Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine

Sharpe, Paul T.; Klein, Julianne; Thompson, Jonathan P.; Rushman, S.; Sherwin, Jennifer; Wandless, J.G.; Fell, David

doi:10.1046/j.1460-9592.2001.00748.x

Cited by 65 publications

(66 citation statements)

References 27 publications

(75 reference statements)

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“…This result is not consistent with the results of the studies that used clonidine (2 µg/kg) with a low concentration (0.125%) of bupivacaine (1 mL/kg), in which analgesic efficacy was not significantly improved. [22][23][24] The authors of those studies speculated that clonidine 2 µg/kg may not be effective with a lowconcentration of bupivacaine, although the exact mechanism is unclear. However, DEX is a more selective α2-adrenoceptor agonist and is eight times potent than clonidine.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, caudal DEX with a low-concentration of local anesthetics induces less adverse effects (motor weakness, delayed micturition of urinary retention) that may affect early discharge from hospital, compared with a higher concentration of local anesthetics. 3,4,10,12,13,23) DEX has anxiolytic, sedative, and hypnotic properties caused by stimulation of the α2-adrenoceptor in the locus coeruleus in brain where it decreases a neuronal activation 9,24) and can reduce the requirement of concomitantly administered hypnotics, analgesics, or anesthetics. 25) Intravenous DEX significantly decreases the sevoflurane requirement 5,26) for anesthesia and EA during recovery.…”

Section: Discussionmentioning

confidence: 99%

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The Effect of 1 µg/kg Dexmedetomidine Combined with High-Volume/Low-Concentration Caudal Ropivacaine in Children Undergoing Ambulatory Orchiopexy

Cho

Kim

Park

et al. 2015

Biological & Pharmaceutical Bulletin

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When local anesthetics are used, the administration of dexmedetomidine (DEX) can prolong analgesic duration. However, the effect of caudal DEX on high volume/low concentration (HVLC) local anesthetics has not been studied. We investigated the analgesic effect of DEX added to a HVLC of ropivacaine for caudal block in children. Eighty children (the American Society of Anesthesiologists (ASA) status I; age, 1-6 years) undergoing ambulatory orchiopexy were enrolled in the study. Children were randomly assigned to undergo a caudal block with 1.5 mL/kg of 0.15% ropivacaine and either 1 µg/kg of DEX (DEX group, n 40) or the same amount of saline (Control group, n 40) under general anesthesia. The results showed that the time to first analgesic request was significantly longer in the DEX group than in the control group. The sevoflurane requirement for anesthesia and frequency of emergence agitation (EA) were also significantly lower in the DEX group. There was no difference in adverse events between the two groups. In conclusion, a dose of 1 µg/ kg of caudal DEX prolonged the first analgesic request time, although the immediate postoperative pain scores were comparable in both groups. Furthermore, caudal DEX significantly reduced the sevoflurane requirement and the frequency of EA.Key words dexmedetomidine; caudal block; child; orchiopexy Caudal block is common method for postoperative analgesia in children undergoing infra-umbilical surgery. One major limitation of caudal block is a relatively short analgesic duration owing to the single-injection. Thus, adjuvants such as ketamine, clonidine, or opioids are frequently added to the local anesthetics in order to improve analgesic efficacy and duration.1,2) The effectiveness of local anesthetics using in caudal block is dependent upon the dose, volume, and concentration of the local anesthetic solution, but high-concentration local anesthetics can increase the incidence of motor weakness, delayed micturition, or urinary retention. In children undergoing ambulatory surgery, such adverse effects can prolong the discharge time and may result in inadvertent admission. Recently, high-volume/low-concentration (HVLC) regimens for caudal blocks in children (1.5 mL/kg of 0.1-0.2% local anesthetics) have gained popularity following a report by Silvani et al. that demonstrated that a HVLC regimen provides a longer analgesic duration with less adverse effects than conventional dose/concentration. [3][4][5][6][7][8] However, the analgesic duration is still limited in caudal block with single-injection.Dexmedetomidine (DEX) is a highly selective α 2 adrenoceptor agonist with an α2/α1 selectivity ratio of 1600 : 1, and is eight times more potent than clonidine. 9) DEX is successfully used as an adjuvant in caudal blocks for children in order to reduce pain without inducing any significant respiratory and hemodynamic effects. Several studies have reported that in children, caudal DEX (1-2 µg/kg) with 0.25% bupivacaine (1 mL/kg) prolongs postoperative analgesic duration by 2.5-3 fold comp...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The Effect of 1 µg/kg Dexmedetomidine Combined with High-Volume/Low-Concentration Caudal Ropivacaine in Children Undergoing Ambulatory Orchiopexy

