Analgesia In Pediatric Patients Research Articles

Safety and Analgesic Efficacy of Spinal Versus Caudal Block in Pediatric Infra-Umbilical Surgery

AbstractBackground: Neuraxial analgesia may improve post-operative outcomes for high-risk children who are susceptible to respiratory complications (e.g. post-operative apnea). The use of spinal anesthesia in infants and children requiring surgeries of sub-umbilical region is gaining considerable popularity worldwide. Caudal analgesia along with general anesthesia is a very popular regional technique for prolonged post-operative analgesia in different pediatric surgical proce-dures where the surgical site is sub-umbilical. Bupivacaine has been thoroughly studied, and a large global experience exists.Aim of Study: Was to investigate the safety and analgesic efficacy of spinal versus caudal bupivacaine combined with sevoflurane anesthesia in children undergoing infra-umbilical surgeries.Material and Methods: One hundred thirty patients of either sex aged between 2-7 years, (ASA I or II) were randomly assigned into two groups of 65 subjects each; Group A (caudal bupivaciane group) and Group B (spinal bupivaciane group). Group A received caudal isobaric bupivacaine, Group B received spinal hyper baric bupivacaine. Both after anesthesia induction and before surgery. Assessment parameters included; time to 1st oral rescue analgesics, post-operative (FLACC scale), post-operative agitation, post-operative motor block component, haemodynamics, perioperative adverse effect.Results: There were no significant differences between the two studied groups in the mean post-operative FLACC scores at any time except in the second post-operative hour in the spinal group (0.84±0.07 Vs. 1.13±0.08, p<0.01). The time to first request for rescue analgesia was significantly lower in the spinal group (6.60±1.82 Vs. 9.23±2.47, p<0.00), compared with the caudal group. There were no differences between the two studied groups in the total IV paracetamol consumption in the 1st 24h post-operatively (p=0.0674). There were no significant differences in the mean post-operative modified bromage scale scores between the two studied groups at any time. The block was associated with few complications in both groups.Conclusion: This study demonstrated that the spinal analgesia is fairly comparable to caudal analgesia in pediatric patients undergoing sub-umbilical surgeries. And we recom-mend the addition of an adjuvant to the intrathecal bupivacaine to prolong its analgesic effect making spinal analgesia a suitable alternative to caudal analgesia.

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

Background:Caudal block is a simple, safe procedure with fewer side effects to provide intraoperative and postoperative analgesia in pediatric patients. Many drugs were used as an additive to local anesthetics in caudal block. All these drugs had their own side effects.Aims:In this study, we compare the effects of tramadol and clonidine as an additive to levobupivacaine in caudal block in children undergoing perineal surgeries regarding hemodynamic changes, analgesic effects, and side effects.Settings and Design:This is a prospective, double-blind randomized, controlled study, conducted in Department of Paediatric Surgery, at King George's Medical University, Lucknow, Uttar Pradesh during 2017–2018.Materials and Methods:After informed consent and ethical clearance from institutional ethics committee, King Georges Medical University, Lucknow. Total 66 patients aged 1–10 year, planned for perineal surgery were randomly allocated according to computer-generated random number, into three groups. Group I - 0.25% levobupivacaine (1 mL.kg-1) alone, Group II - 0.25% levobupivacaine (1 mL.kg-1) with tramadol 1 mL.kg-1, and Group III - 0.25% levobupivacaine (1 mL.kg-1) with clonidine 1 μg.kg-1. Perioperative pain was the primary outcome. Hemodynamic parameters: heart rate, mean arterial pressure, and peripheral oxygen saturation were recorded. Postoperative pain assessed by Children and Infants Postoperative Pain Scale (CHIPPS), sedation by Ramsay sedation score and requirement of rescue analgesia were recorded at predetermined time intervals.Statistical Analysis:The values were represented in number (%) and mean ± standard deviation. Comparison of quantitative variables between the study groups was done using ANOVA test and Mann–Whitney U-test. Categorical data were analyzed using Chi-square test.Results:Postoperative analgesic effect was significantly longer in levobupivacaine with clonidine group as compared to tramadol with levobupivacaine group and levobupivacaine alone group.Conclusion:Clonidine in a dose of 1 μg.kg-1 when added to levobupivacaine in caudal block significantly prolongs the duration of analgesia as compared to tramadol with levobupivacaine and levobupivacaine alone without any clinically significant side effects. Thus, it is better to add additive like clonidine to enhance the effect of analgesia.

