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Efficacy of post-operative analgesia: A comparison of Caudal Epidural Block, Rectal Diclofenac S
- Pavan Kumar B C Raju, Dr. K.D.Harnagale, Associate Professor, Department of Anaesthesia, Grant Medical College, Sir J.J. Group of Hospitals, Mumbai, India. (19 December 2005)
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Caudal opioids in chidren: The sedation angle.
- Sumit Kumar Jha, Swati Daftary, Consultant Anaesthetist, Paediatric Surgery Theatre, LTMG Hospital, Mumbai. India. (8 December 2005)
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Site of operation is important in determining the analgesic efficacy of technique
- Jamil Sharif Anwari, Riyadh , Saudi Arabia (26 November 2005)
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Pavan Kumar B C Raju, Senior Resident Department of Anaesthesia, Grant Medical College, Sir J.J.Group of Hospitals, Mumbai, India., Dr. K.D.Harnagale, Associate Professor, Department of Anaesthesia, Grant Medical College, Sir J.J. Group of Hospitals, Mumbai, India.
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It is a well known fact that Paediatric age group is undertreated for pain as compared to adults and caudal epidural block has revolutinised the treatment of pain in them, both intra operatively and post operatively. I read this well written and informative article about the epidural analgesia. During my postgraduation, I had carried out a similar study along with my consultant in Grant Medical College, Sir JJ Group of Hospitals, Mumbai, India and I would like to share my experiences with you. It was a double blinded, prospective, randomised study carried out on 90 ASA I & II children undergoing various infra umbilical surgeries. 0.25% bupivacaine was used for caudal epidural block in 30 children and Rectal Diclofenac suppository was used at a dose of 2mg/kg in 30 children and both in the rest of the 30 children. All were used at the beginning of the surgery after administering general anaesthesia. Also, a special test was used to assess the efficacy of Caudal Block called SWOOSH TEST where a stethescope was used to listen to the swoosh sound of the injecting solution over the lower back area and its correlation was effective in more than 95% of cases. All the children were monitored for Haemodynamic parameters intra operatively. Post operatively, they were monitored for haemodynamic parameters, pain using mCHEOPS score and sedation using simple four point sedation score for 4 hours every 30minutes. All the cases were discharged after they satisfy the hospital protocol. All the parents were taught about simple pain score and sedation score and were asked to monitor their children on the night of the surgery and on the next morning. Feedback was collected through phone calls. Statistical analysis was carried out with a help of a statistician. Conclusion: Both Caudal Bupivacaine and Rectal Diclofenac Suppository were equally effective for Post operative pain relief. Intraoperatively, mean values of haemodynamic parameters were slightly higher in children with only Rectal Diclofenac. Combination of Caudal Epidural Block and Rectal Diclofenac gave better results than either given alone. None of the children suffered from side effects such as sedation, Respiratory depression. Only a minor percentage suffered from nausea and vomiting. Hence, it was a reasonably safe practice for Post operative analgesia. Swoosh test is an effective way to detect the efficacy of Caudal Epidural Block. Conflict of Interest:None declared |
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Sumit Kumar Jha, Senior House Officer Addenbrooke's Hospital NHS trust, Cambridge., Swati Daftary, Consultant Anaesthetist, Paediatric Surgery Theatre, LTMG Hospital, Mumbai. India.
