Caudal Analgesia Research Articles

Caudal additives do not improve the analgesia afforded by levobupivacaine after hypospadias repair.

Background:Caudal analgesia is commonly employed to provide excellent intra- and postoperative analgesia for primary hypospadias repair in children. Several additives to local anesthetics are commonly employed to increase the block duration, although these have uncertain benefits.Objectives:This study investigated whether, in caudal analgesia with levobupivacaine 0.25%, the addition of S (+)-ketamine, clonidine, or both agents combined, would prolong postoperative analgesia in patients undergoing primary hypospadias repair.Patients and Methods:We conducted a retrospective chart analysis for all patients who underwent hypospadias repair with caudal analgesia over a consecutive 3-period at this institution. The study examined four patient groups, classified according to the analgesia used:No additive, levobupivacaine aloneLevobupivacaine and S (+)-ketamineLevobupivacaine and clonidineLevobupivacaine, S (+)-ketamine, and clonidinePrimary outcome measures were as follows: time to the first postoperative request for analgesia, total first 24-hour postoperative analgesia, and time to hospital discharge.Results:The 87 patients included had a mean ± SD age of 21.4 ± 13.5 months and weight of 11.9 ± 2.4 kg. The median doses of levobupivacaine, S (+)-ketamine, and clonidine were 0.7 mg/kg (range, 0.4–1.3), 0.5 mg/kg (0.2–1.1), and 1.8 μg/kg (0.8–2.3), respectively. The addition of S(+)-ketamine, clonidine, or both did not increase the time to first oral analgesia request. Neither did it reduce the total first 24-hour postoperative analgesia requirements or alter hospital discharge time. However, the additive drugs in combination did increase postoperative sedation.Conclusions:The addition of S (+)-ketamine or clonidine to levobupivacaine 0.25% in caudal analgesia for hypospadias repair appears to be of no benefit. However, use of the additives in combination increased postoperative sedation.

Delayed Onset Seizures after Inguinal Herniotomy in a Premature Infant: a Case Report

We report a case of a premature neonate born at 34 weeks and operated at 6 weeks of age developing unexplained seizures 10 hours after the end of surgery under single shot caudal epidural analgesia with bupivacaine and lidocaine combined with general anesthesia.

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.

Comparison of caudal analgesia between ropivacaine and ropivacaine with clonidine in children: A randomized controlled trial

Background:Addition of clonidine to ropivacaine (0.2%) can potentially enhance analgesia without producing prolonged motor blockade. The aim of the present study was to compare the post-operative pain relieving quality of ropivacaine 0.2% and clonidine mixture to that of plain ropivacaine 0.2% following caudal administration in children.Methods:In a prospective, double-blinded, randomized controlled trial, 30 ASA 1 pediatric patients undergoing infraumbilical surgery were randomly allocated to receive a caudal injection of either plain ropivacaine 0.2% (1 ml/kg) (group A) or a mixture of ropivacaine 0.2% (1 ml/kg) with clonidine 2 μg/kg (group B). Objective pain score and need for supplemental analgesics were compared during the 1st 24 hours postoperatively. Residual post-operative sedation and motor blockade were also assessed.Results:Significantly prolonged duration of post-operative analgesia was observed in group B (P<0.0001). Heart rate and blood pressure were not different in 2 groups. Neither motor blockade nor post-operative sedation varied significantly between the groups.Conclusion:The combination of clonidine (2 μg/kg) and ropivacaine 0.2% was associated with an improved quality of post-operative analgesia compared to plain 0.2% ropivacaine. The improved analgesic quality of the clonidine-ropivacaine mixture was achieved without causing any significant degree of post-operative sedation or prolongation of motor blockade.

Efficacy of clonidine as an adjuvant to ropivacaine for caudal analgesia in children undergoing subumbilical surgery

