Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block

Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis

Background

Caudal block is a well-established technique for providing perioperative analgesia in pediatric genitourinary surgery, but abdominal wall blocks such as ilioinguinal–iliohypogastric (II-IH) and transversus abdominis plane (TAP) block are increasingly being used.

Methods

Our protocol for this meta-analysis was registered on PROSPERO (CRD42020163497). Central, CINAHL, Embase, Global Health, LILACS, MEDLINE, Scopus and Web of Science were searched from inception to 11 December 2019 for randomized controlled trials that included pediatric patients having genitourinary surgery with II-IH or TAP block as the intervention and caudal analgesia as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenzel method.

Results

In all, 23 trials with 1399 patients were included. II-IH and TAP block were similar to caudal analgesia in the coprimary outcomes of the postoperative pain score at 0–2 hours (high-quality evidence) and the need for in-hospital rescue analgesia (moderate-quality evidence consequent to downgrading by publication bias). No subgroup differences in regard to the type of abdominal wall block or the method of block localization were demonstrated for these primary outcomes. Relative to caudal analgesia, II-IH and TAP block reduced the incidence of postoperative motor blockade and the time to micturition.

Conclusions

This meta-analysis was limited by unclear risk of selection and performance biases and significant heterogeneity. In summary, II-IH and TAP block are a non-invasive and reasonable alternative to caudal analgesia in pediatric genitourinary surgery.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

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 systematic review and meta-analysis of caudal block as compared to noncaudal regional techniques for inguinal surgeries in children

This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE, EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from 1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively. Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99], P = 0.04) and late (RR = 0.81 [0.69, 0.96], P = 0.01) periods, but with a significant risk of motor block and urinary retention. According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound translates into better clinical success with the inguinal nerve blocks.

The effects of single-dose rectal midazolam application on postoperative recovery, sedation, and analgesia in children given caudal anesthesia plus bupivacaine

BACKGROUND

This study aimed to compare the effects of rectal midazolam addition after applying bupivacaine and caudal anesthesia on postoperative analgesia time, the need for additional analgesics, postoperative recovery, and sedation and to find out its adverse effects in children having lower abdominal surgery.

METHODS

40 children between 2 and 10 years of ASA I-II were randomized, and they received caudal anesthesia under general anesthesia. Patients underwent the application of caudal block in addition to saline and 1 mL/kg bupivacaine 0.25%. In the postoperative period, Group C (n = 20) was given 5 mL saline, and Group M (n = 20) was given 0.30 mg/kg rectal midazolam diluted with 5 mL saline. Sedation scale and postoperative pain scale (CHIPPS) of the patients were evaluated. The patients were observed for their analgesic need, first analgesic time, and adverse effects for 24 hours.

RESULTS

Demographic and hemodynamic data of the two groups did not differ. Postoperative sedation scores in both groups were significantly lower compared with the preoperative period. There was no significant difference between the groups in terms of sedation and sufficient analgesia.

CONCLUSIONS

We conclude that caudal anesthesia provided sufficient analgesia in peroperative and postoperative periods, and rectal midazolam addition did not create any differences. This trial is registered with ClinicalTrials.gov NCT02127489.

Improved outcomes in paediatric anaesthesia: contributing factors

PURPOSE

To discuss developments in paediatric anaesthesia and explore the factors which have contributed to improved anaesthetic-related patient outcomes.

METHODS

Narrative review of findings in the literature retrieved from MEDLINE/Pubmed and manual search.

RESULTS

Adverse perioperative outcomes related to anaesthesia have been extensively debated over the past few decades, with studies implicating factors such as major human error and equipment failure. Case series and event registries have enlightened physicians on sources of error and patient risk factors such as extremes of age, comorbidity and emergent circumstances. Anaesthetic-related deaths in children fell from 6.4 per 10,000 anaesthetics in the early 1950s to as low as 0.1 per 10,000 anaesthetics by the end of the century. Advances in anaesthetic agents, techniques, monitoring technologies and training programmes in paediatric anaesthesia play a vital role in driving this downward trend.

CONCLUSION

Despite substantial progress, there is still much room for improvement in areas such as adverse-event reporting, anaesthetic-related risk and late neurocognitive outcomes. Systematic reviews comparing paediatric patient outcomes after neuroaxial block versus general anaesthesia are currently unavailable. The future of paediatric anaesthesia will most likely be influenced by much-needed large prospective studies, which can provide further insight into patient safety and service delivery.

Pediatric regional anesthesia: abdominal wall blocks

Abdominal wall blocks are an effective regional anesthetic technique to provide sufficient analgesia in abdominal surgery. This article reviews the use of abdominal wall blocks in pediatric regional anesthesia.

