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Caudal neostigmine; an adjuvant for postoperative analgesia in paediatric anaesthesia
- Rajesh Mahajan, Sushil Kumar, Yk Batra (17 August 2005)
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Rajesh Mahajan, doctor pgimer, chandigarh, Sushil Kumar, Yk Batra
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We were interested in the recent article on postoperative analgesia in children in recent issue of British Journal of Anaesthesia 1 .Although authors have mentioned most of the drugs used for Single-shot "kiddie caudal" with local anaesthetics , we could not find any reference of caudal neostigmine. Neostigmine has been known to produce analgesia in both adults and children2-10 . Presently there is substantial data and evidence to support the use of neostigmine for neuraxial block in paediatric population. Dose dependent analgesia has been observed with caudal neostigmine alone in dose range of 20-50 ųg.kg-1 2 . Caudal neostigmine (2, 3 and 4 ųg.kg-1) co-administered with bupivacaine produces a dose –independent analgesic effect (≈ 16-17 hours )in children as compared to those receiving caudal bupivacaine alone(≈ 5 hours )3. Most of studies have found that a single caudal injection of neostigmine 2 ųg.kg-1 when added to bupivacaine 0.25% or ropivacaine 0.20% has been found to provide extended duration of postoperative analgesia (≈ 20-22 hours ) and diminished requirements of supplementary analgesia in children undergoing herniotomy or genitourinary surgery 4-6. Unlike ketamine and clonidine , use of neostigmine does not require specific preservative free preparations. The neostigmine preparations containing methyl and propyl-parabens as preservative has been safely used in adults and children 2,3,6,9 . Numerous studies involving more than 300 children receiving caudal neostigmine are testimonial to the safety profile of caudal neostigmine 3-8. The main adverse effect reported with the use of neuraxial neostigmine is the frequent nausea and vomiting. However this incidence is low with extradural neostigmine ,especially with a dose of 2 ųg.kg-1, which has been found to be optimal for use with local anaesthetics 4-6. This incidence is comparable or even lower than that has been reported with the use of caudal bupivacaine alone 10,11 . Further, unlike caudal opioids neostigmine is not associated with respiratory depression, sedation or pruritis 2,5,6. Haemodynamic changes akin to caudal clonidine are not seen with caudal neostigmine .This is attributable to the ability of caudal neostigmine to counteract the inhibitory effect of spinal bupivacaine on sympathetic nervous system ,thereby blunting the hypotension induced by neuraxial local anaesthetics and clonidine 12,13 . In conclusion ,considering the reasonably benign side effect profile (dose dependent nausea and vomiting), the safety profile and efficacy of low-dose neostigmine (2 ųg.kg-1) as an adjuvant with local anaesthetics merits its use in mainstream clinical practice. REFERENCES 1. Lonnqvist PA, Morton NS. Postoperative analgesia in infants and children. Br J Anaesth 2005;95:59-68 2. Batra YK , Arya VK ,Mahajan R , Chari P. Dose response study of caudal neostigmine for postoperative analgesia in paediatric patients undergoing genitourinary surgery. Paediatr Anaesth 2003;13:515-21 3. Mahajan R , Grover VK, Chari P. Caudal neostigmine with bupivacaine produces a dose-independent analgesic effect in children. Can J Anesth 2004;51:702-6 4. Kumar P, Rudra A, Pan AK, Acharya A. Caudal additives in pediatrics: a comparison among midazolam, ketamine, and neostigmine coadministered with bupivacaine. Anesth Analg 2005;101:69-73 5. Turan A, Memis D, Basaran UN, Karamanlioglu B, Sut N. Caudal ropivacaine and neostigmine in pediatric surgery. Anesthesiology 2003;98:719-22 6. Abdulatif M, El-Sanabary M.Caudal neostigmine, bupivacaine, and their combination for postoperative pain management after hypospadias surgery in children. Anesth Analg 2002;95:1215-8 7. Almenrader N, Passariello M, D'Amico G, Haiberger R, Pietropaoli P Caudal additives for postoperative pain management in children: S(+)- ketamine and neostigmine. Paediatr Anaesth 2005;15:143-7 8. Memis D, Turan A, Karamanlioglu B, Kaya G, Sut N, Pamukcu Z. Caudal neostigmine for postoperative analgesia in paediatric surgery. Paediatr Anaesth 2003;13:324-8 9. Eisenach JC, Hood DD, Curry R .Phase –1 human safety assessment of Intrathecal neostigmine containing methyl and propyl parabens. Anesth Analg 1997;85:842-6 10. William M, Splinter WM, Reid CW, et al. Reducing pain after inguinal repair in children: caudal anesthesia versus ketorolac tromethamine. Anesthesiology 1997; 87:542-6 11. Hannallah RS, Broadman LM, Belman B, Abromowitz MD, Epstein BS. Comparison of caudal and illioinguinal /illiohypogastric nerve blocks for the control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology 1987;66:832-4 12. Williams JL, Tong C, Eisenbach JC. Neostigmine counteracts spinal clonidine –hypotension in sheep .Anesthesiology 1993;78:301-6 13. Roelants F, Rizzio M, Lavand’ homme P.The effect of epidural neostigmine combined with ropivacaine and sufentanil for neuraxial analgesia during labour . Anesth Analg 2003;96:1161-6 Conflict of Interest:None declared |
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