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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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Opfermann P, Marhofer P, Springer A, Metzelder M, Zadrazil M, Schmid W. A prospective observational study on the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated spontaneously breathing infants with a natural airway. Paediatr Anaesth 2022; 32:49-55. [PMID: 34582607 PMCID: PMC9292952 DOI: 10.1111/pan.14302] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Laparoscopic procedures are usually performed under general anesthesia with a secured airway including endotracheal intubation or supraglottic airways. AIMS This is a prospective study of the feasibility of subumbilical laparoscopic procedures under epidural anesthesia in sedated, spontaneous breathing infants with a natural airway. METHODS We consecutively enrolled 20 children <3 years old with nonpalpable testes scheduled for diagnostic laparoscopy with or without an ensuing orchidopexy, inguinal revision, or Fowler-Stephens maneuver. Inhalational induction for venous access was followed by sedation with propofol and ultrasound-guided single-shot epidural anesthesia via the caudal or thoracolumbar approach using 1.0 or 0.5 ml kg-1 ropivacaine 0.38%, respectively. The primary outcome measure was block success, defined as no increase in heart rate by >15% or other indicators of pain upon skin incision. RESULTS Of the 20 children (median age: 10 months; IQR: 8.3-12), 17 (85%) were anesthetized through a caudal and 3 (15%) through a direct thoracolumbar epidural, 18 (90%) underwent a surgical procedure and 2 (10%) diagnostic laparoscopy only. Five patients (25%) received block augmentation using an intravenous bolus of fentanyl (median dose: 0.9 µg kg-1 ; IQR: 0.8-0.95) after the initial prick test and before skin incision. There was no additional need for systemic pain therapy in the operating theater or recovery room. No events of respiratory failure or aspiration were observed. CONCLUSIONS In experienced hands, given our success rate of 100%, epidural anesthesia performed in sedated spontaneously breathing infants with a natural airway can be an alternative strategy for subumbilical laparoscopic procedures.
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Affiliation(s)
- Philipp Opfermann
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
| | - Peter Marhofer
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria,Department of Anesthesia and Intensive Care MedicineOrthopaedic Hospital SpeisingViennaAustria
| | - Alexander Springer
- Department of SurgeryDivision of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - Martin Metzelder
- Department of SurgeryDivision of Pediatric SurgeryMedical University of ViennaViennaAustria
| | - Markus Zadrazil
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
| | - Werner Schmid
- Department of Anesthesia, General Intensive Care Medicine and Pain TherapyMedical University of ViennaViennaAustria
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Marjanovic V, Budic I, Golubovic M, Breschan C. Perioperative respiratory adverse events during ambulatory anesthesia in obese children. Ir J Med Sci 2021; 191:1305-1313. [PMID: 34089150 PMCID: PMC9135828 DOI: 10.1007/s11845-021-02659-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/21/2021] [Indexed: 11/05/2022]
Abstract
Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.
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Affiliation(s)
- Vesna Marjanovic
- Faculty of Medicine, University of Nis, Blvd. dr Zorana Djindjica 81, 18000, Nis, Serbia. .,Clinic for Anesthesia and Intensive Therapy, Clinical Centre Nis, Blvd. dr Zorana Djindjica 48, 18000, Nis, Serbia.
| | - Ivana Budic
- Faculty of Medicine, University of Nis, Blvd. dr Zorana Djindjica 81, 18000, Nis, Serbia.,Clinic for Anesthesia and Intensive Therapy, Clinical Centre Nis, Blvd. dr Zorana Djindjica 48, 18000, Nis, Serbia
| | - Mladjan Golubovic
- Faculty of Medicine, University of Nis, Blvd. dr Zorana Djindjica 81, 18000, Nis, Serbia.,Clinic for Anesthesia and Intensive Therapy, Clinical Centre Nis, Blvd. dr Zorana Djindjica 48, 18000, Nis, Serbia
| | - Christian Breschan
- Department of Anesthesia, Klinikum Klagenfurt, Feschigstrasse 11, 9020, Klagenfurt, Austria
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Rawat J, Shyam R, Kaushal D. A Comparative Study of Tramadol and Clonidine as an Additive to Levobupivacaine in Caudal Block in Pediatric Patients Undergoing Perineal Surgeries. Anesth Essays Res 2020; 13:620-624. [PMID: 32009705 PMCID: PMC6937898 DOI: 10.4103/aer.aer_127_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/02/2019] [Accepted: 10/21/2019] [Indexed: 11/09/2022] Open
Abstract
Background: Caudal block is a simple, safe procedure with fewer side effects to provide intraoperative and postoperative analgesia in pediatric patients. Many drugs were used as an additive to local anesthetics in caudal block. All these drugs had their own side effects. Aims: In this study, we compare the effects of tramadol and clonidine as an additive to levobupivacaine in caudal block in children undergoing perineal surgeries regarding hemodynamic changes, analgesic effects, and side effects. Settings and Design: This is a prospective, double-blind randomized, controlled study, conducted in Department of Paediatric Surgery, at King George's Medical University, Lucknow, Uttar Pradesh during 2017–2018. Materials and Methods: After informed consent and ethical clearance from institutional ethics committee, King Georges Medical University, Lucknow. Total 66 patients aged 1–10 year, planned for perineal surgery were randomly allocated according to computer-generated random number, into three groups. Group I - 0.25% levobupivacaine (1 mL.kg-1) alone, Group II - 0.25% levobupivacaine (1 mL.kg-1) with tramadol 1 mL.kg-1, and Group III - 0.25% levobupivacaine (1 mL.kg-1) with clonidine 1 μg.kg-1. Perioperative pain was the primary outcome. Hemodynamic parameters: heart rate, mean arterial pressure, and peripheral oxygen saturation were recorded. Postoperative pain assessed by Children and Infants Postoperative Pain Scale (CHIPPS), sedation by Ramsay sedation score and requirement of rescue analgesia were recorded at predetermined time intervals. Statistical Analysis: The values were represented in number (%) and mean ± standard deviation. Comparison of quantitative variables between the study groups was done using ANOVA test and Mann–Whitney U-test. Categorical data were analyzed using Chi-square test. Results: Postoperative analgesic effect was significantly longer in levobupivacaine with clonidine group as compared to tramadol with levobupivacaine group and levobupivacaine alone group. Conclusion: Clonidine in a dose of 1 μg.kg-1 when added to levobupivacaine in caudal block significantly prolongs the duration of analgesia as compared to tramadol with levobupivacaine and levobupivacaine alone without any clinically significant side effects. Thus, it is better to add additive like clonidine to enhance the effect of analgesia.
