Clonidine as an Additive to Local Anesthetics in Caudal Block for Postoperative Analgesia in Pediatric Surgery: A Systematic Review and Meta-Analysis

Background: Clonidine is an anesthetic with favorable efficacy and safety profiles for caudal epidural block, but comparisons with other adjuvants need to be confirmed in pediatric patients.Aim: To investigate the effects of clonidine as an adjuvant in caudal epidural block to improve the intraoperative and postoperative analgesia in pediatric surgery.Methods: PubMed, Embase, and the Cochrane Library were searched for available papers published up to February 2021. The outcomes were pain score, duration of analgesia, complications, and number of analgesic requirements. The meta-analysis was performed using random-effects models.Results: Fifteen randomized controlled trials (RCTs) were included. There were no differences between clonidine and the control drug regarding the duration of analgesia (SMD = −0.71, 95%CI: −1.64, 0.23; I2 = 95.5%, Pheterogeneity < 0.001), pain score (SMD = 0.35, 95%CI: −0.28, 0.98; I2 = 80.8%, Pheterogeneity < 0.001), and requirement for additional analgesia (OR = 8.77, 95%CI: 0.70, 110.58, I2 = 81.9%, Pheterogeneity = 0.004), but using clonidine resulted in fewer complications than the control drugs (OR = 0.33, 95%CI: 0.20, 0.54, I2 = 21.8%, Pheterogeneity = 0.217). The sensitivity analysis showed that the results were robust. A publication bias was observed.Conclusion: Clonidine has the same efficacy as the other adjuvants for caudal epidural block for pediatric surgery but fewer complications. These results support clonidine as an adjuvant to local anesthetic, but additional studies should be conducted.

Comparative study between ultrasound-guided pudendal nerve block and caudal epidural block anesthesia in children undergoing hypospadias surgery

Background The aim of the study is to compare the effectiveness and safety of ultrasound-guided pudendal nerve block versus caudal epidural block as a part of multimodal analgesia in children undergoing hypospadias surgery. In this prospective, single-blinded study, 50 patients were randomized into 2 groups (25 each group) either receiving ultrasound-guided pudendal nerve block group A or caudal epidural block group B. In the pudendal nerve block group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. In the caudal epidural group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. Consumption of paracetamol was assessed during the first 24 h postoperatively. The “objective pain scale” done by Hannalah and Broadman was used to assess postoperative pain. Results This prospective randomized controlled single-blind clinical study was performed on total (50) ASA status I or II patients, of age 3 to 6 years scheduled for hypospadias surgery. For the primary outcome, there was no statistically significant difference found between the two studied groups regarding objective pain score at arrival to PACU with p value = 1.000 while there was a statistically significant increase in pain score in group B than group A at 6 h and 12 h with p value = 0.017 and 0.003, respectively. Also, no statistically significant difference found between the two groups after 18 h with p value = 0.238 may be due to receiving acetaminophen dose in group B. Finally there was a statistically significant increase found in objective pain score in group B at 24 h than group A with p value = 0.015. And there was a statistically significant increase in time to first analgesia in group A than group B with p value < 0.001 while there was a statistically significant increase in total dose of acetaminophen in group B than group A with p value < 0.001. Conclusion Both ultrasound-guided pudendal block and caudal epidural block are effective and safe methods for postoperative analgesia for children undergoing hypospadias surgery but ultrasound-guided pudendal block gives more postoperative pain control.

