Analgesia In Pediatric Patients Research Articles

English

BACKGROUND: Caudal epidural is one of the most popular reliable & safe technique mainly used for intra and post-op analgesia in pediatric patients undergoing infra umbilical surgeries. To prolong the duration of analgesia various adjuvants like epinephrine, opioids, ketamine, midazolam, tramadol, clonidine, were added to local anesthetic. The aim of this study was to evaluate the clinical efficacy and safety of CAUDAL administration of plain Ropivacaine 0.2% (1miligram/kilogram body weight) with and without dexmedetomedine (2 microgram/kilogram body weight) in children undergoing infraumbilical surgeries; in terms of quality of surgical anesthesia and the duration of post-operative analgesia. METHOD: After approval from the institutional ethics committee and written informed consent of the parents, 60 children of (age 1-10 years) ASA gr. I and II undergoing elective lower abdominal and urogenital surgeries, were randomly divided into two groups of 30 each. After careful pre-anesthetic examination, children were kept fasting for an appropriate period prior to surgery. All patients received Injection Glycopyrrolate- 0.01 milligram /kilogram body weight, Injection midazolam- 0.1 milligram /kilogram body weight, Injection ketamine - 1 milligram /kilogram body weight, intravenously, just prior to caudal block. Caudal block was performed under all aseptic precautions. No surgical stimulus was allowed for the next 10 minutes i.e. the onset time for sensory block to occur, after which surgery was performed under the residual effect of ketamine and caudal block only. Patients were randomly allocated to receive Injection Ropivacaine 0.2% (1 milliliter/kilogram body weight; Group R) +1mililitre Normal saline or Injection Ropivacaine 0.2% (1millilitre/kilogram body weight) +Injection dexmedetomedine (2 microgram/kilogram body weight; Group RD) in Normal saline 1 milliliter. Hemodynamic parameters were observed before, during and after the surgical procedure. Quality of surgical anesthesia & requirement of supplemental midazolam/ketamine were also noted. Duration of Post-operative analgesia, pain scores, level of sedation and side effects if any were looked for and duly recorded. All the results were tabulated and analyzed statistically. The variables in the two groups were compared using the non-parametric tests. For all statistical analyses, the level of significance was P <0.05. RESULT: The Mean duration of analgesia was 6.65 +/-0.25 hours in Group R compared with 12.68 +/- 0.36 hours in Group RD, with a P value of <0.05. Quality of surgical anesthesia in Group R was excellent in 20 patients as compared to 24 patients in Group RD. 12 children in group RD and 4 children in group R did not require any additional pain medication during the study period; which was statistically significant. The peri-operative hemodynamics were stable among both the groups, although patients in RD group showed lesser degree of tachycardia as compared to pre op values, but it was statistically insignificant. CONCLUSION: A single caudal injection of dexmedetomidine (2 microgram/kilogram body weight) added to 0.2% ropivacaine (1

A COMPARATIVE STUDY BETWEEN DEXMEDETOMIDINE AND CLONIDINE USED AS ADJUNCTS TO BUPIVACAINE FOR POST-OPERATIVE ANALGESIA BY CAUDAL BLOCK IN PAEDIATRIC PATIENTS

Caudal anaesthesia/analgesia is simple to perform, reliable and safe. Various adjuvants are tried with local anaesthetic to prolong duration of post-operative a nalgesia in caudal block in paediatric patients wit h variable results. This prospective study was designed to ass ess and compare the efficacy of clonidine and dexme detomidine used as an adjuvants to bupivacaine for caudal anal gesia in paediatric patients. A 100 patients of ASA grade I or II ,age group of 6 months to 6 years undergoing infra- umblical surgeries were included in one of the foll owing two groups. Group D received 1 µg/kg Dexmedetomidine while group C received 1 µ g/kg Clonidine both with Bupivacaine plain 0.25% 1 ml/kg. Post-operative analgesia was assessed using CRIES scale. The mean duration of post-operative analgesia in group D was 14.16 ± 1 .65 hours and in group C it was 11.24 ± 2.48. The p rolongation of post-operative analgesia was significantly longe r in group D compared to group C and the requirement of rescue analgesic doses in the first 24 post-operative hour s was less in group D compared to group C. The inci dence of adverse effects were statistically insignificant be tween the two groups.The addition of both dexmedetomidine and clonidine with bupivacaine administered caudally s ignificantly increase the duration of post-operativ e analgesia.