Context:The use of clonidine as an adjuvant to ropivacaine in different concentrations through the caudal space has been shown to improve the analgesic efficacy of local anesthetics.Aims:The purpose of our study was to compare the efficacy of ropivacaine 0.1% with clonidine 1 mcg/kg to that of plain 0.1% and 0.2% ropivacaine for caudal analgesia in children.Settings and Design:Prospective, double blind, randomized controlled trial.Materials and Methods:Sixty children in the age group of 1–6 years undergoing subumbilical surgeries were included in the study. Group A received 1 ml/kg of 0.1% ropivacaine, group B received 1 ml/kg of 0.1% ropivacaine with clonidine 1 mcg/kg, and group C received 1 ml/kg of 0.2% ropivacaine.Results:The mean duration of analgesia was 243.7 ± 99.29 min in group A, 590.25 ± 83.93 min in group B, and 388.25 ± 82.35 min in group C. The duration of analgesia was significantly prolonged in group B compared to groups A and C with the P value of 0.001. At 8 h, all the 20 children in group A had received the first rescue analgesic compared to 18 children in group C and 3 children in group B. The duration of motor blockade after extubation was 30.6 ± 7.8 min and was noted only in group C. Only 1 child in group B received two rescue medications compared to 15 (75%) children in group A and 8 (40%) children in group C. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted.Conclusions:Clonidine 1 mcg/kg with ropivacaine 0.1% prolongs the duration and quality of analgesia compared to plain ropivacaine 0.1% and 0.2% without any significant sedation.

Comparison between S-ketamine and clonidine in caudal analgesia

Nucleo de Estudos, Pesquisas e Assessoria a Saude da Faculdade de Medicina do ABC (NEPAS-FMABC)

Ketamine for perioperative pain management in children: a meta‐analysis of published studies

Balanced analgesia, using both opioid and nonopioids agents, has become the standard care for postoperative pain management. Ketamine, a compound with analgesic and antihyperalgesic properties, has been shown to decrease postoperative pain and opioid requirements in adults. The goal of the present meta-analysis was to investigate postoperative analgesic properties of ketamine in pediatric patients. A comprehensive literature search was conducted to identify clinical trials that used ketamine as a perioperative analgesic compound in children and infants. Outcomes measured were postoperative analgesic consumption, pain intensity and duration of sensory block (when ketamine was used by caudal route) during the postoperative care unit (PACU) stay and the early postoperative period (6-24 h after leaving the operative room). The data from each trial were combined to calculate the pooled odds ratios or standard mean differences and their 95% confidence intervals. Thirty-five randomized, blinded controlled studies were retrieved from the literature. Systemic ketamine was effective in decreasing PACU pain intensity and analgesic requirement but failed to influence early (6-24 h) pain intensity and analgesic requirement. Ketamine administered locally during tonsillectomy, decreased PACU and early (6-24 h) pain intensity and PACU analgesic requirements. Used as an adjuvant for caudal analgesia, ketamine increased the duration of sensory block and PACU analgesic requirement without impacting PACU pain intensity. Ketamine failed to exhibit a postoperative opioid-sparing effect. This meta-analysis found that administration of ketamine was associated with decreased PACU postoperative pain intensity and nonopioid analgesic requirement. However, ketamine failed to exhibit a postoperative opioid-sparing effect.

Minimum local analgesic concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children - analysis using the Dixon method

Deng et al. recently quantified the minimal local anaesthetic concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children [1]. Although in their methods, the authors stated that the concentration of ropivacaine received by a particular subject was determined according to Dixon’s up and down method, the ED50 presented in the results was calculated using probit and logit regression only. We respectfully suggest that for proper analysis of the data, the ED50 with 95% CI should have been estimated from the up-down sequences using the method of Dixon and Massey. The sequences should then have been subjected to probit regression analysis as a backup or sensitivity test. We calculated the ED50 by averaging the midpoint concentration of all independent pairs of patients involving a crossover according to Dixon and Massey’s method [2, 3] using all 25 patients depicted in both groups. The ED50 (95% CI) values for school age and pre-school children are 0.143% (0.139–0.147) and 0.098% (0.093–0.103), respectively, compared with the authors’ results of 0.143% (95% CI: 0.132–0.157%) and 0.107% (95% CI: 0.089–0.122%). This would not have altered the overall result of the study, but is a more accurate presentation of their results. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Anesthetic management of a neonate with arthrogryposis multiplex congenita for emergency laparotomy

Arthrogryposis multiplex congenita is a rare disease, characterized by non-progressive, multiple joint contractures since birth. Anesthetic issues include difficult intravenous access, difficult airway management and regional anesthesia. We report the anesthetic management of a six-day-old neonate presenting to the emergency with features of intestinal obstruction, who was detected for the first time to have arthrogryposis multiplex congenita. General anesthesia along with caudal analgesia for peroperative and postoperative pain relief was used. There was an episode of intraoperative hyperthermia, which was tackled successfully. The child had an uneventful post-anesthesia recovery.

