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Eizaga Rebollar R, Carnota Martín AI, Borreiros Rodríguez E, Rojo Díez R. Tethered Spinal Cord Syndrome Discovered during Ultrasound-guided Caudal Block. Anesthesiology 2024; 140:1203-1204. [PMID: 38498665 DOI: 10.1097/aln.0000000000004899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta de Mar University Hospital, Cádiz, Spain
| | | | | | - Raquel Rojo Díez
- Department of Pediatric Surgery, Puerta del mar University Hospital, Cádiz, Spain
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Xiang J, Cao C, Chen J, Kong F, Nian S, Li Z, Li N. Efficacy and safety of ketamine as an adjuvant to regional anesthesia: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2024; 94:111415. [PMID: 38394922 DOI: 10.1016/j.jclinane.2024.111415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/03/2023] [Accepted: 02/09/2024] [Indexed: 02/25/2024]
Abstract
STUDY OBJECTIVE To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. DESIGN A Systematic review and meta-analysis of randomized controlled trials. SETTING The major dates were obtained in the operating room and the postoperative recovery ward. PATIENTS A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion. INTERVENTIONS After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block. MEASUREMENT The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system. MAIN RESULT Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I2 = 57%). CONCLUSION This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.
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Affiliation(s)
- Jiajia Xiang
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China; Kunming Medical University, Kunming, Yunnan, China
| | - Chunyan Cao
- Department of Obstetrics and Gynecology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China
| | - Jiayu Chen
- Department of Orthopedics, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Fanyi Kong
- Department of Neurology, Affiliated Hospital of Yunnan University, Kunming, Yunnan, China
| | - Sunqi Nian
- Department of Orthopedics, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Zhigui Li
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China.
| | - Na Li
- Department of Anesthesiology, 920th Hospital of Joint Logistics Support Force, Kunming, Yunnan, China.
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Yang W, Han D, Pan S, Zou S, Xie S, Ma Y, Huang G. Evaluation of sacral hiatus changes in children using ultrasound. Heliyon 2024; 10:e31526. [PMID: 38831844 PMCID: PMC11145470 DOI: 10.1016/j.heliyon.2024.e31526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Background and objectives The intercornual distance in the sacral hiatus has yet to be studied precisely in children. This age-stratified, observational study aimed to clarify the changes in sacral hiatus dimensions and to quantify the correlations between the intercornual distance of the sacral hiatus and age, height, weight, and head circumference by using real-time ultrasonography. Methods The patients were stratified into three groups: neonates and infants, toddlers, and schoolchildren. In the operating room, the ultrasonic probe was placed at the sacral cornua to obtain a transverse view of the sacral hiatus, and the intercornual distance was measured three times in millimetres. Results The study included a total of 156 patients. The mean ± SD (95%CI) of intercornual distance in neonates and infants (<12 months) was 11.58 ± 1.79 (11.11-12.04) mm, 13.29 ± 1.97 (12.71-13.86) mm in toddlers (13-36 months), and 13.36 ± 2.49 (12.64-14.08) mm in schoolchildren (>36 months).The mean values of neonates and infants were different from those of toddlers and schoolchildren (p < 0.001), but it was similar between toddlers and schoolchildren (p > 0.05, 95 % CI mean difference -1.10 to 0.95).Intercornual distance was correlated with age, height, weight, and head circumference before one year of age (Spearman's R values > 0.7), but there was no correlation thereafter (Spearman's p value > 0.05). Conclusion In the first year after birth, the intercornual distance increases rapidly with body growth; after one year of age, the sacral hiatus dimension changes significantly. Ultrasound is superior for assessing the gradually ossified cartilage components in older children.
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Affiliation(s)
- Wenshuang Yang
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Ding Han
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Shoudong Pan
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Shiya Zou
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Siyuan Xie
- Anaesthesiology, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Ya Ma
- Ultrasound Department, Affiliated Children's Hospital, Capital Institute of Paediatrics, Beijing, China
| | - Guimin Huang
- Big Data Centre, Capital Institute of Paediatrics, Beijing, China
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Kim HJ, Kim H, Lee S, Koh WU, Park SS, Ro Y. Reconsidering injection volume for caudal epidural block in young pediatric patients: a dynamic flow tracking experimental study. Reg Anesth Pain Med 2024; 49:355-360. [PMID: 37429622 DOI: 10.1136/rapm-2023-104409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/24/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Caudal epidural block is a commonly used analgesic technique in pediatric patients. Ultrasound could be used to increase the accuracy of the block by visual confirmation of the drug-spreading. Therefore, we aimed to estimate the cephalad spread of injection volume by caudal route using dynamic ultrasound imaging in young pediatric patients. METHODS Forty patients, aged 6-24 months, undergoing foot surgery were included. After inducing general anesthesia, an angiocatheter was inserted into the sacral canal under ultrasound guidance. Thereafter, the probe was placed in the paramedian sagittal oblique position, and prepared 0.15% ropivacaine was injected, 1 mL at a time, up to 1.0 mL.kg-1. The ultrasound probe was moved cranially following the bulk flow of local anesthetics. Our primary outcome was the required volume of local anesthetics to reach each level of interlaminar space. RESULTS The dynamic flow tracking was available in 39 patients, and the required volume of the injectate to reach L5-S1, L4-L5, L3-L4, L2-L3, L1-L2, T12-L1, and T11-T12 was 0.125, 0.223, 0.381, 0.591, 0.797, 0.960, and 1.050 mL.kg-1, respectively. The required volume to reach the immediate upper spinal level was inconsistent across various spinal levels. CONCLUSIONS Local anesthetics of 0.223, 0.591, and 0.797 mL.kg-1 could provide sufficient analgesia for localized foot, knee, and hip surgeries, respectively. However, since the required volume of the local anesthetics could not be calculated linearly, the real-time dynamic flow tracking technique for the caudal epidural block is recommended in young pediatric patients. TRIAL REGISTRATIONS ClinicalTrials.gov (NCT04039295).
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Affiliation(s)
- Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
| | - Sooho Lee
- Department of Anesthesiology and Pain Medicine, International Saint Mary's Hospital, Catholic Kwandong University, Incheon, Korea (the Republic of)
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
| | - Soo-Sung Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
| | - Youngjin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea (the Republic of)
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Tamang K, Baral BK, Shah Malla S, KC B, Kuikel S, Shrestha D, Pathak N. Study of caudal ropivacaine with or without dexmedetomidine for postoperative analgesia in paediatric genitourinary infraumbilical surgery: a double-blinded randomized controlled trial. Ann Med Surg (Lond) 2024; 86:1997-2003. [PMID: 38576959 PMCID: PMC10990384 DOI: 10.1097/ms9.0000000000001919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/25/2024] [Indexed: 04/06/2024] Open
Abstract
Various studies have described the use of Dexmedetomidine with local anaesthetic drugs in caudal blocks for the management of postoperative pain in children. This study was designed to determine the analgesic effect of caudal Dexmedetomidine with Ropivacaine in paediatric genitourinary infraumbilical surgeries. Postoperative analgesic effects of caudal Ropivacaine with or without Dexmedetomidine in paediatric genitourinary infraumbilical were evaluated. This study was a prospective, interventional, comparative study conducted after ethical approval from the institute. Informed expressed consent was taken from each patient's guardians. The sample size was calculated to be 31 in each group. The two groups were randomly assigned and the intervention involved caudal epidural injection with either Ropivacaine combined with Dexmedetomidine or Ropivacaine with Normal Saline. Children receiving Ropivacaine with Dexmedetomidine had a significantly prolonged duration of analgesia compared to those receiving Ropivacaine alone (840.35 ± 149.97 vs. 412.90 ± 93.46 min, P < 0.001). Postoperative rFLACC scores were consistently lower in the Dexmedetomidine group, indicating better pain control (P < 0.05 at 6, 12, and 24 h). Total analgesic consumption was lower in the Dexmedetomidine group (500.67 ± 212.92 vs. 741.75 ± 268.06 mg, P < 0.01). No significant differences in adverse effects were observed between the groups. The addition of Dexmedetomidine to Ropivacaine in caudal epidural significantly prolongs analgesia, improves pain control, and reduces analgesic consumption in paediatric genitourinary infraumbilical surgeries.
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Affiliation(s)
| | | | | | | | - Sandip Kuikel
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | | | - Nibesh Pathak
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
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Castillo P, Vanhatalo S, Lundblad M, Blennow M, Lonnqvist PA. EEG response to a high volume (1.5 mL/kg) caudal block in infants less than 3 months. Reg Anesth Pain Med 2024; 49:163-167. [PMID: 37364921 DOI: 10.1136/rapm-2023-104452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION The substantial compression of the dural sac and the subsequent cranial shift of cerebrospinal fluid caused by a high-volume caudal block has been shown to significantly but transiently reduce cerebral blood flow. The aim of the present study was to determine whether this reduction in cerebral perfusion is significant enough to alter brain function, as assessed by electroencephalography (EEG). METHODS Following ethics approval and parental informed consent, 11 infants (0-3 months) scheduled to undergo inguinal hernia repair were included in the study. EEG electrodes (using nine electrodes according to the 10-20 standard) were applied following anesthesia induction. Following a 5 min baseline period, a caudal block was performed (1.5 mL/kg), whereafter the EEG, hemodynamic, and cerebral near-infrared spectroscopy responses were followed during a 20 min observation period that was divided into four 5 min segments. Special attention was given to alterations in delta power activity since this may indicate cerebral ischemia. RESULTS All 11 infants displayed transient EEG changes, mainly represented by increased relative delta power, during the initial 5-10 min postinjection. The observed changes had returned close to baseline values 15 min postinjection. Heart rate and blood pressure remained stable throughout the study. CONCLUSION A high-volume caudal block appears to increase intracranial pressure, thereby reducing cerebral blood flow, to the extent that it transiently will affect cerebral function as assessed by EEG (increased delta power activity) in approximately 90% of small infants. TRIAL REGISTRATION NUMBER ACTRN12620000420943.
