A Comparative Study of Tramadol and Clonidine as an Additive to Levobupivacaine in Caudal Block in Pediatric Patients Undergoing Perineal Surgeries

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.

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

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