The role of regional anesthesia in the postoperative analgesia in pediatric patients

Introduction/Objective. Pain is a disturbing experience associated with existing or potential tissue damage, with a sensory, emotional, cognitive, and social component. The aim of this study was to show the efficiency of regional anesthetic techniques in postoperative pain in children. Methods. The retrospective cohort study was conducted on a group of 564 pediatric patients during the period from 2013 to 2016. Types of regional anesthesia were classified into the following six groups: caudal, epidural, spinal block, upper limb blocks, lower limb blocks, and truncal nerve block. From statistical methods, we used descriptive statistical methods of absolute and relative numbers, measurements of variability, central tendencies for numerical features, and methods of inferential statistics. We used the ?2 test for the attributive features of observations. Results. In relation to the postoperative time when an analgesic was required, a statistically significant difference was observed in the age of children (p = 0.000), disease diagnosis (p = 0.000), type of block (p = 0.000), type of local anesthetic (p = 0.000), and type of anesthesia or sedation preoperatively (p = 0.005). Conclusion. Postoperative analgesia was most needed by older children and children who were awake during surgery. Children with injuries and tumors need postoperative analgesia the earliest. The longest postoperative analgesia was recorded in patients who received caudal block. The longest postoperative analgesia can be seen in patients who received levobupivacaine, bupivacaine or levobupivacaine combined with lidocaine to perform the block.

To Study and Compare Efficacy of Ropivacaine and Bupivacaine for Caudal Analgesia in Paediatric Patients

To Study and Compare Efficacy of Ropivacaine and Bupivacaine for Caudal Analgesia in Paediatric Patients

Ultrasound guided erector spinae plane block provides effective opioid-sparing postoperative visceral pain relief after intussusception surgery: A pediatric case report.

Pediatric postoperative pain management may require a multimodal approach. Single injection erector spinae plane (ESP) block may provide prolonged opioid-sparing postoperative analgesiain pediatric patients. We present a pediatric case of ESP block for postoperative analgesia after intussusception surgery.Surgical reduction was planned for 9-month-old patient after a trial of hydrostatic enema reduction had failed.We performed ultrasound guided unilateral bi-level ESP block. ESP block provided effective postoperative visceral and somatic pain relief and opioid sparing analgesia in our case.

Efficacy of transversus abdominis plane block with dexmedetomidine mixed with ropivacaine for postoperative analgesia in pediatric patients

Objective To evaluate the efficacy of transversus abdominis plane (TAP) block with dexmedetomidine mixed with ropivacaine for postoperative analgesia in pediatric patients. Methods Forty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 1-4 yr, weighing 8-22 kg, scheduled for elective unilateral herniorrhaphy, were assigned into 2 groups (n=20 each) using a random number table method: ropivacaine group (group R) and dexmedetomidine mixed with ropivacaine group (group DR). TAP block was performed at the end of operation under ultrasound guidance, 0.125% ropivacaine 1 ml/kg was injected in group R and 0.075% ropivacaine plus 1 μg/kg dexmedetomidine was injected in group DR.A dose of morphine 0.05 mg/kg was intravenously injected when Face Legs Activity Cry Consolability score ≥4.The duration of postoperative analgesia and consumption of morphine within 24 h after operation were recorded.The development of nausea and vomiting, bradycardia, hypotension, respiratory depression, over-sedation and TAP block-related complications (hematoma or infection at puncture site, peritoneal puncture, local anesthetic toxicity) within 24 h after operation were recorded. Results Compared with group R, the consumption of postoperative morphine within 24 h after operation was significantly reduced, and the duration of postoperative analgesia was prolonged in group DR (P 0.05). Conclusion Dexmedetomidine combined with ropivacaine provides better postoperative analgesic efficacy than ropivacaine alone when used for TAP block in pediatric patients. Key words: Dexmedetomidine; Amides; Nerve block; Abdominal muscles; Child; Analgesia

