A comparative study of clonidine and dexmedetomidine as an adjuvant to levobupivacaine for caudal analgesia in children undergoing below umbilical surgeries: A randomized double-blind controlled trial.

SP38.1 Update on adjuvants for paediatric PNBs

Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. We evaluated the efficacy of clonidine added to bupivacaine in prolonging the analgesia produced by caudal bupivacaine in children undergoing sub-umbilical surgery. One hundred children, age one to three years, undergoing sub-umbilical surgery, were prospectively randomized to one of two groups: caudal analgesia with 1 ml/kg of 0.25% bupivacaine in normal saline (Group A) or caudal analgesia with 1 ml/kg of 0.25% bupivacaine with 1 µg/kg of clonidine in normal saline (Group B). Post-operative pain was assessed for 24 hours using the FLACC scale. The mean duration of analgesia was significantly longer in Group B (593.4 ± 423.3 min) than in Group A (288.7 ± 259.1 min); P < 0.05. The pain score assessed using FLACC scale was compared between the two groups, and children in Group B had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group B. Clonidine in a dose of 1 µg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects.

Background: The goal of postoperative analgesia is to minimise pain with least possible side effects and in our setting be as cost effective as possible. In children, caudal anaesthesia is typically combined with general anaesthesia for intraoperative and postoperative analgesia. Adjuvants can be added to local anaesthetics for prolonging the duration of analgesia. This study was done to find out the duration of analgesia of caudal Bupivacaine in combination with Tramadol.Methods: This prospective, randomised, double-blind, comparative study was done by taking a total of 60 patients, aged between 2 to 7 years undergoing elective lower abdominal, urological and lower extremity surgeries. The patients were randomized to group A (n=30) receiving 1 ml/kg of 0.25% bupivacaine and group B (n=30) receiving 1 ml/kg of 0.25% bupivacaine plus 1mg/kg of tramadol caudally. Duration of analgesia, hemodynamic responses and adverse effects were noted and analysed.Results: Thirty patients in both groups were comparable with regard to demographic data and hemodynamic response and were statistically non-significant (P&gt;0.05). It was observed that the mean duration of analgesia was significantly longer in group B (467.5±164.5 min versus 240.5±69.4 min, P&lt;0.001). One patient in each group had postoperative vomiting.Conclusion: Tramadol 1mg/kg as an adjuvant to bupivacaine 0.25% for caudal analgesia in children is effective in increasing the duration of analgesia without an increase of adverse effects.

Aims: The purpose of our study was to compare the efficacy and safety of Clonidine to that of Ketamine added to 0.25% ropivacaine for caudal analgesia in children. Settings and Design: prospective, double blind randomized controlled trial. Material and Methods: Sixty children in the age group of 1 – 8 years undergoing sub umbilical surgeries were included in the study. After induction with general anaesthesia, caudal block was given with injection Ropivacaine 0.25% 1ml/kg and Clonidine 1µg/kg in group RC and injection Ropivacaine 0.25% 1 ml/kg and Ketamine 0.5 mg/kg in group RK. Results: The mean duration of analgesia was 530±44.2 mins in RC group as compared to 395±43.4 mins in RK group. The duration of analgesia was significantly prolonged in group RC with p value of 0.000. The mean pain score of RK group was higher than RC group at 6th (3.5±0.57 vs. 3.0±0.37) and 8th hour (3.93±0.25vs3.63±0.49) postoperatively which was statistically significant. There was no significant difference between the two groups with respect to haemodynamic parameters as only one patient had bradycardia in RC group. Conclusion: Ropivacaine (0.25%) with Clonidine (1µg/kg) in caudal block significantly prolongs the duration of analgesia compared to Ropivacaine (0.25%) with Ketamine (0.5mg/kg), without any adverse effects, can be used safely in paediatric caudal block.

