Single Level Paravertebral versus Caudal Block in Paediatric Inguinal Surgery

Paravertebral block (PVB) has been used for postoperative analgesia in children since 1992. There are no prospective randomised studies comparing the use of PVB versus caudal block (CB) for outpatient inguinal hernia repair surgery. The hypothesis of this study is that a single level, single injection PVB can provide a longer duration of analgesia and less requirement for supplemental analgesia than single shot CB for children undergoing inguinal surgery.

Seventy children, aged three to seven, American Society of Anesthesiologists score I to II, having unilateral inguinal surgery were enrolled in the study. The patients were divided into two randomised groups. In group PVB, a single shot of 0.2 ml/kg levobupivacaine was administered via the lumbar paravertebral route and in group CB, patients were given 1 ml/kg levobupivacaine caudally. Sevoflurane concentration was evaluated after induction and recorded during incision, sac traction and closure. Face, legs, activity, cry and consolability (FLACC) scores, heart rate, blood pressure and SpO2 were evaluated postoperatively.

Only four (11.4 %) patients in the PVB group needed rescue analgesic drugs compared to 12 (34.3%) patients in the CB group (P=0.044). Patients were given tramadol as rescue analgesia in the first four postoperative hours. No other supplemental analgesic drug was given apart from tramadol. FLACC scores were the same in the both groups. Parental satisfaction was significantly higher in the PVB group compared to the CB group (74.3 vs 40%, P=0.01).

This study has demonstrated that a single level single injection paravertebral block provides superior intraoperative and postoperative analgesia when compared to a caudal block for unilateral inguinal hernia repair.

A double-blind comparison of intrathecal S(+) ketamine and fentanyl combined with bupivacaine 0.5% for Caesarean delivery

BACKGROUND

In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor and analgesic block characteristics of S(+) ketamine, fentanyl and saline given intrathecally (IT) in addition to 0.5% plain bupivacaine (10 mg) for spinal analgesia.

METHODS

Ninety ASA I or II adult patients undergoing Caesarean section were randomly allocated to receive 1.0 mL of 0.9% saline in Group S (n = 30), 0.05 mg kg-1 of S(+) ketamine (1.0 mL) in Group K (n =30) or 25 microg (1.0 mL) of fentanyl in Group F (n =30) following 10 mg of plain bupivacaine 0.5% IT. We recorded onset and duration of sensory and motor block, time to reach the maximal dermatomal level of sensory block and duration of spinal analgesia.

RESULTS

The onset time of sensory and motor block was significantly shorter in Groups K and F than in Group S (P < 0.014). Their duration was significantly longer in Group F than in Groups K and S (P < 0.009). The time to reach the maximal dermatomal level of sensory block was significantly shorter in Groups K and F than in Group S (P < 0.001). The duration of spinal analgesia was significantly longer in Group F than in Groups K and S (P < 0.001).

CONCLUSION

In patients undergoing Caesarean section with spinal analgesia, the addition of S(+) ketamine (0.05 mg kg-1) IT to 10 mg of spinal plain bupivacaine (0.5%) led to rapid onset of both sensory and motor blockade and enhanced the segmental spread of spinal block without prolonging the duration of spinal analgesia, whereas fentanyl provided prolonged analgesia.

Comparison of caudal ketamine with lidocaine or tramadol administration for postoperative analgesia of hypospadias surgery in children

BACKGROUND

This study was designed to investigate whether the addition of tramadol or lidocaine to ketamine would enhance the quality of intra- and postoperative analgesia for hypospadias surgery in children.

METHODS

Sixty-two ASA PS I or II children, between 1 and 10 years of age, scheduled for hypospadias surgery were recruited. Anesthesia was induced with 6-8% sevoflurane and maintained with 0.5-2.5% sevoflurane-50% N2O in oxygen. Children were allocated randomly to receive one of two study drugs. Children in group KL received caudal ketamine (0.25 mg.kg(-1)) plus lidocaine (2%, 2 mg.kg(-1)) and in group KT ketamine (0.25 mg.kg(-1)) plus tramadol (1 mg.kg(-1)). Systemic blood pressure, heart rate, peripheral O2 saturation, sedation, and pain scores (CHEOPS) were recorded at 1, 5, 10, 15, 30, 45 min and 1, 2, 3 h following recovery from anesthesia.