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Affiliation(s)
- Jyoti Rawat
- Department of Anaesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Radhey Shyam
- Department of Geriatric Intensive Care Unit (Anaesthesiology), King George Medical University, Lucknow, Uttar Pradesh, India
| | - Dinesh Kaushal
- Department of Anaesthesiology, King George Medical University, Lucknow, Uttar Pradesh, India
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Hayes SM, El Raouf RA, El Metwally Farahat T, El Deen Hamed E. Efficacy of adding tramadol as adjunctive analgesic with levobupivacaine in modified pectoral nerve block for modified radical mastectomy surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Salwa M.S. Hayes
- Department of Anesthesia and Intensive Care, Mansoura University, Faculty of Medicine, Egypt
| | - Reem Abd El Raouf
- Department of Anesthesia and Intensive Care, Mansoura University, Faculty of Medicine, Egypt
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Haas AI, Koval DO, Haas OO. Regional anesthetics: traditions and innovations. PAIN MEDICINE 2018. [DOI: 10.31636/pmjua.v3i2.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The wide implementation of different regional anesthesia techniques is also actual in pediatric anesthesiology. Using modern methods of regional anesthesia (RA) and modern local anesthetics is a new level in development of pediatric anesthesiology. This article is about advantages of regional pediatric anesthesia in intra- and post-surgery pain management and analgesia. We analyse the techniques of spinal and epidural anesthesia, as well as their varieties such as unipolar spinal block and caudal anesthesia, compare their advantages and disadvantages. Some more techniques such as paravertebral block, TAP-block are considered as an alternative to epidural anesthesia. Methods and possibilities of ilioinguinal, iliohypogastric and TAP-blocks are also mentioned here. The use of the above-mentioned methods allows to reduce the use of narcotic analgesics and hypnotics and, as a consequence, reduces their systemic effects on the child’s body. These methods are safer for use, since they allow you to plan a safe anesthetic for each child and minimize complications.
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Vittinghoff M, Lönnqvist PA, Mossetti V, Heschl S, Simic D, Colovic V, Dmytriiev D, Hölzle M, Zielinska M, Kubica-Cielinska A, Lorraine-Lichtenstein E, Budić I, Karisik M, Maria BDJ, Smedile F, Morton NS. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatr Anaesth 2018; 28:493-506. [PMID: 29635764 DOI: 10.1111/pan.13373] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2018] [Indexed: 12/21/2022]
Abstract
The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.
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Affiliation(s)
- Maria Vittinghoff
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Per-Arne Lönnqvist
- Paediatric Anaesthesia & Intensive Care, Section of Anaesthesiology & Intensive Care, Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Valeria Mossetti
- Department of Anesthesia and Intensive Care, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefan Heschl
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Dusica Simic
- University Children's Hospital, Medical Faculty University of Belgrade, Serbia
| | - Vesna Colovic
- Royal Manchester Children's Hospital, Central Manchester University Hospitals, Manchester, UK
| | - Dmytro Dmytriiev
- Department of Anesthesiology and Intensive Care, Vinnitsa National Medical University, Vinnitsa, Ukraine
| | - Martin Hölzle
- Section of Paediatric Anaesthesia, Department of Anaesthesia, Luzerner Kantonsspital, Luzern, Switzerland
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Anna Kubica-Cielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | | | - Ivana Budić
- Centre for Anesthesiology and Resuscitation, Clinical Centre Nis Department of Anesthesiology, Medical Faculty, University of Nis, Nis, Serbia
| | - Marijana Karisik
- Institute for Children Diseases, Department of Anaesthesiology, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Belen De Josè Maria
- Department of Pediatric Anesthesia, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Francesco Smedile
- Department of Pediatric Anesthesiology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Neil S Morton
- Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, UK
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Dogra N, Dadheech R, Dhaka M, Gupta A. A study to compare caudal levobupivacaine, tramadol and a combination of both in paediatric inguinal hernia surgeries. Indian J Anaesth 2018; 62:359-365. [PMID: 29910493 PMCID: PMC5971624 DOI: 10.4103/ija.ija_747_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Caudal block is a safe and simple method of pain relief in young children with the drawback of a short duration of analgesia which can be overcome by adding various adjuvants to the injected local anaesthetic. We compared the effects of caudal levobupivacaine, tramadol and a combination of both in paediatric patients undergoing inguinal herniotomy. Methods: A total of 78 children aged 1–7 years, planned for inguinal herniotomy were randomly allocated into three groups. Group L received levobupivacaine 0.125% 1 ml/kg, Group T received tramadol 1.5 mg/kg in 0.9% NS and Group LT 1 ml/kg of 0.125% levobupivacaine with 1.5 mg/kg tramadol caudally. The primary outcome was the duration of analgesia. Rescue analgesic doses required, the duration of motor blockade and adverse effects were recorded for 12 h post-operatively. Data was analysed by analysis of variance test, Kruskal-Wallis and Chi-square tests. Results: All groups were comparable with regard to age, sex and duration of surgery. No motor block was observed in any of the patients. The mean duration of analgesia in Group L was 321.46 ± 84.76 min, in Group T was 565.19 ± 107.08 min, and in Group LT was 720 min (P < 0.001). The requirement for rescue analgesia in tramadol group was significantly less as compared to levobupivacaine group. Sedation scores and adverse effects were comparable among all groups. Conclusion: Addition of tramadol to caudal levobupivacaine significantly increased the duration of postoperative analgesia.
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Affiliation(s)
- Neelam Dogra
- Department of Anaesthesiology, S.M.S. Medical College and Attached Hospitals, Jaipur, Rajasthan, India
| | - Rajat Dadheech
- Department of Anaesthesiology, S.M.S. Medical College and Attached Hospitals, Jaipur, Rajasthan, India
| | - Mahipal Dhaka
- Department of Anaesthesiology, S.M.S. Medical College and Attached Hospitals, Jaipur, Rajasthan, India
| | - Anupama Gupta
- Department of Anaesthesiology, S.M.S. Medical College and Attached Hospitals, Jaipur, Rajasthan, India
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Fentie DY, Gebremedhn EG, Denu ZA, Gebreegzi AH. Efficacy of single-injection unilateral thoracic paravertebral block for post open cholecystectomy pain relief: a prospective randomized study at Gondar University Hospital. Local Reg Anesth 2017; 10:67-74. [PMID: 28744155 PMCID: PMC5513842 DOI: 10.2147/lra.s133946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cholecystectomy can be associated with considerable postoperative pain. While the benefits of paravertebral block (PVB) on pain after thoracotomy and mastectomy have been demonstrated, not enough investigations on the effects of PVB on pain after open cholecystectomy have been conducted. We tested the hypothesis that a single-injection thoracic PVB reduces pain scores, decreases opioid consumption, and prolongs analgesic request time after cholecystectomy. Methods Of 52 patients recruited, 50 completed the study. They were randomly allocated into two groups: the paravertebral group and the control group. The outcome measures were the severity of pain measured on numeric pain rating scale, total opioid consumption, and first analgesic request time during the first postoperative 24 hours. Result The main outcomes recorded during 24 hours after surgery were Numerical Rating Scale (NRS) pain scores (NRS, 0–10), cumulative opioid consumption, and the first analgesic request time. Twenty four hours after surgery, NRS at rest was 4 (3–6) vs 5 (5–7) and at movement 4 (4–7) vs 6 (5–7.5) for the PVB and control groups, respectively. The difference between the groups over the whole observation period was statistically significant (P<0.05). Twenty-four hours after surgery, median (25th–75th percentile) cumulative morphine consumption was 0 (0–2) vs 2.5 (2–4) mg (P<0.0001) and cumulative tramadol consumption was 200 (150–250) mg vs 300 (200–350) mg in the paravertebral and in the control group, respectively (P=0.003). After surgery, the median (25th–75th percentile) first analgesic requirement time was prolonged in the PVB group in statistically significant fashion (P<0.0001). Conclusion and recommendations Single-shot thoracic PVB as a component of multi-modal analgesic regimen provided superior analgesia when compared with the control group up to 24 postoperative hours after cholecystectomy, and we recommend this block for post cholecystectomy pain relief.