A comparison of paravertebral nerve block catheters and thoracic epidural catheters for postoperative analgesia following the Nuss procedure for pectus excavatum repair

Thoracic epidurals (TE) have been advocated as a superior method for controlling postoperative pain after repair of pectus excavatum with a Nuss procedure. However, three recent reports of permanent neurologic injury after the Nuss procedure with concurrent TE analgesia have raised concerns about the safety of this combination. Paravertebral nerve blocks (PVNB) are used successfully for analgesia of the chest, but no studies are available comparing TE and PVNB catheters for postoperative analgesia in this patient population. This study was conducted to compare the efficacy of PVNB catheters with TE catheters for postoperative analgesia in pediatric patients undergoing the Nuss procedure. We retrospectively reviewed the medical records of 20 adolescent males undergoing a thoracoscopic Nuss procedure with either bilateral PVNB catheters (n = 10) or TE catheter (n = 10) and compared postoperative opiate consumption and pain scores. There were no statistically significant differences between the groups with respect to demographics, opiate consumption measured in morphine equivalents, and pain scores. In this small series, bilateral PVNB catheters resulted in equivalent opioid consumption and pain scores when compared to TE for postoperative pain management in pediatric patients undergoing the Nuss procedure. Large prospective studies are needed to further compare the efficacy, incidence of side effects, and complications of TE and PVNB catheters for postoperative analgesia in this pediatric population.

A comparison of Ropivacaine alone and in combination with Fentanyl for caudal analgesia in pediatric patients

Caudal analgesia is a very popular route to provide intraoperative and postoperative analgesia in children because of its simple technique, predictable level of blockade, high success rate and smooth recovery. It can be used mainly for perineal and sub umbilical procedures. Ropivacaine, the S-enantiomer of the amide local anesthetic, produces differential neural blockade, with lesser motor blockade; less cardiovascular and neurological toxicity than bupivacaine, making it suitable for day-care surgery in children. The addition of an adjuvant prolongs and intensifies the sensory blockade caused by local anaesthetic and also reduces the dose of local anaesthetic required to provide desired analgesia. Fentanyl is one of the most commonly used adjuvant with local anesthetics in caudal blocks. The aim of our study was to compare the efficacy of ropivacaine alone and in combination with fentanyl via caudal route for postoperative analgesia in children. The primary end point was duration of sensory and motor blockade. Study Design: Double blind, prospective, randomized .The subjects were 40 children aged 1 - 10 years undergoing perineal and sub umbilical procedures. They were randomly divided in two groups of 20 each using chit in box method. Group R received inj ropivacaine 0.2%, 0.5 ml/kg and Group RF received inj ropivacaine 0.2%,0.5 ml/kg in combination with inj fentanyl 0.5mcg/kg via caudal route just after intubation. GA was induced in the standard manner using propofol. Our study showed that patients in group RF required rescue analgesic 16 - 20 hrs later than patients in group R and the pain scores of group RF were better in the postoperative period. There was no significant motor blockade in both the groups. There was also no significant hemodynamic variation and postoperative complications observed in either group. Thus, addition of fentanyl to ropivacaine as caudal analgesic provides prolonged and more intense postoperative analgesia in children.

Caudal anesthesia with sedation versus general anesthesia with local infiltration during pediatric cardiac catheterization: effect on perioperative hemodynamics and postoperative analgesia