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Affiliation(s)
- Paul Castillo
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Sampsa Vanhatalo
- Neurosciences, Helsinki University Central Hospital, Helsinki, Finland
| | - Marit Lundblad
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Mats Blennow
- Women and Child Health, Karolinska Institute, Stockholm, Sweden
| | - P A Lonnqvist
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Sipek J, Pokorna P, Sima M, Styblova J, Mixa V. Disposition of levobupivacaine during intraoperative continuous caudal epidural analgesia in a preterm neonate. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:81-84. [PMID: 37997373 DOI: 10.5507/bp.2023.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Continuous caudal epidural analgesia used intraoperatively in children is an effective and safe technique. However, in preterm neonates, developmental factors may significantly affect levobupivacaine disposition, leading to variable pharmacokinetics, pharmacodynamics, and potential large-variable systemic toxicity of local anesthetics. OBJECTIVE To our knowledge, this is the first case report describing the disposition of levobupivacaine used for intraoperative caudal epidural analgesia in a preterm neonate treated for the postoperative pain profile. METHOD 4-days old neonate (postmenstrual age 35+5, weight 2140 g) with congenital anal atresia received continuous caudal epidural long-term analgesia (loading dose 1.694 mg/kg, initial infusion 0.34 mg/kg/hour) before correction surgery. The blood samples were obtained at 1.0, 1.5, 6.5, 12, and 36.5 h after the start of epidural infusion. The pharmacokinetic profile of levobupivacaine was determined by using the Stochastic Approximation Expectation Maximization algorithm. COMFORT and NIPS pain scores were used for the assessment of epidural analgesia. RESULTS The levobupivacaine absorption rate constant, apparent volume of distribution, apparent clearance, and elimination half-life were 10.8 h-1, 0.9 L, 0.086 L/h, and 7.3 h, respectively. CONCLUSION The results confirm our hypothesis of altered pharmacokinetics in the preterm neonate. Therefore, levobupivacaine therapy in these patients should be carefully monitored. Since therapeutic drug monitoring of levobupivacaine is not established in clinical routines, we suggest monitoring the intraoperative pain profile using validated scores. TRIAL REGISTRATION EudraCT number: 2020-000595-37.
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Affiliation(s)
- Jan Sipek
- Department of Anaesthesia, Resuscitation and Intensive Medicine, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
| | - Pavla Pokorna
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Martin Sima
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jitka Styblova
- Department of Paediatric Surgery, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
| | - Vladimir Mixa
- Department of Anaesthesia, Resuscitation and Intensive Medicine, 2nd Faculty of Medicine, Charles University and Faculty Hospital Motol, Prague, Czech Republic
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Park I, Park JH, Shin HJ, Na HS, Koo BW, Ryu JH, Oh AY. Postoperative analgesic effects of the quadratus lumborum block in pediatric patients: a systematic review and meta-analysis. Korean J Pain 2024; 37:59-72. [PMID: 38123185 PMCID: PMC10764215 DOI: 10.3344/kjp.23268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/22/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
Background This study assessed the postoperative analgesic efficacy and safety of the quadratus lumborum block (QLB) in pediatric patients. Methods Electronic databases were searched for studies comparing the QLB to conventional analgesic techniques in pediatric patients. The primary outcome was the need for rescue analgesia 12 and 24 hours after surgery. Secondary outcomes covered the Face-Legs-Activity-Cry-Consolability Scale (FLACC) scores at various time points; parental satisfaction; time to the first rescue analgesia; hospitalization time; block execution time; block failure rates, and adverse events. Results Sixteen randomized controlled trials were analyzed involving 1,061 patients. The QLB significantly reduced the need for rescue analgesia both at 12 and 24 hours after surgery (12 hours, relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.01, 0.88; 24 hours, RR: 0.51; 95% CI: 0.31, 0.70). In case of 24 hours after surgery, type 1 QLB significantly reduced the need for rescue analgesia (RR: 0.56; 95% CI: 0.36, 0.76). The QLB also exhibited lower FLACC scores at 1 hour (standardized mean difference [SMD]: -0.87; 95% CI: -1.56, -0.18) and 6 hours (SMD: -1.27; 95% CI: -2.33, -0.21) following surgery when compared to non-QLB. Among QLBs, type 2 QLB significantly extended the time until the first rescue analgesia (SMD: 1.25; 95% CI: 0.84, 1.67). No significant differences were observed in terms of parental satisfaction, hospitalization time, block execution time, block failure, or adverse events between QLB and non-QLB groups. Conclusions The QLB provides non-inferior analgesic efficacy and safety to conventional methods in pediatric patients.
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Affiliation(s)
- Insun Park
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyon Park
- Department of Radiology, The Armed Forces Daejeon Hospital, Daejeon, Korea
| | - Hyun-Jung Shin
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo-Seok Na
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bon-Wook Koo
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung-Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicines, Seoul, Korea
| | - Ah-Young Oh
- Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicines, Seoul, Korea
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Hung TY, Bai GH, Tsai MC, Lin YC. Analgesic Effects of Regional Analgesic Techniques in Pediatric Inguinal Surgeries: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Anesth Analg 2024; 138:108-122. [PMID: 36571797 DOI: 10.1213/ane.0000000000006341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Various regional analgesic techniques have been used in pediatric inguinal surgery to facilitate postoperative recovery. However, each technique's relative performance was undetermined owing to the lack of quantitative analysis. METHODS We systematically searched MEDLINE, Cochrane Library, EMBASE, and Web of Science for randomized controlled trials that compared regional analgesia in pediatric inguinal surgeries. After critical study screening and selection, a random-effects network meta-analysis was performed. The primary outcome was the time to the first rescue analgesic after surgery, and the secondary outcomes were the number of patients requiring rescue analgesics after surgery, postoperative pain scores, incidence of postoperative nausea and vomiting, and other adverse events. RESULTS This network meta-analysis included 69 randomized controlled trials (4636 patients) that compared 10 regional analgesic techniques. Our study revealed that the quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic after pediatric inguinal surgeries, by 7.7 hours (95% confidence interval [CI], 5.0-10.3) and 6.0 hours (95% CI, 3.9-8.2) when compared with the control group, respectively. In the subgroup involving only inguinal hernia repair, the quadratus lumborum block significantly prolonged the time to the first rescue analgesic than all other regional analgesics. In contrast, in the subgroup involving orchidopexies, only the caudal block significantly prolonged the time to the first rescue analgesic when compared with the control group (4.1 hours; 95% CI, 0.7-7.5). Wound infiltration and landmark-based ilioinguinal-iliohypogastric block had relatively poor analgesic effects than other regional analgesics. No serious adverse effects related to the regional analgesic techniques were reported in any of the included studies. CONCLUSIONS The quadratus lumborum and transversus abdominis plane blocks had the longest time to the first rescue analgesic and the least rescue analgesic requirement for pediatric inguinal surgeries. Specifically, the quadratus lumborum block had the longest analgesic duration in inguinal hernia repair, and the caudal block was found to be the only regional analgesia that extended the time to the first rescue analgesic in pediatric orchidopexy. Most included randomized controlled trials had some concern or a high risk of bias, and future studies should focus on providing high-quality evidence to further clarify the analgesic effects of regional analgesia for pediatric inguinal surgeries.
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Affiliation(s)
- Tsung-Yu Hung
- From the Department of Anesthesia, MacKay Memorial Hospital, Taipei, Taiwan
| | - Geng-Hao Bai
- Department of General Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Chen Tsai
- Department of General Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ying-Chun Lin
- From the Department of Anesthesia, MacKay Memorial Hospital, Taipei, Taiwan
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
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Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. Int Anesthesiol Clin 2024; 62:69-78. [PMID: 38063039 DOI: 10.1097/aia.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Kathryn Handlogten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Savić Vujović K, Jotić A, Medić B, Srebro D, Vujović A, Žujović J, Opanković A, Vučković S. Ketamine, an Old-New Drug: Uses and Abuses. Pharmaceuticals (Basel) 2023; 17:16. [PMID: 38276001 PMCID: PMC10820504 DOI: 10.3390/ph17010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024] Open
Abstract
Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.
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Affiliation(s)
- Katarina Savić Vujović
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Ana Jotić
- Clinic for Otorhinolaryngology and Maxillofacial Surgery, University Clinical Center of Serbia, Pasterova 2, 11000 Belgrade, Serbia;
| | - Branislava Medić
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | - Dragana Srebro
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
| | | | - Janko Žujović
- Clinical Centre of Montenegro, Centre for Abdominal Surgery, 81000 Podgorica, Montenegro;
| | - Ana Opanković
- Clinical Centre of Serbia, Clinic for Psychiatry, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Sonja Vučković
- Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, 11129 Belgrade, Serbia; (B.M.); (D.S.); (S.V.)
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Nabil F, Rashed MS, Takrouney MH, Ibrahim IA, Abdalla E, Osman HM. Peri-anal infiltration versus caudal block for multimodal analgesia in paediatric patients with Hirschsprung's disease undergoing transanal endorectal pull-through procedure: A randomised trial. Indian J Anaesth 2023; 67:979-984. [PMID: 38213680 PMCID: PMC10779970 DOI: 10.4103/ija.ija_471_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 01/13/2024] Open
Abstract
Background and Aims Transanal endorectal pull-through (TERPT) is a standard procedure for managing paediatric patients with Hirschsprung's disease (HD). This study aimed to evaluate peri-anal infiltration versus caudal block as a part of multimodal analgesia for paediatric patients with HD undergoing the TERPT procedure. Methods This randomised trial included 60 patients of both genders, aged 6 to 18 months who underwent the TERPT procedure under general anaesthesia. The patients were randomly assigned into two groups to receive either peri-anal infiltration or caudal block with 1 ml/kg bupivacaine 0.25% and dexmedetomidine 1 µg/kg in 0.5 ml normal saline. The primary outcome was the time to the first rescue analgesia. The secondary outcomes were the total consumption, the frequency of nalbuphine administration as rescue analgesia within 24 hours and the level of postoperative sedation. Results The time to first rescue analgesia was significantly shorter in the peri-anal infiltration group versus the caudal block group (median [interquartile range] 10 [7.5-12.5] h versus 16 [13.5-18.5] h, respectively, P = 0.008). The frequency of administration and the total dose of nalbuphine was significantly higher in the peri-anal infiltration group (P = 0.003 and 0.013, respectively). The sedation score was significantly higher in the caudal block group postoperatively. Conclusion For paediatric patients undergoing the TERPT procedure, peri-anal infiltration was less effective than caudal block in terms of the duration of postoperative analgesia. However, both techniques were comparable during the first 6 hours postoperatively.
