Abstract
Background: Caudal block has evolved to become the most popular regional anesthetic technique for use in children. It provides excellent analgesia during surgery as well as during postoperative period in subumblical surgeries in children, however one of the major limitations of the single injection is relative short duration of post operative analgesia even with long acting local anesthetics such as Bupivacaine. This problem can be circumvented by the use of different adjunct drugs to the local anesthetic solutions. The aim of the present study was to compare the analgesic efficacy and safety of Neostigmine - bupivacaine mixture to that of bupivacaine- clonidine mixture following caudal administration in children undergoing infra-umbilical surgeries.
Methods: In a prospective, randomized, double blind study, 100 patients of ASA physical status I of either sex in the age range of 1 to 5 years scheduled for elective infra- umbilical surgical procedures were randomly allocated to one of the groups of 50 patients each to receive caudal injection of either 1µg/Kg of clonidine in addition to 1ml/kg of 0.25% bupivacaine hydrochloride in Group BC or 2µg/Kg of neostigmine added to 1ml/kg of 0.25% bupivacaine hydrochloride in Group BN. The perioperative hemodynamic effects, post operative pain scores (OPS), supplementary analgesic requirement and side effects were assessed by a blind observer during 24 hour observation period.
Results: Both the groups were homogenous with reference to age, sex, weight and duration of anesthesia and duration of surgery. No significant differences with respect to mean heart rate, blood pressure (systolic and diastolic) and oxygen saturation were noted during perioperative period between the two groups. The mean duration of analgesia in group BC was 10.87±3.5 hours while in group BN mean duration of analgesia was 4.26±1.6 hours. The duration of analgesia in group BC was longer and the difference was statistically significant (p< 0.05). In the postoperative period rescue analgesia in the form of diclofenac suppository (1mg/kg) was required in 16 patients (32%) in the group BC and 31 (62%) patients in the group BN. Statistically a significant difference (p<0.001) was observed between the two groups. In our study 2 patients in BC (group) had nausea and vomiting (4%), while in group BN 3 patients had nausea and vomiting (6%). The total number of patients who had side effects was less in study group compared to control group. However, the difference was statistically insignificant (p>0.05) between the two groups. None of our patient developed any other complication. In our study there was very low incidence of nausea and vomiting which was probably due to i/v ondansetron given intra operatively.
Conclusion: Caudal clonidine provides effective and prolonged intra and postoperative analgesia in patients undergoing infra-umbilical surgeries. Neostigmine and clonidine when added to caudal bupivacaine are safe and without any significant side effects.
Keywords: caudal anesthesia, neostigmine, clonidine , post operative pain ,children, bupivacaine.
References
- Rowney DA, Doyle E. Epidural and subarachnoid blockade in children. Anaesthesia 1998; 53:980-1001.
- Cook B and Doyle E. The use of additives to local anesthetic solutions for caudal epidural blockade. Review [54 refs]. Pediatric Anesthesia1996;6:353-359.
- Tamsen A, Gordh T. Epidural clonidine produces analgesia (letter). Lancet 1984;2:231-2.
- Eisenach JC, De kock M, Klimscha W. Alpha agonists for regional anesthesia: a clinical review of clonidine(1984 -1995) Anaesthesiology 1996;85:655 -74.
- Jamali S, Monin S, Begon C et al.Clonidine in pediatric caudal anaesthesia. Anaesth Analg 1994;78:663-666.
- Lauretti GR, Reis MP, Prado WA, Klamt JG. Dose – response study of intrathecal morphine versus intrathecal neostigmine, their combination, or placebo for post-operative analgesia in patients undergoing anterior or posterior vaginoplasty. Anesth Analg 1996; 82: 1269-75.
- Lauretti GR, Oliveira R. Reis MP, Julio MC, Pereira N Study of three different doses of epidural neostigmine coadmini-stered with lidocaine for postoperative analgesia.Anesthesiology 1999;90:1534-8.
- Turan A, Memis D, Basaran U, Karamanlioglu B, Sut N. Caudal ropivacaine and neostigmine in pediatric surgery. Anesthesiology 2003; 98: 719-22.
- Iwamoto ET, Marion L: Pharmacologic evidence that spinal muscarinic analgesia is mediated with an L1 arginine/nitric oxide/cyclic GMP in rats. J Phamacol Exp Ther 1994; 271: 601-8.
