|Year : 2018 | Volume
| Issue : 2 | Page : 29-32
Caudal Ropivacaine With Clonidine as Adjuvant for Intraoperative and Postoperative Analgesia in Pediatric Patients Undergoing Infraumblical Surgery: A Prospective Analytical Clinical Study
Vinod Kumar Verma1, Chandrakant Prasad2, Arvind Kumar3, Swati Singh3, Rajesh Kumar Jha2
1 Professor, Department of Anaesthesiology & Critical Care Medicine, IGIMS, Patna, India
2 Junior Resident, Department of Anaesthesiology & Critical Care Medicine, IGIMS, Patna, India
3 Associate Professor, Department of Anaesthesiology & Critical Care Medicine, IGIMS, Patna, India
|Date of Web Publication||10-Dec-2020|
Associate Professor Dept. of Anaesthesiology, IGIMS, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Background: The aim of the study was to assess the efficacy of ropivacaine with clonidine given as single shot caudal epidural in pediatric patients undergoing infraumblical sugary for intraoperative and postoperative pain relief.
Materials and Methods: In this study, 30 children of ASA-I-II, aged 1-6 years scheduled for infraumblical surgical procedures were given ropivacaine 0.125% 1 ml/kg + clonidine 1μmg/kg as single shot caudal epidural analgesia. After induction of general anaesthesia Caudal block was performed. Patients were observed in postoperative ward for relief of pain, sedation, hemodynamic and any adverse effects or complications.
Results: All the patients exhibited stable hemodynamics. There was good intraoperative and postoperative analgesia. No patient required intraoperative rescue analgesic. Adverse effects like respiratory depression, vomiting, bradycardia, hypotension, residual motor blockade, pruritus were statistically insignificant.
Conclusions: Ropivacaine with clonidine has prolonged duration of analgesia after single shot caudal epidural administration. This combination has not clinically and statistically significant adverse effects. So ropivacaine with clonidine can be used as caudal analgesia in children.
Keywords: Caudal epidural, clonidine, pediatric, postoperative analgesia, ropivacaine
|How to cite this article:|
Verma VK, Prasad C, Kumar A, Singh S, Jha RK. Caudal Ropivacaine With Clonidine as Adjuvant for Intraoperative and Postoperative Analgesia in Pediatric Patients Undergoing Infraumblical Surgery: A Prospective Analytical Clinical Study. J Indira Gandhi Inst Med Sci 2018;4:29-32
|How to cite this URL:|
Verma VK, Prasad C, Kumar A, Singh S, Jha RK. Caudal Ropivacaine With Clonidine as Adjuvant for Intraoperative and Postoperative Analgesia in Pediatric Patients Undergoing Infraumblical Surgery: A Prospective Analytical Clinical Study. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:29-32. Available from: http://www.jigims.co.in/text.asp?2018/4/2/29/302950
| Introduction:|| |
In pediatric anaesthesia caudal epidural block is one of the most popular and more commonly performed regional blocks. It is a safe and reliable technique for perioperative and postoperative analgesia in patients undergoing infraumblical surgeries under general anaesthesia. Many of the long acting local anaesthetics have been used for pediatric caudal block with different side effects and safety profiles. Levobupivacaine and Ropivacaine are the long acting amide local anaesthetics used for pediatric caudal block with various concentrations ranging from 0.125% to 0.5% and 0.1% to 0.75% respectively. Higher concentration and volume of local anaesthetics is associated with profound motor block and systemic toxicity that can be decreased by reducing the concentration and dosage of the drugs. Even the longer acting local anaesthetics such as levobupivacaine and ropivacaine when given as single shot caudal block are having shorter duration of action. So the child appreciates pain early post operatively.
Therefore it is the duty of the anaesthesiologist to provide good postoperative analgesia. To provide good and longer duration of postoperative analgesia without puffing epidural catheter various drugs like Opioids,, Midazolam, ketamine, Neostigmine, Clonidine, etc have been used as adjuvant with various results. Clonidine, an alpha 2 adrenergic agonist is known to produce analgesia of variable intensity and duration, which is dose dependent. It has been used as an adjuvant with different dosages ranging from 1μg/kg to 3μg/kg in pediatric caudal block. As an adjuvant clonidine has been used with local anaesthecs like Lignocaine, Bupivacaine, Levobupivacaine and Ropivacaine in caudal block for better intraoperative and postoperative analgesia and dose and toxicity of local anaesthetics can also be reduced.