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Affiliation(s)
- Demeke Yilkal Fentie
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Endale Gebreegziabher Gebremedhn
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zewditu Abdissa Denu
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Hailekiros Gebreegzi
- Department of Anesthesia, School of Medicine, Gondar College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Ran J, Wang Y, Li F, Zhang W, Ma M. Pharmacodynamics and Pharmacokinetics of Levobupivacaine Used for Epidural Anesthesia in Patients with Liver Dysfunction. Cell Biochem Biophys 2017; 73:717-21. [PMID: 27259315 DOI: 10.1007/s12013-015-0677-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The objective of this study was to study the pharmacodynamics and pharmacokinetics of levobupivacaine used for epidural anesthesia in patients with liver dysfunction. Twenty patients aged 20-60, American Society of Anesthesiologists (ASA) graded I-III according to the ASA guidelines, scheduled for elective upper abdominal surgery, were included in the study. They were divided into two groups of ten each. In group I, the patients with liver dysfunction were included, whereas group II was composed of those with normal liver function. In both groups, anesthesia was induced by general anesthesia combined with epidural block, given by T 8-9 interspace injection of 1.8 mg kg(-1) levobupivacaine (0.75 %) with 5 μg mL(-1) of adrenaline in 1.5 min. The sensory and motor blockade indices were recorded for 30 min after the injection. The plasma concentration of levobupivacaine was determined by high performance liquid chromatography from 0 to 1440 min after the injection and pharmacokinetics of the drug were calculated. The onset and recovery time from the sensory block in the two groups were similar with no significant difference (P > 0.05). The maximum spread of anesthetic effect, the number of spinal segments regressed, onset time, and degree of motor block after the injection were also insignificantly different in the two groups. The plasma levobupivacaine concentration/time curve of the liver dysfunction (group I) was significantly higher than that of the controls (group II). In the liver dysfunction patients, the volume of distribution (V/F) was significantly increased, the elimination rate, i.e., half-life (t 1/2β ), was prolonged, and the elimination rate constants (K 12 and K 10) were significantly decreased (P < 0.05 or P < 0.01). The patients with liver dysfunction injected with 0.75 % levobupivacaine exhibited normal onset and recovery time of the sensory and motor blocks within 30 min. However, in these patients, the metabolism of levobupivacaine was significantly slower as evidenced by the higher blood concentration of the drug than in cases with normal functioning liver.
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Affiliation(s)
- Juhong Ran
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Yanping Wang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Fangkun Li
- The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, 450000, Henan, China
| | - Wei Zhang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
| | - Minyu Ma
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China.
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Marjanovic V, Budic I, Stevic M, Simic D. A Comparison of Three Different Volumes of Levobupivacaine for Caudal Block in Children Undergoing Orchidopexy and Inguinal Hernia Repair. Med Princ Pract 2017; 26:331-336. [PMID: 28437787 PMCID: PMC5768116 DOI: 10.1159/000475936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/22/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the efficacy of 3 different volumes of 0.25% levobupivacaine caudally administered on the effect of intra- and postoperative analgesia in children undergoing orchidopexy and inguinal hernia repair. SUBJECTS AND METHODS Forty children, aged 1-7 years, American Society of Anesthesiologists (ASA) physical status I and II, were randomized into 3 different groups according to the applied volumes of 0.25% levobupivacaine: group 1 (n = 13): 0.6 mL∙kg-1; group 2 (n = 10): 0.8 mL∙kg-1; and group 3 (n = 17): 1.0 mL∙kg-1. The age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were compared among the groups. The time to first use of the analgesic and the number of patients who required analgesic 24 h after surgery in the time intervals within 6 h, between 6 and 12 h, and between 12 and 24 h postoperatively were evaluated among the groups. Statistical analyses were performed with a Dunnett t test, ANOVA, or Kruskal-Wallis test and χ2 test. Logistic regression analysis was used in order to examine predictive factors on duration of postoperative analgesia. RESULTS Age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were similar among the groups. The time to first analgesic use did not differ among the groups, and logistic regression modelling showed that using the 3 different volumes of levobupivacaine had no predictive influence on duration of postoperative analgesia. The numbers of patients who required analgesics within 6 h (3/2/3), between 6 and 12 h (3/1/3), and between 12 and 24 h (1/0/2) after surgery were similar among the groups. CONCLUSION The 3 different volumes of 0.25% levobupivacaine provided the same quality of intra- and postoperative pain relief in pediatric patients undergoing orchidopexy and inguinal hernia repair.
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Affiliation(s)
- Vesna Marjanovic
- Center for Anesthesia and Resuscitation, Clinical Centre Nis, Nis, Serbia
- *Vesna Marjanovic, Center for Anesthesia and Resuscitation, Clinical Centre Nis, Bul. Zorana Djindjica 48, RS-18000 Nis (Serbia), E-Mail
| | - Ivana Budic
- Center for Anesthesia and Resuscitation, Clinical Centre Nis, Nis, Serbia
- Department of Anesthesiology, Faculty of Medicine, University of Nis, Nis, Serbia
| | - Marija Stevic
- Department of Anesthesia, University Children's Hospital Belgrade, Belgrade, Serbia
| | - Dusica Simic
- Department of Anesthesia, University Children's Hospital Belgrade, Belgrade, Serbia
- Department of Anesthesiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Effect of nalbuphine as an adjuvant on levobupivacaine induced caudal analgesia in children undergoing surgical procedures, controlled randomized double blinded study. EGYPTIAN JOURNAL OF ANAESTHESIA 2016. [DOI: 10.1016/j.egja.2015.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Cinar SO, Isil CT, Sahin SH, Paksoy I. Caudal ropivacaine and bupivacaine for postoperative analgesia in infants undergoing lower abdominal surgery. Pak J Med Sci 2015; 31:903-8. [PMID: 26430427 PMCID: PMC4590355 DOI: 10.12669/pjms.314.5432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: To compare the postoperative analgesic efficacy of ropivacaine 0.175% and bupivacaine 0.175% injected caudally into infants for lower abdominal surgery. Methods: Eighty infants, aged 3-12 months, ASA I-II scheduled to undergo lower abdominal surgery were randomly allocated to one of the two groups: Group R received 1ml.kg-1 0.175% ropivacaine and Group B received 1ml.kg-1 0.175% bupivacaine via caudal route. Postoperative analgesia, sedation and motor block were evaluated with modified objective pain scale, three-point scale and modified Bromage scale respectively. Postoperative measurements including mean arterial pressure (MAP), heart rate (HR), pain (OPS), sedation and motor block score were recorded for four hours in the postoperative recovery room. Parents were contacted by telephone after 24 hours to question duration of analgesia and side effects. Results: No significant differences were found among the groups in demographic data, MAP, HR, OPS and sedation scores during four hours postoperatively. The duration of analgesia was 527.5±150.62 minutes in Group R, 692.77±139.01 minutes in Group B (p=0.004). Twelve (30%) patients in Group R, 16 (40%) patients in groupB needed rescue analgesics (p=0.348). Rescue analgesics were administered (1 time/2 times) (9/3) (22.5/7.5%) in Group R and 16/0 (40/0%) in Group B, where no statistically significant difference was determined between the groups (p=0.071). Motor blockade was observed in 7 (17.5%) patients in Group R, and 8 (20%) patients in Group B (p=0.774). Conclusion: This study indicated, that a concentration of 0.175% ropivacaine and 0.175% bupivacaine administered to the infants via caudal route both provided effective and similar postoperative pain relief in infants, who underwent lower abdominal surgery.