Assessment of complications of epidural infusion analgesia in pediatric patients- A clinical study

Background: Epidural analgesia is now firmly established in pediatric anaesthetic practice and its popularity continues to grow. The present study was conducted to determine complications due to epidural infusion analgesia in children. Materials & Methods: The present study was conducted on 52 patients of both genders. All children undergoing elective or emergency surgeries under general anaesthesia and given concomitant epidural analgesia for post-operative pain management. In all patients, complications such as at the time of insertion, during maintenance nerve injuries, and during removal catheter breakage was recorded. Results: Out of 52 cases, males were 32 and females were 20. Complications in patients were at the time of insertion such as blood trap in 2, failure to identify space in 1, wet tap in 4, epidural hematoma in 1 and nerve injuries in 1. The difference was significant (P< 0.05). During maintenance of epidural such as peri catheter leaks in 2, catheter migration in 3, during removal such as infections in 5 and other causes were seen in 1 cases. The difference was significant (P< 0.05). Conclusion: Authors stated that epidural infusion analgesia is an effective and safe method of providing analgesia.

Çocuk Hastalarda İlioinguinalL/İliohipogastrik Sinir Bloğunda Bupivakain ve Levobupivakainin Postoperatif Ağrıya Etkilerinin Karşılaştırılması: Retrospektif Çalışma

Objective: Ilioinguinal/iliohypogastric (II/IH) nerve block added to general anesthesia is frequently used for postoperative analgesia in pediatric patients. We aimed to compare the postoperative analgesic effects of bupivacaine and levobupivacaine for II/IH nerve block for inguinal hernia repair in pediatric patients, which is not investigated previously. Materials and Methods: In this 2-year retrospective study, data were collected from the medical charts of patients that underwent unilateral inguinal hernia repair. Patients were included who received an II/IH nerve block with 0.2 mL/kg 0.5% of either bupivacaine (Group B) or levobupivacaine (Group L). Non-elective cases, age under 2 years and patients with multiple procedures were excluded. Demographic properties of the patients (age, weight, and sex), duration and side of surgery, pain scores, additional analgesic requirement and complications were documented. The chi-square test and the Mann-Whitney U test were used for statistical analysis. Results: In both groups, t he pain scores were not significantly different at post anesthesia care unit, 1, 2, 6 and 24th hours; nevertheless, the pain scores at 4th hour were significantly lower in Group L. Conclusion: II/IH nerve block added to general anesthesia is effective in inguinal region surgery of pediatric patients in postoperative pain control, and 0.5% levobupivacaine and bupivacaine had similar analgesic effect.

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.

Treatment of Postoperative Pain in Pediatric Operations: Comparing the Efficiency of Bupivacaine, Bupivacaine-Dexmedetomidine and Bupivacaine-Fentanyl for Caudal Block.