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Affiliation(s)
- Fatma Nabil
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed S. Rashed
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohammed H Takrouney
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ibrahim A Ibrahim
- Department of General Surgery, Pediatric Surgery Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esam Abdalla
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hany M Osman
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
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Portela F, Costa G, Cenicante T. Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical Center. Cureus 2023; 15:e48272. [PMID: 38054162 PMCID: PMC10695668 DOI: 10.7759/cureus.48272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2023] [Indexed: 12/07/2023] Open
Abstract
Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.
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Affiliation(s)
- Filipa Portela
- Anesthesiology, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
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14
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Coşkun İ, Yalçın O. Evaluating Caudal Block Enhancements in Pediatric Circumcision: Do Additional Analgesics Make a Difference? Med Sci Monit 2023; 29:e942557. [PMID: 37904341 PMCID: PMC10625336 DOI: 10.12659/msm.942557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 11/01/2023] Open
Abstract
BACKGROUND Caudal block is widely regarded as the top choice for multimodal analgesia in children undergoing urological surgeries, particularly circumcision. This study investigates the efficacy of caudal block and the necessity of rescue analgesia in circumcision surgeries. MATERIAL AND METHODS A prospective, single-blind study was conducted at Ordu University Training and Research Hospital from December 1, 2022, to July 1, 2023. The study randomly divided ASA class I-II children aged 1-12 years into 3 groups for circumcision surgery. Group C received only caudal block. Group CP received caudal block with 10 mg/kg intravenous paracetamol. Group CM received caudal block with 1 mg/kg intravenous meperidine. In each case, a caudal block was administered using 0.5 ml/kg of 0.125% bupivacaine under ultrasound guidance. The primary outcome of the study was total analgesic consumption; the secondary outcomes were pain scores and time to first analgesic administration. Pain severity was evaluated using FLACC and Wong-Baker scores at 0, 1, 4, and 24 h. RESULTS A total of 120 patients, 40 patients in each group, were included in the study. A significant difference was detected among all 3 groups in the Wong-Baker pain score (24th hour) (P<0.001). The FLACC and Wong-Baker pain scores did not differ significantly in the other time frames. The time of the first rescue analgesia and the total amount of analgesic taken in the first 24 h were the same for both groups (P=0.408 and P=0.238). CONCLUSIONS The addition of paracetamol or meperidine to caudal block does not enhance the quality of analgesia.
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Affiliation(s)
- İlker Coşkun
- Department of Anesthesia and Reanimation, Ordu University Faculty of Medicine, Altınordu/Ordu, Turkey
| | - Onur Yalçın
- Department of Pediatric Surgery, Ordu University Faculty of Medicine, Altınordu/Ordu, Turkey
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15
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Wu L, Wei S, Xiang Z, Yu E, Chen Z, Du Z, Qu SQ. Effect of epidural block on surgical conditions during pediatric subumbilical laparoscopic surgery involving a supraglottic airway: a randomized clinical trial. Front Med (Lausanne) 2023; 10:1250039. [PMID: 37869156 PMCID: PMC10587430 DOI: 10.3389/fmed.2023.1250039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Abstract
Background Few studies have examined the effect of epidural block on surgical conditions during pediatric subumbilical laparoscopic surgery involving a supraglottic airway (SGA). This study investigated the surgical condition scores for such procedures in cases where neuromuscular block, epidural block, or neither was used. Methods A total of 150 patients aged 3-12 years undergoing laparoscopic orchiopexy with a ProSeal SGA device were randomly allocated to one of three groups: the control group (did not receive neuromuscular block and epidural block), the NMB group [received a neuromuscular block (train-of-four 1-2 twitches) using rocuronium], or the EDB group (received an epidural block using ropivacaine). The primary outcome was the quality of surgical conditions evaluated with the Leiden-Surgical Rating Scale by the blinded surgeon. The secondary outcome measures included intraoperative hemodynamic data (including mean arterial pressure and heart rate), the SGA device removal time, the PACU discharge time, the pain score in the PACU and intraoperative adverse events (including bradycardia, hypotension, peak airway pressure > 20 cmH2O, and poor or extremely poor surgical conditions occurred during the operation). Statistical analysis was performed with one-way analysis of variance, the Kruskal-Wallis test, the chi-square test or Fisher's exact test. Bonferroni corrections for multiple comparisons were made for primary and secondary outcomes. Results Surgical condition scores were significantly higher in the NMB and EDB groups than in the control group (median difference: 0.8; 95% confidence interval [CI], 0.5-1.0; p < 0.0001; and median difference: 0.7; 95% CI, 0.5-0.8; p < 0.0001, respectively). Blood pressure and heart rate were significantly lower in the EDB group than in the other two groups (p < 0.0001 and p = 0.004). Patients in the EDB group had significantly lower pain scores during PACU than those in the other two groups (p < 0.0001). The sufentanil dose was lower in the EDB group than in the other two groups (p = 0.001). Conclusion Epidural block can improve surgical conditions during pediatric subumbilical laparoscopic surgery involving a SGA to a degree comparable to that with moderate neuromuscular block.
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Affiliation(s)
| | | | | | | | | | - Zhen Du
- Department of Anesthesiology, Hunan Children’s Hospital, Changsha, China
| | - Shuang Quan Qu
- Department of Anesthesiology, Hunan Children’s Hospital, Changsha, China
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Zundel S, Conz F, Fuchs J, Blumenstock G, Guerrero-Rodrigues A, Grasshoff C, Schlisio B. Caudal Block versus Wound Infiltration for Inguinal Procedures in Young Children: A Randomized Clinical Study. Eur J Pediatr Surg 2023; 33:354-359. [PMID: 36720249 DOI: 10.1055/s-0042-1758155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Inguinal procedures in children are frequent and typically performed in an outpatient setting. We aimed to analyze whether there is a difference in postoperative pain scores and setup time (start of anesthesia management to incision time) when comparing caudal block (CB) with local wound infiltration. MATERIALS AND METHODS We enrolled pediatric outpatients scheduled for inguinal procedures. Patients were randomized to receive either preincision CBs or end-of-procedure local wound infiltration. Postoperative pain scores until 24 hours postoperatively and setup time were analyzed. RESULTS Fifty-two patients were included in the study. Thirty patients received a CB, and 22 patients received local infiltration (LI). There was no significant difference in postoperative pain scores. Setup time was significantly higher in the CB group: median 22.5 minutes IQR (16-46 minutes) compared with 17 minutes in the LI group IQR (10-35 minutes), p-value of 0.0026. CONCLUSION Both CB and LI result in good postoperative pain control after inguinal procedures in pediatric outpatients. Since LI is less time consuming and has lower risks for complications, we recommend this technique for inguinal procedures in pediatric outpatients. Our findings will need to be confirmed in larger cohorts, but we believe the evidence generated with this study has the potential to positively influence patient care, operating room efficiency, and costs.
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Affiliation(s)
- Sabine Zundel
- Department of Pediatric Surgery, Luzerner Kantonsspital, Spitalstrasse, Luzern, Switzerland
| | - Franziska Conz
- Department of Pediatric Surgery, University of Tübingen, Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery, University of Tübingen, Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Medical Biometry, University of Tübingen, Tübingen, Germany
| | - Aida Guerrero-Rodrigues
- Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls Universitat Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Christian Grasshoff
- Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls Universitat Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Barbara Schlisio
- Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls Universitat Tübingen, Tübingen, Baden-Württemberg, Germany
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Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
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Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
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18
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Xie L, Tao H, Bao F, Zhu Y, Fang F, Bao X, Zhu S, Kang X. Major complications of caudal block: A prospective survey of 973 cases in adult anorectal surgery. Heliyon 2023; 9:e20759. [PMID: 37860549 PMCID: PMC10582384 DOI: 10.1016/j.heliyon.2023.e20759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
Background We conducted a prospective study of surgical inpatients at a teaching hospital to assess the incidence and potential risk factors for major complications of caudal anesthesia in anorectal surgery. Methods A total of 973 patients undergoing anorectal surgery under caudal block were included in this prospective, observer-blinded trial after providing consent. Demographic information, detailed perioperative information, anesthesia-related complications and postoperative follow-up information were recorded. Meanwhile, the incidence and risk factors for major caudal anesthesia-related complications were analyzed. Results A total of 973 patients underwent caudal block. The effective rate was 95.38 % (928 cases). However, there were still 38 (3.91 %) cases with insufficient block and 7 (0.72 %) cases with no block. The major anesthesia-related complications were local anesthetic systemic toxicity (9, 0.92 %), cauda equine syndrome (1, 0.10 %), transient neurological symptoms (3, 0.31 %) and localized pain at the caudal insertion site (30, 3.08 %). The identified risk factor for local anesthetic systemic toxicity was multiple attempts locating the caudal space (OR = 5.30; 1.21-23.29). The identified risk factor for localized pain at the caudal insertion site was multiple attempts locating the caudal space (OR = 10.57; 4.89-22.86). Conclusion The main complications of caudal block in adult patients are transient neurological symptoms, cauda equine syndrome, serious local anesthetic systemic toxicity and localized pain at the caudal insertion site. Overall, the incidence of complications is low and symptoms are mild. Caudal block is still a safe and reliable method for anesthesia in adult anorectal surgery.
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Affiliation(s)
- Liwei Xie
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Honglei Tao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Tongde hospital of Zhejiang Province, China
| | - Fangping Bao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yeke Zhu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fuquan Fang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiuxia Bao
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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19
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Alansary AM, Badawy A, Elbeialy MAK. Ultrasound-guided trans-incisional quadratus lumborum block versus ultrasound-guided caudal analgesia in pediatric open renal surgery: a randomized trial. Korean J Anesthesiol 2023; 76:471-480. [PMID: 36704815 PMCID: PMC10562062 DOI: 10.4097/kja.22774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The caudal route is a common approach for postoperative analgesia; however, it is associated with limited duration of action. The quadratus lumborum block (QLB) may produce prolonged postoperative analgesia. Therefore, this study aimed to compare the postoperative analgesic efficacy of the ultrasound-guided caudal block with that of the ultrasound-guided transincisional QLB (TiQLB) in pediatric patients undergoing open renal surgery. METHODS Forty patients of both sexes, aged 2-11 years, were randomly assigned to receive either caudal analgesia with 1.25 ml/kg of bupivacaine 0.2% (Caudal group; n = 20) or a QLB with 0.5 ml/kg of bupivacaine 0.2% (TiQLB group; n = 20) in addition to standard general anesthesia. Time to first analgesia was the primary outcome. Total analgesic consumption in the first 24 h postoperatively, pain scores, and the incidence of side effects were the secondary outcomes. RESULTS The mean time to first analgesic requirement was significantly longer in the TiQLB group than in the Caudal group (18.8 ± 5.1 vs. 6.7 ± 0.7 h, P < 0.001). Total ketorolac consumption and pain scores were significantly lower in the TiQLB group (P < 0.001). A few cases of mild postoperative nausea and vomiting were noted among patients in both groups; however, the difference was not statistically significant. No incidence of pruritus, shivering, or respiratory depression was noted. CONCLUSIONS Analgesia after the ultrasound-guided TiQLB with bupivacaine was superior to that after the ultrasound-guided caudal block, with similar side effects.