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Affiliation(s)
- Surhan Ozer Cinar
- Dr. Surhan Ozer Cinar, Associate Professor, Anesthesiology and Reanimation Clinic, Sisli Etfal Education and Research Hospital, Halaskargazi Cad. Etfal Sok. Sisli, Istanbul, Turkey
| | - Canan Tulay Isil
- Dr. Canan Tulay Isil, Specialist, Anesthesiology and Reanimation Clinic, Sisli Etfal Education and Research Hospital, Halaskargazi Cad. Etfal Sok. Sisli, Istanbul, Turkey
| | - Sevtap Hekimoglu Sahin
- Dr. Sevtap Hekimoglu Sahin, Associate Professor, Anesthesiology & Reanimation Department, Trakya University Faculty of Medicine. Edirne, Turkey
| | - Inci Paksoy
- Dr. Inci Paksoy, Specialist, Anesthesiology and Reanimation Clinic, Sisli Etfal Education and Research Hospital, Halaskargazi Cad. Etfal Sok. Sisli, Istanbul, Turkey
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Ríos-Medina AM, Caicedo-Salazar J, Vásquez-Sadder MI, Aguirre-Ospina OD, González MP. Regional anesthesia in pediatrics – Non-systematic literature review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2015.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Anestesia regional en pediatría – Revisión no sistemática de la literatura. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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El-Anwar MW, Mostafa K, Elsamad AA. Levobupivacaine Alone Versus Levobupivacaine Plus Magnesium Infiltration for Post-Tonsillectomy Analgesia. INT J PHARMACOL 2015. [DOI: 10.3923/ijp.2015.490.495] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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A prospective study comparing the onset and analgesic efficacy of different concentrations of levobupivacaine with/without dexmedetomidine in young children undergoing caudal blockade. J Clin Anesth 2015; 27:17-22. [DOI: 10.1016/j.jclinane.2014.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/10/2014] [Accepted: 09/03/2014] [Indexed: 01/31/2023]
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Regional anesthesia in pediatrics - Non-systematic literature review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543030-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Chipde S, Banjare M, Arora K, Saraswat M. Prospective randomized controlled comparison of caudal bupivacaine and ropivacaine in pediatric patients. Ann Med Health Sci Res 2014; 4:S115-8. [PMID: 25184076 PMCID: PMC4145506 DOI: 10.4103/2141-9248.138025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Bupivacaine and ropivacaine are commonly used agents for caudal anesthesia in pediatric patients. Several studies have shown different motor and cardiovascular effects of two drugs. Aim: The primary objective of this study was to evaluate the efficacy of both drugs and secondary objective was to compare motor blockade and hemodynamic effects caused by them. Subjects and Methods: This was a prospective randomized controlled study including 50 consecutive patients in the age group of 1-10 years, who underwent urogenital surgeries under general anesthesia. Caudal block was given with either bupivacaine (0.25%) 1 ml/kg (Group I) or ropivacaine (0.25%) 1 ml/kg (Group II). Heart rate (HR) and systolic blood pressure (SBP) were recorded as a baseline, before the anesthesia induction and then at 30, 60 and 90 min after incision. Pain scores were assessed post-operatively by a single observer at 30 min and then at 2, 4, 8 and 12 h with a 5-point observer pain score (OPS). Patients and observer were blinded to the medication given. The duration of absolute analgesia was defined as the time from caudal injection until the pain score was >2. Motor block was assessed by modified Bromage scale. Statistical analysis was performed with Chi-square test, Student's t-test and log-rank test. P < 0.05 were considered as significant. Results: HR and SBP measured at a specific time intervals showed no significant difference. All the patients had adequate intraoperative analgesia. Mean OPS were comparable between two groups. Duration of absolute analgesia was 276.8 (11) min in Group I and 284.8 (12) min for Group II. The only significant difference was the motor-block score at 2, 3 and 4 h after surgery, although the score was same 1 h post-operatively. Conclusion: The efficacy of both ropivacaine and bupivacaine is almost same in terms of onset and duration of analgesia. Therefore, the motor blockade caused by ropivacaine is less; there is no significant difference in cardiovascular events.
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Affiliation(s)
- Ss Chipde
- Department of Anesthesiology, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - M Banjare
- Department of Anesthesiology, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - Kk Arora
- Department of Anesthesiology, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
| | - M Saraswat
- Department of Anesthesiology, M.G.M. Medical College and M.Y. Hospital, Indore, Madhya Pradesh, India
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Suresh S, Schaldenbrand K, Wallis B, De Oliveira G. Regional anaesthesia to improve pain outcomes in paediatric surgical patients: a qualitative systematic review of randomized controlled trials. Br J Anaesth 2014; 113:375-390. [DOI: 10.1093/bja/aeu156] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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The effects of dexamethasone and levobupivacaine on postoperative pain in Modified Radiofrequency Assisted Uvulopalatoplasty (MRAUP) surgery. Eur Arch Otorhinolaryngol 2013; 271:1803-8. [DOI: 10.1007/s00405-013-2859-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 12/04/2013] [Indexed: 11/26/2022]
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ENGELMAN E, MARSALA C. Bayesian enhanced meta-analysis of post-operative analgesic efficacy of additives for caudal analgesia in children. Acta Anaesthesiol Scand 2012; 56:817-32. [PMID: 22313028 DOI: 10.1111/j.1399-6576.2012.02651.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND The authors calculated the effect size for post-operative analgesia of three additives, clonidine, neostigmine, and tramadol to bupivacaine, ropivacaine, or levobupivacaine used for single-dose caudal extradural blockade in children. METHODS A meta-analysis was performed for three end points of efficacy: the increase of time until administration of analgesic drugs, the proportion of patients requiring analgesic drugs during the initial 24 post-operative hours, and the amounts of post-operative analgesic drugs. A Bayesian inference supporting direct statements about the probability of the magnitude of an effect was used to compare the effects size. RESULTS Neostigmine increased the duration of analgesia by 9.96 h (95% confidence interval: 7.75 to 12.16), as compared with 3.68 h (2.65 to 4.7) with clonidine and 4.45 (2.84 to 6.07) with tramadol. There is a 95% probability that neostigmine increases the duration of post-operative analgesia by more than 8 h, clonidine by more than 2.8 h, and tramadol by more than 3.25 h, as compared with local anesthetics alone. The odds ratios for the proportion of patients requiring analgesic drugs were 0.22 [0.13 to 0.37] for clonidine and 0.28 [0.10 to 0.75] for neostigmine. With tramadol, there was no statistically significant difference. All three additives reduced the amounts of post-operative analgesic drugs. Neostigmine and tramadol increase the probability for post-operative nausea or vomiting (PONV). CONCLUSIONS Neostigmine provides the longest post-operative analgesia. With clonidine, the duration of analgesia is shorter and sedation is increased, but the probability for PONV could be decreased.
