjuvants to levobupivacaine for caudal analgesia in children undergoing lower limb orthopedic surgery

Background:

Levobupivacaine is an effective local anesthetic agent with less systemic toxicity than racemic bupivacaine, but it has short postoperative analgesic duration. Dexmedetomidine and fentanyl are promising adjuncts to provide excellent and prolonged postoperative caudal analgesia. This study compared the effects of caudal levobupivacaine plus dexmedetomidine and levobupivacaine plus fentanyl for postoperative analgesia and sedation in children undergoing lower limb orthopedic surgery.

Patients and Methods:

Ninety children, whose age ranged from 1 to 7 years, American Society of Anesthesiologists I-II, undergoing orthopedic lower limb surgery under general anesthesia received caudal block for postoperative analgesia. The children were randomly allocated into three groups: Group L (control) received 0.75 ml/kg levobupivacaine 0.25% diluted in saline; Group LD received 0.75 ml/kg levobupivacaine 0.25% with dexmedetomidine 1 μg/kg; and Group LF received 0.75 ml/kg levobupivacaine 0.25% with fentanyl 1 μg/kg. Following the administration of the drugs; hemodynamic variables, the total anesthesia time, sedation score, Face, Legs, Activity, Cry, Consolability score, duration of analgesia, and side effects were recorded.

Results:

Demographically, all the groups were comparable, both the baseline and the intraoperative hemodynamic profile were similar in all groups. The mean duration of analgesia and the mean sedation score in the Group LD were significantly greater as compared to both the other groups.

Conclusion:

Dexmedetomidine may be a better additive to levobupivacaine than fentanyl for caudal postoperative analgesia, arousable sedation with comparable hemodynamic and side effect profile in children.

Comparison of caudal bupivacaine alone with bupivacaine plus two doses of dexmedetomidine for postoperative analgesia in pediatric patients undergoing infra-umbilical surgery: a randomized controlled double-blinded study

BACKGROUND

Data are still insufficient about the effects of different concentrations of caudal dexmedetomidine when used to prolong postoperative analgesia in children. The aim of this study was to assess the analgesic efficacy and side effects of two doses of caudal dexmedetomidine (1 and 2 μg·kg(-1)) co-administered with bupivacaine in terms of postoperative pain scores and requirement of postoperative analgesia over 24 h in children undergoing infra-umbilical surgery.

METHODS

Ninety-one children, aged 1-6 years, undergoing infra-umbilical surgery were included and randomly allocated into three groups of caudal block. Group B received 0.25% bupivacaine 2 mg·kg(-1) (0.8 ml·kg(-1)). Groups BD1 and BD2 received dexmedetomidine 1 and 2 μg·kg(-1), respectively along with bupivacaine 2 mg·kg(-1) in a total volume of 0.8 ml·kg(-1). Anesthesia was induced and maintained with sevoflurane in 100% oxygen. Hemodynamic and other routine intraoperative monitoring was carried out in addition to endtidal sevoflurane concentration. Time to spontaneous eye opening and postoperative pain and sedation scores were recorded in addition to time to first analgesia, paracetamol analgesic requirements, and any side effects during the first 24 postoperative hours.

RESULTS

Time to first analgesia requirement was significantly longer in BD1 and BD2 groups compared to B group with mean values (95% CI) of 809 min (652-965), 880 (733-1026), and 396 (343-448), respectively, P < 0.001. Postoperative paracetamol analgesic requirements over 24 h were higher in group B compared to BD1 and BD2 groups (Mean (95% CI): 3.2 (2.9-3.5) doses, 1.9 (1.5-2.3), and 1.6 (1.3-1.9), respectively), P < 0.001. The dexmedetomidine groups had significantly higher postoperative sedation scores compared to plain bupivacaine group that were dose dependent and for longer time in BD2 group. Two patients in BD2 group developed bradycardia and hypotension, and one developed urine retention compared to none in other groups.

CONCLUSION

A 1 μg·kg(-1) dose of caudal dexmedetomidine achieved comparable prolongation of postoperative analgesia to 2 μg·kg(-1) dose, with shorter duration of postoperative sedation and lower incidence of other side effects.

Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: a meta-analysis

BACKGROUND

Dexmedetomidine has become a popular additive for regional anesthesia. Aim of this meta-analysis was to assess the effect of this additive on the duration of postoperative analgesia and possible adverse events in pediatrics undergoing orchidopexy or lower abdominal surgery.

METHODS

The literature databases of PubMed, Google Scholar, and Cochrane Library were searched for randomized, controlled trials (RCTs). Odds ratio (OR), weighted mean difference (WMD), and the corresponding 95% confidence intervals (CIs) were calculated using the RevMan software, version 5.2, for data synthesis and statistical analysis, which in accordance with the PRISMA statement.

