Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study

Evaluation of USG-guided novel sacral erector spinae block for postoperative analgesia in pediatric patients undergoing hypospadias repair: A randomized controlled trial

Background and Aims

Erector spinae plane block (ESPB) has been found to be simple, safe, and effective at thoracic and lumbar levels. There is no randomized controlled trial evaluating its effectiveness at sacral level. The present study was conducted to evaluate its effectiveness at sacral level for postoperative analgesia in pediatric patients undergoing hypospadias repair.

Material and Methods

Forty children of 2-7 years with ASA grade I or II were included. They were randomly allocated to one of the two groups of 20 patients each. After induction of general anesthesia, patients of group I were given ultrasound-guided sacral ESPB with 1 ml/kg of 0.25% bupivacaine, and patients of group II were not given block. Postoperatively, pain was assessed using face, legs, activity, cry, consolability (FLACC) scale at 0 hour, every 15 min up to 1 hour, every half an hour up to 2 hours, 2 hourly up to 12 hours, and at 18th hour and 24th hour postoperatively. At FLACC score ≥4, rescue analgesia was given using 15 mg/kg paracetamol infusion. Primary objective was to compare postoperative analgesic (paracetamol) consumption, and secondary objective was time to first rescue analgesia.

Results

Mean postoperative paracetamol consumption was 360 ± 156.60 mg in group I and 997.50 ± 310.87 mg in group II (P = 0.001). Time to first rescue analgesia was 906 ± 224.51 min in group I and 205.00 ± 254.92 min in group II (P = 0.001).

Conclusion

Sacral ESPB has been found to be effective in reducing postoperative analgesic consumption in pediatric patients undergoing hypospadias repair.

Comparison of adjuvant pharmaceuticals for caudal block in pediatric lower abdominal and urological surgeries: A network meta-analysis

STUDY OBJECTIVE

Caudal block helps relieve pain after sub-umbilical surgery in pediatric patients; however, the duration for which it exerts its analgesic effect is limited. The addition of certain adjuvant agents to local anesthetics (LAs) that are used to administer caudal block can prolong postoperative analgesia. Therefore, we aimed to compare the efficiencies and side effects of caudal adjuvants in the settings of pediatric lower abdominal and urological surgeries.

DESIGN

A network meta-analysis (NMA).

PATIENTS

One hundred and twelve randomized controlled trials (RCTs) involving 6800 pediatric patients were included in the final analysis.

INTERVENTIONS

Different adjuvant agents, namely clonidine, dexamethasone, dexmedetomidine, fentanyl, ketamine, magnesium, midazolam, morphine, neostigmine, and tramadol.

MEASUREMENTS

The primary outcome was the duration of analgesia. The secondary outcomes included the requirement for additional analgesia, analgesic consumption, and postoperative complications. The effects and rankings were evaluated using NMA and the surface under the cumulative ranking curve scores, respectively.

RESULTS

Neostigmine, dexmedetomidine, and dexamethasone were found to be the three most effective adjuvants that prolong the duration of analgesia for caudal block, and these adjuvants extended this duration by 8.9 h (95% confidence interval [CI], 7.1-10.7), 7.3 h (95% CI, 6.0-8.6), and 5.9 h (95% CI, 4.0-7.7), respectively. Caudal neostigmine was associated with an increase in the incidence of postoperative nausea and vomiting, whereas dexmedetomidine and dexamethasone showed no postoperative complications.

CONCLUSIONS

This NMA provided evidence and suggested that dexmedetomidine and dexamethasone may be the most beneficial adjuvant pharmaceutics adding to LAs for caudal block in children. However, given the off-label status of caudal dexmedetomidine and dexamethasone, further high-quality RCTs are still warranted, especially to determine whether delayed neurological complications will occur.