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Affiliation(s)
- E. ENGELMAN
- Department of Anaesthesia; CUB Hopital Erasme; Brussels; Belgium
| | - C. MARSALA
- Department of Anaesthesia; CUB Hopital Erasme; Brussels; Belgium
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Comparison of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block in dogs. Reg Anesth Pain Med 2011; 35:409-11. [PMID: 20814280 DOI: 10.1097/aap.0b013e3181e6acf1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to compare the potency of bupivacaine, ropivacaine, and levobupivacaine in an equal dose and concentration for sympathetic block. METHODS We measured mean arterial pressure, heart rate (HR), and right and left brachial artery blood flow (BABF) before and after cervicothoracic sympathetic block in 24 dogs. The experimental protocol was designed as follows: (1) left cervicothoracic sympathetic block with 1.0 mL of 0.25% bupivacaine (n = 8), (2) left cervicothoracic sympathetic block with 1.0 mL of 0.25% ropivacaine (n = 8), and (3) left cervicothoracic sympathetic block with 1.0 mL of 0.25% levobupivacaine (n = 8). RESULTS Mean arterial pressure and heart rate did not change significantly throughout the study in either group. Left cervicothoracic sympathetic block with 0.25% bupivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 20 mins after the block, 218% +/- 48%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% ropivacaine increased left BABF significantly from 5 to 100 mins after the block (baseline, 100%; peak at 10 mins after the block, 254 +/- 38%; P < 0.01). Left cervicothoracic sympathetic block with 0.25% levobupivacaine increased left BABF significantly from 5 to 80 mins after the block (baseline, 100%; peak at 20 mins after the block, 183% +/- 38%; P < 0.01). CONCLUSIONS Ropivacaine may induce a greater increase in vasodilation than bupivacaine and levobupivacaine at the same dose and concentration for sympathetic block in dogs.
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Thies KC, Driessen J, Kho HG, Kwak K, Knoll J, de Gier R, Feitz W. Longer than expected-duration of caudal analgesia with two different doses of levobupivacaine in children undergoing hypospadias repair. J Pediatr Urol 2010; 6:585-8. [PMID: 20171143 DOI: 10.1016/j.jpurol.2010.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2009] [Accepted: 01/18/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess our study design and to obtain preliminary data for a dose-effect study on levobupivacaine for caudal analgesia in patients undergoing hypospadias repair. STUDY DESIGN non randomised, non-blinded pilot study. METHOD For this non-randomized, non-blinded pilot study, 20 patients (median age 17 months, median weight 10.5 kg) were allocated to two groups receiving either 0.5 mL kg(-1) levobupivacaine 0.125% (Group 0) or 0.5 mL kg(-1) levobupivacaine 0.375% (Group 1) caudally after induction of anaesthesia for pain control. No further analgesia was given before, during or after the procedure. Pain scores (Children's and Infants' Postoperative Pain Scale) were recorded throughout the observation period, which lasted from the start of the procedure until hospital discharge on the following day. RESULTS Group 0: six out of 10 patients remained pain free throughout the observation period. Group 1: six out of seven patients remained pain free throughout the observation period. CONCLUSION Both concentrations of levobupivacaine provided excellent analgesia throughout surgery. The postoperative analgesia with both doses of levobupivacaine was found to be significantly longer lasting than previously reported. The study design, with a tight and extensive observation scheme, proved to be feasible, but given the surprisingly long-lasting analgesia, the observation period needs to be extended in future studies.
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Affiliation(s)
- Karl-Christian Thies
- Radboud University Nijmegen Medical Centre, Dept. of Anaesthesia, The Netherlands.
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Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects? Can J Anaesth 2010; 57:1102-10. [DOI: 10.1007/s12630-010-9386-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 09/01/2010] [Indexed: 10/19/2022] Open
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Yildiz TS, Ozdamar D, Bagus F, Solak M, Toker K. Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study. Paediatr Anaesth 2010; 20:524-9. [PMID: 20412459 DOI: 10.1111/j.1460-9592.2010.03296.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg.kg(-1) and mixture of both in children undergoing day-case surgery. METHODS Sixty-three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg.kg(-1) (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml.kg(-1)). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children's and Infants' Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was > or =4. RESULTS No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 +/- 160 min vs 322 +/- 183 min and 248 +/- 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. CONCLUSION Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.
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Affiliation(s)
- Tulay S Yildiz
- Department of Anesthesiology, Medical Faculty, University of Kocaeli, Kocaeli, Turkey.
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Hong JY, Han SW, Kim WO, Cho JS, Kil HK. A Comparison of High Volume/Low Concentration and Low Volume/High Concentration Ropivacaine in Caudal Analgesia for Pediatric Orchiopexy. Anesth Analg 2009; 109:1073-8. [DOI: 10.1213/ane.0b013e3181b20c52] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yilmaz S, Demiraran Y, Akkan N, Yaman H, Iskender A, Güçlü E, Oztürk O. The effects of topical levobupivacaine on morbidity in pediatric tonsillectomy patients. Int J Pediatr Otorhinolaryngol 2009; 73:1208-10. [PMID: 19500860 DOI: 10.1016/j.ijporl.2009.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 03/11/2009] [Accepted: 05/07/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To reduce the post-tonsillectomy morbidity by swab soaked with 5 ml levobupivacaine hydroclorur (25 mg/10 ml). STUDY DESIGN A double-blind prospective randomized controlled clinical study. METHODS In this randomized double-blind study in group I (30 children, mean age 7.5+/-2.6) we tightly packed swab soaked with 5 ml levobupivacaine hydroclorur (25mg/10 ml) and in group II (21 children, mean age 7.9+/-3.7) we used 5 ml saline swabs into each of the two tonsillar fossae after tonsillectomy for 5 min. We used McGrath's face scale to compare the two groups in respect of pain control. RESULTS There was statistically significant pain relieving effect in the levobupivacaine group in the first 24h (p<0.05). But after 24h pain relieving effect of levobupivacaine was not significant (p>0.05). We did not see any serious complications for both groups. Postoperative morbidity mean results (nausea, vomiting, fever, bleeding, halitosis and ear pain) were not statistically different between the two groups (p>0.05). CONCLUSION Topical levobupivacaine seems to be a safe and easy medication for postoperative pain control in pediatric tonsillectomy patients.
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Affiliation(s)
- Süleyman Yilmaz
- Duzce University, Duzce Medical Faculty, Department of ENT and Head & Neck Surgery, Duzce, Turkey.
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Menzies R, Congreve K, Herodes V, Berg S, Mason DG. A survey of pediatric caudal extradural anesthesia practice. Paediatr Anaesth 2009; 19:829-36. [PMID: 19691690 DOI: 10.1111/j.1460-9592.2009.03116.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Caudal extradural blockade is one of the most commonly performed procedures in pediatric anesthesia. However, there is little information available on variations in clinical practice. OBJECTIVES To perform a survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland who undertake caudal anesthesia. METHODS An 'online' World Wide Web questionnaire collected information on various aspects of clinical practice. The survey ran from April to June 2008. RESULTS There were 366 questionnaires completed. The majority of respondents had >5 years of pediatric experience and performed up to ten caudal extradural procedures a month. The commonest device used was a cannula (69.7%) with 68.6% using a 22G device. There was a trend toward the use of a cannula in those anesthetists with <15 years experience, while those with >15 years experience tended to use a needle. Most anesthetists (91.5%) did not believe that there was a significant risk of implantation of dermoid tissue into the caudal extradural space. The majority used a combination of clinical methods to confirm correct placement. Only 27 respondents used ultrasound. The most popular local anesthetics were bupivacaine (43.4%) and levobupivacaine (41.7%). The most common additives were clonidine (42.3%) and ketamine (37.5%). The caudal catheter technique was used by 43.6%. Most anesthetists (74%) wear gloves for a single shot caudal injection. CONCLUSIONS This survey provides a snapshot of current practice and acts a useful reference for the development of enhanced techniques and new equipment in the future.