RESULTS

Six RCTs were selected for this meta-analysis, involving a total of 328 pediatric patients. There was a significant longer duration of caudal analgesia (time to first analgesic requirements) in patients receiving dexmedetomidine with CA compared with CA alone (WMD: -8.21 h; 95% CI: -11.40 to -5.02; P < 0.00001). Side effects in these two groups were comparable (OR: 1.02; 95% CI: 0.51-2.04; P = 0.95). Subgroup analysis indicated there was no significant difference in hemodynamic changes during operation (WMD: 1.78; 95% CI: -3.20 to 6.77; P = 0.48) and the emergence time (time from the end of surgery to opening the eyes on calling) after surgery (WMD: 0.47 min; 95% CI: -5.27 to 6.22; P = 0.87).

CONCLUSIONS

Dexmedetomidine as an additive to local anesthetic provides a significantly longer postoperative analgesia with comparable adverse effects and hemodynamic changes, when compared to local anesthetics alone. There were insufficient data of the effects of different concentrations of dexmedetomidine; further studies are required to explore this issue.

Comparative evaluation of ropivacaine versus dexmedetomidine and ropivacaine in epidural anesthesia in lower limb orthopedic surgeries

BACKGROUND

Various adjuvant are being used with local anesthetics for prolongation of intra operative and postoperative analgesia in epidural block for lower limb surgeries. Dexmedetomidine, the highly selective α2 adrenergic agonist is a new neuroaxial adjuvant gaining popularity. The aim of the present study was to compare the hemodynamic, sedative and analgesia potentiating effects of epidurally administered dexmedetomidine when combined with ropivacaine.

MATERIALS AND METHODS

The study was conducted in prospective, randomized double-blind manner in which 100 patients of American Society of Anesthesiologist Grade I and II in the age group of 20-65 years of either sex under going lower limb surgeries were included after taking informed consent. The patients were randomly allocated into two groups of 50 each. Epidural anesthesia was given with 150 mg of 0.75% ropivacaine in Group A (n = 50) and 150 mg of 0.75% ropivacaine with dexmedetomidine (1 μg/kg) in Group B (n = 50). Two groups were compared with respect to hemodynamic changes, block characteristics which included time to onset of analgesia at T10, maximum sensory analgesic level, time to maximum sensory and motor block, time to regression at S1 dermatome and time to the first dose of rescue analgesia for 24 h. At the end of study, data was compiled and analyzed statistically using Chi-square test, Fisher's exact test and Student t-test. P < 0.05 was considered to be significant and P < 0.001 as highly significant.

RESULTS

Significant difference was observed in relation to the duration of sensory block (375.20 ± 15.97 min in Group A and 535.18 ± 19.85 min in Group B [P - 0.000]), duration of motor block (259.80 ± 15.48 min in Group A and 385.92 ± 17.71 min in Group B [P - 0.000]), duration of post-operative analgesia (312.64 ± 16.21 min in Group A and 496.56 ± 16.08 min in Group B [P < 0.001]) and consequently low doses of rescue analgesia in Group B (1.44 ± 0.501) as compared to Group A (2.56 ± 0.67). Sedation score was significantly more in Group B in the post-operative period.

CONCLUSION

Epidural Dexmedetomidine as an adjuvant to Ropivacaine is associated with prolonged sensory and motor block, hemodynamic stability, prolonged postoperative analgesia and reduced demand for rescue analgesics when compared to plain Ropivacaine.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

A comparative study of the effect of caudal dexmedetomidine versus morphine added to bupivacaine in pediatric infra-umbilical surgery

BACKGROUND

One of the most commonly used regional anesthetic techniques in pediatric surgeries is the caudal epidural block. Its main disadvantage remains the short duration of action. Hence, different additives have been used. Dexmedetomidine is a potent as well as highly selective α2 adrenergic receptor agonist. The aim of this randomized, double-blinded, study was to compare the duration of postoperative analgesia of caudal dexmedetomidine versus morphine in combination with bupivacaine in pediatric patients undergoing lower abdominal or perineal surgery.

PATIENTS AND METHODS

A total of 50 pediatric patients 1-5 years old The American Society of Anesthesiologists status I, II scheduled for lower abdominal and perineal surgeries were included in the study. The patients were enrolled into 2 equal groups: Group A patients (n = 25) received dexmedetomidine with bupivacaine while Group B patients (n = 25) received morphine with bupivacaine. Patients were placed in a supine position then inhalational general anesthesia was induced, and laryngeal mask airway (LMA) was placed. Patients were then given caudal epidural analgesia. By the end of surgery reversal of muscle relaxation was done and the LMA was removed. Post-operatively, the sedation as well as pain score were observed and recorded.

RESULTS

The current study showed that minor complications were recorded in the post-anesthesia care unit; in addition, significantly longer periods of analgesia and sedation were detected in Group A. However, no significant differences in demographic data, as well as in the duration of surgery, and the time of emergence from anesthesia and patient condition during recovery were detected.

CONCLUSION

The present study suggested that use of dexmedetomidine, during single dose injection, as an additive to the local anesthetic bupivacaine in caudal epidural analgesia prolongs the duration of post-operative analgesia following lower abdominal as well as perineal surgery compared with caudal morphine with no side-effects on the vital signs. Postoperative side effects were seen with caudal morphine injection rather than with dexmedetomidine.

