Caudal additives to ropivacaine in children: preservative free S‐ketamine versus clonidine

Abstract

recorded and interpreted by content analysis. Children were encouraged to draw a picture of what it was like to be on the PICU. Results A total of 38 interviews were carried out and 44 speci®c recollections were reported; the majority being neutral (60%) or positive (25%). Only 15% of recollections were negative. Negative recollections related to aspects of medical care and environmental factors. Only one ventilated child could clearly rememeber the presence of the tracheal tube, and she highlighted the anxiety that resulted from inability to communicate. No child treated with neuromuscular blocking agents remembered any period of therapeutic paralysis. The majority of children drawing pictures drew themselves standing beside or lying in their bed (Figure 1).Discussion Adult patients frequently remember extensive unpleasant details of the therapy received during intensive care admissions, including therapeutic paralysis. Our data suggests that children's recollections are more positive, although almost one-third of children remembered being in pain and several complained about noise levels. Conclusion Children's recollections of PICU are mainly neutral or positive. Mechanically ventilated children who are sedated with infusions of midazolam and morphine remember little of tracheal intubation. The effects on subsequent patient recall should be considered when assessing the ef®cacy of sedation regimes in intensive care.

Effect of epidural clonidine on minimum local anesthetic concentration (ED50) of levobupivacaine for caudal block in children

“…In the clonidine group, 90% of patients required no analgesia within the first 24 h compared to 55% in the plain ropivacaine group. DeNegri (30) demonstrated a 100% increase in mean duration of analgesic effect with 2 μg·kg −1 clonidine and 0.2% ropivacaine compared to 0.2% ropivacaine alone. Akbas (27) reported increased duration of postoperative analgesia (14 vs 4 h) in patients receiving 0.75 ml·kg −1 ropivacaine with 2 μg·kg −1 clonidine.…”

Local anesthetics in infants and children: an update

“… Combine local anesthetics with either opioids (17), clonidine (18), or S+ ketamine (19,20) in the epidural infusion, to provide synergistic analgesic effects while maintaining safe local anesthetic dosing. Administer acetaminophen and either NSAIDs or COX‐2 inhibitors round‐the‐clock to provide an additional systemic analgesic effect. Permit low‐dose intravenous opioids as rescue analgesics. …”

“…Combine local anesthetics with either opioids (17), clonidine (18), or S+ ketamine (19,20) in the epidural infusion, to provide synergistic analgesic effects while maintaining safe local anesthetic dosing.…”

“…Currently available local anesthetics have limitations, including local and systemic toxicities, insufficient sensory selectivity, and insufficient duration of analgesia following single‐shot injection. One approach intended to reduce cardiotoxicity and improve sensory selectivity is to use single stereoisomers, including ropivacaine (15,19,32–35) and levo‐bupivacaine (36,37). These agents may provide modest increases in therapeutic index.…”

S(+)‐ketamine in paediatric anaesthesia

“…Based on the results of previous studies that tested the epidural and caudal administration of racemic ketamine (12,13), several recent investigations in children have examined the caudal approach for using S(+)‐ketamine (7,9,10,14,15). Racemic ketamine has been used for paediatric caudal blocks (13) and has demonstrated an analgesic potency comparable with that of bupivacaine.…”