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I read with interest the article of Dr Y. Demiraran and colleagues on comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children. I would like to share my experiences and conclusions in a similar study we conducted last year. We studied 50 ASA I/II children at Paediatric Surgery Theatre suite, LTMG Hospital, Mumbai. India. We used 0.25% bupivacaine caudally and additives in the form of either 0.5mg/kg preservative-free ketamine or 5micrograms/mL adrenaline for postoperative pain relief in children undergoing infraumbilical surgery. We studied children, aged up to 8 yr, undergoing infraumbilical surgeries. After standard induction of anaesthesia and intraoperative pain control with fentanyl, Group K received 0.25% Bupivacaine with 0.5 mg/kg preservative –free ketamine and Group A received 0.25 % Bupivacaine with 5micrograms/mL adrenaline via the caudal route at the end of surgery. Heart rate, mean arterial pressure, and pulse oximetry were recorded before induction, after induction, intraoperatively and then postoperatively every 10 min after caudal anaesthesia. Haemodynamic, sedation score values were recorded 30 min after extubation and at hours 2, 4, 6, 12, and 24. The rescue analgesic used was rectal paracetamol. There were no differences between the groups in demographic data, duration of surgery/anaesthesia and time to extubation. The pain scores were significantly lower in ketamine group at 6, 12 h and up to 18 hours (P < 0.05). Time to first analgesic requirement was statistically prolonged in this group (18.1 +/- 3.2h) when compared with adrenaline (11.2 +/- 2.6 h) (P <0.05). The sedation scores were also higher in the ketamine group. We concluded that: 1. Preservative-free Ketamine as additive to Bupivacaine significantly prolonged the duration of postoperative pain relief in children as compared to adrenaline as additive. We found that it is an effective agent especially in the setting of single-shot caudal techniques. 2. Sedation scores were higher in the ketamine group and this necessitated that patients were cared for in an HDU environment at least for 24 h with pulse oximetry and apnoea monitoring. 3. Ketamine offered better pain relief in visceral surgery and hypospadias. This we believed to be due to actions of ketamine on peripheral pain receptors at the spinal cord level. 4. On review of literature, ketamine has been demonstrated to have age-related neurotoxicities in rat models related to NMDA antagonism. This necessitated long-term follow-up of these patients and using preservative- free drugs. 5. We also had findings similar to the authors in the present study and patients with urological procedures, e.g. Hypospadias etc, with a significant visceral component to pain experienced the maximum benefit. We believe that long-term follow-up of patients is crucial to know if there are any long-term side- effects attributable to ketamine. The ethical issues involved especially in the context of paediatric anaesthesia cannot be overemphasised. Having said that, the pain relief issues, especially postoperative pain relief, in the paediatric population remains a pertinent question and challenges the paediatric anaesthetist. References: 1. Jha S, Daftary S: Caudal additives for postoperative pain relief in children. A prospective, randomized study of 50 ASAI/II children undergoing infraumbilical surgeries. 2. Comparison of the effects of adrenaline, clonidine and ketamine on the duration of caudal analgesia produced by bupivacaine in children. British Journal of Anaesthesia, Vol 75, Issue 6 698-701 3. Comparison of the effect of ketamine added to bupivacaine and ropivacaine, on stress hormone levels and the duration of caudal analgesia Acta Anaesthesiologica Scandinavica: Volume 49 Issue 10 Page 1520 - November 2005 4. Age-specific neurotoxicity in the rat associated with NMDA receptor blockade: potential relevance to schizophrenia? Nuri B. Farber , David F. Wozniak, Madelon T. Price, Joann Labruyere, Janice Huss, Heidi St. Peter and John W. Olney. Biol Psychiatry. 1995 Dec 15; 38(12): 788-96. 5. Y. Demiraran, B. Kocaman1 and R. Y. Akman. A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children. British Journal of Anaesthesia. 2005 95(4):510-513; doi:10.1093/bja/aei214 6. Dalens B, Abdou H: Caudal anesthesia in pediatric surgery: Success rate and Adverse effects in 750 Consecutive patients. AnesthAnalgesia 68: 83-89, 1989 [Abstract] 7. Pharmacology of Pediatric Anesthesia (pg. 168-170) Ed-Cook R.D., Davis P.J., Lerman J. In-Anesthesia for Infants and Children, Sixth edition: Lee and Smiths. Motoyama E.K, Davis P.J. Mobsy, Missouri. 8. Joel B Gunter, Catherine M Dunn, Jeffery B; Optimum Concentrations of Bupivacaine for Combined Caudal- General Anesthesia in children. Anesthesiology 75: 57-61, 1991. (Abstract) 9. Beer DAH, Thomas M.L. Caudal additives in children- solutions or problems? Br. J. Anaesth. 2003 90: 487-498. [Abstract] [FREE Full Text] [PDF] Conflict of Interest:None declared |
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Jamil Sharif Anwari, Anaesthetist Riyadh Armed Forces Hospital, Riyadh , Saudi Arabia
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I read with interest the article "A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children Br. J. Anaesth. 2005; 95: 510-513". I would like to comment few points; A) The authors mentioned the details of the anaesthetic drugs and Tuohy needle (such as Tracrium 25mg 2.5 ml-1; Glaxo-Wellcome, Philadelphia,USA), but did not mention any information about more relevant (morphine & Tramadol) drugs. There is no mention whether morphine was preservative free or not? B) Site or the name of operations not mentioned. Conflict of Interest:None declared |
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