BackgroundCaudal analgesia is a common method for postoperative pain management in pediatric patients. Additive agents such as opioids and α2 agonists have been used to enhance the analgesic effects of local anesthetics for caudal block.ObjectivesThe aim of this study was to compare the additive effects of dexmedetomidine and fentanyl on bupivacaine-induced caudal analgesia in pediatric patients who had undergone elective inguinal hernia repair.MethodsThis randomized, double-blind clinical trial included children aged 1 - 5 years who were divided into three groups: the bupivacaine group (Group B) received 0.25% bupivacaine (1 ml/kg), the bupivacaine-dexmedetomidine group (Group BD) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg dexmedetomidine, and the bupivacaine-fentanyl group (Group BF) received 0.25% bupivacaine (1 mL/kg) plus 2 µg/kg fentanyl. The hemodynamic variables (heart rate, systolic blood pressure, respiratory rate, and peripheral arterial oxygen saturation) were measured perioperatively. Pain, sedation and motor block scores and adverse events (nausea and vomiting, pruritis, hypotension, bradycardia, urinary retention and respiratory depression) were documented at 30 and 60 minutes, and the 1st, 2nd, 4th, 6th, 12th and 24th hours after the operation. The other recordings include the duration of surgery and analgesic requirement.ResultsA total of 61 patients were analyzed. The lowest pain scores were found in the BD group at all time points (P < 0.001). The sedation scores were higher in the BD group than in the other two groups at all time points (P < 0.001). No motor block was observed after the operation. Only three patients required analgesic administration 2 to 6 hours after the operation in group B. No side effects were observed in any of the groups, and there was no significant difference in the duration of surgery among the three groups.ConclusionsThe results show that the analgesic and sedative effects were better when dexmedetomidine was added to bupivacaine than when fentanyl was added or bupivacaine alone was administered in the pediatric population studied here that underwent elective inguinal hernia repair.

Comparative study between caudal bupivacaine and caudal midazolam for post-operative analgesia in paediatric patients

Introduction: Caudal epidural block is the most commonly used regional technique for post-operative analgesia in children. Because of the side effects of bupivacaine which include motor weakness, urinary retention and cardiovascular and central nervous system toxicity, this study was conducted to evaluate the use of epidural midazolam as an alternative analgesic to bupivacaine for children undergoing inguinal hernoitomy Methods: After prior permission from the Institutional Ethical Committee, 60 boys, aged 1-10 years, posted for unilateral inguinal herniotomy were selected. The patients were allocated randomly into two groups (n=25) to receive caudal injection of either 0.25% Bupivacaine 1 ml/kg (group B) or Midazolam 50 microg/kg with normal saline 1 ml/kg (group M). In the post operative period heart rate, blood pressure, pain score, recovery to first analgesic time, total number of analgesics required in 24 hours and side effects if any were noted and analysed. Results: There were no significant differences in quality of pain relief, postoperative behaviour or analgesic requirements between the Midazolam group and the Bupivacaine group. Recovery to first analgesic time though was longer in the Bupivacaine group (9.65 hr) than Midazolam group (7.32 hr); it was statistically not significant (P= 0.9). Any of the side effects such as motor weakness, urinary retention, and respiratory depression were not observed in both the groups. However in both the groups, few of the patients had post-operative vomiting. Conclusion: We conclude that caudal Midazolam in a dose of 50 microg/kg provides equivalent analgesia to Bupivacaine 0.25%, when administered in a volume of 1 ml/kg for children undergoing unilateral inguinal herniotomy for hernia or high ligation of processus vaginalis for hydrocoele.

Comparison of caudal tramadol versus caudal fentanyl with bupivacaine for prolongation of postoperative analgesia in pediatric patients.