Randomized controlled trial comparing morphine or clonidine with bupivacaine for caudal analgesia in children undergoing upper abdominal surgery

BackgroundVarious additives have been used to increase the duration of analgesia provided by bupivacaine administered by single-shot caudal injection in children. MethodsA prospective, randomized, double-blind controlled study in 50 ASA I–II children (34 boys and 16 girls) aged 1–6 yr undergoing upper abdominal surgery was conducted. Patients were divided into two groups to receive either morphine 30 µg kg−1 (MB) or clonidine 2 µg kg−1 (CB) in bupivacaine 0.2% (1.25 ml kg−1) for caudal analgesia. The duration of analgesia (FLACC scale) and sedation and side-effects such as vomiting, itching, respiratory depression, hypotension, and bradycardia were observed. ResultsThe mean duration of analgesia was 16.5 (3.6) h in the CB group compared with 10.2 (2.3) h (P<0.01) in the MB group. Subjects who received clonidine (CB) were sedated for longer [7.1 (0.8) h] compared with the MB group [3.8 (0.7) h; P<0.01]. Vomiting was observed in 4% and 12% of subjects in the CB and MB groups, respectively. Sixteen per cent of subjects reported itching in the MB group (P=0.03), and none in the CB group. No hypotension, bradycardia, or respiratory depression was observed in any subjects. ConclusionsCaudal clonidine 2 µg kg−1 in bupivacaine 0.2% provides a longer duration of analgesia and sedation compared with caudal morphine 30 µg kg−1 in bupivacaine 0.2% without significant side-effects in children undergoing upper abdominal surgery.

Comparison of pre- vs. post-incisional caudal bupivacaine for postoperative analgesia in unilateral pediatric herniorrhaphy: A double-blind randomized clinical trial

Introduction:This study was designed to evaluate the pre- vs. post-incisional analgesic efficacy of bupivacaine administered caudally in children undergoing unilateral hernia repair.Methods:Fifty children aged 6 months to 6 years were included in the study. Children were divided blindly between the two groups to receive pre- vs. post-incisional caudal bupivacaine. The preincisional group received 1 ml/kg of 0.125% bupivacaine caudally after induction of anesthesia and the postincisional group received the same dose caudally at the end of surgery. Heart rate, SaO2, end tidal CO2, and noninvasive arterial blood pressure were recorded every 10 min. The duration of surgery, extubation time, and duration of recovery period were also recorded. The pain scores were measured with using an Oucher chart in the recovery room, 2, 4, 6, 12, and 24 h after surgery. Time to first analgesia, numbers of supplementary analgesics required by each child in a 24-h period and total analgesic consumptions were recorded. Any local and systemic complications were recorded. Quantitative data were compared using a two-tailed t-test. Sex distribution and frequency of acetaminophen consumption were measured using χ2 test. P < 0.05 was considered statistically significant.Results:The Oucher pain scale at 4, 6, 12, and 24 h after surgery, the total analgesic consumption and the numbers of demand for supplemental acetaminophen were lower statistically in preincisional group (P < 0.05). Extubation time and duration were higher in preincisional group (P < 0.05). Mean changes of heart rates were statistically lower during the anesthesia period and recovery time in preincisional group (P < 0.05).Conclusion:Preincisional caudal analgesia with a single injection of 0.125% bupivacaine is more effective than the postincisional one for postoperative pain relief and analgesic consumption in unilateral pediatric herniorrhaphy.

Optimizing caudal analgesia for minor urologic procedures

Optimizing caudal analgesia for minor urologic procedures

Entropy monitoring decreases isoflurane concentration and recovery time in pediatric day care surgery -a randomized controlled trial