Introduction Children undergoing cardiac catheterization are usually in need for perioperative analgesia. Aim and objective We studied the effects of local infiltration of bupivacaine at the groin in generally anesthetized children as against caudal bupivacaine combined with dexmedetomidine-ketamine sedation on intraoperative and postoperative hemodynamics and duration of postoperative analgesia in pediatric patients undergoing cardiac catheterization. Materials and methods A total of 40 patients (1-7 years) were randomly assigned into one of the two groups: one group (group GI) received general anesthesia (GA) together with local infiltration using 5 ml bupivacaine 0.25% at the beginning and at the end of the procedure and the other group (group SC) received sedation by ketamine at 3 mg/kg followed by infusion at a rate of 1 mg/kg/h to maintain sedation with caudal administration of a mixture of bupivacaine 0.25% at 3 mg/kg with dexmedetomidine 0.5 μcg/kg both diluted in normal saline to a volume of 1.2 ml/kg. Hemodynamic variables (blood pressure (BP) and heart rate (HR)) were evaluated at T1 (baseline, after induction), T2 (10 min after local infiltration/caudal administration), T3 (at time of puncture for vascular access), T4 (10 min after emergence), T5 (1 h after the procedure), and T6 (4 h after the procedure). Pain was evaluated 10 min after emergence (P1), after 1 h in the ICU (P2), after 4 h in the ICU (P3), and after 8 h (P4) by the FLACC (Face, Leg, Activity, Crying, Consolability) score. Side effects were observed for 12 h. Results The severity of pain was much less in the SC group than in the GI group. FLACC pain score was evaluated at P1 (10 min after emergence), P2 (1 h after procedure), P3 (4 h after procedure), and P4 (8 h after procedure) and it was found that pain is much less in the SC group than in the GI group during the first 4 h after the procedure with significant difference between the two groups (P There was a more stable hemodynamic profile for the SC group than for the GI group. The mean arterial pressure (MAP) and HR decreased from the baseline in both groups and they decreased more significantly in the SC group than in the GI group. In addition, the decrease in MAP and HR continued for a longer duration in the SC group than in the GI group. We observed a slightly prolonged analgesia with less need for supplemental analgesics in the SC group than in the GI group. Conclusion Combining caudal anesthesia using bupivacaine and dexmedetomidine with ketamine sedation provided prolonged and potent analgesia with much stable perioperative hemodynamic parameters than giving general anesthesia combined with local infiltration in the setting of pediatric cardiac catheterization.

Procedural sedation and analgesia in pediatric patients.

A spectrum of conditions requires sedation and analgesia in pediatric population. Ineffective treatment of pain may result in physiological and behavioral responses that can adversely affect the developing nociceptive system. The recognition of pain in children can be facilitated by different pain scales. This article reviews the procedural sedation and analgesia (PSA) practices in children along with pharmacology of the drugs used for this purpose.

Perioperative epidural analgesia in children undergoing major abdominal tumor surgery — a single center experience

PurposeThe purpose of this study was to assess the use of continuous epidural analgesia in pediatric patients undergoing major abdominal tumor surgery. MethodsChildren undergoing major abdominal tumor surgery at our institution between 2008 and 2012 (n=40) received continuous epidural analgesia via an epidural catheter. Surgical trauma scores, pain scores, and clinical data of the children were compared to a pair-matched historical control group operated on between 2002 and 2007 without epidural analgesia. ResultsPain levels in the study group on day 1 and 3 after surgery were lower compared to the control group. The differences did, however, not reach statistical significance (p=0.15 and 0.09). Children in the study group received significantly fewer additional doses of piritramide or morphine (45% versus 82%, p<0.001). Despite significantly higher surgical trauma scores in the study group (p=0.018), there were no statistical differences regarding clinical parameters, such as mechanical ventilation time, time on intensive care unit, and total hospital stay. There were no catheter-related complications. ConclusionsContinuous epidural analgesia is beneficial for children undergoing complex abdominal tumor surgery with regard to pain levels, postoperative recovery, and general clinical course. Expertise of the managing team, a careful patient selection, and a continuous quality assessment are essential for success.

Comparison of local infiltration anesthesia with different concentrations of ropivacaine for postoperative analgesia in pediatric patients undergoing tonsillectomy

