Caudal Bupivacaine Research Articles

Neostigmine as an Adjuvant to Caudal Bupivacaine in Paediatric Population

Neostigmine as an Adjuvant to Caudal Bupivacaine in Paediatric Population

Comparison of Morphine with Nalbuphine as an Adjuvant to Caudal Bupivacaine: A Double blinded Randomized Study

Comparison of Morphine with Nalbuphine as an Adjuvant to Caudal Bupivacaine: A Double blinded Randomized Study

Caudal Analgesia for Hypospadias in Pediatrics: Comparative Evaluation of Adjuvants Dexamethasone and Dexmedetomidine Combination versus Dexamethasone or Dexmedetomidine to Bupivacaine: A Prospective, Double-Blinded, Randomized Comparative Study.

Background:Caudal block is the most commonly used regional anesthetic technique in pediatric surgeries; different additives have been used for better and safer outcome.Aim:The aim of this study is to compare the combination of dexamethasone and dexmedetomidine as adjuvants to bupivacaine versus using each agent solely with bupivacaine in pediatric caudal block as regards their efficiency in pain relief (the duration of postoperative analgesia, first time to request analgesia, and modified objective pain score [MOPS]).Study Design:This was a prospective, double-blinded, randomized study.Patients and Methods:Patients and Methods: Sixty-three children scheduled for hypospadias surgery wererandomized into three groupsaccording to the adjuvant drug added to caudal bupivacaine : Group I (n = 21): dexamethasone 0.1 mg/kg + 0.5 mg/kg bupivacaine 0.25%, Group II (n = 21): dexmedetomidine0.01 μg/kg + 0.5 mg/kg bupivacaine 0.25% and Group III (n = 21): dexamethasone 0.1 mg/kg + dexmedetomidine 0.01 μg/kg + 0.5 mg/kgbupivacaine 0.25%. Intraoperative and postoperative hemodynamics were recorded. In postoperative anesthesia care unit and then the ward, MOPS and sedation score were recorded at 30 min and 1, 2, 3, 6 and 12 h. Further, the time of first analgesic request and side effects were recorded.Statistical Analysis:Categorical data were presented as frequencies (%) and analyzed using Chi-square test. Continuous data were presented as mean (standard deviation) and median (quartiles). Continuous data were analyzed using one-way analysis of variance for single measures and two-way mixed model for repeated measures. Kaplan–Meier analysis was performed for the duration of analgesia.Results:In Group III, MOPS was lower than Groups I and II at the study times. Further, Group III had prolonged time for first request of analgesic. Sedation scores were prolonged in Group III and Group II than in Group I. There was a reduction in heart rates in Group III more than Group I and Group II but with no significant difference. However, there was a significant reduction in mean arterial blood pressure 30 min intraoperatively and postoperatively in Group III as compared to Groups I and II.Conclusion:The addition of combined dexmedetomidine at a dose of 1 μg/kg and dexamethasone 0.1 mg/kg to caudal bupivacaine seemed to be an attractive alternative to each drug if used alone with more prolonged analgesia and almost no adverse effects.

Comparison of postoperative analgesic effect of caudal bupivacaine with and without ketamine in Pediatric subumbilical surgeries.

Background and Aims:Management and assessment of postoperative pain in children is often a tough task as they cannot effectively communicate their discomfort. Caudal block is an excellent means of providing postoperative analgesia. In this study, we compared the postoperative analgesic effect of bupivacaine with and without ketamine when given caudally in children undergoing subumbilical surgeries.Material and Methods:Fifty-eight American Society of Anesthesiologists grades I and II children of either gender undergoing subumbilical surgeries were randomly allocated into two groups B and BK of 29 each. Group B received 0.75 ml/kg 0.25% bupivacaine and Group BK received 0.75 ml/kg 0.25% bupivacaine plus ketamine 0.5 mg/kg. A standardized anesthetic protocol was used. The duration of postoperative analgesia, motor block, sedation score, and hemodynamic parameters were assessed. Statistical analysis was performed using Mann–Whitney U test, independent-samples t-test, and Chi-square test.Results:The hemodynamic parameters and motor block were comparable between the groups. Duration of analgesia was prolonged in Group BK compared to Group B 11.3 ± 2.2, vs. 7.0 ± 2.3 hours, p < 0.001. However, sedation score was found to be higher in BK group compared to B Group (P < 0.001).Conclusion:Ketamine as an adjuvant to bupivacaine in caudal block is associated with a significant prolongation of postoperative analgesia.