Background and Aims:Caudal block is a common technique for pediatric analgesia for infraumblical surgeries. Because of the short duration of analgesia with bupivacaine alone various additive have been used to prolong the action of bupivacaine. The present study was aimed to evaluate the analgesic effect of tramadol or fentanyl added to bupivacaine for infraumblical surgeries in pediatric patients.Materials and Methods:We conducted a prospective, randomized, single-blind controlled trial. After written informed consent from parents, 100 patients belonging to American Society of Anesthesiologist physical status I-II, in the age group of 1-12 years, of either sex undergoing infraumblical surgery under general anesthesia were divided into two groups. Group BT received 1 ml/kg of 0.25% bupivacaine with tramadol 2 mg/kg in normal saline and Group BF received 1 ml/kg of 0.25% bupivacaine with fentanyl 2 μg/kg in normal saline with maximum volume of 12 ml in both groups. All patients were assessed intraoperatively for hemodynamic changes, the requirement of sevoflurane concentration, as well as postoperatively for pain by using FLACC (F = Face, L = Leg, A = Activity, C = Cry, C = Consolability), pain score and for sedation by using four point sedation score.Results:The mean duration of analgesia was 10–18 h in Group BT while in Group BF it was 7-11 h. The postoperatively period up to 1½ h, Group BF had higher sedation score up to two as compared to that below one on Group BT.Conclusion:Caudal tramadol significantly prolongs the duration of analgesia as compared to caudal fentanyl without any side effects.

Comparison between caudal bupivacaine and bupivacaine with ketamine for postoperative analgesia in children: A prospective randomized clinical study.

Background:Efficacy of caudal bupivacaine plus ketamine on postoperative pain in children.Aims:The aim of this study was to compare the analgesic efficacy and safety of caudal block with mixture of bupivacaine and ketamine to bupivacaine alone for postoperative analgesia in pediatric patients undergoing infraumbilical surgery.Settings and Design:A prospective randomized study was conducted in a tertiary care teaching hospital.Statistical Analysis:Data were collected; mean value and standard deviation were computed for age, weight, duration of surgery, and duration of analgesia. Then, the mean values of the two groups were compared using ANOVA. P < 0.05 was considered statistically significant.Materials and Methods:A total of 60 American Society of Anesthesiologists I and II pediatric patients of either sex, aged 1–10 years, undergoing herniotomy, orchidopexy, and urethroplasty were randomly allocated to receive one of the two analgesic regimens. Group A (30 patients) received caudal bupivacaine 0.25% in a dose of 1 ml/kg, and Group B received caudal block with 0.25% bupivacaine 1 ml/kg and preservative-free ketamine 0.5 mg/kg; duration of analgesia was recorded by objective pain scale to equate pain and discomfort in young children with changes in standardized behavioral and physiological parameters.Results:Mean duration of analgesia in Group A was 5.63 ± 0.98 h while the mean duration of analgesia in Group B was 10.18 ± 2.24 h with P < 0.001. There were no differences between groups in the incidence of motor block and side effects.Conclusion:On the basis of results derived from this study, it is concluded that addition of ketamine 0.5 mg/kg to caudal bupivacaine 0.25% in a dose of 1 ml/kg significantly prolonged the postoperative analgesia compared with administration of caudal bupivacaine 0.25% in a dose of 1 ml/kg alone.

Preservative-free racemic ketamine with bupivacaine: a desirable option for extended caudal analgesia in pediatric surgery

Introduction Caudal epidural block is a commonly performed procedure in pediatric anesthesia worldwide. Ketamine is used as an adjuvant in single-shot caudal blocks to prolong postoperative analgesia. Aims of the study This randomized double-blind study was carried out to evaluate the effect of the addition of preservative-free racemic ketamine 0.5 mg/kg to 0.25% bupivacaine (1 ml/kg) in caudal block on the duration of postoperative analgesia in pediatric patients and to observe adverse effects, if any. Materials and methods Sixty children, aged 2–9 years, undergoing infraumbilical surgical procedures were assigned randomly to one of two groups, B or BK, to receive 1 ml/kg of 0.25% bupivacaine or a mixture of 0.5 mg/kg of preservative-free racemic ketamine with 1 ml/kg of 0.25% bupivacaine, respectively, for single-shot caudal anesthesia. The postoperative pain score was assessed. Sedation, motor weakness, and other adverse effects were also observed. Observations and results The mean duration of analgesia was significantly longer ( P P > 0.05). Conclusion Preservative-free racemic ketamine at a dose of 0.5 mg/kg may be used as a safe and reliable adjunct to caudal bupivacaine for prolongation of postoperative analgesia in children. As racemic ketamine is less expensive and more easily available than S(+)-ketamine, further studies comparing their cost-effectiveness may help to establish the racemic preparation as an appropriate adjuvant for single-shot caudal analgesia, especially in nations where cost constraints exist.

