A comparative study of levobupivacaine alone and in combination with dexamethasone in caudal block for pediatric patient undergoing infraumbilical surgeries

Background: The caudal epidural block is one of the most commonly used regional techniques for post-operative pain management in pediatric age group patients undergoing infraumbilical surgeries. Adjuvants use increases the duration of analgesia and decrease local anesthetic dose requirement so decreasing the risk of toxicity. Aims and Objectives: The aim of present study was to evaluate and compare the efficacy of caudal block with 0.25% levobupivacaine 1 mL/kg and 0.25% levobupivacaine 1 mL/kg+dexamethasone 0.1 mg/kg for post-operative pain relief in pediatric patients undergoing infraumbilical surgeries. The secondary objective of the study was to compare hemodynamic parameters and side effects if any. Materials and Methods: A prospective, randomized, comparative, and double-blind study design was conducted in 60 patients in JAH super specialty group of hospitals. All patients belonging to physical status of American Society of Anesthesiologists Grade I and II, aged 1–6 years, were randomly allocated into two groups: Group 1 (n=30) received levobupivacaine 0.25% 1 mL/kg in 0.5 mL saline and Group 2 (n=30) received levobupivacaine 0.25% 1 ml/kg with dexamethasone 0.1 mg/kg for caudal block in pediatric patients undergoing infraumbilical surgeries. Primary outcome was duration of analgesia using face, legs, activity, cry, and consolability scale at interval of 0, 15, 30, 60, 90, 120, 150, and 180 min postoperatively. The secondary outcome of study included hemodynamic parameters and adverse events during the post-operative period. Results: The mean duration of analgesia in Group 1 (L) was 430.77±16.71 min and in Group 2 (L+D) was 805.00±36.71 min with statistically significant result. Conclusion: On adding dexamethasone to levobupivacaine in caudal block significantly prolongs duration of analgesia in post-operative period. It also provides more hemodynamic stability during intraoperative and post-operative period and associated with minimal side effects

Analgesic effects of caudal dexmedetomidine versus midazolam combined with bupivacaine on postoperative pain following paediatric infraumbilical surgeries

Background: There is continued search for an ideal adjuvant necessitated by the limited duration of singleshot caudal block. The study aimed to compare the analgesic effects of caudal 1.5 µg/kg dexmedetomidine versus 50 µg/kg midazolam combined with 0.20% bupivacaine in children.Methods: Following ethical approval and parental consent, 66 American Society of Anesthesiologists (ASA) class I or II children aged 1-6 years were randomized into three groups (A, B, and C) of 22 each. All patients had laryngeal mask airway (LMA) general anaesthesia induced with propofol and maintained with isoflurane in 100% oxygen. Group A received 1 ml/kg 0.20% bupivacaine and 1.5 µg/kg dexmedetomidine (1 ml), B received 1 ml/kg 0.20% bupivacaine plus 50 µg/kg midazolam (1 ml) while C received 1 ml/kg 0.20% bupivacaine and 0.9% normal saline (1 ml), via the caudal space. Pain was assessed using the face, leg, arm, cry, consolability (FLACC) scale. The time to first analgesic request, (TTFAR) was defined as the period from caudal injection to pain score of ≥4. Analgesic was given when FLACC score was ≥4.Results: All 66 children completed the study. The TTFAR was longest in group A (14.4±2.36), followed by group B (12.0±3.69), and shortest in group C (5.6±1.45), p=0.01, with greatest 24 hours analgesic consumption in group C, p=0.01.Conclusions: Caudal dexmedetomidine or midazolam combined with bupivacaine significantly prolonged the analgesic duration, with superiority of dexmedetomidine over midazolam group in analgesic profile

Comparison of adding neostigmine and fentanyl to bupivacaine in caudal analgesia in pediatric inguinal herniorrhaphy

AbstractObjective: The aim of the present trial was to compare efficacy and adverse effects of neostigmine against fentanyl when used as adjuvant to bupivacaine in caudal anesthesia.Method: A total of 140 children, aged 1-6 year scheduled to elective herniorrhaphy, were enrolled. Exclusion criteria were sacral area infection, history of allergic reactions to local anesthetics, bleeding tendency, neurological or spinal disease and lack of parent consent. Patients were assigned, using permuted block randomization method, into four groups of 35. Children in the first group received a caudal injection of 0.5 ml/kg bupivacaine 0.25% plus fentanyl 1µ/kg. The second group received 0.5 ml/kg bupivacaine 0.25% plus neostigmine 1µ/kg. Patients in the third group received 0.5 ml/kg bupivacaine 0.25% plus combination of fentanyl 1µ/kg and neostigmine 1µ/kg, and those in the fourth group only received 0.5 ml/kg bupivacaine 0.25% concentration. To assess pain intensity, Wong-Baker Scale was used. Time to first analgesic request and the dosage of analgesic agent was recorded. Data were analyzed using SPSS 17.0.Results:Significant differences were observed among groups in terms of number of patients needing analgesic (p=0.01), time to first analgesic request (p=0.005) and analgesic dose. (p=0.05) The lowest number of requests for analgesia, lowest dose of pethidine and longest time to first analgesic request were in patients receiving combination of bupivacaine, neostigmine and fentanyl.Conclusion: The present study shows that the combination of fentanyl and neostigmine, could prolong duration of analgesia, and decrease severity of pain when added to bupivacain