Analgesic Efficacy of Adjuvant Medications in the Pediatric Caudal Block for Infraumbilical Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Various adjuvants are added to local anesthetics in caudal block to improve analgesia. The comparative analgesic effectiveness and relative rankings of these adjuvants are unknown. This network meta-analysis (NMA) sought to evaluate the comparative analgesic efficacy and relative ranking of caudal adjuvants added to local anesthetics (versus local anesthetics alone) in pediatric infra-umbilical surgery. We searched the United States National Library of Medicine database (MEDLINE), PubMed, and Excerpta Medica database (Embase) for randomized controlled trials (RCTs) comparing caudal adjuvants (clonidine, dexmedetomidine, ketamine, magnesium, morphine, fentanyl, tramadol, dexamethasone, and neostigmine) among themselves, or to no adjuvant (control). We performed a frequentist NMA and employed Cochrane's 'Risk of Bias' tool to evaluate study quality. We chose the duration of analgesia (defined as 'the time from caudal injection to the time of rescue analgesia') as our primary outcome. We also assessed the number of analgesic dose administrations and total dose of acetaminophen within 24 h. The duration of analgesia [87 randomized control trials (RCTs), 5285 patients] was most prolonged by neostigmine [mean difference: 513 min, (95% confidence interval, CI: 402, 625)]. Dexmedetomidine reduced the frequency of analgesic dose administrations within 24 h [29 RCTs, 1765 patients; -1.2 dose (95% CI: -1.6, -0.9)] and the total dose of acetaminophen within 24 h [18 RCTs, 1156 patients; -350 mg (95% CI: -467, -232)] the most.  Among caudal adjuvants, neostigmine (moderate certainty), tramadol (low certainty), and dexmedetomidine (low certainty) prolonged the duration of analgesia the most. Dexmedetomidine also reduced the analgesic frequency and consumption more than other caudal adjuvants (moderate certainty).

A Comparative Study of Tramadol and Clonidine as an Additive to Levobupivacaine in Caudal Block in Pediatric Patients Undergoing Perineal Surgeries

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.

A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial

Background

Medial sternotomy is commonly used in cardiac surgery, although it results in intense post-operative pain. The placement of a sternal wound catheter for the administration of local anesthetic represents an effective technique. An initial bolus of tramadol in the sternal wound catheter could potentiate the effect of the local anesthetic and decrease both the post-operative pain and the morphine consumption.

Patients and methods

We conducted a prospective, randomized, double-blind study at the University Hospital Center, Dijon, France. Patients requiring scheduled or non-extreme emergency surgery for valve disease, aorta disease, atrial myxoma, or coronary artery bypass graft via sternotomy were included. A sternal wound catheter was inserted at the end of the surgery. The patients were randomized to receive either a 2 mg/kg bolus of tramadol (n=80) or a placebo (n=80) in the wound catheter. The bolus administration was followed by a continuous infusion of 1.25% levobupivacaine for the first 48 hrs following surgery. The patients’ morphine consumption during the first 48 hrs after extubation was recorded. The other investigated variables were the patients’ rescue analgesia, arterial blood gasses, and length of stay in the intensive care unit and in hospital, as well as the incidence of chronic pain at the four-month follow-up point.

Results

The morphine consumption was found to be comparable in the two groups (38 mg vs 32 mg, p=0.102). No effect was found in terms of the arterial blood gasses, lengths of stay, or incidence of chronic pain.

Conclusion

The addition of tramadol to the local anesthetic delivered via a wound catheter following sternotomy did not reduce the patients’ post-operative morphine consumption.

Trial registration

Clinicaltrials.gov identifier: NCT02851394.

Caudal Anesthesia for Pediatric Subumbilical Surgery, Less Load on the Postoperative Recovery Unit

Introduction

Caudal epidural anesthesia, when used as a sole method for surgical anesthesia, has favorable effects on the recovery duration and the time spent in the recovery unit. In this study we made a retrospective analysis of pediatric surgery operations under local, regional and general anesthesia. We aimed to find shorter postoperative recovery times with local and regional anesthesia.

Materials and methods

Data of the pediatric patients undergone subumbilical surgery during the two-year period in Pediatric Surgery clinic were collected. The patients’ age, sex, surgery type, anesthesia and airway control routes, as well as duration of anesthesia, operation and recovery were obtained.

Results

Data of 937 patients were analyzed, of whom 811 (86.6%) were males. Caudal anesthesia was performed in 240 patients (25.6%) and the mean age of these patients was 3.83 ± 3.00 years. The patients with caudal and local anesthesia spent significantly less time in the postoperative recovery unit, compared with general anesthesia groups (P < 0.001).

Conclusion

Caudal anesthesia as a sole method for pediatric subumbilical surgery is a relatively safe method. Patients having operation under caudal anesthesia have faster discharge times from postoperative recovery units, compared with general anesthesia. This probably reduces recovery unit expenditures.

A study to compare caudal levobupivacaine, tramadol and a combination of both in paediatric inguinal hernia surgeries

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.