Cho

Kim

Park

et al. 2015

Biological & Pharmaceutical Bulletin

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“…167,168 There is good evidence for a high incidence of mild postoperative motor block and delay in walking after the CB procedure (21% to 44%) in older children. 167,169,170 Caudal analgesia may be less available in facilities that do not treat many pediatric patients.…”

Section: Caudal Blockmentioning

confidence: 99%

Male Circumcision

Blank¹,

Brady²,

Buerk³

et al. 2012

Pediatrics

299

149

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Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP’s 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association’s template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners’ competency in discussing circumcision’s benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.Elective circumcision should be performed only if the infant’s condition is stable and healthy.Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;Teach the procedure and analgesic techniques during postgraduate training programs;Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.

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“…Our findings corroborate with previous studies. 7,8,9,10 which have reported clonidine 1-2mcg/kg added to bupivacaine for caudal block increase the duration of analgesia in small children undergoing ambulatory hernia repair and sub umbilical surgeries compared to bupivacaine alone.…”

Section: Discussionmentioning

confidence: 99%

“…10 which can be explained by the fact that the quality, level and duration of caudal blockade depends on the dose, volume and concentration of the drugs injected authors compared the duration of postoperative analgesia in children undergoing hypospadiasis repair with different volumes and concentration of fixed doses of ropivacaine local anaesthetic and concluded that high volume low concentration regime produces prolonged analgesia as compared to low volume high concentration. Our data with clonidine for caudal block corroborate with those results of previous studies.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of Clonidine as an Adjuvant to Bupivacaine for Caudal Block in Children Undergoing Infra - Umbilical Surgery

G¹,

Hiremath²

2015

jemds

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Caudal epidural analgesia with bupivacaine is common in paediatric anaesthesia for providing intra and postoperative analgesia. But duration of analgesia even with bupivacaine; long acting anaesthetic is short only 4-6hrs. Hence, several adjuvants have been tried to prolong the duration of action of bupivacaine. We evaluated the efficacy of clonidine added to bupivacaine in prolonging the analgesic effect provided by caudal bupivacaine in children undergoing infraumbilical surgery. Forty children, aged one to seven years, American Society of Anaesthesiologists (ASA) Grade I/II, undergoing infra-umbilical surgery, were included in prospective randomized double blind study to one of two groups: caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine in normal saline (Group A) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with 1 µg/kg of clonidine in normal saline (Group B). Post-operative pain was assessed for 24 hours using the Objective Pain Scale (OPS). The mean duration of analgesia was significantly longer in Group B (10.2 Hrs.) than in Group A (4.2 1Hrs); P<0.05, which was statistically significant. In both the groups, there were no significant changes in the heart rate and mean arterial pressure from the baseline value, in the intraoperative as well as postoperative period (p>0.05). The requirement of rescue medicine was lesser in Group B. Clonidine as an adjunct to bupivacaine prolongs the post-operative pain relief in children and is safe compared to bupivacaine alone in paediatric infra umbilical surgeries.

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Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine

Abstract: For paediatric circumcision, under general anaesthesia, the addition of clonidine 2 microg x kg(-1) to low volume (0.5 ml x kg(-1)) caudal anaesthetics has a limited clinical benefit for children undergoing circumcision.

Cited by 65 publications

References 27 publications

The Effect of 1 µg/kg Dexmedetomidine Combined with High-Volume/Low-Concentration Caudal Ropivacaine in Children Undergoing Ambulatory Orchiopexy

The Effect of 1 µg/kg Dexmedetomidine Combined with High-Volume/Low-Concentration Caudal Ropivacaine in Children Undergoing Ambulatory Orchiopexy

Male Circumcision

Efficacy of Clonidine as an Adjuvant to Bupivacaine for Caudal Block in Children Undergoing Infra - Umbilical Surgery

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