Objective To compare local infiltration anesthesia with different concentrations of ropivacaine for postoperative analgesia in pediatric patients undergoing tonsillectomy.Methods Sixty ASA physical status Ⅰ patients of both sexes,aged 6-12 yr,weighing 18-41 kg,scheduled for elective tonsillectomy,were randomly divided into 3 groups (n =20 each) using a random number table:control group (group C); 0.2％ ropivacaine group (group R1) ; 0.5 ％ ropivacaine group (group R2).Anesthesia was induced with inhalation of sevoflurane,injection of sufentanil and cisatracurium and maintained with inhalation of sevoflurane and iv infusion of remifentanil.The tonsil was locally infiltrated vith 0.2 ％ and 0.5％ ropivacaine (3-5 ml on each side of the tonsil) before surgery in R1 and R2 groups,respectively.Tonsillectomy was performed under general anesthesia.At 1,3,6,12,and 24 h after surgery,pain was assessed using faces pain scale-revised (FPS-R).Paracetamol 5 mg/kg was used as rescue analgesic when FPS-R scores ≥4.The interval between awake extubation and the first request for analgesic,requirement for postoperative analgesic and development of adverse effects were recorded.Results Compared with group C,the interval between awake extubation and the first request for analgesic was significantly prolonged,and the requirement for postoperative analgesic was decreased in R1 and R2 groups (P ＜ 0.05).Compared with group R1,the interval between awake extubation and the first request for analgesic was significantly prolonged,and the requirement for postoperative analgesic was decreased in R2 group (P ＜ 0.05).There was no significant difference in the incidence of adverse effects between the two groups (P ＞ 0.05).Conclusion The optinum concentration of locally infiltrated ropivacaine is 0.5 ％ for postoperative analgesia in pediatric patients undergoing tonsillectomy. Key words: Amides ; Anesthesia, local ; Tonsillectomy ; Pain, postoperative ; Child

A prospective randomized double blind Study of the effects of caudal clonidine and dexmedetomidine as an adjunct to caudal bupivacaine for postoperative analgesia in paediatric patients undergoing subumblical surgery.

In this study, we compared the analgesic efficacy and safety of caudal dexmedetomidine and clonidine added to caudal bupivacaine for postoperative analgesia in children undergoing subumblical surgeries.90 patients aged 1 to 8 years scheduled for subumblical surgeries were randomly allocated into three groups of 30 patients each. Group A received 1ml/kg of 0.25% bupivacaine with dexmedetomidine 2μg/Kg in normal saline 1 ml. Group B received 1ml/kg of 0.25% bupivacaine with clonidine 2μg/Kg in normal saline 1 ml and Group C received 1ml/kg of 0.25% bupivacaine with normal saline 1ml. All the patients in our study remained hemodynamically stable throughout the intraoperative and postoperative period. Addition of either dexmedetomidine 2μg/kg or clonidine 2μg/kg to 0.25% caudal bupivacaine significantly prolonged the postoperative analgesia time without increasing the incidence of side effects like nausea, vomiting, pruritis or urinary retention. Moreover dexmedetomidine did not offer significant advantage over clonidine as regards the duration of postoperative analgesia.

Intravenous infusion of ketamine-propofol can be an alternative to intravenous infusion of fentanyl-propofol for deep sedation and analgesia in paediatric patients undergoing emergency short surgical procedures

Background:Paediatric patients often present with different painful conditions that require immediate surgical interventions. Despite a plethora of articles on the ketamine–propofol combination, comprehensive evidence regarding the suitable sedoanalgesia regime is lacking due to heterogeneity in study designs.Methods:This prospective, randomized, double-blind, active–controlled trial was conducted in 100 children, of age 3–14 years, American Society of Anesthesiologist physical status IE-IIE, posted for emergency short surgical procedures. Patients were randomly allocated to receive either 2 mL of normal saline (pre-induction) plus calculated volume of drug from the 11 mL of ketamine–propofol solution for induction (group PK, n=50) or fentanyl 1.5 μg/kg diluted to 2 mL with normal saline (pre-induction) plus calculated volume of drug from the 11 mL of propofol solution for induction (group PF, n=50). In both the groups, the initial bolus propofol 1 mg/kg i.v. (assuming the syringes contained only propofol, for simplicity) was followed by adjusted infusion to achieve a Ramsay Sedation Scale score of six. Mean arterial pressure (MAP) was the primary outcome measurement.Results:Data from 48 patients in group PK and 44 patients in group PF were available for analysis. Hypotension was found in seven patients (14.6%) in group PK compared with 17 (38.6%) patients in group PF (P=0.009). Intraoperative MAP was significantly lower in group PF than group PK when compared with baseline.Conclusion:The combination of low-dose ketamine and propofol is more effective and a safer sedoanalgesia regimen than the propofol–fentanyl combination in paediatric emergency short surgical procedures in terms of haemodynamic stability and lesser incidence of apnoea.