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Affiliation(s)
- Amin M. Alansary
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Atef Badawy
- Department of Urology, Menoufia University, Cairo, Egypt
| | - Marwa A. K. Elbeialy
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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Gökçek E, Gökçe R, Kaçar CK. The effect of Caudal Epidural Injection on healing in the treatment of chronic anal fissure. Medicine (Baltimore) 2023; 102:e35160. [PMID: 37713828 PMCID: PMC10508418 DOI: 10.1097/md.0000000000035160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/18/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Chronic anal fissure is called the reaching the muscle layer under the skin by deepening of the fissure in the breech skin. Our purpose is to enable the tissue to heal by relaxing the anal sphincter with caudal epidural injection. METHODS One hundred twenty cases were included in this randomized, controlled study. The cases were categorized into 2 groups; Under ultrasound guidance, the first group, caudal epidural injection group (Group CE, n = 60) was treated with 5 cc bupivakain + 5 cc isotonic from a caudal epidural for a total of 3 sessions at the beginning, 1 week and 2 weeks later; the second group, control group (Group C, n = 60) were provided medical treatment (cream, pill etc.) every day for 2 weeks. Wexner's constipation score was used to assess constipation severity and visual analog scale was used to assess pain severity. Short Form-36 was used to determine the patient's quality of life. RESULTS This study was conducted with 2 groups of 60 people and a total of 120 patients. There was no statistically significant difference between the groups in terms of demographic characteristics (age, body mass index, gender, American Society of Anesthesiologist, mean blood pressure, heart rate) (P > .05). Out of the detected fissures, 32 (26.7%) were located anteriorly and 88 (73.3%) were located posteriorly. The groups were statistically same in terms of fissure location (P = .423). When groups were compared with pain, Wexner constipation and visual analog scale scores decreased significantly in Group CE compared to Group C after 2.and 3.sessions (P = .001 and P = .002, respectively). In Group CE, the Short Form-36 subscales increased significantly (P = .003). CONCLUSION Caudal epidural injection has a potential to be an alternative treatment option for chronic anal fissure.
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Affiliation(s)
- Erhan Gökçek
- Department of Anaesthesiolgy, Health Sciences University Diyarbakir Gazi Yasargil Research and Education Hospital, Diyarbakir, Turkey
| | - Recep Gökçe
- Department of Anaesthesiolgy, Health Sciences University Diyarbakir Gazi Yasargil Research and Education Hospital, Diyarbakir, Turkey
| | - Cem Kivilcim Kaçar
- Department of Anaesthesiolgy, Health Sciences University Diyarbakir Gazi Yasargil Research and Education Hospital, Diyarbakir, Turkey
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Radkowski P, Fadrowska-Szleper M, Podhorodecka K, Mieszkowski M. Neurological Complications of Regional Anesthesia: An Updated Review with Clinical Guidelines. Med Sci Monit 2023; 29:e940399. [PMID: 37691286 PMCID: PMC10503399 DOI: 10.12659/msm.940399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 06/07/2023] [Indexed: 09/12/2023] Open
Abstract
The main purpose of this article is to present the neurological complications of regional anesthesia. Our analysis may help clinicians determine when regional anesthesia can be administered safely and in which patients it needs additional precautions. Regional anesthesia has a major role in anesthesia practice. Here, we focus especially on the most common neurological complications: epidural hematoma, post-anesthesia headaches, and peripheral nerve function defect. We investigated risk factors of these states and propose ways of reducing the risks. This work is based on the available literature and the authors' experience. The research process involved using relevant keywords in various electronic databases, resulting in the selection of 32 articles published between 1989 and 2022. This manuscript provides an overview and analysis of the existing literature related to neurological complications of regional anesthesia. We believe that our article provides up-to-date information on the most common regional anesthesia complications, emphasizing differences concerning children and pregnant women and provides important guidance for clinicians in preparing for and performing anesthesia.
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Affiliation(s)
- Paweł Radkowski
- Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Hospital zum Heiligen Geist in Fritzlar, Fritzlar, Germany
| | | | - Katarzyna Podhorodecka
- Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
| | - Marcin Mieszkowski
- Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, Olsztyn, Poland
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
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22
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Xiao D, Sun Y, Gong F, Yin Y, Wang Y. A Systematic Review and Meta-Analysis Comparing the Effectiveness of Transversus Abdominis Plane Block and Caudal Block for Relief of Postoperative Pain in Children Who Underwent Lower Abdominal Surgeries. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1527. [PMID: 37763646 PMCID: PMC10533035 DOI: 10.3390/medicina59091527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Postoperative pain after lower abdominal surgery is typically severe. Traditionally, in pediatric anesthesia, a caudal block (CB) has been used for pain management in these cases. Nowadays, a transversus abdominis plane block (TAPB) seems to be an effective alternative. However, which technique for perioperative analgesia is better and more effective remains unclear in children who undergo abdominal surgeries. The aim of this study was to compare the efficacy and safety of a TAPB and CB for pain management in children after abdominal surgery by conducting a meta-analysis of published papers in this area. Methods: We conducted a thorough search of PubMed, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that compared a TAPB and CB for pain management in children who had abdominal surgery. Two researchers screened and assessed all the information with RevMan5.3 used for this meta-analysis. Pain scores, the total dose of rescue analgesic given, the mean duration of analgesia, the intraoperative and postoperative hemodynamic conditions 24 h after surgery, and adverse events were compared. Results: 15 RCTs that involved a total of 970 pediatric patients were included in this study. The results of this meta-analysis showed that there were no significant differences between the 2 groups in terms of postoperative pain scores at 1 h (SMD = 0.35; 95% CI = -0.54 to 1.24; p = 0.44, I2 = 94%), 6 h (SMD = -0.10; 95% CI = -0.44 to -0.23; p = 0.55, I2 = 69%), 12 h (SMD = -0.02; 95% CI = -0.45 to -0.40; p = 0.93, I2 = 80%), and 24 h (SMD = -0.66; 95% CI = -1.57 to -0.25; p = 0.15, I2 = 94%); additional analgesic requirement (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004, I2 = 72%); total dose of rescue analgesic given in 24 h (SMD = -0.37; 95% CI = -1.33 to -0.58; p = 0.44; I2 = 97%); mean duration of analgesia (SMD = 1.29; 95% CI = 0.01 to 2.57; p = 0.05, I2 = 98%); parents' satisfaction (SMD = 0.44; 95% CI = -0.12 to 1.0; p = 0.12; I2 = 80%); and intraoperative and postoperative hemodynamic conditions 24 h after the surgery and adverse events (SMD = 0.78; 95% CI = 0.22 to 2.82; p = 0.70; I2 = 62%). Compared to a CB, a TAPB resulted in a small but significant reduction in additional analgesic requirement after surgery (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004). Conclusions: TAPBs and CBs result in similar efficient early analgesia and safety profiles in children undergoing abdominal surgeries. Moreover, no disparities were observed for adverse effects between TAPBs and CBs.
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Affiliation(s)
- Dan Xiao
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
| | - Yiyuan Sun
- Day Surgery Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610017, China; (Y.S.); (Y.Y.)
| | - Fang Gong
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
| | - Yu Yin
- Day Surgery Center, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610017, China; (Y.S.); (Y.Y.)
| | - Yue Wang
- Department of Pediatrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing 402160, China; (D.X.); (Y.W.)
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Ranjan V, Singh S. Comparison of ultrasound-guided transversus abdominis plane block and caudal epidural block for postoperative analgesia in paediatric lower abdominal surgeries: A randomised controlled trial. Indian J Anaesth 2023; 67:720-724. [PMID: 37693033 PMCID: PMC10488568 DOI: 10.4103/ija.ija_420_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background and Aims Ultrasound-guided transversus abdominis plane (TAP) block is an effective technique for postoperative analgesia in lower abdominal surgeries. This study aims to compare the duration and efficacy of an ultrasound-guided TAP block with those of a caudal epidural for paediatric unilateral lower abdominal surgeries. Methods After ethical approval, sixty children aged 1 to 9 years were randomised into ultrasound-guided TAP block or caudal block with general anaesthesia for unilateral lower abdominal surgeries. The primary endpoint was time for the first rescue analgesia in the postoperative period. The secondary endpoints were total postoperative opioid consumption, modified Children Hospital of Eastern Ontario Pain Scale (CHEOPS) and the Face, Legs, Activity, Cry and Consolability (FLACC) scale in the postoperative period. Results The mean time for first rescue analgesia was 11.33 ± 2.80 h in the TAP block group, while in the caudal group, it was 13.18 ± 2.67 h (95% confidence interval [CI] mean difference 2.58-10.58, P = 0.017). The total postoperative morphine requirement was comparable in both groups at both 12 h (TAP block group 0.50 ± 0.12 mg vs. caudal block group 0.56 ± 0.12 mg, 95% CI mean difference 0.09-0.02, P = 0.08) and 24 h (TAP block group 0.96 ± 0.30 mg vs. caudal block group 0.81 ± 0.34 mg, 95% CI mean difference 0.06-0.32, P = 0.06) time period. Conclusion The mean time for first rescue analgesia was lesser in the TAP block group as compared to caudal group.
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Affiliation(s)
- Vivek Ranjan
- Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Swati Singh
- Department of Anaesthesiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Fischer KM, Van Batavia J, Hyacinthe N, Weiss DA, Tan C, Zderic SA, Mittal S, Shukla AR, Kolon TF, Srinivasan AK, Canning DA, Zaontz MR, Long CJ. Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair. J Pediatr Urol 2023; 19:374-379. [PMID: 37002025 DOI: 10.1016/j.jpurol.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/27/2022] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. OBJECTIVE Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. STUDY DESIGN We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. RESULTS Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. DISCUSSION Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. CONCLUSIONS After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.