Efficacy of tramadol as an adjuvant to bupivacaine for caudal analgesia in children: a randomised controlled trial

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

Analgesic efficacy of dexamethasone as an adjuvant to caudal bupivacaine for infraumbilical surgeries in children: A prospective, randomized study.

Background and Aims:Provision of adequate perioperative analgesia in children is important to attenuate the stress response to surgery. Caudal analgesia using local anesthetics is a traditionally used technique but provides a limited duration of analgesia. Several adjuvants can be added to local anesthetics to increase the duration of action. This study was undertaken to evaluate the efficacy of dexamethasone added to bupivacaine for caudal block in children.Material and Methods:This was a prospective, double-blinded trial on 130 children aged between 6 months and 6 years of age allocated randomly into one of two groups for elective subumbilical surgeries. Children in Group C received caudal bupivacaine and those in Group D received caudal bupivacaine with 0.1 mg/kg of dexamethasone.Results:The mean duration of analgesia when dexamethasone was added to caudal bupivacaine was 1044.92 (±48.66) min, while it was 435.85 (±17.95) min with plain bupivacaine. The number of doses of rescue analgesics required and the mean pain score was also lesser in this group.Conclusion:The addition of 0.1 mg/kg of dexamethasone to caudal bupivacaine increases the duration of analgesia of caudal bupivacaine without any side effects in children undergoing subumbilical surgeries.

A New Look on Adding Dexamethasone as an Adjuvant to Caudal Bupivacaine; Efficacy on Postoperative Pain and Vomiting in Pediatric Patients

Background: Controlling postoperative pain and vomiting in children remains a great challenge. Objective: Study the efficacy of adding dexamethasone to caudal bupivacaine on postoperative analgesia and vomiting. Study Design: Prospective, randomized double blind controlled clinical trial. Setting: Assiut University Hospital. Patients: Ninety children ASA I-II, undergoing lower orthopedic surgeries. Methods: Patients were randomly allocated into 3 equal groups. All received caudal block after induction of anesthesia with 0.5 mL/kg of 0.25% bupivacaine in addition to 5 mL intravenous (IV) normal saline in the control group, IV 0.5 mg/kg dexamethasone in IV dexamethasone group and lastly 0.1 mg/kg dexamethasone in the caudal dexamethasone group. Postoperative pain scores and rescue analgesic consumption were recorded. Blood glucose, postoperative vomiting, and other side effects were evaluated up to 24 hours after extubation. Results: The time of first analgesia and the number of patients requiring rescue analgesics were significantly decreased with intravenous or caudal dexamethasone. No significant increase in postoperative blood glucose levels were observed. A significant increase in β- Endorphin level at 3 and 24 hours postoperative was found in both dexamethasone groups when compared with the preoperative baseline value. The incidence of postoperative vomiting was significantly decreased in both dexamethasone groups in comparison with the control group. No other side effects were detected. Limitations: Measurement of serum cortisol. Conclusion: Analgesic and antiemetic effects of dexamethasone as an adjunct to caudal block with bupivacaine (0.25%) 0.5 mL/kg is similar whether administered intravenously 0.5 mg/kg or caudally 0.1 mg/kg. Key words: B-Endorphin, bupivacaine, caudal, dexamethasone, pediatric, postoperative analgesia, vomiting

The effects of caudal or intravenous dexmedetomidine on postoperative analgesia produced by caudal bupivacaine in children: a randomized controlled double-blinded study

