Combination of clonidine-bupivacaine in caudal epidural anesthesia for hypospadias surgery in children: prospective, randomized, blind study / Associação clonidina-bupivacaína na anestesia peridural caudal para cirurgia de hipospádia em crianças: estudo prospectivo, randomizado, encoberto

Abstract Background and objectives: The combination of clonidine with local anesthetic administered for epidural anesthesia via caudal route seems to improve the quality of postoperative analgesia, but with conflicting results. This study compared the postoperative analgesia of three different doses of clonidine combined with bupivacaine in caudal epidural anesthesia in children undergoing hypospadias repair. Methods: Eighty children aged 1-10 years, candidates for surgical repair of hypospadias, were randomly divided into four groups of 20 patients to receive general anesthesia combined with caudal epidural anesthesia with bupivacaine 0.165% alone or in combination with 1, 2 or 3 µg.kg- 1 of clonidine. The primary outcome was morphine consumption in the first 24 h postoperatively. Mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, time to awakening, pain severity (FLACC scale), level of sedation (RAMSAY), duration of analgesia, and occurrence of adverse effects were also compared. Results: Intraoperatively, there was no difference between groups regarding mean arterial pressure, heart rate, end-tidal concentration of sevoflurane, and time to awakening. Postoperative morphine consumption and pain severity were similar between groups, but the group receiving clonidine (3 µg.kg-1) had lower heart rate and higher sedation level than the group receiving bupivacaine alone. Conclusions: The combination of clonidine at doses of 1, 2 or 3 µg.kg-1 with bupivacaine 0.16% via caudal epidural route did not alter the consumption of morphine in the early postoperative period of children undergoing hypospadias repair.

Resumo Justificativa e objetivos: A associação de clonidina ao anestésico local administrado por via peridural caudal parece melhorar a qualidade da analgesia pós-operatória, mas com resultados conflitantes. Este estudo comparou a analgesia pós-operatória de três diferentes doses de clonidina associada à bupivacaína na anestesia peridural caudal em crianças submetidas à correção de hipospádia. Método: Oitenta crianças entre um e dez anos, candidatas à correção cirúrgica de hipospádia, foram divididas, aleatoriamente, em quatro grupos de 20 pacientes para receber anestesia geral associada à anestesia peridural caudal com bupivacaína 0,166% isolada ou associada a 1, 2 ou 3 µg.Kg-1 de clonidina. Como desfecho principal avaliou-se o consumo de morfina nas primeiras 24 horas de pós-operatório. Compararam-se também pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano, tempo de despertar da anestesia, intensidade da dor pela escala FLACC, nível de sedação (Ramsay), tempo de duração da analgesia e ocorrência de efeitos adversos. Resultados: No transoperatório, não houve diferença entre os grupos quanto à pressão arterial média, frequência cardíaca, concentração expirada de sevoflurano e ao tempo de despertar. No pós-operatório, o consumo de morfina e a intensidade da dor foram similares entre os grupos, mas o grupo que recebeu 3 µg.Kg-1 de clonidina apresentou menor frequência cardíaca e maior sedação do que o grupo que recebeu somente bupivacaína. Conclusões: A associação de clonidina nas doses de 1, 2 ou 3 µg.Kg-1 à bupivacaína 0,166% por via peridural caudal não alterou o consumo de morfina no pós-operatório imediato de crianças submetidas à correção de hipospádia.

Study of dorsal wall of sacrum.

Background: Sacrum is a large triangular bone formed by fusion of five sacral vertebrae. The opening present at the caudal end of sacral canal is known as sacral hiatus and is formed due to the failure of fusion of lamina of fifth sacral vertebra. Objective of current study was to study the anatomical variations of dorsal wall of sacrum in order to clarify the structural variations of sacral hiatus and surrounding structures for improving the reliability of caudal epidural block Methods: The present study was done on 50 male and 50 female dry human sacra after calculating the sacral indices and sexing of sacra. The dorsal wall of sacrum was studied with respect to composition of sacrum, level of sacral hiatus, deficiencies and apertures in the bony dorsal wall and also for the presence and absence of sacral cornua. Results: The level of apex of sacral hiatus can vary from upper part of S2 to lower part of S5. The most common position was at S4 (64%). Elongated sacral hiatus at the level of S2 was present in 4% of cases. Sacrum had normal 5 segments in 70% of cases, 4 segmented sacra were observed in 4% of cases, sacralization of 5th lumbar vertebra in 7%, coccygeal ankylosis in 19% of cases. Less extensive apertures in the bony dorsal wall of sacral canal were observed in 29% of sacra. Conclusion: The dorsal wall of sacrum has anatomical variations. Understanding these variations may improve the reliability and success of caudal epidural anesthesia.

Importance of knowing the level of sacral hiatus for caudal epidural anesthesia

Introduction and Materials and Methods: The Study was carried out on 100 dry human sacra to know the Anatomical variations of sacral hiatus. Results: Different shapes of sacral hiatus were observed which included- Inverted U (56%), Inverted V (14%), Irregular (16%), Dumb-bell (10%), Bifid (2%) and Elongated (2%). The apex of the sacral hiatus was most commonly found at the level of 3rd sacral vertebrae in 62%. The mean length of sacral hiatus was 25.2mm, the mean anteroposterior diameter of sacral canal at the apex of sacral hiatus was 5.53mm. The mean distance between sacral cornu at the base of sacral hiatus was observed to be 19.5mm. Conclusion: This study was done to clarify the anatomical variations of sacral hiatus using bony landmarks of sacrum for improving the reliability of caudal epidural anesthesia and to improve its success rate and reduce the complications and failure rate.(AU)

Simple Modification of Caudal Epidural Anesthesia Technique in Pre-school Children for Improved Success rate, Safety and Quality of Block.

Caudal Epidural Anesthesia (CEA) or Kiddy caudal is a safe and effective method of anesthesia in paediatric patients. Incidence of failed or incomplete block of CEA could be reduced by simple modification of technique with early onset of analgesia, adequate surgical relaxation, rapid and smooth recovery from anesthesia and freedom from post-operative pain. Identification of epidural space using small volume of air and using mixture of lidocaine with epinephrine and bupivacaine for block provides excellent operating conditions with improved success rate avoiding supplementary general anesthetic requirement. Our experience in 120 pre-school children for infraumbilical surgery is described.

Analgesic effect of caudal epidural ketamine in cattle

This study was performed to clarify the analgesic effect of ketamine injected into the first intercoccygeal (Co1-Co2) epidural space in standing cattle. Five adult cows were randomly received 3 treatments at least 1 week interval: 5, 10 and 20 mL of 5% ketamine. Sedation, analgesia, ataxia and other effects on cardiopulmonary and rumen functions were assessed before ketamine administration and until 120 min. The analgesia without sedation was shown at tail and perineum about 5 min after all three treatments. The duration of analgesia was significantly increased according to the volume of ketamine (p < 0.01). There was a similar tendency of ataxia with individual variation. There were minimal effects on cardiopulmonary and rumen functions. The present study showed that caudal epidural ketamine administration induced analgesia without sedation in cows, and the duration of analgesia was dose dependent with ataxia. However, the duration of analgesia after 5 and 10 mL ketamine administration is short for common surgical procedures and pain relief of perineum. Further studies are needed to prolong the duration of analgesia without side effects.