Elective orchidopexy in the paediatric population: a trial of intra-operative spermatic cord block

It is well established that pre-emptive and multimodal analgesia improve pain control and decrease narcotic use as well as the length of stay. Whilst some form of local anaesthetic (LA) block is almost routine for most inguinal procedures in children, the best modality is uncertain for orchidopexy. We sought to explore as to whether the addition of spermatic cord block (SCB) to our standard ilio-inguinal block (IIB) in this situation had any impact on analgesic requirements post-operatively. A retrospective review of a single surgeon and single centre experience of LA block for elective orchidopexy is described for a 9-year period. In the first half of the study, the LA technique was an IIB. An SCB was added to the IIB in the second half using the same total dose of 0.8 ml/kg bupivacaine. In the entire group, 35% of the SCB + IIB boys required narcotics as compared to 56% with IIB alone (p > 0.05). On subgroup analysis of a "medium risk" procedure (i.e. inguinal approach for a superficial pouch testis) only 35% required narcotics in the SCB + IIB group as compared to 70% in the IIB (p < 0.05). Use of a SCB + IIB in elective orchidopexy in a paediatric population has additional benefit to IIB alone.

Does adding intravenous fentanyl to caudal block in children enhance the efficacy of multimodal analgesia as reflected in the plasma level of catecholamines?

BACKGROUND AND OBJECTIVE

Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children.

METHODS

Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 microg kg(-1) (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T(0)), at the end of surgery (T(1)) and when the children were fully awake in the postanaesthesia care unit (T(2)).

RESULTS

There was a significant reduction in the catecholamine levels in the two groups when (T(1)) and (T(2)) were compared with T(0). When plasma epinephrine levels (at T(0), T(1) and T(2)) between the two groups were compared, a statistically significant reduction at T(2) was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T(0), T(1) and T(2)).

CONCLUSION

These findings suggest that the multimodal analgesic approach of adding i.v. low-dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.

Epidural anaesthesia and analgesia for surgery: still going strong?

PURPOSE OF REVIEW

The discussion on the value of epidural anaesthesia and analgesia for surgery is fuelled by current controversies regarding effects on postoperative morbidity and mortality, potential benefits for outcome and the fear of rare, but catastrophic neurological complications. This review of the most recent publications on the topic since April 2002 illustrates some of the aspects contributing to the ongoing discussion.

RECENT FINDINGS

In contradiction to previous meta-analyses, recent trials could not demonstrate significant improvements of overall morbidity or mortality by epidural anaesthesia and analgesia. However, the technique was shown again to provide superior analgesia and a reduction of perioperative stress response and respiratory complications. Analysis of the current literature strongly supports that epidural anaesthesia and analgesia remains a safe practice with a low rate of severe complications, in particular in paediatric surgery. Several developments in equipment, techniques and especially drugs have been reported, resulting in improved balanced anaesthesia and analgesia and contributing to the safety of this technique.

SUMMARY

In an era of evidence-based medicine, further meta-analyses and well-planned large randomized trials have to address the controversial issues of epidural anaesthesia and analgesia and postoperative outcome. In the context of a more holistic 'rehabilitative' management of the perioperative period, this technique might well represent a key factor to improve outcome, reduce hospital stay and thereby healthcare costs. Recent innovations and developments in techniques and drugs as well as established guidelines should further minimize potential errors and harmful complications.

A pilot study of the rectus sheath block for pain control after umbilical hernia repair

BACKGROUND

Umbilical hernia repair, a common day surgery procedure in children, is associated with significant postoperative discomfort. The rectus sheath block may offer improved pain management following umbilical hernia repair. In this pilot study, we compared the efficacy of the rectus sheath block with that of our current standard practice--local anesthetic infiltration into the surgical wound--for pain control after umbilical hernia repair in children.

METHODS

Fourteen children, aged 1-8 years, undergoing umbilical hernia repair were randomly assigned to receive either a rectus sheath block or local anesthetic infiltration into the surgical wound at completion of surgery. Anesthetic management was standardized. Each analgesic technique was performed using 0.8 ml x kg(-1) of 0.25% bupivacaine with epinephrine 1:200,000. Postoperatively, an investigator who was blinded to the analgesic technique recorded the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores and sedation scores every 10 min, and administered intravenous morphine 50 microg x kg(-1) for cases with CHEOPS scores > or = 8. Total morphine dose was recorded. Parents were telephoned the day after surgery to determine the overall satisfaction with pain control.

RESULTS

Total postoperative morphine consumption did not differ significantly between groups, averaging 0.10 +/- 0.09 and 0.10 +/- 0.07 mg x kg(-1) for the local infiltration and rectus sheath groups, respectively. There were no significant differences in pain or sedation scores, and no complications related to either analgesic technique.

DISCUSSION

Our results suggest that the rectus sheath block has no advantage over infiltration of local anesthetic into the surgical wound for postoperative pain management in children undergoing umbilical hernia repair.