Study ObjectivesThe aim of this study was to compare the effects of caudal and intravenous (IV) dexmedetomidine (1 μg/kg) on postoperative analgesia after caudal bupivacaine in pediatric patients undergoing lower abdominal and perineal surgeries. DesignA randomized controlled double-blind study. SettingUniversity-affiliated teaching hospital. PatientsSeventy-five American Society of Anesthesiologists I children, aged 1 to 6 years. InterventionPatients were randomly allocated to 3 groups. All patients received 1 mL/kg caudal 0.25% bupivacaine. In addition, those in group B (n=25) received 10-mL IV saline, those in group B-Dcau (n=25) received 1 μg/kg caudal dexmedetomidine and 10-mL IV saline, and those in group B-DIV (n=25) received 1 μg/kg IV dexmedetomidine in 10-mL saline. MeasurementsIntraoperative mean blood pressure, heart rate, peripheral oxygen saturation, end-tidal sevoflurane, and bispectral index as well as postoperative pain and behavior scores and time to first analgesia were assessed. Main resultsGroup B-Dcau had a significantly longer time to first rescue analgesia than groups B-DIV and B, with mean (SD) values of 14.4 (7.5), 9.18 (2.7), and 6.6 (2.5) hours, respectively (P<.05). Fewer patients in group B-Dcau (n=16) required rescue analgesia during the first 24 hours postoperatively compared to group B (n=24) and group B-DIV (n=20) (P<.05).Groups B-Dcau and B-DIV had lower pain and behavior scores than Group B. Eight patients Group B had agitation compared to 2 in Group B-DIV and 0 in Group B-Dcau. Four patients in Group B-DIV developed bradycardia and hypotension during surgery. ConclusionsCompared to IV administration, caudal administration of dexmedetomidine during caudal bupivacaine anesthesia provided prolonged postoperative analgesia and a greater analgesic sparing effect without significant side effects. This suggests a greater role of neuraxial compared to that of peripheral α-2 adrenoceptors in pain processing.

The Effect of Adding Midazolam in Caudal Block for Prolongation of Post-Operative Analgesia in Children Underwent Hypospadias Repair, in Soba University Hospital; “Parallel Randomized Trial”

Introduction: Single shot plain bupivacaine is the most popular local anesthetic being used worldwide for caudal anesthesia. There are many agents used as adjunct such as ketamine, clonidine, morphine, adrenaline and midazolam. Objective: This study aimed to assess the effect of adding midazolam to bupivacaine caudally for prolongation of post-operative analgesia. Methods: A double blind controlled trial was conducted in Soba University Hospital from October 2014 to May 2015 among children who underwent surgical repair of hypospadias. 50 children were assigned randomly in two groups the study group (A) n=25 received midazolam 50μg/kg plus bupivacaine 0.5 ml/kg of 0.25%, while the control group (B) n=25 received bupivacaine alone 0.5 ml/kg of 0.25%. The study used FLACC pain scale. The vital signs and pain score were recorded hourly for the first three hours and then every 3 hours for the rest of 24 hours. Results: Two groups were comparable concerning the age, weight, and ASA classification. All patients in the two groups did not feel pain post-operatively throughout the first four hours. Two patients (8%) in group B started to feel pain after four hours, while one patient (4%) in group A felt pain after five hours post-operatively. 11 patients (44%) in group A felt pain while 14 patients (56%) did not feel pain during the first 24 hours post-operatively, however 8 patients (32%) in group B felt pain, while 17 patients (68%) did not feel pain throughout the first 24 hours. Among those who experienced pain in the two groups the majority of group A felt pain after 10 hours (n= 3 &12%), while most of group B felt pain after 6 hours (n=4 & 16%). In both groups rescue analgesia was given according to the severity of pain, as for mild pain the patients were received oral paracetamol/Ibuprofen and those with moderate pain received diclofenac injections. Among those who felt pain in the two groups the mean duration of post operative analgesia was significantly longer in group A than in group B (10.72± 4.07 & 6.31± 1.98) hours respectively) with P-value (0.007). There were no side effects recorded in the study group. However two patients developed nausea and vomiting in the study group. Conclusion: Addition of midazolam 50 μg/kg to caudal bupivacaine 0.5ml/kg of 0.25% significantly resulted in prolongation of post operative analgesia duration.

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 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.

Postoperative analgesia in pediatric herniotomy - Comparison of caudal bupivacaine to bupivacaine infiltration with diclofenac suppository.