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Affiliation(s)
- Robert Menzies
- Nuffield Department of Anesthetics, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, UK
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Ingelmo P, Frawley G, Astuto M, Duffy C, Donath S, Disma N, Rosano G, Fumagalli R, Gullo A. Relative analgesic potencies of levobupivacaine and ropivacaine for caudal anesthesia in children. Anesth Analg 2009; 108:805-13. [PMID: 19224787 DOI: 10.1213/ane.0b013e3181935aa5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Comparing relative potency of new local anesthetics, such as levobupivacaine and ropivacaine, by the minimum local analgesic concentration model has not been described for caudal anesthesia. Therefore, we performed a prospective, randomized, double-blind study to determine the minimum local analgesic concentrations of a caudal single shot of ropivacaine and levobupivacaine in children and to describe the upper dose-response curve. METHODS We performed a two-stage prospective, randomized, double-blind study comparing the dose-response curves of caudal ropivacaine and levobupivacaine in children. In phase 1, 80 boys were randomized to receive either ropivacaine or levobupivacaine. In the second phase a further 32 patients were randomly allocated to receive caudal anesthesia with doses designed to delineate the upper dose-response range (the 50% effective dose [ED(50)]-ED(95) range). RESULTS There were no significant differences in ED(50) values for caudal ropivacaine and levobupivacaine. The ED(50) for levobupivacaine estimated from the Dixon Massey method was 0.069% (95% CI 0.056%-0.082%) and for ropivacaine was 0.075% (95% CI 0.058%-0.092%). Estimated by isotonic regression the ED(50) and ED(95) respectively of levobupivacaine were 0.068 (0.04-0.09) and 0.20% (95% CI 0.16%-0.24%). For ropivacaine ED 50 and ED95 were 0.066 (0.033-0.098) and 0.225% (95% CI 0.21%-0.24%). CONCLUSIONS In children receiving one minimum alveolar anesthetic concentration of sevoflurane, there were no significant differences in the ED(50) for caudal levobupivacaine and ropivacaine. The potency ratio at ED(50) was 0.92 and 0.89 at ED(95), indicating that caudal levobupivacaine and ropivacaine have a similar potency.
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Affiliation(s)
- Pablo Ingelmo
- Department of Perioperative Medicine and Intensive, A.O. San Gerardo, Monza, Italy
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Dadure C. [Postoperative pain management using regional anaesthesia in the child. Pain and Locoregional Anesthesia Committee and the Standards Committee of the French Society of Anesthesia and Intensive Care]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:e67-e70. [PMID: 19186026 DOI: 10.1016/j.annfar.2008.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- C Dadure
- Département d'anesthésie-réanimation, CHU Lapeyronie, 375 avenue du Doyen-Gaston-Giraud, Montpellier cedex 5, France.
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Alves MMO, Carvalho PRA, Wagner MB, Castoldi A, Becker MM, Silva CC. Cross-validation of the Children's and Infants' Postoperative Pain Scale in Brazilian Children. Pain Pract 2008; 8:171-6. [DOI: 10.1111/j.1533-2500.2008.00192.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker S, Williams G. Postoperative pain. Paediatr Anaesth 2008; 18 Suppl 1:36-63. [PMID: 18471177 DOI: 10.1111/j.1460-9592.2008.02431.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Karaaslan K, Yilmaz F, Gulcu N, Sarpkaya A, Colak C, Kocoglu H. The effects of levobupivacaine versus levobupivacaine plus magnesium infiltration on postoperative analgesia and laryngospasm in pediatric tonsillectomy patients. Int J Pediatr Otorhinolaryngol 2008; 72:675-81. [PMID: 18325601 DOI: 10.1016/j.ijporl.2008.01.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Revised: 01/22/2008] [Accepted: 01/22/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether the addition of magnesium to levobupivacaine will decrease the postoperative analgesic requirement or not, and to investigate the possible preventive effects on laryngospasm. METHODS Seventy-five children undergoing elective tonsillectomy and/or adenoidectomy surgery. The drug was prepared as only NaCl 0.9% for the first group (Group S, n=25), levobupivacaine 0.25% for the second group (Group L, n=25), and levobupivacaine 0.25% plus magnesium sulphate 2mg/kg for the third group (Group M, n=25). Pain was recorded at 15th minute, 1st, 4th, 8th, 16th, and 24th hour postoperatively. Pain was evaluated using a modified Children's Hospital of Eastern Ontario pain scale (mCHEOPS). Incidence of postoperative nausea and vomiting (PONV) was assessed at various time intervals (0-2, 2-6, 6-24h) by numeric rank score. Patients were followed for laryngospasm for 1h in recovery room after extubation. Other complications appeared within 24h postoperatively were recorded. RESULTS All postoperative CHEOPS values were lower than control in both groups. Analgesic requirement was decreased significantly in both groups in comparison with control patients, but this requirement was significantly lower in Group M (p<0.05). Although laryngospasm was not observed in Group M, the difference between groups was not statistically significant. PONV was similar in both groups. CONCLUSIONS Levobupivacaine and Levobupivacaine plus magnesium infiltration decrease the post-tonsillectomy analgesic requirement. Insignificant preventive effect of low doses of magnesium infiltration on laryngospasm observed in this study needs to be clarified by larger series.
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Affiliation(s)
- Kazim Karaaslan
- Abant Izzet Baysal University, Faculty of Medicine, Department of Anesthesiology, Bolu, Turkey.
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Ingelmo P, Locatelli BG, Frawley G, Knottenbelt G, Favarato M, Spotti A, Fumagalli R. The optimum initial pediatric epidural bolus: a comparison of four local anesthetic solutions. Paediatr Anaesth 2007; 17:1166-75. [PMID: 17986035 DOI: 10.1111/j.1460-9592.2007.02327.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no consensus on the concentration or type of local anesthetic used for initiation of epidural anesthesia. The aim of this randomized, double-blind, controlled trial was to compare the clinical effectiveness of epidural administration of both levobupivacaine and bupivacaine in 0.2% and 0.25% concentrations in pediatric patients undergoing abdominal and urological surgery. METHODS One hundred and forty-one children scheduled for lower abdominal and urological surgery were randomized to receive 0.4-0.6 ml.kg(-1) epidural, 0.25% bupivacaine, 0.2% bupivacaine, 0.25% levobupivacaine or 0.2% levobupivacaine. Initial epidural volumes, onset times; hemodynamic consequences, postoperative pain scores and degree of residual postoperative motor block were all recorded. RESULTS There were no significant differences in the proportion of children with effective analgesia after incision [0.20% bupivacaine 97%, 0.25% bupivacaine 94%, 0.20% levobupivacaine 91%, 0.25% levobupivacaine 92% (P=0.73)] when a median volume of 0.55 ml.kg(-1) was used. There was no association between the volume used for thoracic, lumbar, or sacral epidural anesthesia and the effectiveness of the agents used. There was a significantly greater incidence of pain on awakening with the 0.2% solutions compared with the 0.25% solutions, but no differences in the incidence of residual motor block between groups. CONCLUSIONS While there is no difference in the proportion of effective surgical anesthesia, the lower incidence of pain and distress with the 0.25% solutions suggests that this concentration has clinical advantages over the 0.2% solutions for pediatric epidural anesthesia.