In infraumblical surgeries where we are mainly concerned with postoperative analgesia, not with motor blockade we can use lower concentration and volume of local anaesthetics with lower dosage of clonidine.
In this study we assessed the safety, efficacy and duration of analgesia of low volumes and concentrations of local anesthetics (Ropivacaine 0.125% at a volume of 1 ml/kg) with a low dose of Clonidine (1μg/kg) as an adjuvant for caudal block in children undergoing infraumblical surgeries.
| Material and Methods:|| |
Approval from institutional ethical committee was taken. After taking informed written consent from parents, 30 ASA I-II patients, aged 1-6 years, weighing 5-20 kg, who were planned for infraumblical surgeries like herniotomy, orchidopexy, hypospadias repair and urethroplasty were enrolled in the study [Power of the study was 80% (alpha error = 05%). Children with local infection at caudal region, allergic to local anesthetics, bleeding diathesis, preexisting neurological or spinal diseases and mental retardation were excluded from the study.
Basal vital parameters like heart rate, blood pressure and Oxygen saturation of patient were recorded after connecting with monitor. Children were premedicated with atropine 0.01 mg/kg and midazolam 0.03mg/kg intravenously 1 hour before induction. Patients were induced with inj. Propofol 2mg/kg IV + inj atracurium 0.5 mg/kg IV and then endotracheal intubation was done. After confirmation of bilateral air entry ET tube was fixed at the angle of mouth to secure its position. Anaesthesia was maintained with Oxygen, nitrous oxide, halothane by using the Jackson Rees circuit. Intermittent atracurium was given as per requirement. Intraoperative pain management was done with paracetamol i.v. infusion 10 mg/kg over 15 mins. Under aseptic measures and left lateral position sacral hiatus was located. Using the loss of resistance technique caudal epidural space was confirmed and the studied drug (Ropivacaine 0.125% 1 ml/kg with clonidine 1μg/kg) was deposited after confirming negative aspiration for blood and CSF. Time of administration of drug was noted. At the end of surgery neuromuscular blockade was reversed with the usual reversal agent (neostigmine 0.05mg/kg + glycopyrrolate 0.01 mg/kg).
Before induction of general anaesthesia as a baseline heart rate (HR), mean arterial pressure (MAP) and oxygen saturation (SpO2) were noted and the same parameters were noted after induction but before caudal anaesthesia, every 5 mins intraoperatively and every 15 mins postoperatively. An increase in the HR > 15% from the baseline values was considered as tachycardia and decrease of the same >15% as bradycardia. Similarly, fluctuation of MAP >15% was considered as hypertension or hypotension accordingly. Analgesia was considered adequate when rise of heart rate or mean arterial pressure compared to baseline values was less than 15%. Failure of analgesia was considered when HR or MAP increased > 15% after 15 minutes of administration of caudal anesthesia. Inadequate analgesia was considered when HR, MAP
increased 45 min after surgical incision. Fentanyl 1 mg/kg intravenously was given when there was inadequate or failure of analgesia. Patients were excluded from the study in whom caudal analgesia was failed or found inadequate. Time from caudal block to skin incision, duration of surgery and duration of general anesthesia were recorded. In PACU analgesia, sedation, HR, MAP, SPO2, and side effects were monitored every 15 mins for 6 hours, and thereafter½ hourly till 12 hrs after caudal block.
Pain was assessed using observational Pain Scale [Table 1]. Paracetamol suppository 15 mg/kg was given as rescue analgesic when patient showed pain score >3 on at least 2 occasions or having obvious sign of pain. Time interval between caudal blockade and first complaint of pain was defined as the duration of post-operative analgesia... Assessment of sedation was done every 15 mins after surgery using 3 point sedation score [Table 2]. SpO2 was monitored continuously and SpO2<95% was defined as desaturation. Duration of motor blockade was assessed by noting the time from caudal block to regain modified bromage score 0 [Table 3]. Time of spontaneous voiding of urine from administration of caudal blockade was defined as time of micturition. Undesirable effects like nausea, vomiting, respiratory depression, pruritus hypotension, and bradycardia were also noted. Student t-test and chi- square test was used for statistical analysis.