Introduction: The purpose of analgesia in postoperative period is to minimize pain with the fewest probable side effects and to obtain the highest possible cost-effectiveness in our environment. In children, caudal anesthesia is often given in combination with general anesthesia for postoperative and intraoperative anesthesia. To extend the length of anesthesia; adjuvants can be further added to local anaesthetics. This research was performed to determine the caudal bupivacaine anesthesia duration given in combination with tramadol. Study Design: A prospective, comparative, randomized, double-blinded study Place and duration: In the department of Anesthesia, Khyber Teaching Hospital, Peshawar for one-year duration from 21st January 2021 to 20th January 2022. METHODS: 80 patients, 3-8 years of age, enduring elective urological, lower limb and lower abdominal surgery. Patients were randomised in to group A (n = 40) given 0.25% bupivacaine 1 ml / kg and group B (n = 40) receiving bupivacaine 0.25% in dose of 1 ml / kg plus 1 mg / kg tramadol. The hemodynamic responses, side effects and analgesia total duration were observed and analyzed. Results: The patients were comparable in groups A and B in terms of hemodynamic response and demographics and were not significant statistically (p greater than 0.05). It was detected that the analgesia mean time was longer significantly in B group (464.2 ± 167.1 minutes vs 238.1 ± 71.5 minutes, P &lt;0.001). The postoperative vomiting was perceived in two cases, one in each group. Conclusions: One mg / kg Tramadol adjuvant to 0.25% bupivacaine for caudal anesthesia in children effectively lengthens the analgesia duration deprived of increasing side effects. Keywords: bupivacaine; tramadol and caudal analgesia.

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.

Background: Caudal epidural block is the most popular regional anesthesia technique in pediatrics. Several agents are required as an adjuvant with a local anesthetic to prolong the duration of caudal analgesia by single shot technique in children. The aim of this study was to compare the efficacy of clonidine with ropivacaine versus ropivacaine alone for caudal analgesia in children undergoing infraumbilical surgeries under general anesthesia. Methods: Sixty patients of ASA grade I – II between the ages of 1-12 years, of either sex, undergoing infraumbilical surgeries under general anesthesia were included randomly into two groups: Control group (Group A) ropivacaine 0.2% (1ml/kg) with maximum volume 12 ml and clonidine group (Group B) ropivacaine 0.2% (1ml/kg) with clonidine 1μg/kg with maximum volume 12 ml. The changes of hemodynamic parameters were recorded intraoperatively. The FLACC pain score, sedation score, duration of analgesia and requirement of analgesic were recorded in the recovery room. Results: The demographic characteristic were comparable in both the groups. The mean duration of analgesia was significantly prolonged (707.3 ± 59.56 minutes) in group B compared to (411.83 ± 14.82 minutes) in group A. The requirement of first rescue analgesic medication was significantly prolonged in group B compared to group A (P < 0.05). Total analgesic consumption was significantly higher in group A (180 ± 70 mg) compared to group B (90 ± 70 mg) (P < 0.05) Conclusion: Addition of clonidine 1μg/kg to ropivacaine 0.2 % in caudal analgesia significantly increases the duration of postoperative analgesia compared to plain ropivacaine 0.2% without any significant sedation.

Background: Alpha-2 adenoreceptors as an adjuvant to local anesthetic during caudal analgesia in children prolongs the duration of analgesia. This study was designed to compare the analgesic efficacy and adverse effects of dexmedetomidine and clonidine when added to ropivacaine for caudal analgesia in children undergoing lower abdominal surgeries. Methods: In a prospective study, Seventy-eight children received block with either 0.2% ropivacaine 1.5 mg/kg (Group R; n = 26) or 0.2% ropivacaine 1.5 mg/kg + 1 mcg/kg clonidine (Group RC; n = 26) or 0.2% ropivacaine 1.5 mg/kg + dexmedetomidine 1 mcg/kg (Group RD; n = 26). Results: Duration of analgesia was 7.15 ± 1.00 h in Group R, 11.57 ± 1.27 h in Group R + C, and 14.73 ± 1.53 h in Group R + D (P 0.05). Conclusion: Addition of clonidine and dexmedetomidine to caudal ropivacaine significantly prolongs the duration of analgesia without adverse effects.

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.