Comparison of caudal epidural clonidine with fentanyl as an adjuvant to ropivacaine 0.25% for postoperative analgesia in children undergoing various infraumbilical surgeries: A prospective randomized study

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.

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.

Comparative study of ultrasound-guided paravertebral block with ropivacaine versus bupivacaine for post-operative pain relief in children undergoing thoracotomy for patent ductus arteriosus ligation surgery.

Background and Aims:Thoracotomy incision following patent ductus arteriosus (PDA) ligation surgery is often associated with severe post-operative pain that has deleterious effects on respiratory function. We aimed to assess pain relief with thoracic paravertebral block using either bupivacaine or ropivacaine in these surgeries.Methods:One hundred paediatric patients of age group between 2 and 10 years undergoing PDA ligation surgery were randomised either to bupivacaine or ropivacaine group in this prospective double-blinded study. After induction of general anaesthesia, the ultrasound-guided paravertebral block was carried out using 0.25% bupivacaine 0.4 ml/kg in Group B patients and 0.2% ropivacaine 0.4 ml/kg in Group R patients. Monitoring included minimum mandatory monitoring with pulse rate, pulseoximetry (SpO2), electrocardiogram, blood pressure, temperature during surgery and also in Intensive Care Unit (ICU). Additionally, modified objective pain score (MOPS) was used in ICU for assessment of pain for 12 h after surgery. Incidence of complications was noted.Results:Mean values of MOPSs were comparable in both the groups. The time to rescue analgesic was 8 to 10 h in over 80% of patients in both the groups. More patients had hypotension and bradycardia in bupivacaine group compared to ropivacaine group.Conclusion:Paravertebral injection of 0.4 ml/kg of either 0.2% ropivacaine or 0.25% bupivacaine provided equipotent analgesia, but ropivacaine had a better side effect profile. Ultrasound-guided paravertebral block is a safe and effective mode of analgesia in paediatric patients undergoing thoracotomy.

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

Caudal epidural block is one of the most commonly performed neuraxial block techniques with reliable peri-operative and post-operative analgesia in pediatric patients. In our randomized, prospective, double-blinded, open level, parallel group study, we have established the effect of caudal epidural block on maintenance requirement of intravenous (IV) propofol in targeted bispectral (BIS) monitored patients.Context:Neuraxial anesthesia exhibits sedative properties that may reduce the requirement for general anesthesia. TIVA with propofol has been administered as an established method of maintaining general anesthesia in children. Caudal analgesia being a type of neuraxial block, also seems to reduce the requirement of sedative hypnotics in pediatric patients. Numerous studies show that for patients, administered with caudal epidural block, they require reduced intra-operative volatile inhalation anesthetics. In the present study, we have established the anesthetic sparing effect of Caudal Epidural Analgesia in children undergoing infra-umbilical surgical procedure and calculated the efficacy of propofol-infusion in maintaining adequate depth of anesthesia.Aims:(1) To study and compare the dose requirements of propofol using caudal epidural analgesia. (2) To calculate the efficacy of propofol as maintenance anesthetic agent in both groups and to compare hemodynamic stability of patients in both the techniques.Settings and Design:In our study, after administering general anesthesia to pediatric patients, we have administered caudal analgesia and IV analgesia to monitor the requirement of intra-operative propofol infusion using BIS monitor with a target value of 40-60 in both groups.Materials and Methods:82 patients (aged between 3 and 6 years) have been selected undergoing infra-umbilical surgery and randomly allocated into two groups containing 41 patients in each group. Both the groups group B and group A then intubated with glycopyrrolate, 2 mg/kg injection fentanyl, propofol till loss of verbal contact and atracurium at the rate of 0.5 mg/kg and group B has been administered caudal epidural blockade with 1 ml/kg 0.2% ropivacaine. Propofol infusion at the rate of 10 mg/kg/h is given as maintenance. BIS value has been recorded throughout and propofol requirement at the end of surgery has been calculated.Statistical Analysis Used:Numerical variables between groups have been analyzed using the Student's t-test and the Mann-Whitney U-test as applicable. Categorical variables have been analyzed using the Pearson's Chi-square test. P < 0.05 is considered statistically significant.Results:Consumption of propofol at the start of operation in the group A is 2.9 ± 0.17 and group B is 2.91 ± 0.17, which is not statistically significant (P > 0.05), whereas at the end of the operation in the group A is 11.33 ± 0.17 and group B is 7.83 ± 0.63, which is statistically significant (P < 0.05). Incidence of adverse effects is statistically insignificant between the two groups. The time for administration of rescue analgesic is 2.1 ± 0.88 in group A and 6.5 ± 0.17 in group B, which is statistically significant due to caudal analgesia.Conclusions:We conclude that in BIS-monitored patients (3-6 years) with infra-umbilical surgeries have shown a reduction in consumption of IV propofol due to caudal epidural blockade.