Context:Perioperative analgesia in paediatric herniotomies demand safe, effective and less invasive strategies. Local infiltration with Bupivacaine, rectal Diclofenac and caudal Bupivacaine are widely used for pain relief.Aims:To compare the analgesic effects of caudal epidural using 1 mlkg-1 of 0.25% Bupivacaine against a combination of local infiltration 0.25% Bupivacaine 0.5 mlkg-1 with Diclofenac suppository 2 mgkg-1 in the management of post-operative pain following paediatric inguinal herniotomy.Settings and Design:This is an observational study from a tertiary care teaching hospital.Methods and Material:A total of 60 children for elective unilateral inguinal herniotomy were assigned to two groups of 30 each. Patients who received caudal block with 1 mlkg-1 of 0.25% Bupivacaine were allocated to Group A and who received Diclofenac suppository 2 mgkg-1 and infiltration with 0.25% Bupivacaine 0.5 mlkg-1 were allocated to Group B. Post operative Pain was assessed using Hannallah's modified objective pain scale. At score ≥3 rescue analgesic oral Paracetamol 15 mgkg-1 was given. Pain was assessed at 0,15,30,45,60 minutes and half hourly thereafter until 8 hours following surgery or until patient requires rescue analgesic whichever happens first.Statistical Analysis Used:Employed SPSS software. Data was analysed using sample t test and P-value was calculated.Results:The demographic profile was comparable between two groups. The mean analgesic duration in group A and group B was 228.5 and 331.0 minutes respectively and is found to be statistically significant (P < 0.05).Conclusions:Diclofenac suppository with local infiltration is a less invasive and effective alternative to caudal Bupivacaine for analgesia in paediatric herniotomy.

Efficacy and Safety of Clonidine as an Adjuvant to Bupivacaine for Caudal Analgesia in Paediatric Infra-Umbilical Surgeries.

Caudal analgesia, has gained popularity in paediatric intraoperative and postoperative pain management, more so with the use of adjuvants to prolong its duration, each of them having various results. Clonidine, an alpha2-adrenergic agonist is being used for its analgesic effects in various doses with 0.25% Bupivacaine. The study was conducted to compare the analgesic efficacy, haemodynamic safety and side effects of 1 μg/kg Clonidine added to 1 ml/kg of 0.125% Bupivacaine solution for caudal analgesia. A prospective, randomised, double-blind, controlled study was carried out in 60 children of ASA Physical Status I, aged 1-10 years, scheduled for infraumbilical operations in a tertiary care centre. They were randomly assigned for caudal analgesia, to either group B: 1ml/kg of 0.125% Bupivacaine solution or group BC: 1ml/kg of 0.125% Bupivacaine and preservative free Clonidine 1μ/kg. All were premedicated with midazolam 0.75 mg/kg orally 30 minutes prior to induction of anaesthesia. Heart rate (HR), Mean Arterial blood Pressure (MAP) and oxygen saturation (SpO2) were monitored. General anaesthesia was induced with thiopentone (1.25%) 5mg/kg and inhalation of oxygen, nitrous oxide and sevoflurane. Postoperative pain, sedation and motor block was assessed by the various scores and patients were monitored for adverse effects. The mean duration of postoperative analgesia was 3 times longer in group BC. Group B received significantly more doses of rescue analgesic than group BC (p-value of 0.004). There was no significant bradycardia, hypotension, sedation or urinary retention in either of the groups. There was no residual motor blockade at 6 hours. Incidence of vomiting was similar in both the groups. Caudal Clonidine in the dose of 1 μg/kg in children is a satisfactory and efficacious adjuvant to caudal Bupivacaine for producing prolonged postoperative analgesia with minimum side effects.

Evaluation of the analgesic effect of caudal dexamethasone combined with bupivacaine in hypospadias repair surgery

Background Caudal analgesia is the most popular regional technique in infants and children for the infraumbilical surgeries. Its main disadvantage though is its short duration. The aim of this prospective, randomized, double-blind study was to examine the effect of dexamethasone (when added to the caudal bupivacaine) on the duration of postoperative analgesia and the intensity of postoperative pain during hypospadias repair surgeries. Patients and methods A total of 70 patients aged 2–5 years with American Society of Anesthesiologists (ASA) physical status classification I or II were randomly divided into two equal groups in a double-blinded manner. The first group (group B) (n = 35) received caudal analgesia with 0.25% bupivacaine 1 ml/kg, whereas the second group (group D) (n = 35) received caudal analgesia with bupivacaine 0.25% 1 ml/kg plus 0.1 mg/kg dexamethasone. After inhalational induction with sevoflurane and tracheal intubation, patients were turned to lateral position and were given the caudal analgesia. After the end of surgery, postoperative pain score was measured by using Children's and Infants' Postoperative Pain Score (CHIPPS). The primary outcome of this study was the duration of the postoperative caudal analgesia. Severity of postoperative pain, number of rescue analgesic doses, residual motor block, and side effects like nausea and vomiting (secondary outcomes) were monitored. Results The second group (group D) showed significantly longer duration of postoperative analgesia when compared with the first (group B) group. CHIPPS was less in group D compared with group B at 3, 6, 12, and 24 h. Number of rescue analgesic doses of was less in group B than in group D. Modified Bromage scale score were comparable in both groups. Conclusion Adding dexamethasone 0.1 mg/kg to the caudal bupivacaine significantly prolonged the duration of postoperative caudal analgesia and decreased the intensity of postoperative pain during hypospadias repair surgery.