A comparative study of caudal bupivacaine and midazolam for post operative analgesia in pediatric patients

Background: Postoperative discomfort that arises from pain is annoying for the child and parents. Genital and perineal surgical procedures are followed by moderate to severe pain resulting in postoperative complications like infection and also long term psychological effects on children. Under treatment of children for pain in post operative period has been reported in several centers. Intramuscular or intravenous analgesics have unpredictable effects and not accepted by children. Caudal bupivacaine with midazolam prolongs post operative pain relief. Aim: To evaluate the relative efficacy and duration of caudal extradural bupivacaine 0.25% and a combination of bupivacaine and midazolam for intra and post operative analgesia. Materials and Methods: This study was conducted in 50 ASA I children from pediatric surgery department requiring general anaesthesia for infra umbilical surgeries. After induction of general anaesthesia the children were given caudal extradural 1 ml/kg bupivacaine (0.25%) or bupivacaine with midazolam (0.50 micromg/kg) intra operative vitals, response to surgical stimulus measured. Post operatively assessment of pain was done by using objective pain score up to 24 hrs in the ward. Results: The mean basal values of systolic blood pressure in both the group were comparable intraoperatively and didn't show any statistical significance indicating adequate analgesia intra operatively. Postoperatively 68% children in the bupivacaine group were pain free until 3 hours as compared to 80% children in bupivacaine with midazolam. Only 4% children in bupivacaine group were pain free until 6 hours post operatively, compared to 72% children in bupivacaine with midazolam indicating prolonged analgesia in this group. There was no significant changes hemo- dynamically in both groups post operatively. Conclusion: Caudal extradural analgesia with bupivacaine and midazolam gives prolonged analgesia postoperatively and can be used safely in children. It will also reduce the use of parenteral analgesics significantly with minimum side effects.

Parasternal Intercostal Block With Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study

The objective of this study was to assess the effectiveness of 0.5% ropivacaine used for parasternal intercostal blocks for postoperative analgesia in pediatric patients undergoing cardiac surgery. A randomized, controlled, prospective, double-blind study. A tertiary care teaching hospital. Thirty children scheduled for cardiac surgery with a median sternotomy. A 0.5% ropivacaine injection with 5 doses of 0.5 to 2.0 mL on each side in the 2nd to 6th parasternal intercostal space with a total dose of ropivacaine below 5 mg/kg or the same volume of saline before sternal wound closure. The time to extubation was significantly lower in patients administered the parasternal blocks with ropivacaine than in the control group; the mean values were 2.66 hours and 5.31 hours, respectively (p < 0.001). The pain scores were lower in the ropivacaine group compared with the saline group; mean values were 2.20 for the ropivacaine group and 4.83 for the saline group on a scale of 10. The cumulative fentanyl dose requirement over a 24-hour period was higher in the saline group than the ropivacaine group (p < 0.001). Parasternal blocks with ropivacaine appear to be a simple, safe, and useful technique of supplementation of postoperative analgesia in pediatric patients undergoing cardiac surgery with a median sternotomy.

Comparison of bupivacaine alone and in combination with fentanyl or pethidine for bilateral infraorbital nerve block for postoperative analgesia in paediatric patients for cleft lip repair: A prospective randomized double blind study

Cleft lip repair is one of the common surgeries performed in India and the usual method used for post operative analgesia is perioperative opioids and NSAIDs. There has been an increase in use of regional techniques and Opioids are the common adjuvants but their efficacy and safety have not been studied extensively in children. PATIENTS #ENTITYSTARTX00026; A prospective, randomized, double blind study was done to compare the efficacy, duration and safety of intraoral infraorbital nerve block on post operative pain relief using bupivacaine alone or in combination with fentanylor pethidine in paediatric cleft lip repair. 45 children between the age group 5 - 60 months undergoing cleft lip surgery randomly allocated into 3 groups of 15 each received bilateral intraoral infraorbital nerve block with 0.75ml of solution. Group B received 0.25% bupivacaine; group P received 0.25% bupivacaine with 0.25mg kg(-1) pethidine, group F received 0.25% bupivacaine with 0.25microgm kg(-1) fentanyl. Sedation after recovery, post operative pain intensity and duration of post operative analgesia were assessed using Modified Hannallah Pain Score. The mean duration of analgesia was 17.8 hrs in Group B, 23.53 hrs in Group F and 35.13 hrs in Group P. There was statistically significant difference between the means of the three groups- ANOVA (p < 0.05). Thus we conclude that addition of fentanyl or pethidine to bupivacaine for Bilateral Intraoral Infraorbital Nerve Block prolong the duration of analgesia with no complications and can be used safely in paediatric patients.