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Affiliation(s)
- Katherine M Fischer
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason Van Batavia
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nathan Hyacinthe
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dana A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connie Tan
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Steve A Zderic
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sameer Mittal
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aseem R Shukla
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas F Kolon
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arun K Srinivasan
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Douglas A Canning
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark R Zaontz
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher J Long
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Opfermann P, Schmid W, Obradovic M, Kraft F, Zadrazil M, Marhofer D, Marhofer P. Sex differences in pediatric caudal epidural anesthesia under sedation without primary airway instrumentation. PLoS One 2023; 18:e0288431. [PMID: 37440538 DOI: 10.1371/journal.pone.0288431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
STUDY OBJECTIVE To identify sex differences associated with caudal epidurals, the most commonly used technique of pediatric regional anesthesia, based on individually validated data of ultrasound-guided blocks performed between 04/2014 and 12/2020. METHODS Prospectively collected and individually validated data of a cohort of children aged between 0-15 years was analyzed in a retrospective observational study. We included pediatric surgeries involving a primary plan of caudal epidural anesthesia under sedation (without airway instrumentation) and a contingency plan of general anesthesia. Sex-specific rates were analyzed for overall failure of the primary anesthesia plan, for residual pain, for block-related technical complications and for critical respiratory events. We used Fisher´s exact tests and multivariable logistic regressions were used to evaluate sex-specific associations. RESULTS Data from 487 girls and 2060 boys ≤15 years old (ASA status 1 to 4) were analyzed. The primary-anesthesia-plan failure rate was 5.5% (95%CI 3.8%-7.8%) (N = 27/487) among girls and 4.7% (95%CI 3.9%-5.7%) (N = 97/2060) among boys (p = 0.41). Residual pain was the main cause of failure, with rates of 4.5% (95%CI 2.9-6.6%) (N = 22/487) among girls and 3.0% (95%CI 2.3-3.8%) (N = 61/2060) among boys (p = 0.089). Block-related technical complications were seen at rates of 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls vs 2.5% (95%CI 0.5-2.7%) (N = 51/2060) among boys and, hence, significantly more often among male patients (p = 0.023). Male sex was significantly associated with higher odds (adjusted OR: 3.18; 95% CI: 1.12-9; p = 0.029) for such technical complications regardless of age, ASA status, gestational week at birth or puncture attempts. Critical respiratory events occurred at a 1.7% (95%CI 1.2%-2.3%) rate (N = 35/2060) twice as high among boys as 0.8% (95%CI 0.3%-1.9%) (N = 4/487) among girls (p = 0.21). CONCLUSIONS While the the primary-anesthesia-plan failure rate was equal for girls and boys, technical complications and respiratory events are more likely to occur in boys.
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Affiliation(s)
- Philipp Opfermann
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Werner Schmid
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Mina Obradovic
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Felix Kraft
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Markus Zadrazil
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Daniela Marhofer
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
| | - Peter Marhofer
- Department of Anesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna,Vienna, Austria
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Chen YH, Sadhasivam S, DeMedal S, Visoiu M. Short-acting versus long-acting opioids for pediatric postoperative pain management. Expert Rev Clin Pharmacol 2023; 16:813-823. [PMID: 37531096 PMCID: PMC10529420 DOI: 10.1080/17512433.2023.2244417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article. AREAS COVERED Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population. EXPERT OPINION Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.
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Affiliation(s)
- Yun Han Chen
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Senthilkumar Sadhasivam
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Spencer DeMedal
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mihaela Visoiu
- Department of Anesthesiology and Pain Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
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Elshazly M, Shaban A, Gouda N, Rashad M, Soaida SM. Ultrasound-guided lumbar erector spinae plane block versus caudal block for postoperative analgesia in pediatric hip and proximal femur surgery: a randomized controlled study. Korean J Anesthesiol 2023; 76:194-202. [PMID: 36274252 DOI: 10.4097/kja.22421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/21/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND According to previous research, 20% of infants experience prolonged postsurgical pain 6-12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries. METHODS Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia. RESULTS The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups. CONCLUSIONS The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.
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Affiliation(s)
- Mohamed Elshazly
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - AbdelKhalek Shaban
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevine Gouda
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahitab Rashad
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sherif M Soaida
- Department of Anesthesia, Surgical Intensive Care Unit, and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
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He J, Lai H, Zhang T, Ye L, Yao B, Qu H, Ma B, Guo Q, Zhang Y, Qiu J, Wang D. Enhanced recovery management in pediatric pyeloplasty: outcomes in a single institution and tips for improvement. World J Urol 2023; 41:1667-1673. [PMID: 37219585 DOI: 10.1007/s00345-023-04422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE We report the application of enhanced recovery after surgery (ERAS) regimens to pediatric patients undergoing laparoscopic pyeloplasty (LP), aiming to guide the practice of ERAS in pediatric LP. METHODS From October 2018, we prospectively implemented a twenty-point ERAS regimen, including a modified LP procedure, for pediatric UPJO patients in a single institution. Data from 2018 to 2021 were collected and analyzed retrospectively. The variables gathered included: demographics, preoperative details and recovery elements. Outcomes were postoperative length of stay (POS), readmission rate, operation time and blood loss. RESULTS A total of 75 pediatric patients (0-14 years) were included. The mean POS was 2.4 ± 1.4 days, shorter than that in recent studies in China (3.3 ± 1.4 days, 6 (3-16) days). None were redo, and six restenosis (8%) were improved after treatment with ureteral balloon dilatation. The mean operation time was 257.9 ± 54.4 min, and blood loss was 11.8 ± 10.0 ml. In the univariable analysis and multivariable analysis, no external drainage, sacral anesthesia, and withdrawal of the catheter on day one were independently associated with a POS of ≤ 2 d (p < 0.05). CONCLUSION The implementation of this ERAS protocol for pediatric LP has resulted in a shorter length of stay without a higher readmission rate. Surgery techniques, drainage management and analgesia are the key to further improvement. ERAS for pediatric pyeloplasty should be encouraged.
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Affiliation(s)
- Jiannan He
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Huajian Lai
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Tianyou Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Lei Ye
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bing Yao
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Hu Qu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Bo Ma
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Qiang Guo
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Yifei Zhang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China
| | - Jianguang Qiu
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
| | - Dejuan Wang
- Department of Urology, The Sixth Affiliated Hospital, Sun Yat-Sen University, Yuancun Erheng Road 26, Guangzhou, 510655, Guangdong, China.
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Yao PY, Shaw SJ, Gabriel RA, Soria CS. Does caudal analgesia improve pain control for pediatric burn surgery: A retrospective study. PAEDIATRIC & NEONATAL PAIN 2023; 5:10-15. [PMID: 36911788 PMCID: PMC9997120 DOI: 10.1002/pne2.12091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/14/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
Pediatric burns affect approximately 15-20 patients per 100 000 hospital admissions, but unfortunately there is a lack of evidence to guide optimal strategies for acute pain control. The aim of this study was to evaluate whether caudal analgesia with single injection of local anesthetics reduced pain medication consumption in pediatric patients who required surgical intervention for burn injuries. Retrospective data from patients <7 years old who had burn surgery in the operating rooms at a single regional burn center from 2013 to 2021 was obtained and analyzed. A 1:1 propensity-score matching method using nearest neighbor matching without replacement was utilized to create matched cohorts. Primary outcome was opioid consumption, which is presented as opioid equivalents divided by patient weight in kilograms, at 24 h after surgery. Comparing propensity-score matched groups, there were no statistically significant differences in adjusted morphine equivalents received by the caudal group (0.122 [0.0646;0.186]) and the no caudal group (0.0783 [0.0384;0.153]) at 24 h after surgery (p = 0.06). This is the first study to the best of our knowledge of the association of caudal analgesia in pediatric burn patients with postoperative pain control. The data showed an increase in pain medication consumption postoperative at 24 h and intraoperative for patients who received single injection caudal blocks, but when adjusted using propensity-score matching, the difference was no longer statistically significant.
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Affiliation(s)
- Phil Y Yao
- Department of Anesthesiology University of California San Diego San Diego California USA
| | - Susanna J Shaw
- Department of Anesthesiology University of California San Diego San Diego California USA
| | - Rodney A Gabriel
- Department of Anesthesiology University of California San Diego San Diego California USA
| | - Claire S Soria
- Department of Anesthesiology University of California San Diego San Diego California USA
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A Response to: Letter to the Editor Regarding "Comparison of Ultrasound-Guided Caudal Epidural Blocks and Spinal Anesthesia for Anorectal Surgery: A Randomized Controlled Trial". Pain Ther 2023; 12:319-320. [PMID: 36447042 PMCID: PMC9845436 DOI: 10.1007/s40122-022-00461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022] Open
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Kiblawi R, Beck C, Keil O, Schukfeh N, Hofmann AD, Ure BM, Kuebler JF. Laparoscopic versus Open Inguinal Hernia Repair Is Feasible in Infants with Caudal Anesthesia and Spontaneous Respiration. Eur J Pediatr Surg 2023; 33:26-34. [PMID: 36220133 DOI: 10.1055/a-1958-7989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants. METHODS Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications. RESULTS A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant). CONCLUSION This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration.
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Affiliation(s)
- Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Christiane Beck
- Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Oliver Keil
- Clinic for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Nagoud Schukfeh
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | | | - Benno Manfred Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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Zhang P, Chang H, Yang T, Fu Y, He X, Li J, Yang M, Wang R, Li X. Study on MEV90 of 0.5% ropivacaine for US-guided caudal epidural block in anorectal surgery. Front Med (Lausanne) 2023; 9:1077478. [PMID: 36743672 PMCID: PMC9892538 DOI: 10.3389/fmed.2022.1077478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 01/20/2023] Open
Abstract
Background Choosing the appropriate concentration and volume of anesthetics is critical for a successful nerve block. The current study aimed to determine the minimum effective volume (MEV) of 0.5% ropivacaine for US-guided CEB in 90% of patients (MEV90) undergoing anorectal surgery. The aims were to reduce the occurrence of complications associated with a sacral blockade in anorectal surgery, broaden the indications for surgical procedures and treatment, and improve patient satisfaction. This study presents the groundwork for the development of individualized anesthetic programs. We believe that the study would serve as a reference for the use of caudal epidural block (CEB) in lower abdominal surgery for intraoperative and postoperative analgesia. Methods This study used a biased coin design (BCD) up-and-down method (UDM). We divided the participants into two groups based on gender, and each group independently performed the biased coin design up-and-down method. We used 0.5% ropivacaine for the first patient in each group; however, the volume was 10 ml for men and 8 ml for women. Therefore, the dose of anesthetics given to each patient was determined by the response of the previous patient. If the block of the previous patient failed, the volume was increased by 2 ml in the following patient. Otherwise, the next subject had an 11% chance of receiving a volume of 2 ml less or an 89% chance of receiving no volume change. We defined a successful block as painless surgery with anal sphincter relaxation 15 min after the drug injection. Enrollment was completed after 45 successful caudal blocks for each group. Results Caudal epidural block was successfully performed on 50 men and 49 women. The MEV90 of ropivacaine for CEB was calculated to be 12.88 ml (95% CI: 10.8-14 ml) for men and 10.73 ml (95% CI: 9.67-12 ml) for women. Men had a MEV99 of 13.88 ml (95% CI: 12.97-14 ml), and women had a MEV99 of 11.87 ml (95% CI: 11.72-12 ml). Conclusion With operability and general applicability, it is possible to increase the success rate of CEB for anorectal surgery to 99% as well as decrease the incidence of anesthesia-related complications. CEB can meet the needs of patients for rapid postoperative rehabilitation, improve patient satisfaction, and lay a solid foundation for postoperative analgesia.