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.

EVALUATION OF SAFETY AND EFFICACY OF CAUDAL ADMINISTRATION OF BUPIVACAINE/ DEXMEDETOMIDINE VERSUS BUPIVACAINE/FENTANYL IN PEDIATRIC UNILATERAL HERNIA REPAIR

Background& Aim: Effective postoperative analgesia is important from the patient’s perspective and can also improve clinical outcomes. This study aimed to compare the effect of caudal bupivacaine plus fentanyl versus caudal bupivacaine plus dexmedetomidine on the recovery of anesthesia, postoperative analgesia required, hemodynamic stability& neurological complications in pediatric unilateral hernia repair patients. Patients & Methods: 50 (ASA) grade I patients, aged 2-4 years with uncomplicated unilateral inguinal hernias treated as day cases were randomly allocated into either; Group I (BF), received Bupivacaine 0.25 % 1 ml kg, and fentanyl 1 μg kg, or Group 2 (BD), received Bupivacaine 0.25 % 1 ml kg, and dexmedetomidine 1 μg kg. Patients were evaluated in terms of pain and sedation using FLACC scale and Ramsay Sedation Scale, respectively. Haemodynamic stability and Neurological complications were assessed during the postoperative period and one day postoperatively.

Caudal bupivacaine and morphine provides effective postoperative analgesia but does not prevent hemodynamic response to pneumoperitoneum for major laparoscopic surgeries in children.

The use of a caudal block in laparoscopic surgery in children is limited to minor procedures like inguinal hernia repair, and intravenous opioids remain the analgesic modality of choice in major laparoscopic surgery. However, a caudal block is frequently performed at our institute even for laparoscopic surgery. Therefore, we planned to evaluate the analgesic efficacy of caudal bupivacaine and morphine in major laparoscopic surgery as compared to intravenous opioids. Our hypothesis was that a single-shot caudal block would increase the duration of analgesia and minimize the hemodynamic response to pneumoperitoneum. After institutional ethics committee clearance, data were collected for 65 ASA I-II children aged 6 months to 12 years who underwent laparoscopic surgery in the last 14 months. Demographic, surgical, and perioperative anesthetic and analgesic data were noted and analyzed. Twenty-four children received a caudal block with 0.25 % bupivacaine (1-1.25 ml/kg) with morphine (30-50 mcg/kg). In the caudal group, the time to first analgesic request was increased (165 vs. 45 min; p = 0.00) and tachycardia response to port site incision was less observed (33 vs. 63 % children; p = 0.019). Hemodynamic response to pneumoperitoneum was equal in both of the groups. Single-shot caudal injection of local anesthetic with morphine reduces port site skin incision response and increases the duration of postoperative analgesia but fails to prevent hemodynamic response to pneumoperitoneum.

A Comparative Study between Caudal Bupivacaine (0.25%) and Caudal Bupivacaine (0.25%) with Dexmedetomidine in Children Undergoing Elective Infra-Umbilical Surgeries

Background: 74 children, either sex, aged 2-7 years, ASA grade I, II, scheduled to undergo infra-umbilical surgeries included in a prospective, double blind, randomized, parallel group study. Aim was to compare duration of analgesia and level of sedation after single dose caudal bupivacaine versus caudal bupivacaine with dexmedetomidine. Methods: The children were randomly allocated into Group B (n=37) and Group BD (n=37). Group B children received caudal bupivacaine (0.25%) 1 ml/Kg B/W in 1ml normal saline and Group BD children received same with dexmedetomidine 2 μg/kg B/W in 1ml normal saline after induction . Pulse rate, blood pressure, SPO2 were monitored and recorded at 0min (after administration of caudal anesthesia) and intra-operatively at 15 minutes interval till the end of operation. Postoperative hemodynamic monitoring, FLACC pain scoring and Ramsay sedation scoring was done at 2 hour interval after extubation upto 8 hrs., then 4 hrly upto 24 hrs. Rescue analgesia was administered when pain score was 4. Results: The study groups were comparable in terms of demographic characteristics, body weight, duration and type of surgeries. Decrease in mean intraoperative heart rate, systolic blood pressure, diastolic blood pressure, postoperative pulse rate, systolic and diastolic blood pressure in Group-BD was statistically significant. Mean FLACC pain scores were significantly low in group BD compared to group B at 0 mins, 120 mins, 240 mins and 360 mins after extubation (p<0.001). Mean duration of analgesia in group BD 648.9 ± 130.59 mins compared to 289.7 ± 78.21 mins in group B. Mean Ramsay sedation scores were significantly high in group BD compared to group B at 0 mins,120 mins and 240 mins after extubation (p<0.001). Conclusion: The study demonstrated that addition of dexmedetomidine to caudal bupivacaine prolongs duration of analgesia, provides better quality of sleep, prolong duration of arousal sedation and better hemodynamic stability to the children compared to caudal bupivacaine.