A controlled, randomised trial comparing single to multiple application lidocaine analgesia in paediatric patients undergoing urethral catheterisation procedures

The aim of this study was to evaluate if discomfort levels are statistically significant when two different topical and intraurethral precatheterisation analgesia strategies are used. The primary objective of this research project was to examine methods to decrease pain experienced by paediatric cystogram patients. Paediatric patients undergoing urinary catheterisations frequently report discomfort. To alleviate catheterisation discomfort in children, some institutions have either used sedation techniques or topical analgesia strategies. Standardisation of topical anaesthetic application prior to paediatric urinary catheterisation has not been demonstrated in the research literature. A prospective, single-blind, randomised, controlled trial. The trial was performed with infants and children aged two months-eight years. The first group received one application of lidocaine five minutes prior to catheterisation. The control group received two applications, spaced five minutes apart prior to catheterisation. The FLACC pain score, as the primary outcome variable, was assessed at the time of the catheterisation. Secondary outcome variables including pre- and postcatheterisation heart rate and parental perception were also measured. Two hundred children between two months-eight years of age were randomly assigned for study inclusion with 91 patients enrolled into the two application groups and 109 patients into the single application group. No statistically significant differences (p = 0.779) in the mean FLACC pain score at the time of the catheterisation between the intervention (single application) group (mean = 3.30) and the control (two application) group (mean = 3.39), heart rate or parental perceptions were observed. Topical and intraurethral lidocaine analgesia strategies prior to urinary catheterisation provide an important tool in reducing discomfort for paediatric patients undergoing urinary catheterisation procedures. This study confirms that multiple applications of intraurethral lidocaine gel add little additional benefits in reducing discomfort over single intraurethral application techniques.

A comparative study between clonidine and dexmedetomidine used as adjuncts to ropivacaine for caudal analgesia in paediatric patients

A comparative study between clonidine and dexmedetomidine used as adjuncts to ropivacaine for caudal analgesia in paediatric patients

Effects of perioperative intravenous low dose of ketamine on postoperative analgesia in children

Low dose of ketamine reduces postoperative pain and opioid consumption in adult studies. However, there are only a few data with controversial results in the paediatric population. The aim of this randomized controlled trial was to evaluate the use of low doses of intravenous ketamine on postoperative pain in children after surgery on the lower part of the body. Thirty-seven children with ASA 1 or 2 from 6 to 60 months of age, undergoing scheduled surgery, were prospectively enrolled in a double blind sequential trial using a triangular test, with analysis every 10 patients treated. The children were randomly assigned to intravenously receive saline or 0.15 mg kg(-1) ketamine before surgery, followed by a continuous infusion of 1.4 microg kg(-1) min(-1) over 24 h. After sevoflurane induction and tracheal intubation, a caudal anaesthesia was performed in all children (1 ml kg(-1) of bupivacaine 0.25% with epinephrine). The postoperative analgesic technique was standardized with intravenous paracetamol 15 mg kg(-1) 6 h(-1), rectal morniflumate (20 mg kg(-1) 12 h(-1)) and intravenous nalbuphine infusion 1.2 mg kg(-1) 24 h(-1) for 24 h. The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, additional bolus of nalbuphine (if CHEOPS >7) and side effects were recorded from eye opening every 2 h over 24 h. The primary endpoint was the CHEOPS area under the curve. There was no difference in terms of additional bolus of nalbuphine as well as CHEOPS score area under the curve between groups, that is, 76 +/- 10 in the ketamine group versus 74 +/- 7 in the control group. No psychomimetic side effects were noted. The study failed to show any evidence of benefit of ketamine to improve analgesia in children when given in addition to a multimodal analgesic therapy with paracetamol, a NSAID and an opiate.