Does dexmedetomidine as a neuraxial adjuvant facilitate better anesthesia and analgesia? A systematic review and meta-analysis

Background

Neuraxial application of dexmedetomidine (DEX) as adjuvant analgesic has been invetigated in some randomized controlled trials (RCTs) but not been approved because of the inconsistency of efficacy and safety in these RCTs. We performed this meta-analysis to access the efficacy and safety of neuraxial DEX as local anaesthetic (LA) adjuvant.

Methods

We searched PubMed, PsycINFO, Scopus, EMBASE, and CENTRAL databases from inception to June 2013 for RCTs that investigated the analgesia efficacy and safety for neuraxial application DEX as LA adjuvant. Effects were summarized using standardized mean differences (SMDs), weighed mean differences (WMDs) or odds ratio (OR) with suitable effect model. The primary outcomes were postoperative pain intensity and analgesic duration, bradycardia and hypotension.

Results

Sixteen RCTs involving 1092 participants were included. Neuraxial DEX significantly decreased postoperative pain intensity (SMD, −1.29; 95% confidence interval (CI), −1.70 to −0.89; P<0.00001), prolonged analgesic duration (WMD, 6.93 hours; 95% CI, 5.23 to 8.62; P<0.00001) and increased the risk of bradycardia (OR, 2.68; 95% CI, 1.18 to 6.10; P = 0.02). No evidence showed that neuraxial DEX increased the risk of other adverse events, such as hypotension (OR, 1.54; 95% CI, 0.83 to 2.85; P = 0.17). Additionally, neuraxial DEX was associated with beneficial alterations in postoperative sedation scores and number of analgesic requirements, sensory and motor block characteristics, and intro-operative hemodynamics.

Conclusion

Neuraxial DEX is a favorable LA adjuvant with better and longer analgesia. The greatest concern is bradycardia. Further large sample trials with strict design and focusing on long-term outcomes are needed.

New therapeutic uses for an alpha2 adrenergic receptor agonist--dexmedetomidine in pain management

Dexmedetomidine was initially approved for clinical use as a sedative. Its development in pain management has been limited. Dexmedetomidine has analgesic effects and analgesic-sparing properties, especially for patients with obstructed airways. Mixing dexmedetomidine with local anesthetics is a promising new avenue to enhance local anesthetics' effectiveness. Peripheral, spinal and supraspinal α(2A)-ARs are responsible for the analgesic function of dexmedetomidine. Animal studies have shown that antinociceptive synergism results from co-application of dexmedetomidine and opioids or local anesthetics. Dexmedetomidine has potential adverse effects such as hypotension and bradycardia. Therefore, dexmedetomidine is contraindicated for patients suffering from bradycardia or using β-adrenergic antagonists. Clinical trials of dexmedetomidine in chronic pain or hyperalgesia are lack.

Caudal dexmedetomidine decreases the required concentration of levobupivacaine for caudal block in pediatric patients: a randomized trial

BACKGROUND AND OBJECTIVES

Dexmedetomidine (D) can prolong the duration of local anesthetics, but the effect of caudal dexmedetomidine on the potency of levobupivacaine (L) for caudal block has not been investigated. This study was designed to determine the effect of caudal dexmedetomidine on levobupivacaine for caudal block in pediatric patients.

METHODS

Eighty-nine children scheduled for elective inguinal hernia repair or hydrocele were randomly assigned to one of the three groups: Group L (caudal levobupivacaine), Group LD1 (levobupivacaine plus 1 μg·kg(-1) dexmedetomidine), or Group LD2 (levobupivacaine plus 2 μg·kg(-1) dexmedetomidine). The primary endpoint was the minimum local anesthetic concentration (MLAC), which was determined using the Dixon up-and-down method. The secondary endpoints were the duration of analgesia and sedation.

RESULTS

The MLAC values (sd) of caudal levobupivacaine were 0.103 (0.01)%, 0.068 (0.02)%, and 0.055 (0.03)% in Groups L, LD1, and LD2, respectively. The values of EC50 and EC95 (95% CI) of caudal levobupivacaine from logistic regression analysis were 0.094 (0.083-0.105)% and 0.129 (0.1-0.159)%, 0.058 (0.044-0.072)% and 0.106 (0.067-0.144)%, and 0.046 (0.033-0.059)% and 0.091 (0.055-0.127)% in Groups L, LD1, and LD2, respectively. The mean durations of analgesia in the postoperative period were 141, 378, and 412 min in Groups L, LD1, and LD2, respectively (L vs LD1 or LD2, P < 0.001). The mean durations of sedation in both Groups LD1 and LD2 also were significantly prolonged, compared with Group L (P < 0.01).

CONCLUSIONS

Caudal dexmedetomidine reduces the MLAC values of levobupivacaine and improves postoperative analgesia in children without any neurological side effects.