To assess if titrating anesthesia with entropy would result in faster awakening in children undergoing day care surgery. Entropy, an EEG-based anesthesia depth monitor, has been used in children; however, only one other study has evaluated the effectiveness of entropy monitoring in decreasing awakening time and for titrating anesthetic agents in children undergoing short procedures under anesthesia. In a randomized prospective single-blind parallel group trial, 50 ASA grade I-II children, aged 2-12 years, scheduled for lower abdominal or urological surgeries were studied after ethics committee approval and parental consent. The children were randomized to the entropy or control group. Following laryngeal mask airway insertion and caudal analgesia, anesthesia was maintained with nitrous oxide, oxygen, isoflurane. In the control group, anesthesia was titrated according to the hemodynamic parameters and the simultaneously monitored entropy values obscured from the anesthesiologist. In the entropy group, the entropy values (between 45 and 65) were used to titrate the anesthesia. Time to awakening from anesthesia was 7 (3-18) min in the entropy group when compared to 10 (5-21) min in the control group. (P < 0.05) The difference in the mean time to awakening was 2.72 min 95% CI (0.34, 5.1). The end tidal isoflurane concentrations were lower in the entropy group when compared to the control group 15 s following airway insertion (0.78 ± 0.14 vs 1.24 ± 0.19), 15 s post caudal and skin incision (0.68 ± 0.40 vs 0.84 ± 0.05, 0.68 ± 0.03 vs 0.77 ± 0.32, respectively) as well as 5 min after skin incision 0.67 ± 0.04 vs 0.79 ± 0.02), (P ≤ 0.05). In pediatric day care surgery, entropy monitoring resulted in statistically though not clinically significant faster awakening and significantly lower end – tidal isoflurane concentrations.

Transient Paraplegia due to Accidental Intrathecal Bupivacaine Infiltration Following Pre-Emptive Analgesia in a Patient With Missed Sacral Dural Ectasia

A case report with review of the literature. To highlight the need for careful magnetic resonance imaging evaluation for the presence of incidental lumbosacral dural anomalies before attempting caudal epidural interventions. Pre-emptive analgesia through the caudal epidural route provides good postoperative pain relief in spine surgeries. Several precautions have been advised in the literature. Presence of sacral-dural ectasia should be considered a relative contraindication for this procedure. A 50-year old woman underwent posterior instrumented spinal fusion for L4-L5 spondylolisthesis under general anesthesia. She received single shot caudal epidural analgesia at the start of the procedure. After complete emergence from anesthesia, she had complete motor and sensory loss below the T12 spinal level, which reversed to normal neurology in 6 hours. Retrospective evaluation of the patient's magnetic resonance imaging showed an ectatic, low lying lumbosacral dural sac which had been overlooked in the initial evaluation. The drugs given by the caudal route have been accidentally administered into the thecal sac causing a brief period of neurologic deficit. This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.

Effect of dexamethasone in combination with caudal analgesia on postoperative pain control in day-case paediatric orchiopexy

BackgroundDexamethasone has a powerful anti-inflammatory action and has demonstrated reduced morbidity after surgery. The aim of this study was to examine the effects of a single i.v. dose of dexamethasone in combination with caudal block on postoperative analgesia in children. MethodsSeventy-seven children (aged 1–5 yr) undergoing day-case orchiopexy were included in this prospective, randomized, double-blinded study at a single university hospital. After inhalation induction of general anaesthesia, children received either dexamethasone 0.5 mg kg−1 (maximum 10 mg) (n=39) or the same volume of saline (n=38) i.v. A caudal anaesthetic block was then performed using 1.5 ml kg−1 of ropivacaine 0.15% in all patients. After surgery, rescue analgesic consumption, pain scores, and adverse effects were evaluated for 24 h. ResultsSignificantly, fewer patients in the dexamethasone group required fentanyl for rescue analgesia (7.9% vs 38.5%) in the post-anaesthetic care unit or acetaminophen (23.7% vs 64.1%) after discharge compared with the control group. The time to first administration of oral acetaminophen was significantly longer in the dexamethasone group (646 vs 430 min). Postoperative pain scores were lower in the dexamethasone group and the incidence of adverse effects was similar in both groups. ConclusionsIntravenous dexamethasone 0.5 mg kg−1 in combination with a caudal block augmented the intensity and duration of postoperative analgesia without adverse effects in children undergoing day-case paediatric orchiopexy.Trial registration: ClinicalTrials.gov. The number of registration: NCT01041378.

Minimum local analgesic concentration of ropivacaine for intra‐operative caudal analgesia in pre‐school and school age children

We compared the minimum local analgesia concentration of ropivacaine for intra-operative caudal analgesia in pre-school and school age children. Fifty-one boys, undergoing hypospadius repair surgery, were stratified into pre-school or school age groups. After induction of anaesthesia, caudal block was performed with ropivacaine 1 ml.kg⁻¹ of the desired concentration. The first child in each group received ropivacaine 0.125%, and subsequent concentrations were determined by the analgesic response of the previous patient using Dixon's up-and-down method. Under general anaesthesia with 0.7 minimum alveolar concentration of sevoflurane, the minimum local analgesia concentration of ropivacaine for intra-operative caudal block was 34% greater in school age than in pre-school age boys (0.143% (95% CI 0.132-0.157%) vs 0.107% (95% CI 0.089-0.122%), respectively; p < 0.001). This study indicates that a higher concentration of ropivacaine is needed for school age than pre-school age children to provide intra-operative caudal analgesia when combined with general anaesthesia.