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Affiliation(s)
- Pei Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hong Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China,West China School of Nursing, Sichuan University, Chengdu, China,Chengdu Shang Jin Nan Fu Hospital, Chengdu, China
| | - Taoran Yang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yalong Fu
- Department of Anus Intestine, Karamay People's Hospital, Xinjiang, China
| | - Xuemei He
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jun Li
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mingan Yang
- Division of Biostatistics and Epidemiology, School of Public Health, San Diego State University, San Diego, CA, United States
| | - Rurong Wang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China,Chengdu Shang Jin Nan Fu Hospital, Chengdu, China,Rurong Wang ✉
| | - Xuehan Li
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China,*Correspondence: Xuehan Li ✉
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Pearson AME, Roberts S, Turbitt LR. New blocks on the kids: core basic nerve blocks in paediatric anaesthesia. Anaesthesia 2023; 78:3-8. [PMID: 36220155 DOI: 10.1111/anae.15876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 12/13/2022]
Affiliation(s)
- A M E Pearson
- Department of Anaesthesia, Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - S Roberts
- Department of Anaesthesia, Alder Hey Children's Hospital, Liverpool, UK
| | - L R Turbitt
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
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Gupta A, Kaur J, Kumar R. Unilateral sacral erector spinae plane block for lower limb surgery in children. Anaesth Rep 2022; 10:e12199. [PMID: 36530341 PMCID: PMC9751388 DOI: 10.1002/anr3.12199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
The erector spinae plane block is a versatile regional anaesthesia technique used for a variety of truncal surgeries. A novel variation is the sacral erector spinae plane block which is gaining popularity for perineal and anorectal procedures. Local anaesthetic injected at this level blocks the sacral dermatomes and has the potential for more proximal spread to involve lumbar nerve fibres via spread to the lumbar plexus or the epidural space. The advantage of a sacral erector spinae plane block over a neuraxial block is that it is less invasive and may have a better safety profile: there is a reduced risk of epidural haematoma, epidural abscess, haemodynamic instability and motor weakness of the lower extremities. Until now, this approach has been used for midline surgical procedures when the local anaesthetic was injected bilaterally. Its application for lower limb procedures with a single unilateral injection has not been described. We report the use of a unilateral sacral erector spinae plane block at the level of the S2 median crest in two children undergoing lower limb procedures of the hip and thigh. The block was found to provide effective peri-operative analgesia with minimal need for any opioid analgesics and without any significant adverse effects.
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Affiliation(s)
- A. Gupta
- Department of Anaesthesiology, Pain Medicine and Critical CareAll India Institute of Medical SciencesDelhiIndia
| | - J. Kaur
- Department of Anaesthesiology, Pain Medicine and Critical CareAll India Institute of Medical SciencesDelhiIndia
| | - R. Kumar
- Department of Anaesthesiology, Pain Medicine and Critical CareAll India Institute of Medical SciencesDelhiIndia
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Zhang Y, Wang YP, Wang HT, Xu YC, Lv HM, Yu Y, Wang P, Pei XD, Zhao JW, Nan ZH, Yang JJ. Ultrasound-guided quadratus lumborum block provided more effective analgesia for children undergoing lower abdominal laparoscopic surgery: a randomized clinical trial. Surg Endosc 2022; 36:9046-9053. [PMID: 35764836 DOI: 10.1007/s00464-022-09370-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postoperative pain treatment for pediatrics is often inadequate and the evidence of pediatric postoperative analgesia is scarce. To our knowledge, no report regarding the comparison among caudal block, transversus abdominis plane (TAP) block and quadratus lumborum (QL) block for children undergoing lower abdominal laparoscopic surgery was found at present. Thus this trial aimed to compare the efficacies of them for children undergoing lower abdominal laparoscopic surgery. METHODS One hundred and eighty children aged from 1 to 12 years undergoing lower abdominal laparoscopic surgery were included and randomized to receive caudal block, TAP block or QL block. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) score at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h and tramadol consumption during first 24 h postoperatively. Secondary outcomes included the number of children received tramadol, time to first tramadol request, parents' satisfaction and postoperative adverse reactions. RESULTS The QLB group had lower postoperative FLACC scores at 8 h (median difference - 0.43, P = 0.03) than the Caudal group and at 4 h (median difference - 0.6, P = 0.001) and 8 h (median difference - 0.43, P = 0.03) than the TAPB group. The tramadol consumption was lower in the QLB group (28.43 ± 6.55) than the TAPB group (37.17 ± 6.12, P = 0.023). Although the number of children received tramadol did not differ among the three groups, the time to first tramadol request was longer in the QLB group (7.20 ± 0.79) than the caudal group (8.42 ± 0.61, P = 0.008). No statistical difference was observed concerning other secondary outcomes. CONCLUSIONS QLB produced more effective postoperative analgesia for children undergoing laparoscopic abdominal surgery compared with the TAPB and caudal block.
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Affiliation(s)
- Yue Zhang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yan-Ping Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Hai-Tao Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yu-Can Xu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Hui-Min Lv
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Yang Yu
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Peng Wang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Xiang-Dong Pei
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Wei Zhao
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Zhen-Hua Nan
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China
| | - Jian-Jun Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, China.
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Naznin RA, Haq MA, Sumi SA, Ahmad R, Haque M. A Semi-quantitative Evaluation of Out-to-Out Agenesis of Posterior Wall in a Dry Human Sacrum in Bangladesh. Cureus 2022; 14:e31163. [DOI: 10.7759/cureus.31163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2022] [Indexed: 11/07/2022] Open
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Xie G, Zhao J, Chu L, Song S, Wang Y, Lai D, Cheng B, Fang X. Establishment of Difficult Caudal Epidural Blockade Prediction Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:2037904. [PMID: 36387347 PMCID: PMC9652077 DOI: 10.1155/2022/2037904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/12/2022] [Accepted: 07/22/2022] [Indexed: 07/29/2023]
Abstract
Background We aimed to develop a predictive difficult caudal epidural blockade (pDCEB) model when ultrasound was not available and verified the role of ultrasound in difficult caudal epidural blockade (CEB). Methods From October 2018 to March 2019, this study consisted of three phases. First, we prospectively enrolled 202 patients scheduled to undergo caudal epidural anesthesia and assessed risk factors by binary logistic regression to develop the predictive scoring system. Second, we enrolled 87 patients to validate it. The receiver operating characteristic (ROC) curve was used to evaluate the performance of the prediction model. Youden-index was used to determine the cut-off value. Third, we enrolled 68 patients with a high risk of difficult CEB (pDCEB score ≥3) and randomized them into ultrasound and landmark groups to verify the role of ultrasound. Result The rate of difficult CEB was 14.98% overall 289 patients. We found a correlation between unclear palpation of the sacral hiatus (OR 9.688) and cornua (OR 4.725), the number of the sacral hiatus by palpation ≥1 (OR 4.451), and history of difficult CEB (OR 39.282) with a higher possibility of difficult CEB. The area under the receiver operating characteristic curve of the pDCEB model involving the aforementioned factors was 0.889 (95% CI, 0.827-0.952) in the development cohort and 0.862 (95% CI, 0.747-0.977) in the validation cohort. For patients with a pDCEB score ≥3, a preprocedure ultrasound scan could reduce the incidence of difficult CEB (55.56% in the Landmark group vs. 9.38% in the ultrasound group, p < 0.001). Conclusion This novel pDCEB score, which takes into account palpation of the sacral hiatus/cornua, number of the sacral hiatus by palpation ≥1, and history of difficult CEB, showed a good predictive ability of difficult CEB. The findings suggested that performing an ultrasound scan is essential for patients with a pDCEB score ≥3. Trial registration: No: ChiCTR1800018871, Site URL: https://www.chictr.org.cn/edit.aspx?pid=31875&htm=4; Principal investigator: Jialian Zhao, Date of registration: 2018.10.14.
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Affiliation(s)
- Guohao Xie
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jialian Zhao
- Departments of Anesthesiology, The Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lihua Chu
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shengwen Song
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ya Wang
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Dengming Lai
- Departments of Neonatal Surgery, The Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Baoli Cheng
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Departments of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Hüppe T, Pattar G, Maass B. Kaudalanästhesie: Übersicht und praktische Handlungsempfehlungen. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:724-736. [DOI: 10.1055/a-1467-8624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Mahrous RSS, Ahmed AAA, Ahmed AMM. Comparison Between Ultrasound-guided Caudal Analgesia versus Peripheral Nerve Blocks for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Prospective Study. Local Reg Anesth 2022; 15:77-86. [PMID: 36117554 PMCID: PMC9480592 DOI: 10.2147/lra.s372903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Aim Ultrasound (US) guided regional analgesia is a safe and effective method in providing perioperative analgesia in pediatrics with a high success rate rapid onset and fewer side effects. The aim of this study was to compare the efficacy of US-guided caudal block versus US-guided peripheral nerve blocks (femoral and sciatic nerve blocks) in providing perioperative analgesia in pediatrics undergoing unilateral lower limb surgery. Methods Children aged 1–12 years scheduled for unilateral lower limb surgery during the period from January 2020 to December 2021 were randomly allocated into two groups. Group C where pediatrics received US-guided caudal block, while in group P, pediatrics received US-guided femoral and sciatic nerve blocks after the induction of general anesthesia (GA). The primary aim was to compare the postoperative pain (evaluated by the COMFORT pain score) between the two groups. Secondary aims were to compare perioperative opioids used parents’ satisfaction and occurrence of side effects. Results Pediatrics who underwent unilateral lower limb surgeries were allocated into two groups (group C and group P). There was no significant difference between patients’ baseline characteristics and the postoperative pain score at 2, 4, 16, and 20 h.’ However there was a statistical significance at 6, 8, 12, and 24 h postoperatively, frequency of analgesia as well as the total postoperative dose of opiates (nalbuphine). Time to first analgesic (nalbuphine) requirement was significantly less in group C with a mean of (9.6±2.9 h) than in group P with a mean of (15.1±3.5 h). Parents of children in group P were more satisfied than those in group C with no recorded complications for both techniques. Conclusion US-guided lower limb peripheral nerve block is a simple and safe method to provide adequate and more prolonged analgesia compared to US-guided caudal block for lower limb surgeries in pediatrics.