Continuous epidural analgesia for post-operative pain relief in paediatric patients

The safety of epidural analgesia in paediatric patients has been well established. It was used as a single shot technique for intra and immediate post-operative pain relief, which helped to reduce the requirement of potent opiate analgesics with their attendant unwanted side effects. There was some initial hesitation in using continuous epidural techniques by placing a catheter in paediatric population because of the fear of local anaesthetic systemic toxicity (LAST) and the immaturity of enzyme systems of the liver to metabolize the local anaesthetic agents, especially in neonates and pre-maturely born infants.[1] Several studies and review papers have proved this fear to be unfounded, and no serious complications have been encountered in practice. Hence, the exclusion of neonates and infants from receiving this continuous technique for post-operative pain relief is no longer advocated.

Propofol-ketamine or propofol-remifentanil for deep sedation and analgesia in pediatric patients undergoing burn dressing changes: a randomized clinical trial.

In this study, we compared the propofol-ketamine and propofol-remifentanil combinations for deep sedation and analgesia during pediatric burn wound dressing changes. Fifty pediatric patients aged 12-36 months, undergoing burn wound dressing changes, were randomly assigned to receive propofol-remifentanil (group PR) or propofol-ketamine (group PK) for deep sedation and analgesia. Patients in the group PR received 2 mg·kg(-1) propofol and 0.1 μg·kg(-1) remifentanil, and 0.05 μg·kg(-1) ·min(-1) remifentanil was infused continuously until the end of the procedure. Patients in the group PK received 2 mg·kg(-1) propofol and 1 mg·kg(-1) ketamine, and the same volume of isotonic saline was infused continuously until the end of the procedure. Additional propofol with remifentanil or ketamine was administered when required. Hemodynamic variables, drug requirements, occurrence of patient movement, surgeon's satisfaction score, recovery time, and the incidence of adverse events were recorded throughout the procedure and recovery. Recovery time was significantly shorter in the group PR compared to that in the group PK (10.3 [9.1-11.5] min vs 22.5 [20.3-25.6] min, median [interquartile range], respectively; P < 0.001). No significant hypotension or bradycardia occurred throughout the procedure. No significant differences were observed in terms of drug requirements, occurrence of patient movement, surgeon's satisfaction, incidence of respiratory depression, hypoxia, or nausea and vomiting The combinations of propofol-ketamine and propofol-remifentanil were effective for sedation and analgesia in pediatric patients undergoing burn dressing changes, but the propofol-remifentanil combination provided faster recovery compared to the propofol-ketamine combination.