Caudal bupivacaine plus ketamine compared with bupivacaine plus tramadol for postoperative analgesia in children

Background Caudal epidural block has been used commonly in pediatric postoperative pain management. However, the analgesic effect of caudal of bupivacaine lasts for 4-12 h. Aim The aim of this study was to compare the analgesic efficacy of the coadministration of tramadol (2 mg/kg) and ketamine (0.25 mg/kg) on the duration of caudal block produced by 0.25% bupivacaine 0.75 ml/kg on postoperative pain after an elective subumbilical surgery in children. Settings and design This is a controlled, randomized, single-blinded study. Patients and methods This study was carried out on 40 children between 2 and 12 years of age, ASA grade 1, of both sexes in Tanta University after obtaining the approval of the local hospital organization and parents' consent. The patients were divided into two equal groups. The patients in the bupivacaine plus ketamine group (group 1) received caudal bupivacaine 0.25%, 0.75 ml/kg mixed with ketamine 0.25 mg/kg, diluted in a 0.9% NaCl solution to a total volume of 1 ml/kg. The patients in the bupivacaine plus tramadol group (group 2) were administered caudal bupivacaine 0.25%, 0.75 ml/kg mixed with tramadol 2 mg/kg, diluted in a 0.9% NaCl solution to a total volume of 1 ml/kg. Statistical analysis Mean and SD were calculated as numerical data. Continuous variables were compared using the unpaired Student's t -test. Nominal nonparametric data were analyzed using the χ 2 -test. Results Patients were monitored over the first 24 h postoperatively to assess analgesia using the All India Institute of Medical Science (AIIMS) objective pain discomfort scale and associated hemodynamic and respiratory changes. Our results showed that the addition of tramadol in group 2 significantly prolonged the analgesic effect of bupivacaine; also, there was hemodynamic stability and pain scores indicated minimal pain. Conclusion Caudal epidural tramadol has been proven to be safe at the concentration used and to prolong bupivacaine's analgesic duration postoperatively in children.

Caudal Neostigmine and Bupivacaine Facilitates Early Extubation and Provides Prolonged Postoperative Analgesia in Children Undergoing Open Heart Surgery

Objective: This study was designed to examine the effect of single shot of caudal neostigmine with bupivacaine on early extubation versus standard intravenous fentanyl regimen without caudal block. Design: Prospective, randomized double blind controlled clinical trial Setting of the study: Children University Hospital Patients: 80 children (4 to 12 years) undergoing correction of congenital heart defects Methods: Patients were randomized into two equal groups (caudal neostigmine group and non-caudal group); Anesthesia was provided with sevoflurane, midazolam, plus fentanyl 5 mcg/kg and cisatracurium 0.1 mg/kg and maintained with sevoflurane, fentanyl 1 mcg/kg/h. and cisatracurium 0.05 mg/kg. In caudal group; caudal block with bupivacaine (0.125%) in a dose of 1.5 ml/kg plus neostigmine in a dose of 2 mcg/kg was performed after endotracheal intubation in the caudal group only. In non-caudal group intravenous fentanyl was continuously infused postoperatively until weaning from mechanical ventilation. Measurements and Main Results: Both groups were comparable as regard age, sex, weight, and bypass and aortic cross clamp times. In the caudal neostigmine group patients were early extubated, with shorter Pediatric Intensive Care Unit (PICU) stay and prolonged postoperative analgesia. Eleven patients had nausea and vomiting in caudal versus four in non-caudal group. Conclusion: Single dose of caudal bupivacaine with neostigmine provided optimum conditions for extubation and good control of postoperative pain in children undergoing cardiac surgery.