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Affiliation(s)
- Rabab S S Mahrous
- Department of Anaesthesia and Surgical Intensive Care Alexandria University Alexandria Egypt
| | - Amin A A Ahmed
- Department of Orthopedic Surgery and Traumatology Alexandria University Alexandria Egypt
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Choudhry DK, Heredia L, Brenn BR, Brown M, Carvalho NF, Whaley MC, Shaik SS, Hagerty JA, Bani Hani A. Nerve stimulation guided bilateral pudendal nerve block versus landmark-based caudal block for hypospadias repair in young children: a prospective, randomized, pragmatic trial. Reg Anesth Pain Med 2022; 47:744-748. [DOI: 10.1136/rapm-2022-103680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
IntroductionCaudal block is frequently performed to provide analgesia for hypospadias repair. Literature suggests that pudendal block provides prolonged postoperative analgesia as compared with caudal block in children between 2 and 5 years. We compared the efficacy of pudendal and caudal blocks in children less than 2 years.Methods60 children scheduled for hypospadias repair received standard general anesthesia along with either pudendal or caudal block (groups of 30 each). Variables collected were demographic data, block time, operating room time, intraoperative pain medication need, pain assessment score and medication need in the recovery room and pain assessment at home.ResultGroups were demographically similar. No differences were observed in the following recorded times (minutes): block procedure (caudal: 9.5±4.0, pudendal: 10.6±4.1, p=0.30), anesthesia (caudal: 17.3±5.3, pudendal: 17.7±4.3, p=0.75), total OR (caudal: 171±35, pudendal: 172±41; p=0.95) and postanesthesia care unit (PACU) stay (caudal: 88±37, pudendal: 86±42; p=0.80). Additionally, no differences were observed in rescue pain medication need in the operating room (caudal: 0, pudendal: 2 (p=0.49), in PACU (caudal: 4, pudendal: 4, p=0.99), pain assessed at home, time to pain level 2 (caudal: 13.93±8.9, pudendal: 15.17±8.7), average pain scores (p=0.67) and total pain free epochs (pain level of zero) (p=0.80) in the first 24 hours.DiscussionIn children less than 2 years, both blocks provide comparable intraoperative and postoperative pain relief in the first 24 hours after hypospadias surgery.Trial registration numberNCT03145415.
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Bhati K, Saini N, Aeron N, Dhawan S. A Comparative Study to Evaluate the Efficacy of Dexmedetomidine and Clonidine to Accentuate the Perioperative Analgesia of Caudal 0.25% Isobaric Levobupivacaine in Pediatric Infraumbilical Surgeries. Cureus 2022; 14:e27825. [PMID: 36106237 PMCID: PMC9455914 DOI: 10.7759/cureus.27825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/05/2022] Open
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Ragab SG, El Gohary MM, Abd El baky DL, Nawwar KMA. Ultrasound-Guided Quadratus Lumborum Block Versus Caudal Block for Pain Relief in Children Undergoing Lower Abdominal Surgeries: A Randomized, Double-Blind Comparative Study. Anesth Pain Med 2022; 12:e126602. [PMID: 36937088 PMCID: PMC10016135 DOI: 10.5812/aapm-126602] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/18/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background The quadratus lumborum (QL) block, also known as the abdominal truncal block, was developed to provide visceral and somatic analgesia during abdominal procedures. Objectives This study aimed to assess pain alleviation, the incidence of complications in lower abdominal procedures, and hemodynamic stability between the caudal block and ultrasound-guided QL block. Methods Fifty-two patients aged 1 to 7 years old from both genders scheduled for unilateral lower abdominal surgery were randomly assigned to 2 study groups: group QL, unilateral QL block (n = 26), and group C, caudal block (n = 26). In group C, children received caudal block. In group QL, an ultrasound-guided QL block was performed. The time to first rescue analgesia was evaluated as a primary outcome. The quality of analgesia was determined using the face, legs, activity, cry, consolability scale (FLACC scale), hemodynamic parameters, and incidence of complications because hemodynamic instability was recorded under ultrasound guidance. Signs of local anesthetics toxicity and the parents' satisfaction were secondary outcomes. Results The time until the first demand for analgesia postoperatively was statistically longer in group QL compared to group C. A non-significant difference was observed between the 2 groups (P > 0.05) regarding age, weight, gender, duration of surgery, type of surgery, FLACC scale, and hemodynamics (SBP, systolic blood pressure), except at 30 minutes, which was significant in QL block. Also, a non-significant difference was observed in the severity of postoperative pain up to 1 day postoperatively. Group QL showed more satisfaction than group C. No intraoperative complications were detected. Conclusions Compared to caudal block, QL block produced sustained and adequate analgesia time postoperatively, with higher satisfaction.
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Affiliation(s)
- Safaa Gaber Ragab
- Anesthesia Departement, Faculty of Medicine, Fayoum University Hospital, Fayoum University, Fayoum, Egypt
- Corresponding Author: Anesthesia Departement, Faculty of Medicine, Fayoum University Hospital, Fayoum University, Fayoum, Egypt.
| | | | - Doaa Lotfy Abd El baky
- Surgical ICU, Pain Medicine Fayoum University Hospital, Fayoum University, Fayoum, Egypt
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Naznin RA, Moniruzzaman M, Sumi SA, Benzir M, Jahan I, Ahmad R, Haque M. Sacralization of Coccygeal Vertebra: A Descriptive Observational Study in Bangladesh. Cureus 2022; 14:e27496. [PMID: 35919212 PMCID: PMC9339143 DOI: 10.7759/cureus.27496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background: In the sacrococcygeal region, anatomical variation is due to the sacralization of the coccygeal vertebra, which is the due union of/fusion of the fifth sacral with the first coccygeal vertebra of five couples of sacral foramina under-detected or asymptomatic beyond radiological assessment. That is why it is challenging to know the cause of coccydynia, caudal block failure, the difficult second stage of labor, and perineal tears. The present study aims to improve knowledge about the anatomical variation of sacralization of the coccygeal vertebra. Additionally, to find the prevalence of sacralization of coccygeal vertebra in Sylhet, Bangladesh. Methods: This study was performed on 60 parched, totally calcified, typical sacra of mature-age individuals of undetermined sexes, fulfilling the inclusion criteria from the bone bank of the osteology museum of the Department of Anatomy, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh, from July 2017 to June 2018. Sex determination of the collected unknown sacra was conducted using discriminant function analysis. It was found that 50% (30) were male and 50% (30%) were female. The unpaired t-tests and chi-square were utilized to determine the statistical significance. Results: Out of 60 sacra, eight (13.33%) samples presented with sacralization. This study found that males had significantly higher straight (p=0.05) and curved (p=0.05) lengths of sacrococcygeal vertebrae. The sacrococcygeal curvature index (SCI) showed statistically significant (p=0.05) differences between the sexes. Conclusion: Sacralization may exert an impact on the caudal block. It could extend the second stage of the labor process with perineal tears. Therefore, knowledge about the anatomical variation of the coccygeal vertebra is essential.
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Meier KM, Zheng A, Rollins ZH, Asantey KA, Shah MD, Banooni AB, Liss ZJ. Elimination of postoperative narcotics in infant robotic pyeloplasty using caudal anesthesia and a non-narcotic pain pathway. J Endourol 2022; 36:1431-1435. [PMID: 35850585 DOI: 10.1089/end.2022.0263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for post-operative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics following infant robotic pyeloplasty. METHODS We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes and unscheduled healthcare encounters within 30 postoperative days. RESULTS 63% (15/24) patients were male and average age was 12.1 months (range 4-34 months). 58% (9/15) underwent surgery on the left. 16.7% (4/24) of patients received a single postoperative dose of narcotics in the PACU. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related, unscheduled visits or phone calls after discharge. CONCLUSIONS This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Post procedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.
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Affiliation(s)
- Kristen M Meier
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Anna Zheng
- Michigan Institute of Urology, 20952 Twelve Mile Road, Suite #200, St. Clair Shores , Michigan, United States, 48081;
| | - Zach H Rollins
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Kwesi A Asantey
- Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States;
| | - Mit D Shah
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States;
| | - Andrew B Banooni
- Beaumont Health System, 7005, Department of Anesthesia, Royal Oak, Michigan, United States;
| | - Zachary J Liss
- Beaumont Health System, 7005, Department of Urology, Royal Oak, Michigan, United States.,Oakland University William Beaumont School of Medicine, 159878, Rochester, Michigan, United States.,Michigan Institute of Urology, St. Clair Shores , United States;
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Mindler GT, Ganger R, Stauffer A, Marhofer P, Raimann A. [Osteogenesis imperfecta : A multidisciplinary challenge]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:595-606. [PMID: 35776152 DOI: 10.1007/s00132-022-04260-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
Osteogenesis imperfecta (OI) describes a group of rare diseases which are associated with an increased tendency to bone fractures. In addition to the main symptom of fractures, OI is characterized by a variety of pediatric, pediatric orthopedic and anesthesiological challenges. The multidisciplinary expertise is mostly concentrated at specialized centers. The current treatment concepts aim at minimizing the fracture rate, prevention and treatment of deformities, pain reduction and improved mobility. In addition to pharmacotherapy, conservative and surgical measures are also applied. Scheduled interventions on the extremities are one of the most commonly performed operations in children with OI. Various intramedullary nailing techniques are available. This article addresses the important aspects of multidisciplinary care of children with OI concerning the treatment of the lower extremities.