Comparison of analgesic efficacy of caudal dexmedetomidine versus caudal tramadol with ropivacaine in paediatric infraumbilical surgeries: A prospective, randomised, double-blinded clinical study

Background and Aims:

Caudal epidural analgesia is commonly practised regional block technique in children undergoing infraumbilical surgeries but has a short duration of action after single shot local anaesthetic injection. The aim of this study was to compare ropivacaine 0.25% with dexmedetomidine and tramadol in caudal anaesthesia in paediatric infraumbilical surgeries.

Methods:

In a randomised, prospective, double-blinded study, sixty children (1–8 years) belonging to American Society of Anesthesiologists’ physical status I or II scheduled for infraumbilical surgeries were included. They were randomly assigned into two groups: Group ropivacaine with tramadol (RT) (n = 30) received 0.25% ropivacaine 1 mL/kg with 2 mg/kg of tramadol, and Group ropivacaine with dexmedetomidine (RD) (n = 30) received 0.25% ropivacaine 1 mL/kg with dexmedetomidine 2 μg/kg. The primary outcome variable was the duration of analgesia, and the secondary outcome variables included motor block, sedation score, time from caudal block to skin incision, emergence time and adverse effects.

Results:

The mean duration of analgesia was 654.20 ± 78.38 min in Group RT, while in Group RD, it was 780.29 ± 71.21 min (P = 0.0001). The difference between the mean sedation score and mean emergence time between the two groups were statistically significant (P = 0.0001 and 0.0411, respectively). No significant difference was observed in the incidence of haemodynamic changes or side effects.

Conclusion:

Caudal dexmedetomidine with ropivacaine prolongs post-operative analgesia compared to caudal tramadol with ropivacaine.

Dose effect of local anesthetics on analgesic outcomes for the transversus abdominis plane (TAP) block in children: a randomized, double-blinded, clinical trial

BACKGROUND

Current knowledge on local anesthetic dosage for the TAP block in pediatric patients is very limited.

OBJECTIVE

To evaluate the effect of two escalating local anesthetic doses on postsurgical analgesic outcomes in children receiving a TAP block.

METHODS

The study was a prospective, randomized, double-blinded, clinical trial. Children (<8 years) were randomized to one of the two intervention groups: TAP block with bupivacaine at a dose of 2.5 mg · kg(-1) or 1.25 mg · kg(-1). Analgesic outcomes included pain scores in the postanesthesia care unit (PACU), time to analgesic requirement and total number of analgesic requirements.

RESULTS

Thirty-six patients were recruited in the study. Pain scores in PACU were not different between study groups. The total number of analgesic dosage required in 24 h after surgery was higher in the lower dose group, median (IQR) of 4 (3 to 5) compared to 2.5 (1.5 to 3) in the greater dose group, P = 0.03. There was a clinically but not statistically significant difference in the time to first analgesic requirement in the 2.5 mg · kg(-1) group, median (IQR) of 248 (130 to 367) minutes compared to 146 (95 to 261) minutes in the 1.25 mg · kg(-1) dose group, P = 0.15.

CONCLUSIONS

The use of higher local anesthetic doses for the TAP block in children does not provide benefits on early pain scores but seems to improve analgesic duration and decrease the need for additional analgesics over 24 h after surgery. The use of higher, but yet safe, local anesthetic dosages for TAP blocks is a viable strategy to improve analgesia in children.

Analgesic effect and adverse events of dexmedetomidine as additive for pediatric caudal anesthesia: a meta-analysis

BACKGROUND

Dexmedetomidine has become a popular additive for regional anesthesia. Aim of this meta-analysis was to assess the effect of this additive on the duration of postoperative analgesia and possible adverse events in pediatrics undergoing orchidopexy or lower abdominal surgery.

METHODS

The literature databases of PubMed, Google Scholar, and Cochrane Library were searched for randomized, controlled trials (RCTs). Odds ratio (OR), weighted mean difference (WMD), and the corresponding 95% confidence intervals (CIs) were calculated using the RevMan software, version 5.2, for data synthesis and statistical analysis, which in accordance with the PRISMA statement.