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Affiliation(s)
- Pablo Ingelmo
- Department of Anaesthesia and Intensive Care, A.O San Gerardo, Monza, Italy
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Abstract
PURPOSE OF REVIEW New topics in pediatric regional anesthesia are discussed. RECENT FINDINGS Continuous peripheral nerve blocks, new local anesthetics and the performance of regional blocks with ultrasonography guidance are summarized. SUMMARY Prolonged analgesia with continuous peripheral nerve blocks in the treatment of pediatric postoperative limb pain, sometimes with patient-controlled regional analgesia, should be preferred instead of continuous epidural analgesia. Levobupivacaine and ropivacaine display the same pharmacokinetic profile as racemic bupivacaine with less cardiac toxicity. Conversely, continuous infusion of these new local anesthetics offers the safest therapeutic index, especially in infants. Many adjuvants have been used, but clonidine offers clear advantages. Ultrasonography guidance blocks will probably become the reference technique for local anesthetics injection and regional anesthesia catheter placement; new training in this field should be available.
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Affiliation(s)
- Claude Ecoffey
- Service d'Anesthésie-Réanimation Chirurgicale 2, Université de Rennes 1, Hôpital Pontchaillou, Rennes, France.
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Ingelmo PM, Bendall EJ, Frawley G, Locatelli BG, Milan B, Lodetti D, Fumagalli R. Bupivacaine caudal epidural anesthesia: assessing the effect of general anesthetic technique on block onset. Paediatr Anaesth 2007; 17:255-62. [PMID: 17263741 DOI: 10.1111/j.1460-9592.2006.02090.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The primary objective of this prospective, randomized trial was to compare the effect of propofol and sevoflurane on effectiveness of regional anesthesia. As a secondary objective, we aimed at evaluating the influence of age on neuraxial block profile. METHODS One hundred and thirteen healthy children aged <10 years, scheduled for general or urological surgical procedures were randomly allocated to receive either propofol or sevoflurane induction and maintenance. Children received caudal or lumbar epidural block depending on their weight and expected surgery. Time to onset of surgical anesthesia, intraoperative analgesic effectiveness, residual motor blockade, postoperative pain, and adverse effects were evaluated. To assess the influence of age on these measures children were further divided into three age groups: 0-24, 25-60 and >60 months. RESULTS The mean time to onset of surgical anesthesia was significantly shorter in the sevoflurane group than the propofol group (3.1 vs 4.7 min, P < 0.01), independent of the type of regional technique employed. Distress on arousal in recovery was increased in children receiving sevoflurane (P = 0.03). There was no significant difference in residual motor blockade between the groups but children between 0 and 24 months receiving sevoflurane had a higher incidence of residual motor blockade 3 h after local anesthetic injection (P = 0.01). CONCLUSIONS This study has demonstrated that general anesthesia with sevoflurane decreases the time to onset of surgical anesthesia relative to propofol anesthesia. This effect was most marked when sevoflurane anesthesia preceded caudal epidural blockade. The basis for this effect is most likely to be related to differential binding of the two anesthetic agents to receptors in the spinal cord that mediate immobility in response to surgical stimuli.
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Affiliation(s)
- P M Ingelmo
- Department of Anaesthesia and Intensive Care, A.O. San Gerardo, Monza, Italy
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Schug SA, Saunders D, Kurowski I, Paech MJ. Neuraxial drug administration: a review of treatment options for anaesthesia and analgesia. CNS Drugs 2007; 20:917-33. [PMID: 17044729 DOI: 10.2165/00023210-200620110-00005] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Neuraxial drug administration describes techniques that deliver drugs in close proximity to the spinal cord, i.e. intrathecally into the CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion. This approach was initially developed in the form of spinal anaesthesia over 100 years ago. Since then, neuraxial drug administration has evolved and now includes a wide range of techniques to administer a large number of different drugs to provide anaesthesia, but also analgesia and treatment of spasticity in a variety of acute and chronic settings. This review concentrates on the pharmacological agents used and the clinical basis behind currently utilised approaches to neuraxial drug administration. With regard to local anaesthetics, the main focus is on the development of the enantiomer-specific compounds ropivacaine and levobupivacaine, which provide similar efficacy to bupivacaine with a reduced risk of severe cardiotoxicity. Opioids are the other group of drugs widely used neuraxially, in particular to provide analgesia alone or more commonly in combination with other agents. The physicochemical properties of the various opioids explain the main differences in efficacy and safety between these drugs when used intrathecally, of which morphine, fentanyl and sufentanil are most commonly used. Another group of drugs including clonidine, dexmedetomidine and epinephrine (adrenaline) provide neuraxial analgesia via alpha-adrenergic receptors and are used mainly as adjuvants to local anaesthetics and opioids. Furthermore, intrathecal baclofen is in routine clinical use to treat spasticity in a number of neurological conditions. Beside these established approaches, a wide range of other drugs have been assessed for neuraxial administration to provide analgesia; however, most are in various early stages of investigation and are not used routinely. These drugs include neostigmine, ketamine, midazolam and adenosine, and the conotoxin ziconotide. The latter is possibly the most unusual compound here; it has recently gained registration for intrathecal use in specific chronic pain conditions.
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Affiliation(s)
- Stephan A Schug
- Pharmacology Unit, School of Medicine and Pharmacology, UWA Anaesthesia, University of Western Australia, Perth, WA, Australia.
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Dadure C, Capdevila X. [Perioperative analgesia with continuous peripheral nerve blocks in children]. ACTA ACUST UNITED AC 2006; 26:136-44. [PMID: 17174518 DOI: 10.1016/j.annfar.2006.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 10/09/2006] [Indexed: 10/23/2022]
Abstract
Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.
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Affiliation(s)
- C Dadure
- Département d'anesthésie et de réanimation A, centre hospitalier universitaire Lapeyronie, 371, avenue du Doyen-Giraud, 34295 Montpellier, France
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Naja ZM, Raf M, El-Rajab M, Daoud N, Ziade FM, Al-Tannir MA, Lönnqvist PA. A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children. Anaesthesia 2006; 61:1064-8. [PMID: 17042844 DOI: 10.1111/j.1365-2044.2006.04833.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93%vs 69%) and surgeon satisfaction (93%vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.