Caudal bupivacaine-neostigmine for perioperative analgesia in pediatric patients undergoing infraumbilical surgeries: A prospective, randomized, double blind, controlled study

Background: Perioperative pain is of great concern for the anesthesiologist in pediatric patients. As presurgical caudal analgesia attenuates the stress response to anesthesia and surgery, we co-administered neostigmine with bupivacaine to prolong the duration of single shot caudal block. Objective: To compare the efficacy of caudal bupivacaine with or without neostigmine for perioperative analgesia in children undergoing infraumbilical surgery. Study design: A randomized, double-blinded, controlled, prospective study. Methods: 90 children, aged 2-10 years of ASA class I or II of either sex were randomly allocated into three groups (n=30) to receive a caudal injection of either 0.25% bupivacaine 1ml/kg or with 2μg/kg or 5μg/kg neostigmine, after induction of general anesthesia. Results: All children were hemodynamically stable intra and postoperatively. The caudal bupivacaine/neostigmine mixture resulted in superior analgesia compared with bupivacaine alone. Recovery to first rescue analgesic times were (mean ± SD), 6.05±2.04 h, 11.5±3.42h, and 16.86 ± 4.92 h in the bupivacaine alone, bupivacaine neostigmine 2 μg/kg and bupivacaine neostigmine 5μg/kg groups, respectively (p<.05). In addition, patients in plain bupivacaine group received more doses of paracetamol than in the bupivacaine/neostigmine groups to maintain adequate analgesia in the first 24 postoperative h. Postoperative nausea and vomiting occurred in 6.7%, 16.7% and 33.3% patients in caudal bupivacaine, bupivacaine 2μg/kg neostigmine and bupivacaine 5μg/kg neostigmine groups, respectively (p<.05). Conclusion: Coadministration of caudal neostigmine with bupivacaine significantly extends the duration of postoperative analgesia with reduced need for supplementary analgesics.

A comparison of analgesic efficacy of tramadol and pethidine for management of postoperative pain in children: a randomized, controlled study

Prevention of postoperative pain in children is one of the most important objectives of the anesthesiologist. Opioids have been used as an analgesic for postoperative pain in children for many years. Tramadol has both opioid and monoaminergic agonist actions. The aim of the study was to determine if the analgesic potency and occurrence of adverse effects of tramadol differ from pethidine when administered to children. A total of 110 healthy children, aged 2-12 years, scheduled for elective lower abdominal surgery were randomized to receive either pethidine 1 mg/kg (Group I, n = 60) or tramadol 2 mg/kg (Group II, n = 50) for postoperative pain after anesthesia induction. Pain intensity, adverse effects, heart rate, and systolic and diastolic blood pressure were recorded at regular intervals. The mean pain scores on postoperative 24 h were significantly greater with tramadol than with pethidine. Sedation scores, heart rate and systolic and diastolic blood pressure showed no significant differences between the groups. We conclude that pethidine and tramadol are effective in providing analgesia in pediatric patients, but pethidine provided better postoperative analgesia than tramadol. Changes in blood pressure, heart rate and arterial oxygen saturation were minimal and were similar in both drugs.

Clinical Uses of Dexmedetomidine in??Pediatric Patients

Dexmedetomidine is being used off-label as an adjunctive agent for sedation and analgesia in pediatric patients in the critical care unit and for sedation during non-invasive procedures in radiology. It also has a potential role as part of anesthesia care to prevent emergence delirium and postanesthesia shivering. Dexmedetomidine is currently approved by the US FDA for sedation only in adults undergoing mechanical ventilation for <24 hours. Pediatric experiences in the literature are in the form of small studies and case reports. In patients sedated for mechanical ventilation and/or opioid/benzodiazepine withdrawal, the loading dose ranged from 0.5 to 1 microg/kg and was usually administered over 10 minutes, although not all patients received loading doses. This patient group also received a continuous infusion at rates ranging from 0.2 to 2 microg/kg/h, with higher rates used in burn patients and those with withdrawal following > or =24 hours of opioid/benzodiazepine infusion. The dexmedetomidine dosage used for anesthesia and sedation during non-invasive procedures, such as radiologic studies, ranged from a loading dose of 1-2 microg/kg followed by a continuous infusion at 0.5-1.14 microg/kg/h, with most patients spontaneously breathing. For invasive procedures, such as awake craniotomy or cardiac catheterization, dosage ranged from a loading dose of 0.15 to 1 microg/kg followed by a continuous infusion at 0.1-2 microg/kg/h. Adverse hemodynamic and respiratory effects were minimal; the agent was well tolerated in most patients. The efficacy of dexmedetomidine varied depending on the clinical situation: efficacy was greatest during non-invasive procedures, such as magnetic resonance imaging (MRI), and lowest during invasive procedures, such as cardiac catheterization. Dexmedetomidine may be useful in pediatric patients for sedation in a variety of clinical situations. The literature suggests potential use of dexmedetomidine as an adjunctive agent to other sedatives during mechanical ventilation and opioid/benzodiazepine withdrawal. In addition, because of its minimal respiratory effects, dexmedetomidine has also been used as a single agent for sedation during non-invasive procedures such as MRI. However, additional studies in pediatric patients are warranted to further evaluate its safety and efficacy in all age ranges.