Comparison of High Volume/Low Concentration and Low Volume/High Concentration Ropivacaine in Caudal Analgesia for Pediatric Orchiopexy

Comparison of High Volume/Low Concentration and Low Volume/High Concentration Ropivacaine in Caudal Analgesia for Pediatric Orchiopexy

A Retrospective Audit of three Different Regional Anaesthetic Techniques for Circumcision in Children

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB-LM and ultrasound-guided dorsal penile nerve block (DPNB-US) in our institution over a six-year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from five months to 15 years. One hundred and fifteen patients received CEA, 46 DPNB-LM and 55 DPNB-US. Patients in the DPNB-LM group required rescue morphine administration in the recovery unit more frequently (30.4%) than either the DPNB-US (3.5%) or CEA groups (3.6%). Similarly, the DPNB-LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB-US groups. Time to first analgesia was greatest for the CEA group while there was no significant difference between time to first analgesia for DPNB-LM and DPNB-US. Sixty-three percent of patients in the DPNB-LM group, 1.7% of CEA and 5.5% of the DPNB-US required intraoperative opiates (P < 0.0001). There was no difference in time to hospital discharge.

Caudal analgesia for prostate biopsy

Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)-guided prostate biopsy, the best method has not yet been defined. The present prospective, double-blind, randomized study aims to investigate the clinical efficacy of 'walking' caudal block compared with an intrarectal lidocaine gel for this procedure. One hundred patients were randomly assigned to two groups. In the lidocaine gel group, 10 ml of gel containing 2% lidocaine was given intrarectally. In the caudal group, 20 ml 0.1% bupivacaine with 75 microg fentanyl was injected. Pain scores, anal sphincter tone and patient satisfaction were evaluated. The pain scores were significantly lower in the caudal group at all stages. Verbal rating scores (scale 1-4) during probe insertion, probe maneuver and biopsies were 1 (0-2), 1 (0-2) and 1 (0-2) vs. 3 (0-5), 2 (1-3) and 4 (2-6), respectively (P value <0.0001 at all stages). The anal sphincter was more relaxed in the caudal group than in the gel group (P value <0.0001 in all categories). Highly satisfied patients were more frequently encountered in the caudal group, 34 (68%) vs. 8 (16%), P<0.0001, and unsatisfied patients were more frequently found in the gel group 1 (2%) vs. 12 (24%); P<0.001. All patients were able to walk without any assistance immediately after the procedures. 'Walking' caudal analgesia is an efficacious method for relieving the pain during TRUS-guided prostate biopsies in ambulatory practice.

Lumbosacral spinal cord somatosensory evoked potentials for quantification of nociception in horses

There is a need for objective evaluation and quantification of the efficacy of analgesic drugs and analgesic techniques in horses. To determine whether lumbosacral spinal cord somatosensory evoked potentials (SSEP) can be a useful and reliable tool to assess nociception in equines. SSEPs and electromyograms (EMG) from the epaxial muscles were recorded simultaneously, following electrical stimulation applied to the distal hindlimb in lightly anaesthetised Shetland ponies (n=7). In order to validate the model, the effect of increasing stimulus intensity was documented and the conduction velocities (CV) of the stimulated nerves were calculated. The effect of epidurally applied methadone (0.4 mg/kg bwt) in a randomised, crossover design was investigated. Two distinct complexes (N1P1 and N2P2) were identified in the SSEP waveform. Based on their latency and conduction velocity and the depressant effect of epidurally applied methadone, the SSEP N2P2 was ascribed to nociceptive Adelta-afferent stimulation. The SSEP N1P1 originated from non-nociceptive Abeta-afferent stimulation and was not influenced by epidurally applied methadone. The nociceptive Adelta component of the SSEP, the N2P2 complex, is presented as a valid and quantitative parameter of spinal nociceptive processing in the horse. Validation of the equine SSEP model enables the analgesic effects of new analgesics/analgesic techniques to be quantified and analgesia protocols for caudal epidural analgesia in equidae improved.