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Affiliation(s)
- Z M Naja
- Department of Anaesthesia, Makassed General Hospital, Beirut, Lebanon
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Abstract
BACKGROUND Capsicum plaster at a classical Chinese acupoint is an alternative to acupuncture, which has been used as a supplemental therapy to opioid analgesics for pain control during the postoperative period. We investigated the postoperative analgesic efficacy of capsicum plaster at Zusanli (ST-36) points after pediatric hernia repair. METHODS This double-blind, sham-controlled study was designed in 108 children, aged 4 month to 9 year, undergoing unilateral hernia repair, and was randomly assigned to three treatment regimens: group Zusanli (Z)=capsicum plaster at Zusanli acupoints and placebo tape on the shoulder as a nonacupoint, group Sham (S)=capsicum plaster on the shoulders and placebo tape at Zusanli acupoints, and group control (C)=placebo tape at Zusanli acupoints and on the shoulder. The postoperative pain scores and analgesic requirements during 24 h postoperatively were assessed. RESULTS Total meperidine consumption was significantly lower in group Z (0.87+/-0.35 mg.kg-1) compared with group C (1.27+/-0.41 mg.kg-1) and S (1.22+/-0.45 mg.kg-1) (P<0.001). The pain scores on both the objective pain scale (OPS) and the Children Hospital of Ontario Pain Scale (CHEOPS), were significantly lower in group Z compared with the other groups at 6 and 24 h postoperatively, but not at the 10 min and 1 h postoperative time periods. CONCLUSIONS Placement of capsicum plaster at the Zusanli points reduces pain and postoperative opioid consumption in children undergoing inguinal hernia repair, but not in the first six postoperative hours.
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Affiliation(s)
- Kyo S Kim
- Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea.
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Ingelmo PM, Locatelli BG, Sonzogni V, Gattoni C, Cadisco A, Lorini M, Sora GN, Fumagalli R. Caudal 0.2% ropivacaine is less effective during surgery than 0.2% levobupivacaine and 0.2% bupivacaine: a double-blind, randomized, controlled trial. Paediatr Anaesth 2006; 16:955-61. [PMID: 16918658 DOI: 10.1111/j.1460-9592.2006.01903.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND We hypothesized that without the analgesic effects of volatile anesthetics, caudal 0.20% ropivacaine would be less effective during surgical stimulation than 0.20% bupivacaine or 0.20% levobupivacaine. This trial was designed to examine whether the combination of a caudal block with 0.20% ropivacaine and i.v. anesthesia resulted in reduced analgesic efficacy during surgery compared with caudal 0.20% levobupivacaine or 0.20% bupivacaine in children. METHODS Ninety ASA I-II children between 1 and 7 years old, scheduled for inguinal hernia repair or orchidopexy under propofol anesthesia were randomized to receive a caudal block with 1 ml x kg(-1) of 0.2% bupivacaine, 0.2% ropivacaine or 0.2% levobupivacaine. The primary outcome measure of the study was the clinical efficacy of the caudal block during surgery. Secondary outcome measures were postoperative pain relief and residual motor blockade. RESULTS Four children were excluded and 86 were analyzed. The proportion of children with effective caudal block during surgery was significantly higher in children receiving levobupivacaine (26/28) or bupivacaine (27/29) compared with patients receiving ropivacaine (21/29) (P = 0.03). There were no significant differences among groups in the analgesic onset time (P = 0.1), incidence of residual motor blockade (P = 0.4), number of patients requiring analgesia after operation or in the time from caudal injection to the first administration of analgesic medication (P = 0.3). CONCLUSIONS Combined with propofol anesthesia, 0.2% levobupivacaine and 0.2% bupivacaine are more effective than 0.2% ropivacaine for caudal use in children undergoing inguinal hernia repair or orchidopexy.
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Affiliation(s)
- Pablo M Ingelmo
- Anaesthesia and Intensive Care Department, Ospedali Riuniti di Bergamo, Bergamo, Italy.
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Frawley GP, Downie S, Huang GH. Levobupivacaine caudal anesthesia in children: a randomized double-blind comparison with bupivacaine. Paediatr Anaesth 2006; 16:754-60. [PMID: 16879518 DOI: 10.1111/j.1460-9592.2006.01841.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Levobupivacaine is the pure S-enantiomer of bupivacaine. Despite obvious benefits in the event of accidental intravascular injection there has been no studies demonstrating a clinically significant benefit to levobupivacaine over racemic bupivacaine for pediatric regional anesthesia. Given the similar pharmacokinetic profiles of both drugs the studies to date have been underpowered to demonstrate what is likely to be a small difference in clinical effectiveness. Our aim was to determine if there are significant differences in the clinical effectiveness of levobupivacaine compared with racemic bupivacaine for caudal anesthesia in children having lower abdominal surgery. A secondary aim was to determine if there are differences in the incidence of postoperative motor blockade between these agents. METHODS Three hundred and ten children ranging in age from 1 month to 10.75 years in age having lower abdominal surgery were enrolled. Patients were randomized in a double blind manner to receive a caudal block with either 0.25% bupivacaine (n = 152) or 0.25% levobupivacaine (n = 155) to a total volume of 1 ml x kg(-1). Motor blockade (modified Bromage scale) and postoperative pain or distress (FLACC behavioral scale for postoperative pain) were measured at predetermined time points during the subsequent 120 min. RESULTS There were no significant adverse effects attributable to levobupivacaine. Success rates were defined as a lack of hemodynamic response to first surgical incision and low postoperative pain scores. At a mean duration of 5 min between block completion and first incision success for 1 ml x kg(-1) of 0.25% bupivacaine was 91% and 94% for 0.25% levobupivacaine. Satisfactory postoperative analgesia was present in 98% of patients after bupivacaine caudal anesthesia and 97.5% for levobupivacaine. At 30 min following caudal anesthesia the incidence of postoperative motor block with racemic bupivacaine was 84% and decreased to 7% at 120 min. For levobupivacaine motor block at 30 min postcaudal was present in 85% and decreased to 11% at 120 min. CONCLUSIONS Levobupivacaine is an effective agent for caudal anesthesia in children at a recommended dose of 2.5 mg x kg(-1). The rapidity of onset was suitable for establishment of surgical anesthesia and postoperative analgesia was achieved in greater than 97.5% of patients. It appears to be of equivalent potency to racemic bupivacaine in children requiring lower abdominal surgery.
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Affiliation(s)
- Geoff P Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Children's Hospital, Flemington Road Parkville, Melbourne, Vic., Australia.
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Abstract
PURPOSE OF REVIEW Controversial topics in paediatric regional anaesthesia are discussed. RECENT FINDINGS The performance of blocks under general anaesthesia, new local anaesthetics, adjuvants, location techniques, and risks of masking compartment syndromes are contemplated. SUMMARY The performance of regional blocks in anaesthetized patients is generally contra-indicated in adults but accepted in children. Levobupivacaine displays the same pharmacokinetic profile as racemic bupivacaine with possibly less cardiac toxicity. Ropivacaine undergoes slower absorption and, in some studies, concomitant increase in peak plasma concentration in infants. Conversely, continuous infusion of ropivacaine offers the safest therapeutic index. Many adjuvants have been used but only epinephrine, clonidine, and preservative-free ketamine offer clear advantages. Midazolam and neostigmine are effective but have potential drawbacks and raise safety questions. Needle and catheter positioning is critical. Electrocardiogram guidance and electrical stimulation occasionally help identify the migration of epidural catheters. Stimulating catheters might be useful for continuous peripheral blockade. Ultrasonography will probably become the reference technique for peripheral catheter placement. Patients at risk of compartment syndrome must be monitored (measurement of compartmental pressures); adequate pain management does not 'hide' this complication but, on the contrary, can facilitate early diagnosis since the increase in requirement for pain medication precedes other clinical symptoms by an average of 7.3 h.
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Affiliation(s)
- Bernard Dalens
- Department of Anaesthesiology, Quebec Central University Hospital Sainte-Foy, Quebec, Canada.
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