P value <0.05 was considered as statistically significant.
| Results:|| |
Thirty pediatric patients were studied. Demographic and clinical data is given in table. The baseline mean heart rate was 132.72±11.86/min and at the end of the procedure was 115.25±6.36/min. The baseline mean arterial pressure was 69.13±3.16mmHg and at the end of the procedure was 64.33±3.54mmHg. There was no notable variation in heart rate and mean arterial pressure intraoperatively [Table 5]. Mean duration of surgery was 54.22 ± 5.42 mins. Surgical analgesia was found to be adequate. No patient required intraoperative rescue analgesia. Post-operative vital parameters were not changed significantly till the child appreciated pain. There was an increase in heart rate when child experienced pain. The mean duration of sedation was 138.66±13.21mins. There was no motor blockade in any of the patient. The duration of analgesia was 423±23.21mins. Rescue doses of Paracetamol suppository 15mg/kg was given when the child complained of pain or when the pain/ discomfort score >/=3. Two patients suffered from vomiting and bradycardia occurred in 1 patient. No patient had urinary retention or pruritus [Table 6]
| Discussion:|| |
Caudal epidural block is a simple and routinely used method which gives excellent pain relief both intra- and postoperatively in pediatric patients undergoing surgeries below the umbilicus. The ideal combination of drugs for caudal anesthesia in pediatric patients is being searched.
Ropivacaine a local anesthetic has better safety margin and reduced risk of cardiac toxicity. Separation of sensory and motor effects is more with ropivacaine than with bupivacaine. Ropivacaine is more commonly used for caudal blocks in pediatric patients. This study demonstrates that in a single shot caudal block with clonidine added to ropivacaine prolongs analgesia.
Bosenberg A et al. showed that ropivacaine 0.2% gives satisfactory postoperative pain relief, 0.1% had lesser effect and 0.3% had higher incidence of motor block with minimal improvement in pain relief. We designed this study keeping this in mind.
Various drugs were tried to increase the duration of analgesia with lesser adverse effects. As an additive to local anaesthetic fentanyl, a lipophillic opioid is frequently in children. Fentanyl has undebatable beneficial effects but adverse effects like respiratory depression, nausea, and vomiting are also common., Clonidine an a2 agonist has also been used as additive to local anesthetics, e.g., bupivacaine,, mepivacaine, lignocaine. Its addition increases duration and also improves quality of analgesia provided by single shot caudal block. Clonidine when given extradurally provides pain relief by nonopioid spinal effects. Clonidine is not having opioid side effects but may produce excessive sedation, hypotension, and bradycardia in adults.
In the present study, addition of clonidine to ropivacaine was found to be effective in providing satisfactory intraoperative and postoperative analgesia.
Respiratory depression is an expected but unwanted side effect of extradural opiod; it has also been noticed in adult patients who received clonidine 300 mg extradurally. However a number of previous studies have not reported respiratory depression after caudal blockade with clonidine,,, in pediatric patients.
In adults sedative effect was observed after giving clonidine in epidural space and to a lesser degree in children., Hypotension and bradycardia are expected side effect of extradural clonidine in adults and it is dose dependent. However hemodynamic effects of extradural clonidine are less pronounced in children than in adults.,, No patient had hypotension. One patient suffered from bradycardia, but this was not significant. No patient had a fall in HR to less than 80 beats per minute. So they exhibited stable hemodynamics.
Two patients out of 30 had vomiting in postoperative period. When administered orally or intravenously clonidine has antiemetic properties while opiod has emetic effect when given extradurally. So clonidine has lesser side effects when used as adjuvant to local anaesthetics in pediatric caudal block.
| Conclusion:|| |
Ropivacaine with clonidine has prolonged duration of analgesia after single shot caudal epidural administration. This combination has not clinically and statistically significant adverse effects. So ropivacaine with clonidine can be used as caudal analgesia in children.
| References|| |
J C Sanders, "Pediatric regional anaesthesia, a survey of practice in the United Kingdom" British Journal of Anaesthesia 2002; 89:707-710
T G Hansen et al, S W Henneberg, S Walther Larsen, J Lund, M Hansen, "Caudal Bupivacaine supplemented with caudal or intravenous Clonidine in children undergoing hypospadias repair: a double blind study" British Journal of Anaesthesia 2004; 92:223-227
Pankaj Kundra, K Deepalakshmi, M Ravishankar, "Preemptive Caudal Bupivacaine and Morphine for Postoperative Analgesia in Children" Anaesthesia Analgesia 1998; 87:52-56
A Hom Choudhuri, P Dharmani, N Kumarl, A Prakash, "Comparison of caudal epidural Bupivacaine with Bupivacaine plus Tramadol and Bupivacaine plus Ketamine for postoperative analgesia in children" Anaesthesia and Intensive Care 2008; 36(2):174-179
Meena Doda, Sambrita Mukherjee, "Postoperative Analgesia in Children- Comparative Study between Caudal Bupivacaine and Bupivacaine plus Tramadol" Indian Journal of Anaesthesia 2009; 53(4):463-466
Mohamed Naguib, Mohamed El Gammal, Yasser S Elhattab, Mohamed Seraj, "Midazolam for caudal analgesia in children: comparison with caudal Bupivacaine" Canadian Journal of Anaesthesia 1995; 42(9):758-76.
