Analgesic efficacy of caudal dexamethasone combined with bupivacaine 0.25% in ilioinguinal pediatric surgery

Anouar Jarraya | Sahar Elleuch | Manel Kammoun | Saloua Ammar | Kamel Kolsi |

La tunisie chirurgicale - 2018 ; Vol 2017

Resumé

Introduction: The epidural administration of dexamethasone was recently used in adults to reduce postoperative pain and   analgesic requirements. The aim of the study was to assess the efficacy of caudal dexamethasone with bupivacaine 0.25% for postoperative pain relief in children undergoing sub-umbilical surgical procedures.

Patient and Methods: In this prospective randomized double blind study, 56 children of ASA-I class aged from 1 to 5 years scheduled for sub-umbilical surgical procedures were randomly allocated to two groups:

  • group I received caudal block with : bupivacaine 0.25% (1 ml/kg) with placebo
  • group II received caudal block with : bupivacaine 0.25% (1 ml/kg) with dexamethasone 0.1 mg/ml.

Postoperatively patients were assessed for analgesia and side effects.

Results:  Demographic parameters (age, weight, size, sex) and per operative heart rate and blood pressure were similar in both groups. Significantly high levels and prolonged duration of post-operative analgesia were observed from the 6th to the 24th post operative hours in group II (P<0.005) with no increased side effects.   

Conclusion:  Caudal dexamethasone may safely improve and prolong post operative analgesia for sub-umblical surgical procedures in children.

Mots Clés

Caudal epidural, dexamethasone, pediatric surgery, postoperative analgesia, children, sub-umbilical surgery

Introduction :

The epidural administration of dexamethasone was recently used in adults to reduce postoperative pain and   analgesic requirements. The aim of the study was to assess the efficacy of caudal dexamethasone with bupivacaine 0.25% for postoperative pain relief in children undergoing sub-umbilical surgical procedures.

Article

In pediatric surgery, caudal block is commonly used with several adjuncts like sufentanil [1] or clonidine [2].  However, the analgesic effect of caudal dexamethasone is still under evaluation in children [3]. The aim of this study is to assess the efficacy of caudal dexamethasone on pain relief in children undergoing sub-umbilical surgery.  

After obtaining the   ethics committee  and informed written consent from parents, 56 ASA I class patients aged from 1 to 5 years, weighting from 5 to 20 kg, scheduled for sub-umblical surgical procedures (hernia repair or orchidopexy ) under general anesthesia with caudal block,  were enrolled in this prospective randomized double blinded  controlled trial.   The anesthesia protocol (with sevoflurane) was standardized for all patients.  Then, caudal anesthesia was practiced with 23G short bevel hypodermic needle in left lateral position.

The anesthetist and nurses in-charge of the patient were completely blinded to the content of syringes.

Patients were randomized into 2 groups using a computer generated list:

  • Group I :  received bupivacaine 2.5 mg/kg with placebo
  • Group II:  received bupivacaine 2.5 mg/kg with dexamethasone 0.1mg/kg.

Peroperatively, the increase of Heart rate  or Mean arterial pressure  more than 20%  compared with baseline values, 15 minutes after the  caudal anesthesia was considered as failure of caudal block and in this case, an intravenous dose of Alfentanyl (20 µg/Kg) was administrated. Patients, in whom caudal anesthesia failed, were excluded from the study.

In the post operative period, another investigator who was blinded to group allocation provided postoperative care and assessments. Pain was assessed by using CHEOPS Score. In the PACU, if patients had CHEOPS score superior to 7, or if they requested additional analgesia, they were given 0.2 µg/ kg of nalbuphine.  After the exit of PACU, all patients received 15 mg/kg of paracetamol orally 4 times a day. Oral ibuprofen was prescribed for analgesia after discharge. Children received 5 mg /kg of ibuprofen for pain scores of 7or greater on CHEOPS.

The main outcome of the study was the pain scores.  Secondary outcomes were the need for rescue analgesics, the time for the first request of additional analgesia and side effects. 

Data were analyzed with the IBM SPSS Statistics 20.0 for Windows®.

In this study, 56 pediatric patients were included, 28 in each group. No case of caudal block failure was noted and no patient was excluded. No patient received alfentanil per-operatively.

Demographic data (age, weight, gender) and per operative data (duration of general anesthesia and the  duration of surgery were comparable in the two groups (table 1). 