Analgesic and Sedative Effects of Epidural Lidocaine-Xylazine in Elective Bilateral Laparoscopic Ovariectomy in Standing Mule Mares

The purpose of this study was to determine the analgesic efficacy and safety of epidural lidocaine-xylazine administration in standing mules undergoing elective bilateral laparoscopic ovariectomy in order to suppress unwanted behaviour. Eight mule mares were sedated with intramuscular 0.05 mg/kg acepromazine followed by 1.3 mg/kg of xylazine and 0.02 mg/kg of butorphanol intravenously. Sedation was maintained by a constant rate infusion of 0.6 mg/kg/h of xylazine. The paralumbar fossae were infiltrated with 30 mL of 2% lidocaine. Epidural anaesthesia was performed at the first intercoccygeal space with 0.2 mg/kg of lidocaine and 0.17 mg/kg of xylazine. After 15 min, bilateral laparoscopic ovariectomy was performed. Heart rate, respiratory rate, rectal temperature, invasive arterial blood pressure, degree of analgesia, sedation and ataxia were evaluated during surgery. The laparoscopic ovariectomy was successfully completed in all animals. Sedation and analgesia were considered satisfactory in six out of the eight mules. In conclusion, caudal epidural block allowed surgery to be easily completed in six out of eight. The animals did not show any signs of discomfort associated with nociception and were mostly calm during the procedures, however additional studies are needed to establish epidural doses of xylazine and lidocaine that result in reliable abdominal pain control in mules for standing ovariectomy.

Continuous Caudal Catheters in Neonatal Population: A Focussed Review

Caudal epidural block is one of the most commonly administered blocks in paediatric population. Continuous caudal technique offers several advantages like its ability to cater to long duration surgeries, higher thoracic procedures and to deliver extended, titratable post-operative pain relief. Current advances in this technique like use of fluoroscopy, electrical stimulation and Ultrasound to secure continuous caudal catheters facilitate enhanced accuracy and safety and should be adopted wherever feasible. An understanding of local anaesthetic dosages for infusion and their fine tuning is a prerequisite. The potential benefits and risks should be assessed on a case-to-case bases Keywords: Caudal anaesthesia, Post-operative pain, Neonatal regional anaesthesia

Ultrasound-Guided Caudal Epidural Block for Bilateral Testicular Ectopy and Circumcision in Child above 6 Years with Joubert Syndrome

Background: Abnormal respiratory control has been clearly documented in infants and children with Joubert Syndrome (JS) by polygraphic recordings, characterized by episodes of apnea, tachypnea, and/or hyperpnea and the risk of recurrence of these episodes increase probably in perioperative period. In those cases, the choice of anesthesia technique and postoperative pain protocol, constitute a challenge for anesthesiologists. Case: We describe a case of successful ultrasound-guided Caudal Epidural Block (CEB) for children above 6 years with Joubert Syndrome undergoing bilateral testicular ectopy and circumcision avoiding opioid-use. Conclusions: Despite the difficulty to achieve CEB in child above 6 years, the ultrasound-guided can increase the success providing effective analgesia in-patient with a high-risk of respiratory failure as child with JS.

Evaluation of Adding Dexmedetomidine to Ropivacaine in Pediatric Caudal Epidural Block: A Randomized, Double-blinded Clinical Trial

Background: Caudal block is one of the methods of pain management performed following lower abdominal surgery, though having its own limitations. Objectives: In the present study, the effects and side effects of adding dexmedetomidine to ropivacaine in the caudal epidural block were investigated in children after lower abdominal surgery. Methods: In this randomized, double-blinded clinical trial, 46 children aged three to six years were divided into two groups to perform a caudal block following lower abdominal surgery under general anesthesia. The injectable solution contained ropivacaine in the R group (1 mL/kg ropivacaine 0.2%), as the control group, and dexmedetomidine (2 µg/kg) and ropivacaine 0.2% (1 mL/kg) in the DR group. The pain score (modified CHEOPS score), duration of analgesia, amount of analgesia consumed (i.v. paracetamol), hemodynamic changes, and possible adverse effects were assessed at one, two, and six hours in both groups. Results: The pain score at one and two hours showed no significant difference between the two study groups (P > 0.05). In the DR group, however, the pain score at the sixth hour was significantly lower, and the duration of analgesia was longer (P = 0.001). The amount of analgesic consumption was also lower in the DR group (P = 0.001). However, there was no significant difference in systolic blood pressure and heart rate (P < 0.05), in the case of diastolic blood pressure, a significant difference (P < 0.05) was seen (DR group lower than the R group). There was no statistically significant difference between the study groups in the duration of surgery, recovery time, and side effects (P < 0.05). Conclusions: In the present study, the addition of dexmedetomidine to ropivacaine in the caudal epidural blockade improved postoperative analgesia without significant adverse effects in pediatric patients.