IntroductionClonidine, a selective α2 adrenergic receptor agonist, combined with caudally administered bupivacaine, is frequently used in children to prolong the duration of postoperative analgesia following infraumbilical surgery. On the other hand, dexmedetomidine is highly selective and has a greater affinity toward α2 adrenergic receptors, especially toward its α2a subtype, accountable for more analgesic and hypnotic effects than clonidine.Aims and objectivesWe designed a prospective, double-blinded, randomized controlled trial to compare the analgesic efficacy and adverse effects of clonidine and dexmedetomidine when combined with bupivacaine for caudal analgesia in children undergoing infraumbilical surgeries.Materials and methodsA total of 60 children aged one to eight years were randomly assigned into two different groups in a double-blinded manner. Following induction of general anesthesia, every patient received a single dose of caudal bupivacaine 0.25% (0.75 ml/kg) mixed with either clonidine (1 µ/kg) in normal saline or dexmedetomidine (1 µ/kg) in normal saline. We noted the hemodynamic variables and postoperative sedation scores. Duration and quality of postoperative analgesia and the number of rescue analgesic drug doses required were recorded during the first 24 hours postoperatively. We also observed the patients for any adverse effects to the study drugs.ResultAdding dexmedetomidine to caudally administered bupivacaine significantly increased the duration of analgesia (15 ± 0.78 hours) and decreased the need for rescue drug doses than the addition of clonidine to bupivacaine (9.63 ± 1.95 hours) in children undergoing infraumbilical surgeries. Incidences of hemodynamic changes or other side effects were comparable between patients of two groups.ConclusionThe addition of dexmedetomidine to caudally administered bupivacaine in children undergoing infraumbilical surgeries may provide a longer duration of analgesia than the addition of clonidine, with less requirement of rescue analgesic doses and without any significant differences in the hemodynamic parameters or other side effects.

In a prospective randomized study in children, we compared caudal bupivacaine-clonidine with bupivacaine-morphine to evaluate whether clonidine can be used as an alternative to morphine in caudal anaesthesia. Caudal anaesthesia was administered in 36 children undergoing orchidopexy, hernia repair or circumcision, using 1.5 mL kg−1 bupivacaine 0.18% with either 1 μg kg−1 clonidine (group 1) or 30 μg kg−1 morphine (group 2). Haemodynamic and respiratory parameters, anaesthetic requirements, recovery time and pain score were monitored for 24 h. Eleven children in group 1 and nine children in group 2 did not need any supplementary systemic analgesics throughout the 24-h observation period. Mean (±SD) duration of analgesia in the remaining patients was 6.3 h (±3.3 h) in group 1 and 7.1 h (±3.4 h) in group 2 (P=0.43). Recovery time after anaesthesia was significantly longer in group 1 (16.6 ± 8.8 min) than in group 2 (11.5 ± 4.7 min) (P< 0.05). We conclude that analgesia provided by 1 μg kg−1 clonidine added to caudal bupivacaine is comparable with that provided by 30 μg kg−1 caudal morphine with bupivacaine. Clonidine at this low dose did not cause respiratory depression.

In a prospective randomized study in children, we compared caudal bupivacaine-clonidine with bupivacaine-morphine to evaluate whether clonidine can be used as an alternative to morphine in caudal anaesthesia. Caudal anaesthesia was administered in 36 children undergoing orchidopexy, hernia repair or circumcision, using 1.5 mL kg-1 bupivacaine 0.18% with either 1 microgram kg-1 clonidine (group 1) or 30 micrograms kg-1 morphine (group 2). Haemodynamic and respiratory parameters, anaesthetic requirements, recovery time and pain score were monitored for 24 h. Eleven children in group 1 and nine children in group 2 did not need any supplementary systemic analgesics throughout the 24-h observation period. Mean (+/- SD) duration of analgesia in the remaining patients was 6.3 h (+/- 3.3 h) in group 1 and 7.1 h (+/- 3.4 h) in group 2 (P = 0.43). Recovery time after anaesthesia was significantly longer in group 1 (16.6 +/- 8.8 min) than in group 2 (11.5 +/- 4.7 min) (P < 0.05). We conclude that analgesia provided by 1 microgram kg-1 clonidine added to caudal bupivacaine is comparable with that provided by 30 micrograms kg-1 caudal morphine with bupivacaine. Clonidine at this low dose did not cause respiratory depression.