Comparison of Analgesic Effect of Dexmedetomidine versus Tramadol as Adjuvants to Caudal Ropivacaine in Infraumbilical Surgeries among Pediatric Patients: A Randomized Double Blind Interventional Study

Objective: To compare the postoperative analgesic effects of 0.2% ropivacaine with Dexmedetomidine (2 g/kg) and tramadol (2 mg/kg) among pediatric patients undergoing infra umbilical surgery. Material and Methods: This hospital based, randomized double blind interventional study included 60 pediatric patients, aged 1–7 years, having American Society of Anaesthesiology grade I and II, weighing 7-25 kg, and undergoing infraumbilical surgeries under general anesthesia. Subjects were randomly allocated into two groups to receive either: 2 mcg/ kg of Dexmedetomidine or 2 mg/kg of Tramadol, as adjuvant to 0.2% of Ropivacaine. Pain intensity was assessed using the pediatric observational Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) score. Rescue analgesia was given, when the CHEOPS score was ≥6. Duration of analgesia was defined as: the time period between administrations of block until rescue analgesia was given. Level of sedation was assessed by the Ramsay sedation score. Results: Kaplan Meier analysis showed that the median time to first rescue analgesia (duration of analgesia) was significantly (p-value<0.001) prolonged with Dexmedetomidine (780 minutes; 95% CI: 760.68–799.32 minutes) as compared to Tramadol (648 minutes; 95% CI: 635.92–660.38 minutes). Mean emergence time and duration of sedation were also significantly prolonged with Dexmedetomidine as compared to Tramadol. Conclusion: In pediatric patients undergoing infraumbilical surgeries, Dexmedetomidine as adjuvant to Ropivacaine provides an advantage of longer post-operative analgesia and lack of opioid related adverse events associated with Tramadol

Epidural bupivacaine combined with dexmedetomidine or clonidine in infraumbilical surgeries: a comparative evaluation

Background: Alpha-2 agonist are being extensively evaluated as an alternative to neuraxial opoids, as an adjuvants in regional anaesthesia The faster onset of action of local anaesthetics, rapid establishment of both sensory and motor blockade, prolonged duration of analgesia into postoperative period, dose sparing action of local anaesthetics and stable cardiovascular parameters make these agents a very effective adjuvant in regional anaesthesia.Methods: Our study had 45 patients, all patients belonged to ASA Grade-I or II, between 20 and 55 years of age with an average height of 150 and 170 cm and have ideal body weight requiring neuraxial blockade for lower abdominal surgeries. All the patients were randomly allocated into two groups Group-I: Epidural bupivacaine 0.5% (16 ml) + clonidine 75 µgm (1 ml) Group-II: Epidural bupivacaine 0.5 % (16 ml) + Dexmedetomidine 50 µgm (1 ml) Patients were monitored for sensory and motor blockade, hemodynamic parameters, rescue analgesia, sedation and adverse effects in perioperative period.Results: The time of onset of sensory block at T10 and time to reach maximum sensory block (T6) in group-I was significantly longer as compared to group-II. The complete motor blockade (grade-3) was achieved much later and time taken for recovery to grade-0 was significantly shorter in group-I. The time for rescue analgesia in group-I was significantly shorter as compared to group-II. Hypotension was the most common side effect in both the groups. Dry mouth is a known side effect of alpha-2 agonists. Epidural dexmedetomidine produced profound sedation.  Conclusions: We conclude from this study that dexmedetomidine is a better adjuvant than clonidine for providing early onset of sensory analgesia, superior sedative properties and prolonged post-operative analgesia.

Prospective Randomized Control study on effect of Adding Dexmedetomidine to Caudal Bupivacaine for Postoperative Analgesia in Children

SUMMARY: This study was conducted to evaluate the efficacy of dexmedetomidine as an adjuvant to Bupivacaine in caudal analgesia for paediatric patients undergoing lower abdominal surgeries. The following observations were made - Duration of analgesia was higher in bupivacaine with dexmedetomidine (307 minutes)group when compared to the bupivacaine group(682 mins), which was statistically significant. - FLACC scores for analgesic assessment was better in the bupivacaine with dexmedetomidine group when compared to bupivacaine group which was statistically significant. FLACC score less than 4 was seen for upto 8 hours in the group BD than group B which was upto 4 hours. - Sedation score as assessed by Ramsay’s sedation score was better with the bupivacaine with dexmedetomidine group when compared to the bupivacaine group which was statistically significant. - Hemodynamic changes were minimal and manageable in both the groups. CONCLUSION: We conclude that addition of Dexmedetomidine as an adjuvant to Bupivacaine provides prolonged analgesia and better quality of sedation with minimal hemodynamic changes when compared to Bupivacaine in caudal block for paediatric patients undergoing lower abdominal surgeries