RESULTS

Six RCTs were selected for this meta-analysis, involving a total of 328 pediatric patients. There was a significant longer duration of caudal analgesia (time to first analgesic requirements) in patients receiving dexmedetomidine with CA compared with CA alone (WMD: -8.21 h; 95% CI: -11.40 to -5.02; P < 0.00001). Side effects in these two groups were comparable (OR: 1.02; 95% CI: 0.51-2.04; P = 0.95). Subgroup analysis indicated there was no significant difference in hemodynamic changes during operation (WMD: 1.78; 95% CI: -3.20 to 6.77; P = 0.48) and the emergence time (time from the end of surgery to opening the eyes on calling) after surgery (WMD: 0.47 min; 95% CI: -5.27 to 6.22; P = 0.87).

CONCLUSIONS

Dexmedetomidine as an additive to local anesthetic provides a significantly longer postoperative analgesia with comparable adverse effects and hemodynamic changes, when compared to local anesthetics alone. There were insufficient data of the effects of different concentrations of dexmedetomidine; further studies are required to explore this issue.

Bayesian enhanced meta-analysis of post-operative analgesic efficacy of additives for caudal analgesia in children

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.

Comparison of epidural tramadol-ropivacaine and fentanyl-ropivacaine for labor analgesia: a prospective randomized study

BACKGROUND

To test the hypothesis that 5 mg/mL tramadol is superior to 3 ?g/mL fentanyl when combined with 0.125% ropivacaine in parturients undergoing labor during epidural analgesia.

METHODS

Sixty-one parturients undergoing labor selected for delivery with epidural analgesia were randomized into two groups: Group tramadol (0.125% ropivacaine plus tramadol 5 mg/mL) and Group fentanyl (0.125% ropivacaine plus fentanyl 3 ug/mL). Hemodynamics, rate of cesarean delivery, sensory block level, Bromage motor scale scores, instrument-assisted delivery, oxytocin use, visual analog scale (VAS) scores, Apgar scores, umbilical cord artery gas analysis, and maternal side-effects including nausea, vomiting, pruritus, urinary retention, shivering, hypotension, and respiratory depression were recorded.

RESULTS

The two groups had no significant differences with respect to maternal hemodynamics, neonatal heart rate, VAS scores, rate of cesarean delivery, sensory block level, Bromage motor scale scores, instrument-assisted delivery, oxytocin use, hypotension, nausea, vomiting, and respiratory depression (p > 0.05). The incidence of pruritus, shivering, and urinary retention were more commonly observed in Group fentanyl despite there was no significant difference between the two groups. Umbilical artery pH was significantly lower while PCO(2) was higher in Group fentanyl than Group tramadol (p = 0.003 and p = 0.026, respectively). Birth-weight, umbilical artery PO(2) and base deficit, and Apgar scores at 1 and 5 min were comparable between the two groups (p > 0.05).

CONCLUSIONS

Our observations suggest that tramadol seems to be a safe alternative to fentanyl for labor analgesia due to its similar analgesic efficacy.

Pharmacotherapy for acute pain in children: current practice and recent advances

INTRODUCTION

Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach.

AREAS COVERED

Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010.

EXPERT OPINION

A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.

Efficacy of bupivacaine-neostigmine and bupivacaine-tramadol in caudal block in pediatric inguinal herniorrhaphy

BACKGROUND

Limited duration of analgesia is among the limitations of single caudal injection with local anesthetics. Therefore, the purpose of this study was to evaluate the effectiveness and safety of bupivacaine in combination with either neostigmine or tramadol for caudal block in children undergoing inguinal herniorrhaphy.

METHODS

In a double-blinded randomized trial, sixty children undergoing inguinal herniorrhaphy were enrolled to receive a caudal block with either 0.25% bupivacaine (1 ml x kg(-1)) with neostigmine (2 microg x kg(-1)) (group BN) or tramadol (1 mg x kg(-1)) (group BT). Hemodynamic variables, pain and sedation scores, additional analgesic requirements, and side effects were compared between two groups.

RESULTS

Duration of analgesia was longer in group BT (17.30 +/- 8.24 h) compared with group BN (13.98 +/- 10.03 h) (P = 0.03). Total consumption of rescue analgesic was significantly lower in group BT compared with group BN (P = 0.04). There were no significant differences in heart rate, mean arterial pressure, and oxygen saturation between groups. Adverse effects excluding the vomiting were not observed in any patients.

CONCLUSION

In conclusion, tramadol (1 mg x kg(-1)) compared with neostigmine (2 microg x kg(-1)) might provide both prolonged duration of analgesia and extended time to first analgesic in caudal block.