RESULTS

Duration of analgesia was similar in the two groups (P > 0.05). CHEOPS in group KL was lower than in group KT during the study period, except at first 15 min. Sedation scores were higher in group KL than group KT in the first 10 min (P < 0.05). Incidence of postoperative nausea and vomiting was similar in the two groups (P > 0.05) Sevoflurane concentration required was significantly lower in group KL than group KT peroperatively (P < 0.001).

CONCLUSIONS

Caudal ketamine (0.25 mg.kg(-1)), plus lidocaine (2% 2 mg.kg(-1)) significantly reduced sevoflurane concentration compared with ketamine (0.25 mg.kg(-1)) + tramadol (1 mg.kg(-1)). We suggested that both ketamine + lidocaine and ketamine + tramadol provided very effective and long duration of analgesia, similarly. However, analgesia quality is superior in the ketamine-lidocaine group postoperatively.

Comparison of caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol administration for postoperative analgesia in children

BACKGROUND

The aim of this study was to compare the effect of single-dose caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol in children for postoperative pain management.

METHODS

Following ethics committee approval and informed parental consent, 99 ASA PS I or II children, between 1 and 10 years of age, scheduled for elective inguinal hernia repair with general anaesthesia, were recruited. After induction of anaesthesia and placement of a laryngeal mask airway (LMATM), the patients were randomly divided into three groups to receive either caudal ropivacaine alone (0.4%, 2 mg x kg(-1)) in group R (n = 32) or ropivacaine (0.2%, 1 mg x kg(-1)) plus ketamine (0.25 mg x kg(-1)) in group RK (n = 33) or ropivacaine (0.2%, 1 mg x kg(-1)) plus tramadol (1 mg x kg(-1)) in group RT (n = 34) with a total volume of 0.5 ml x kg(-1). Systemic blood pressure (SBP and DBP), heart rate (HR), peripheral O2 saturation (SpO2), respiratory rate (RR), sedation and pain scores were recorded at 5, 10, 15 and 30 min, 1, 3, 4 and 6 h following recovery from anaesthesia. Pain was evaluated by Children's Hospital of Eastern Ontario Pain Scale, and sedation with a five-point sedation test.

RESULTS

No difference was found regarding age, weight and duration of operation between the groups (P > 0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was longer in group RT (1377 +/- 204 min) than group R (1006 +/- 506 min) (P = 0.001). In the tramadol group, fewer patients required supplementary analgesics in the first 24 h (P = 0.005). Sedation scores were below 2 in all groups. Incidence of postoperative nausea and vomiting was higher in group RT (eight patients) and group RK (seven patients) than group R (one patient, P = 0.032).

CONCLUSIONS

Ropivacaine (0.4%), ropivacaine (0.2%) plus ketamine (0.25 mg x kg(-1)) and ropivacaine (0.2%) plus tramadol (0.5 mg x kg(-1)) provided sufficient analgesia in children, but the duration of analgesia was longer in the RT group.

Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy

OBJECTIVES

We compared the quality and duration of analgesia, the effect on perioperative sevoflurane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efficacy of morphine administered caudally in children.

METHODS

Patients were randomly divided into three groups to receive 2 mg.kg-1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mg.kg-1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mg.kg-1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia.

RESULTS

There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevoflurane concentration was significantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications.

CONCLUSION

Caudal tramadol (2 mg.kg-1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mg.kg-1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevoflurane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia.

A comparison of single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine administration for postoperative analgesia in children

BACKGROUND

Our aim was to compare the effect of single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine on the management of postoperative pain in children.

METHODS

Sixty-three children in ASA groups I-II, between the ages of 1 and 5 were evaluated for postoperative pain randomly divided into three groups as follows: In group T, only tramadol was given caudally; in group TB, tramadol-bupivacaine was given caudally; in group B, bupivacaine was given alone. Pain was evaluated by using the paediatric objective pain scale (POPS). Sedation was evaluated with a 5-point test. There were no differences with age, weight, haemodynamic and respiratory parameters between groups.

RESULTS

For 24 h postoperatively, the POPS value showed no statistically significant difference among groups (P > 0.05). Postoperative analgesia was maintained for 24 h. Nausea and vomiting was found to be higher in the tramadol group than in the bupivacaine group and tramadol-bupivacaine group (P < 0.001 and P < 0.01, respectively).

CONCLUSION

Tramadol used caudally is as effective as bupivacaine in the management of postoperative pain in children and the addition of tramadol to bupivacaine, when both drugs were administered caudally, did not prolong the duration of action of bupivacaine and is a safe agent in children.