M Naguib, A M Y Sharif, M Seraj, M El Gammal, A A Dawlatly, "Ketamine for Caudal analgesia in children: comparison with caudal Bupivacaine" British Journal of Anaesthesia 1991;67:559-564
Mohamed Abdulatif, Mohga El Sanabary, "Caudal Neostigmine, Bupivacaine and their combination for postoperative pain management after Hypospadias surgery in children" Anaesthesia Analgesia 2002; 95:1215-1218
I Constant, O Gall, L Gouyet, M Chauvin, I Murat, "Addition of Clonidine or Fentanyl to local anaesthetics prolongs the duration of surgical analgesia after single shot caudal block in children" British Journal of Anaesthesia 1998;80:294- 298
Joel G Hardman, "Pharmacological basis of therapeutics" Goodman and Gilman, 10th edition, 2001, 233-234
Reiz S, Häggmark S, Johansson G, Nath S. Cardiotoxicity of ropivacaine: A new amide local anaesthetic agent. Acta Anaesthesiol Scand 1989;33:93-8.
Markham A, Faulds D. Ropivacaine: A review of its pharmacology and therapeutic use in regional anaesthesia. Drugs 1996;52:429- 49.
Hannallah RS, Broadman LM, Belman AB, Abramowitz MD, Epstein BS: Comparison of Caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology 1987; 66:832-4.
Eisenach JC, De Kock M, Klimscha W. Alpha (2) - adrenergic agonist for regional anesthesia: A clinical review of clonidine (1984-1995). Anesthesiology 1996; 85:655-74.
Bosenberg A, Thomas J, Lopez T, Lybeck A, Huizar K, Larsson LE. The efficacy of caudal ropivacaine 1, 2 and 3 mg x l(-1) for postoperative analgesia in children. Paediatr Anaesth 2002; 12:53 -8.
Campbell FA, Yentis SM, Fear DW, Bissonnette B. Analgesic efficacy and safety of a caudal bupivacaine-fentanyl mixture in children. Can J Anaesth 1992; 39:661-4.
Jamali S, Monin S, Begon C, Dubousset AM, Ecoffey C. Clonidine in pediatric caudal anaesthesia. Anesth Analg 1994;78:663-6.
Lee JJ, Rubin AP. Comparison of a bupivacaine-clonidine mixture with plain bupivacaine for caudal analgesia in children. Br J Anaesth 1994;72:258-62.
Ivani G, Mattioli G, Rega M, Conio A, Jasonni V, de Negri P. Clonidine- mepivacaine mixture vs plain mepivacaine in paediatric surgery. Paediatr Anaesth 1996; 6:111-4.
Beauvoir C, Rochette A, Raux O, Ricard C, Canaud N, D'Athis F. Clonidine prolongation of caudal anesthesia in children. Anesthesiology 1994;81:A1347.
Jones RD, Gunawardene WM, Yeung CK. A comparison of lignocaine 2% with adrenaline 1; 200,000 and lignocaine 2% with adrenaline 1:200,000 plus fentanyl as agents for caudal anaesthesia in children undergoing circumcision. Anaesth Intensive Care 1990;18:194-9.
Scott DA, Beilby DS, McClymont C. Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients. Anesthesiology 1995;83:727-37.
Penon C, Ecoffey C, Cohen SE. Ventilatory response to carbon dioxide after epidural clonidine injection. Anesth Analg 1991;72:761-4.
Motsch J, Böttiger BW, Bach A, Böhrer H, Skoberne T, Martin E. Caudal clonidine and bupivacaine for combined epidural and general anaesthesia in children. Acta Anaesthesiol Scand 1997; 41:877-83.
Mikawa K, Nishina K, Maekawa N, Asano M, Obara H. Oral clonidine premedication reduces vomiting in children after strabismus surgery. Can J Anaesth 1995;42:977-81.
Saumpelmann R, Busing H, Schroder D, Rekersbrink M, Krohn S, Strauss JM. Patient-controlled analgesia with clonidine and npiritramide. Anaesthesist 1996;45:88-94.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]