The Use of “Off-Label” Drugs

To the Editor: We would like to respond to a statement contained in Dr. Rowlingson’s editorial (1) concerning the “off-label uses of non-opioid drugs.” We must point out that if it were not for the courageous off-label use of bupivacaine 25 years ago by the National Children’s Hospital Group and our pediatric colleagues in Boston, Toronto, Baltimore, and Seattle, we would not be where we are today with our efforts to provide profound postoperative analgesia to suffering children through the use of caudal, epidural and peripheral nerve blocks. When we began this research there was no Federal Food and Drug Administration (FDA) approval for the use of bupivacaine in infants and children, and it was only through off-label use that this effort was launched. In fact, even now the PDR states: “Until further experience is gained in children younger than 12 years, administration of Sensorcaine (bupivacaine HCl) Injection in this age group is not recommended.”(2). When Broadman administered the first epidural opioid to a 6-year-old boy, the only drug available in the United States was Winthrop® preservative-free meperidine (unpublished data, 1983). The information on how to safely use neuraxialmeperidine was obtained from Lloyd Reddick (personal communication). This axis opioid was administered to a suffering child in an off-label manner but with IRB approval. The opioid provided this boy with several days of profound analgesia, without any adverse side effects. This event may have launched a new era: the use of spinal axis opioid analgesia in pediatric patients. In our opinion, the neuraxial opioid of choice in infants and children today is hydromorphone (3), because, in equianalgesic doses, it appears to have fewer adverse side effects than morphine (i.e., pruritus, nausea, and vomiting). Hydromorphone also has better rostral spread, allowing caudal administration in abdominal cases in young children. The use of this drug is still off-label and will likely remain so, because pharmaceutical manufacturers have no financial incentive to conduct the necessary safety/efficacy research trials to obtain a FDA-approved indication for this generic medication. Perhaps, the most classic case of off-label use of an anesthetic is the millions of times per year that caudal/epidural bupivacaine is safely and effectively used to perform spinal blocks, even though the package warns “NOT FOR SPINAL ANESTHESIA.” This is a prime example that off-label use does not necessarily mean unsafe. This logic is very true in the case of gabapentin, the medication implicated by Dr. Rowlingson in his editorial. If it had not been for the off-label use of gabapentin by the Mellick brothers (4) for reflex sympathetic dystrophy in 1997, we would have lost access to what has become the first-line drug in the management of neuropathies associated with diabetes (5), Acquired Immune Deficiency Syndrome (6), and Guillain-Barre syndrome (7). The most recent use of gabapentin by Dr. Pandey et al. (8,9), in which gabapentin administered by mouth in a single dose on the evening prior to surgery reduced the need for narcotic analgesics by 50% in the postoperative period, provides hope that similar results can be obtained in children undergoing scoliosis surgery and other painful orthopedic procedures. In our experience, the only adverse side effect one observes with gabapentin is somnolence, a potentially beneficial side effect of a premedication. It is almost certain that FDA approval will neither be sought nor obtained for the perioperative use of gabapentin to promote opioid sparing in the postoperative period in adults. Even more remote is the possibility that the necessary research will be done on behalf of children. Unfortunately, off-label use is the only option for pediatric anesthesiologists in their quest to optimally manage acute and chronic pain in infants and children. Lynn M. Broadman, MD Igor Semenov, MD Department of Anesthesiology Pittsburgh Children’s Hospital Pittsburgh, PA [email protected]