 For pain relief, CHEOPS was significantly higher in group II than group I from H6 to H24 (figure 1). No patient required additional analgesia (Nalbuphine) during their stay in PACU in both groups. However rescue doses of oral Ibuprofen were seen in 16 patients in group I versus 3 patients in group II (p<0.01). Time to the first administration of Ibuprofen recue dose was 7.6 +/- 1.1 h in group I versus 12.2 +/- 2.1 in group II (p<0.01)

Side effects were similar in both groups.  Nausea and vomiting were seen in 2 patients in group I versus no patient in group II. Motor blockade, respiratory depression and Pruritis were not seen in any patient of our study. 

Our results come with agreement with the study done by Kim et al [3]  who studied the effect of addition of dexamethasone to ropivacaine in caudal block in children underwent orchiopexy and concluded that the addition of dexamethasone  to caudal ropivacaine could improve analgesic efficacy, prolong the duration of postoperative analgesia and decrease postoperative analgesic requirements.

  Elham et al [4] reported that both caudal dexmedetomidine and caudal dexamethasone added to local anesthetics are good alternatives in prolongation of postoperative analgesia with less pain score compared to caudal local anesthetic alone or added to caudal fentanyl. Also they showed less side effects compared with caudal fentanyl. These studies [3,4], used dexamethasone with ropivacaine. However, in our study we used bupivacaine that may lead to increased rates of motor blockade [5].

Dexamethasone may have another benefit when bupivacaine is used because it may attenuate the bupivacaine induced neuron injury [6]

One of the limits of our study was that we assessed pain via CHEOPS by parents after hospital discharge because it was a day-case surgery.

Then, we did not evaluate some potential side effects of dexamethasone absorption such as hyperglycaemia [7] and surgical complications such as wound infection [8] 

In conclusion, the addition of 0.1 mg/ kg dexamethasone to bupivacaine in caudal blocks seems to be efficient for pain relief in children undergoing sub umbilical surgery.

Conflict of interest: authors declare no competing interest .

 

Table 1 : demographic and peroperative  data.

 

Group I

Group  II

p value

Age (years)

2.86 (1-5)

2.79 (1-5)

0.823

Weight (Kg)

14.5 +/- 4.6

14.7 +/- 3.2

0.841

Size  (cm)

80.3 +/-  6.3

84.5 +/- 12.1

0.169

Duration of intervention  (min)

34.2 +/- 9.4

37.86 +/- 10.3

0.181

Anesthesia duration  (min)

52.14 +/- 11.9

53.9 +/- 14.4

0.361

+/- : SD.

 

Figure1 : Pain relief according to the CHEOPS.

Références

[1]  Wang T1, Xiang Q, Liu F, Wang G, Liu Y, Zhong L. Effects of caudal sufentanil supplemented with levobupivacaine on blocking spermatic cord traction response in pediatric orchidopexy. J Anesth. 2013;27(5):650-6

[2] Seyedhejazi M, Sheikhzadeh D, Adrang Z, Rashed FK. Comparing the analgesic effect of caudal and ilioinguinal iliohypogastric nerve blockade using bupivacaine-clonidine in inguinal surgeries in children 2-7 years old. Afr J Paediatr Surg. 2014 Apr-Jun; 11(2):166-9.

[3] Kim E, Lee J, Koo B, Im Y, Oh H, Lee J. Analgesic efficacy of caudal dexamethasone combined with ropivacaine in children undergoing orchiopexy. British Journal of Anaesthesia. 2014;112(5):885-891.

[4] Elham M. El-Feky, Ahmed A. Abd El Aziz. Fentanyl, dexmedetomidine, dexamethasone as adjuvant to local anesthetics in caudal analgesia in pediatrics: A comparative study. Egyptian Journal of Anaesthesia 2015;31:175–180

[5] Jarraya A, Elleuch S, Zouari J, Smaoui M, Laabidi S, Kolsi K.   Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally. Pan Afr Med J. 2016; 24: 182.

[6] Ma R, Wang X, Lu C, Li C, Cheng Y, Ding G et al. Dexamethasone attenuated bupivacaine-induced neuron injury in vitro through a threonine–serine protein kinase B-dependent mechanism. Neuroscience. 2010;167(2):329-342.

[7] Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS, Gray J, Landry E. The effect of single low-dose dexamethasone on blood glucose concentrations in the perioperative period: a randomized, placebo-controlled investigation in gynecologic surgical patients. Anesth Analg. 2014 Jun; 118(6):1204-12.

[8] Percival VG, Riddell J, Corcoran TB. Single dose dexamethasone for postoperative nausea and vomiting—a matched case–control study of postoperative infection risk. Anaesth Intensive Care 2010; 38: 661–6