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Affiliation(s)
- Gabriel T Mindler
- Abteilung für Kinderorthopädie, Orthopädisches Spital Speising, Speisinger Str. 109, 1130, Wien, Österreich.
- Vienna Bone and Growth Center, Wien, Österreich.
| | - Rudolf Ganger
- Abteilung für Kinderorthopädie, Orthopädisches Spital Speising, Speisinger Str. 109, 1130, Wien, Österreich
- Vienna Bone and Growth Center, Wien, Österreich
| | - Alexandra Stauffer
- Abteilung für Kinderorthopädie, Orthopädisches Spital Speising, Speisinger Str. 109, 1130, Wien, Österreich
- Vienna Bone and Growth Center, Wien, Österreich
| | - Peter Marhofer
- Vienna Bone and Growth Center, Wien, Österreich
- Abteilung für Anästhesiologie und Intensivmedizin, Orthopädisches Spital Speising, Speisinger Str. 109, 1130, Wien, Österreich
| | - Adalbert Raimann
- Vienna Bone and Growth Center, Wien, Österreich
- Universitätsklinik für Kinder- und Jugendheilkunde, Abteilung für Pädiatrische Pulmologie, Allergologie und Endokrinologie, Medizinische Universität Wien, Spitalgasse 23, 1090, Wien, Österreich
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Hoffmann C, Harb A, Woo LL, Hannick JH. Quadratus Lumborum Block for Upper Tract Urological Surgery in Pediatric Patients. UROLOGÍA COLOMBIANA 2022. [DOI: 10.1055/s-0042-1743510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Objective Among regional blocks, the quadratus lumborum fascial plane block (QLB) has been well described, but the description of its use and efficacy for pediatric patients undergoing upper abdominal urologic surgery is limited. We present a case series examining the use of the QLB for postoperative pain management in children undergoing upper tract surgery.
Methods From August 2019 to August 2020, through a chart review, we identified 5 patients who had undergone a QLB for upper urinary tract surgery via a flank incision. Posterior QLB was performed after induction of general anesthesia. A single injection of 0.5mL/kg of either 0.25% or 0.5% ropivacaine with 1mcg/kg of clonidine was administered. Patients received fentanyl IV (1 mcg/kg), and acetaminophen IV (15mg/kg) as adjuvants during the operation. Postoperative pain was managed with oral acetaminophen and ibuprofen.
Results The average postoperative pain score during the entire admission was 1, with the lowest being 0 and highest, 3. No administration of rescue narcotics was required in the postanesthesia care unit or on the floor. The average length of stay ranged from 0 to 1 day. No complications associated with the regional QLB were identified.
Conclusions Our series suggests the QLB may be considered as a regional anesthetic option to minimize narcotic requirements for children undergoing upper abdominal urological surgery via flank incision. Additional studies are needed to compare the efficacy of the QLB versus alternate regional anesthetic blocks for upper tract urological surgery via flank incision in children and to determine effective dosing and use of adjuvants.
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Affiliation(s)
- Cassandra Hoffmann
- Division of Pediatric Anesthesia, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Alain Harb
- Division of Pediatric Anesthesia, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Lynn L. Woo
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
| | - Jessica H. Hannick
- Division of Pediatric Urology, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, United States
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47
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Pain management during a bromelain-based selective enzymatic debridement in paediatric and adult burn patients. Burns 2022; 48:555-567. [PMID: 34686390 DOI: 10.1016/j.burns.2021.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 05/20/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pain associated with surgical or enzymatic burn wound debridement prevents many burn centres from working outside an operating theatre, creating a burden. Alternatives for general anaesthesia to manage pain in burn patients treated with enzymatic debridements, such as regional anaesthesia, have not been studied in detail. This study explores the different possibilities for pain management during a bedside NexoBrid™ procedure. MATERIAL AND METHODS We performed a single-centre retrospective study that included 82 paediatric, adolescent, and adult patients with deep dermal and full-thickness burns treated bedside with NexoBrid™ under regional or general anaesthesia. Outcome measures were pain during the NexoBrid™ procedure, the safety of the anaesthesia and the NexoBrid™ procedure, logistics of the bedside NexoBrid™ procedure, and time to wound closure. RESULTS Forty-three patients in the adult group (43/67, 64%) only presented with burn wounds on one upper or the one or two lower extremities. In 29 of them (29/43, 67%), a NexoBrid™ procedure was performed under regional anaesthesia, which resulted in low pain levels without any adverse events. All seven patients in the paediatric group, where only one upper or one or two lower limbs were involved (7/15, 47%), underwent a NexoBrid™ procedure performed under regional anaesthesia where no adverse events were reported. In these children, the use of regional anaesthesia was associated with a significant decrease in time to wound closure (average treatment effect on the treated = -22.5 days, p = 0.021). CONCLUSION This study highlights that regional anaesthesia administered at the bedside should be the method of choice for pain management during NexoBrid™ procedures because often, it can be adequately and safely performed in all age groups. This approach will reduce the burden on operating theatres. A flow chart has been developed to guide pain management during a NexoBrid™ procedure.
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48
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Opfermann P, Kraft F, Obradovic M, Zadrazil M, Schmid W, Marhofer P. Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study. Anaesthesia 2022; 77:785-794. [PMID: 35460068 PMCID: PMC9322320 DOI: 10.1111/anae.15738] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/27/2022]
Abstract
Data on safety and success rates of ultrasound‐guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block‐related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal‐plus‐sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain‐related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain‐related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035–1.092, p < 0.001) as well as with mid‐abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69–29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38–9.5, p = 0.009) for respiratory problems. Ultrasound‐guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid‐abdominal surgical procedures are risk factors for pain‐related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.
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Affiliation(s)
- P Opfermann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - F Kraft
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - M Obradovic
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - M Zadrazil
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - W Schmid
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - P Marhofer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.,Department of Anaesthesia and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
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49
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Opfermann P, Zadrazil M, Tonnhofer U, Metzelder M, Marhofer P, Schmid W. Ultrasound-guided epidural anesthesia and sedation for open transvesical Cohen ureteric reimplantation surgery in 20 consecutive children: a prospective case series and proof-of-concept study. Minerva Anestesiol 2022; 88:564-572. [PMID: 35381834 DOI: 10.23736/s0375-9393.22.15904-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Epidural anesthesia is usually combined with general anesthesia (GA) for children undergoing sub-umbilical surgery and GA in children is associated with a potential for respiratory events. Aiming to reduce airway manipulation and the use of GA drugs, we designed a study of transvesical Cohen ureteteric reimplantion under epidural anesthesia in sedated, spontaneously breathing children. METHODS We enrolled 20 children (3-83 months, 6.3-25.0 kg) scheduled for open transvesical abdominal surgery with Pfannenstiel incision. Sedation was followed by ultrasound-guided epidural anesthesia. Increases in heart rate by > 15% and or patient movements upon skin incision were rated as block deficiencies. Intubation equipment for advanced airway management was kept on standby. The primary study endpoint was successful blockade, meaning that no sequential airway management was required for the spontaneous breathing patients during surgery. Secondary endpoints included any use of fentanyl/propofol intraoperatively and of postoperative analgesics in the recovery room. RESULTS All 20 blocks were successful, with no block deficiencies upon skin incision, no need for sequential airway management, and stable SpO2 levels (97-100%). Surgery took a median of 120.5 minutes (IQR: 89.3-136.5) and included one bolus of fentanyl in one patient 120 minutes into a protracted operation. No more systemic analgesia had to be provided in the recovery room. CONCLUSIONS Sedation and epidural anesthesia emerged as a useful alternative to GA from our consecutive case series.
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Affiliation(s)
- Philipp Opfermann
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Zadrazil
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Ursula Tonnhofer
- Department of Surgery, Division of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Metzelder
- Department of Surgery, Division of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anesthesiology and Intensive Care Medicine, Orthopaedic Hospital Speising, Vienna, Austria
| | - Werner Schmid
- Department of Anesthesiology and General Intensive Care Medicine, Medical University of Vienna, Vienna, Austria -
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50
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Priyadarshini K, Behera BK, Tripathy BB, Misra S. Ultrasound-guided transverse abdominis plane block, ilioinguinal/iliohypogastric nerve block, and quadratus lumborum block for elective open inguinal hernia repair in children: a randomized controlled trial. Reg Anesth Pain Med 2022; 47:217-221. [PMID: 35039439 DOI: 10.1136/rapm-2021-103201] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve blocks and transverse abdominis plane (TAP) blocks are widely used for postoperative analgesia in children undergoing inguinal hernia repair (IHR). Quadratus lumborum block (QLB) provides analgesia for both upper and lower abdominal surgery. Very few randomized controlled trials in children have assessed the efficacy of QLB in IHR. Thus, this study was designed to find the comparative effectiveness of QLB versus TAP and II/IH blocks in children undergoing open IHR. MATERIALS AND METHODS Sixty children scheduled for open IHR were randomly allocated in groups of 20 to receive either ultrasound-guided TAP block with 0.4 mL/kg of 0.25% ropivacaine, II/IH nerve block with 0.2 mL/kg of 0.25% ropivacaine, or QLB with 0.4 mL/kg of 0.25% ropivacaine. Anesthesia was standardized for all patients, and an experienced anesthesiologist performed the blocks after anesthesia induction. PRIMARY OUTCOME Time to first analgesia. SECONDARY OUTCOMES Postoperative pain scores, intraoperative and postoperative opioid consumption, cumulative paracetamol usage, block performance time, and block-related complications. RESULTS The median time to first analgesia was 360 (120), 480 (240), and 720 (240) min in the TAP block, II/IH block, and QLB groups, respectively; and was significantly longer in the QLB versus TAP (p<0.001) and II/IH (p<0.001) groups. The time to first analgesia was not significantly different between the TAP and II/IH groups (p=0.596). The mean postoperative tramadol consumption was 11 (12.7), 4 (7.16), and 3 (8) mg in the TAP, II/IH, and QLB groups, respectively (p=0.023); and it was lowest in the QLB group. No significant differences were found between the groups for other secondary outcomes. CONCLUSIONS QLB provides a prolonged period of analgesia and leads to decreased opioid consumption compared with TAP blocks and II/IH nerve blocks in children undergoing open IHR. TRIAL REGISTRATION NUMBER CTRI/2019/09/021377.
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Affiliation(s)
| | | | | | - Satyajeet Misra
- Anesthesiology, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India
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