Transient bladder incontinence following ultrasound guided caudal epidural block

Caudal anesthesia is commonly used a regional anesthesia technique for sub-umbilical surgeries in pediatrics and for chronic pain management in adults. Ultrasound guided caudal epidural block improves the success rate with minimizes complications. We report a patient who underwent lateral sphincterotomy under ultrasound guided caudal epidural anesthesia and developed transient urinary incontinence with prolonged perineal sensory loss postoperatively. Key words: Anesthesia, Caudal epidural, Ultrasound. Citation: Preethipriyadharshini R, Vadhanan CP, Bokka N. Transient bladder incontinence following ultrasound guided caudal epidural block. Anaesth. pain intensive care 2021;25(1):102–104; DOI: 10.35975/apic.v25i1.1437 Received: 17 October 2020; Reviewed: 4 November 2020; Accepted: 5 December 2020

Influence of the choice of the method of perioperative analgesia on the possibility of early initiation of enteral nutrition as part of early rehabilitation in pediatric laparoscopic oncosurgery

Introduction. The need to perform nutritional support for children with cancer is widely recognized. The body of a child suffering from a malignant tumor needs additional amounts of energy and plastic substrates. Patients with signs of protein-energy insufficiency are at risk of developing complications in the early postoperative period. A significant role in compliance with early rehabilitation after surgery (ERAS) protocol is played by the method of perioperative analgesia. Caudal epidural block is the most widely used regional method of analgesia in children, allowing to start earlier enteral nutrition and prevent the development of postoperative paresis of the gastrointestinal tract (GIT), thereby speeding up the recovery of patients after surgery. In this study, we evaluated the effectiveness and safety of early enteral nutrition tactics in oncology children, in the postoperative period during laparoscopic surgical interventions, in order to prevent gastrointestinal paresis in combination with early activation of patients. In the present study, we evaluated the effectiveness of the tactics of choosing perioperative analgesia from the perspective of the possibility of early initiation of enteral nutrition in children with oncopathology, in the postoperative period after laparoscopic surgical interventions, in order to prevent paresis of the gastrointestinal tract in combination with early activation of patients.Materials and methods. The study included 40 patients of the research Institute of Children's Oncology and Hematology of the Russian Ministry of health, ASA II—III, operated in 2017—2019for malignant abdominal tumors by laparoscopic method. Patients were divided into 2 groups randomly. The CB group included 23 children who were treated with caudal epidural block as a regional component of combined anesthesia (CB group, n = 23). The control group-GA included 17 children who underwent General anesthesia (group GA, n = 17).The analysis of the early postoperative period (day 1) was performed. Postoperative nutritional support was performed to prevent gastrointestinal paresis in combination with early activation of patients and consisted of early (from day 1 after surgery) enteral nutrition. We used a therapeutic mixture of Alfare® based on whey protein hydrolysate (for children under 1 year) and Peptamen® Junior based on hydrolyzed whey protein, a complete balanced dry mix (for children from 1 year to 10 years). The volume of enteral nutrition was calculated based on the number of calories per kg of body weight. We started therapeutic nutrition with volumes of 1/2-2/3 of the calculated volume and increased the volume to the required patient tolerance.Results. Enteral nutrition in children in the CB group was connected from 4.7 ± 0.5 hours. In the GA group, enteral nutrition was switched on in 10 (59 %) patients 20 hours after the end of surgery. 5 children developed gastrostasis, which required medication to stimulate the gastrointestinal tract.Conclusions. This study demonstrates that in the conditions of effective neuroaxial blockade in the perioperative period, it is possible to start enteral nutrition as early as possible, reducing to a minimum the frequency of postoperative intestinal paresis during laparoscopic surgical interventions, contributing to early and rapid recovery of patients.