The efficacy of caudal morphine or bupivacaine combined with general anesthesia on postoperative pain and neuroendocrine stress response in children

BACKGROUND

The aim of this study was to compare the effectiveness of caudal morphine and bupivacaine usage on surgical stress response in children undergoing abdominal and genitourinary surgery while keeping anesthesia depth constant utilizing the bispectral index analysis (BIS).

METHODS

Following the approval of Institutional Review Board and informed parental consent, 28 children with ages ranging between 4 and 16 years with ASA physical status I and II , undergoing elective lower abdominal and genitourinary surgery were included in this study. Patients were randomized and separated into two subgroups. Before induction of anesthesia, patients were monitored for BIS. Epidural injection of 30 microg.kg(-1) morphine in 1 ml.kg(-1) saline for the first group (group M) and the same volume of (0.25%) bupivacaine for second group (group B) were administered via the sacral hiatus. We analyzed serum cortisol and glucose concentrations for evaluation of the stress response in the patients. Blood samples for cortisol and glucose were withdrawn at the beginning of induction (first samples), 40 min after surgical incision (second samples), and 40 min after end of the surgery (third samples). BIS scores of the patients were kept between 40 and 60 during the surgical procedure.

RESULTS

Group B had significantly lower levels of cortisol than group M in the second samples. There was a significant increase in serum glucose level in group M compared with group B during the intraoperative and postoperative periods.

CONCLUSIONS

We conclude that, caudal administration of bupivacaine is more effective than morphine for attenuating intraoperative and postoperative stress response to surgery in children.

Clonidine administered as adjuvant for bupivacaine in ilioinguinal-iliohypogastric nerve block does not prolong postoperative analgesia

BACKGROUND

Coadministration of clonidine with local anesthetics is associated with improvement of the quality of peripheral nerve block and significant prolongation of postoperative analgesia. Better analgesia has been reported with clonidine in ilioinguinal nerve block compared with caudal use. The object of this study was to determine whether adding of 1 microg.kg(-1) clonidine to bupivacaine 0.25% in ilioinguinal-iliohypogastric nerve block prolongs postoperative analgesia in children.

METHODS

Ninety-eight children ASA I-II aged between 1 and 12 years, scheduled for elective outpatient herniorrhaphy or orchidopexy were randomly allocated to receive an ilioinguinal-iliohypogastric nerve block either with 0.3 ml.kg(-1) bupivacaine 0.25% plus 1 microg.kg(-1) clonidine or only bupivacaine. Postoperative analgesic needs, time to the first analgesic supplementation and sedation score were assessed in hospital for 6 h postoperatively and at home by telephone call.

RESULTS

Demographic data were similar in both groups. There was no statistical difference in the rate of rescue analgesia between the two groups during the first six postoperative hours (20.4% group clonidine vs 30.6% group no clonidine) (P = 0.17). A slight decrease in systolic blood pressure during surgery was reported in the clonidine group. There was no difference in the scores of sedation between the two groups. At home, 10 patients in the clonidine group and nine patients in the nonclonidine group received analgesic medication. There was no difference between the two groups regarding the number of patients receiving analgesic rescue during the first 24 h (log rank = 0.39). Parental satisfaction was high in both groups.

CONCLUSIONS

Our study failed to demonstrate any advantage in addition of 1 microg.kg(-1) clonidine to 0.25% bupivacaine for ilioinguinal-iliohypogastric nerve block compared with bupivacaine 0.25% alone.

Neuraxial blocks for anaesthesia and analgesia in children

PURPOSE OF REVIEW

The use of regional techniques in paediatric anaesthesia has increased dramatically. Our aim is to produce a comprehensive review of the recent literature on neuraxial blockade in infants and children, focusing on three topics: choice of local anaesthetic and adjunct drugs, technical aspects and complications.

RECENT FINDINGS

The current literature shows a trend towards using the single isomers (levobupivacaine or ropivacaine) rather than racemic bupivacaine. In addition, opioids as adjuncts are being challenged by clonidine and ketamine, which have more benign side effects. The spread of radiopaque dye within the epidural space (which may mimic that of local anaesthetic solutions) appears to be highly variable, although distribution is related to the volume injected. Recent techniques (e.g. ultrasound or stimulating catheters) have been developed to accurately identify the position of epidural catheters. In contrast to adults, neuraxial blockade using local anaesthetic solutions is associated with stable cardiovascular variables, even in children with congenital heart disease. Although the incidence of complications associated with paediatric neuraxial blockade is low, the potential risks must always be considered.

SUMMARY

It is likely that the use of epidural ketamine or clonidine as adjuncts to local anaesthetics will grow. Alternatives, such as midazolam, may offer advantages in particular circumstances, although rigorous evaluation of the safety of these solutions when injected along the neuraxis and the development of formulations without preservatives are needed. The use of stimulating caudal catheters or ultrasound-guided techniques appears to offer promising options for the future to more accurately position catheters.