A Comparative Clinical study of 0.25% Bupivacaine with Dexmedetomidine and 0.2% Ropivacaine with Dexmedetomidine in Paediatric Caudal Block or Infra Umbilical Surgeries: A study of 60 cases

BACKGROUND: Caudal epidural block is one of the most popularly used regional techniques in pediatric patients. Various drugs in different concentrations have been used for the technique. Local anesthetic like Ropivacaine produces differential neuraxial blockade with less motor block and reduced cardiovascular toxicity. To increase the duration of action of local anesthetics and thereby analgesia extending to the post-operative period, various adjuvants like Dexmedetomidine, α2 agonist has been used. Lower concentration of local anesthetics can be used for the procedure as motor blockade is not much required. Hence we have compared Bupivacaine 0.25% combined with 1μg/kg of Dexmedetomidine and Ropivacaine 0.2% combined with 1μg/kg Dexmedetomidine at a volume of 1ml/kg in children undergoing infra umbilical surgeries. AIMS AND OBJECTIVES: To assess the safety, efficacy, onset and duration of analgesia of 0.25% Bupivacaine and 0.2% Ropivacaine when equal volumes of Dexmedetomidine is added as an adjuvant in pediatric caudal block. MATERIAL AND METHODS: The Current Study is a comparative randomized study where sampling method was purposive sampling. Statistical analysis was done using student’s t test and chi square test. 60 children aged between 1 to 6 years weighing < 20 kgs posted for surgery were divided into two groups of 30 each. GROUP BD received 0.25% Bupivacaine 1ml/kg + 1μg/kg Dexmedetomidine and GROUP RD received 0.2% Ropivacaine 1ml/kg + 1μg/kg Dexmedetomidine. Postoperatively, duration of analgesia was assessed using the observational pain scale and FLACC score, duration of sedation was assessed using sedation score and the duration of motor block was assessed using modified bromage scale. RESULTS: The onset of action in Group BD (Bupivacaine) and RD (Ropivacaine) was 6.70±0.23mins and 6.653±0.15mins respectively. The duration of analgesia was 549.66±4.66 mins in group BD (Bupivacaine) and 650.16±6.03 mins in group RD (Ropivacaine). CONCLUSION: There was no significant difference in the onset of action, duration of sedation and vital parameters between the two groups. Ropivacaine with Dexmedetomidine produced longer duration of analgesia compared to Bupivacaine with Dexmedetomidine. Ropivacaine caused less motor blockade than bupivacaine. Hence 0.2% Ropipivacaine 1ml/kg with Dexmedetomidine 1μg/kg is a better choice than 0.25% Bupivacaine 1ml/kg with Dexmedetomidine 1μg/kg

Comparative study of Dexmedetomidine and Fentanyl as Adjuvant to Epidural Ropivacaine for Lower Limb Orthopedic Surgeries

AIM : To evaluate and compare the efficacy, analgesic effects, postoperative analgesia of epidurally administered dexmedetomidine or fentanyl along with ropivacaine for patients undergoing lower limb orthopedic surgeries . STUDY DESIGN : A Prospective randomized double-blinded study METHODS : The study was conducted at chengalpattu medical college after obtaining ethical committee approval,60 patients of both gender aged 18 60 years, American Society of Anaesthesiologist (ASA) physical status I and II who undergoing elective lower limb orthopaedic surgeries were selected and randomly allotted into two groups . Inj. Ropivacaine, 15 ml of 0.5%, was administered epidurally in both the groups with addition of 1 μg/kg of dexmedetomidine in group A and 1 μg/kg of fentanyl in group B. Time of onset of sensory block at T10, maximum sensory level achieved ,time taken for complete motor blockade, sedation score, total duration of analgesia, time of first rescue analgesia ,haemodynamic parameters, side effects were observed. At the end of study, data was analyzed statistically using Two sided Independent Student t test and Mann- Whitney U test for parametric data. Chi-square test for non parametric data. Value of P<0.05 is considered statistically significant. RESULTS : The demographic profile of patients was comparable in both the groups. Onset of sensory analgesia at T10 3.87±0.681 Vs 6.03±1.47 (mins) p= 0.0001 and attainment of complete motor blockade 19±3.151 Vs 23.37±2.58 (mins) p= 0.0001 was significantly earlier in the group A. Total duration of analgesia was prolonged significantly in the group A 335.83±41.316 Vs 285.37±25.914 (mins) p= 0.0001. Sedation scores were much better in the group A and showed significant on statistical comparison (p<0.05). Incidence of nausea and vomiting was higher in the group B, while incidence of dry mouth was higher in the group A. Side effects such as bradycardia and hypotension were more in group A. But easily managed with injection atropine and ephedrine .None of the patients had respiratory depression in both groups. CONCLUSIONS : To conclude , dexmedetomidine seems to be a better adjuvant to epidural ropivacaine for lower limb orthopedic surgeries for attaining early onset of sensory and motor block , providing better sedation and prolonging sensory blockade when compared to epidural fentanyl with minimal side effects