- Klimsha W, Chiari A, Michalek-Sauberer A et al: The efficiency and safety of Clonidine-Bupivacaine combination in caudal blockade for pediatric hernia repair. Anesthesia – Analgesia 1998; 6 : 54-61.
- Wanda Joshi, Neil R Connelly, Scott S, et al. Analgesic effect of clonidine added to bupivacaine 0.125% in pediatric caudal blockade. Pediatric Anesthesia 2004; 14: 483-486.
- Jamali S, Monin S, Begon C et al. Clonidine in pediatric caudal anaesthesia. Anaesth Analg 1994;78:663-666.
- Seyedhijazi M, Kalami L, Negarger S, et al. The effect of clonidine bupivacaine combination on quality and duration of caudal block in children between 2-7 years old. Medical journal of Tabriz 2008; 30(20); 13-16.
- Nishina K ,Mikawa K. Clonidine in pediatric anesthesia. Review. Curr opin anesthesiol 2002; 15:309-316.
- Hansen T.G, Henneberg SW, Walther Larsen S. Caudal bupivacaine supplem-ented with caudal or intra venous clonidine in children undergoing hypospadias repair; a double blind study. British Journal of Anesthesia 2004: 12(2), 223-227.
- Turan A, Memis D, Basaran U, Karamanlioglu B, Sut N. Caudal ropivacaine and neostigmine in pediatric surgery. Anesthesiology 2003; 98: 719-22.
- Motsch J, Bottiger BW, Bach A, et al. Caudal clonidine and bupivacaine for combined epidural and general anesthesia in children. Acta Anesthesiologica scandinavica 1997; 41: 877-83.
- Lee JJ and Rubin AP. Comparison of bupivacaine – clonidine mixture with pain bupivacaine for caudal analgesia in children. British journal of Anesthesia 1994; 72: 258-262.
- Yildiz TS, Korkmaz F, Solak M et al. clonidine addition prolongs duration of caudal analgesia. Acta Anesthesologica Scandinavica. 2006; 50: 501-504.
- Emil Batarseh, Zahi Majli, Nariuman Nsour, Mohammad Dajja, Oksana Nabukhotna. Caudal Bupivacaine – Neostigmine Effect on Post-opeative Pain Relief in children. Journal of the Royal Medical Services Mar. 2015; Vol.22, No. 1.
- Mohamed HYPERLINK "http://lib.bioinfo.pl/auth:Abdulatif,M"Abdulatif, Mohga El-Sanabary. Caudal neostigmine, bupivacaine, and their combination for postoperative pain management after hypospadias surgery in children. AnesthHYPERLINK "http://lib.bioinfo.pl/pmid/journal/Anesth%20Analg" HYPERLINK "http://lib.bioinfo.pl/pmid/journal/Anesth%20Analg"AnalgHYPERLINK "http://lib.bioinfo.pl/pmid/journal/Anesth%20Analg". 2002 Nov; 95 (5): 1215-8HYPERLINK "http://lib.bioinfo.pl/pmid/journal/Anesth%20Analg".
- Rudra A. Dr. Pan A.K. Dr. Acharya A. Dr Ahmad A. Dr Ghosh M.K. Scope of caudal neostigmine with bupivacaine for post-operative analgesia in children: comparison with bupivacaine. Indian J. Anaesth. 2005; 49(3): 191-194.
- Pramod Gupta, Dr Amy Grace MD. Neostigmine as an adjunct to Bupivacaine, for caudal block in burned children, undergoing skin grafting of the lower extremities. Anestesia Pediatricae Neonatale 2011; Vol. 9, N. 1: 1-16.
- Motsch J, Bottiger BW, Bach A, et al. Caudal clonidine and bupivacaine for combined epidural and general anesthesia in children. Acta Anesthesiologica scandinavica 1997; 41: 877-83.
- Naguib M, Sharif AM, Seraj M et al. Ketamine for caudal analgesia in children a comparison with caudal bupivacaine. British journal of Anesthesia 1991; 67: 559-564.
Corresponding Author
Tantry Tariq Gani
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DOI: https://dx.doi.org/10.18535/jmscr/v5i7.253