Background Caudal epidural block is commonly used as a safe, reliable, easy-to-administer technique for abdominal and lower limb surgeries in pediatric patients and allows rapid recovery from anesthesia with effective postoperative analgesia. The aim of our study was to compare the efficacy of clonidine versus fentanyl when used as an additive to ropivacaine during single-shot caudal epidural analgesia in pediatric patients for postoperative pain relief. Patients and methods This randomized prospective double-blind study was conducted on 60 children of American Society of Anesthesiologists grades I and II aged 1–7 years scheduled for various infraumbilical surgical procedures who were randomly allocated into two groups to receive either ropivacaine (0.25%, 1 ml/kg) and clonidine (2 μg/kg) (group RC) or ropivacaine (0.25%, 1 ml/kg) and fentanyl (1 μg/kg) (group RF). Caudal epidural block was performed after induction of general anesthesia. Postoperatively, patients were observed for duration of analgesia, sedation score, recovery time, hemodynamics, and side effects or complications. Results Both groups were similar with respect to patient’s demographic profile, baseline hemodynamic parameters, and duration of surgery. The analgesic properties and hemodynamics were also comparable in both groups (P>0.05). The mean recovery time and sedation score were significantly lower in group RC as compared with group RF (P Conclusion From our study we concluded that both clonidine (2 μg/kg) and fentanyl (1 μg/kg) can be used as an adjuvant to single-shot caudal epidural anesthesia using 0.25% ropivacaine for effective postoperative analgesia in children. Because of its more favorable side-effect profile, with less respiratory depression, nausea, vomiting, and more patient comfort, clonidine is a better choice for use as an adjuvant to caudal epidural anesthesia in children.

Objective: Effective post-operative pain management is crucial in pediatric patients undergoing infraumbilical surgeries. Various regional anesthesia techniques, including caudal block, have been used to provide post-operative analgesia in children. The addition of tramadol, a synthetic opioid analgesic, to bupivacaine in caudal anesthesia has shown potential benefits. This study aims to compare the clinical efficacy of single-shot caudal bupivacaine alone versus bupivacaine plus tramadol for post-operative analgesia in pediatric infra-umbilical surgeries. Methods: A prospective, randomized, double-blinded clinical study was conducted at our institute. The present study will be carried out in 60 pediatric patients of the American Society of Anesthesiologists Grades I and II between the age of 1 and 8 years, undergoing infraumbilical surgeries. These children were randomly divided into 2 groups. Group B (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) and Group BT (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) with tramadol (1 mg/kg). The variables studied were hemodynamic changes, duration of analgesia, and incidence of side effects. Pain assessment was done at 1, 2, 3, 4, 8, 12, and 24 h post-operatively using modified objective pain scale. Results: It was observed that the mean duration of analgesia in Group BT (9.05±2.21) h was significantly longer (p=0.0001) than Group B (3.78±0.94) h. Hemodynamic parameters remained comparable during intraoperative and post-operative periods. There was no incidence of nausea, vomiting, bradycardia, hypotension, pruritus, or decrease in respiratory rate in the two groups. Conclusion: In our study, we concluded that a single-shot caudal block with 0.25% bupivacaine (1 mL/kg) plus tramadol (1 mg/kg) resulted in longer duration of analgesia when compared to 0.25% bupivacaine (1 mL/kg) alone with no incidence of any side effects.

In a double-blind study, 42 children, aged 1-10, undergoing general subumbilical surgery, were randomly allocated to two groups; they received, via caudal extradural, 1% mepivacaine 7 mg.kg-1 and normal saline 1 ml (Group 1) and a mixture of 1% mepivacaine 7 mg.kg-1 plus clonidine 2 micrograms.kg-1 and normal saline up to 1 ml (Group 2) respectively. No significant difference was noticed in age, weight, duration of surgery and onset time of anaesthesia, blood pressure, heart rate and oxygen saturation. Mean duration of analgesia (evaluated with 'Broadman objective pain scale') was 143 min for Group 1 and 218 min for Group 2 (P < 0.05); the time of sedation (evaluated with a sedation score) was statistically longer in Group 2 (172 min vs 89 min in Group 1). This longer sedation is due both to the longer analgesia and partially to a side effect of clonidine. In conclusion the addition of 2 micrograms.kg-1 of clonidine to mepivacaine prolongs the duration of caudal analgesia in children.