COMPARISON OF CAUDAL BLOCK ALONE WITH CAUDAL BLOCK PLUS INTRAVENOUS DEXAMETHASONE FOR POSTOPERATIVE ANALGESIA IN CHILDREN UNDERGOING ORCHIDOPEXY UNDER GENERAL ANAESTHESIA.
Background: Caudal block involves injection of local anaesthetic in the caudal epidural space and is commonly used for providing analgesia in children undergoing infraumbilical surgeries like orchidpexy. The role of intravenous dexamethasone in prolonging the duration of caudal block is a new concept. Prolonged duration of analgesia not only keeps the patient pain free for an extended period of time but also reduces the cost of treatment when it comes to analgesic drugs and duration of hospital stay.
Objective: To compare the efficacy of caudal block alone with caudal block plus intravenous dexamethasone for postoperative analgesia in children undergoing orchidopexy under general anaesthesia.
Methodology: In this randomized controlled trial 100 children (ages 1 5 years) planned to undergo orchidopexy were randomly allocated to two groups A and B. In both groups after induction with halothane and succinylcholine 1.5 mg/kg caudal block was performed by injecting 0.25% bupivacaine 0.5 ml/kg using a 22 gauge needle. Patients in group A were also given injection dexamethasone 1.5 mg/kg intravenously. Surgery was allowed to proceed 10 minutes after caudal block in both groups. Postoperative pain was assessed in both groups using FLACC score 5 minutes after extubation and then after every 30 minutes till a FLACC score of 5 was obtained at which point first dose of acetaminophen was given. Time to first analgesic dose was noted in both groups and compared using Independent sample t test.
Results: Mean duration of analgesia turned out to be 621.60 25.743 and 402.40 34.792 in group A and group B respectively with a P value of less than 0.0001.
Conclusion: Dexamethasone when given intravenously just after caudal block is administered effectively prolongs the duration of caudal block in paediatric patients undergoing orchidopexy.
Key Words: Caudal block dexamethasone analgesia postoperative orchidopexy children.
About 2 5% of full term male babies have cryptorchidism (undescended testes). Cryptorchidism if left untreated not only leads to infertility but also increases the risk for testicular carcinoma.1 The condition is surgically treated by a procedure called orchidopexy. Pain after surgical procedure is one of the most common problems encountered. During any surgical procedure tissue destruction occurs which results in activation of various enzymatic reactions leading to production of prostaglandins and other mediators of pain. This process not only occurs at the site of injury but also via blood borne mechanism centrally.2 Poorly controlled postoperative pain can have various effects on the patient like nausea vomiting elevated blood cortisol levels leading to increase in heart rate and hypertension which are particularly devastating for patients with preexisting cardiovascular compromise.
Urinary retention and reduced immune response leading to increased risk of infection are among the other effetcs.3 For mild to moderate pain nonsteroidal antiinflammatory drugs (NSAIDS) are used. Acetaminophen ibuprofen salicylates and diclofenac are some of the examples of NSAIDS. They inhibit prostaglandin synthesis centrally and peripherally by inhibiting cyclooxygenase I and cyclooxygenase II. They are administered most commonly by oral route. A few of them can be administered intravenously as well e.g. ketorolac. Opioids have also been used for pain management in children; however they have many undesirable side effects including sedation respiratory depression nausea vomiting constipation dependence and hyperalgesia.4 It must be noted that both opioids and NSAIDS demonstrate a ceiling effect" and further pain relief is not possible once that level is achieved.5 Over the past few decades the concept of regional anaesthesia in children has dramatically changed.
It not only provides excellent analgesia but also shortens the duration of hospital stay.5 These blocks also provide an opportunity to limit the use of opioids thereby avoiding their side effects which are very distressing at times for the patients.6
Several treatment modalities are being used to reduce the postoperative pain associated with infraumblical surgeries in children such as orchidopexy. Caudal block being the most common among them.7 Dexamethasone apart from being an antiemetic for postoperative nausea and vomiting also has analgesic and antiinflammatory properties.8 Several studies have shown that dexamethasone prolongs the analgesic effect of non steroidal antiinflammatory drugs. Glucocorticoids exert their analgesic effects by inhibiting phospholipase and COX II thus blocking the synthesis of prostaglandins.2
Jokela et al showed in their study that intravenous dexamethasone 15 mg given prior to induction of anaesthesia reduces the consumption of oxycodone in first 24 hours of postoperative period. During first 2 hours after surgery dexamethasone 10 mg reduces the oxycodone consumption as effectively as the 15 mg dose.8
Hong et al suggested that intravenous dexamethasone when given with caudal block prolonged its duration by 50%.7 Need of administrating first dose of oral acetaminophen was significantly delayed in the dexamethasone group than in control group (646 149 vs. 430 205 min)9.
The use of dexamethasone can effectively prolong the effect of caudal block to nearly double the time as proven in international literature. Data regarding this is not available in our setup as genetic variability has been noted regarding response to various modes of analgesia7 so this study will provide the base line information that benefits the patient in our population in terms of analgesia and cost effectiveness.
MATERIALS AND METHODS
After approval of the ethical committee and informed parental consent 100 ASA I and II male children of ages 1 5 years and weight up to 20kg planned to undergo orchidopexy under general anaesthesia were included in the study (Non probability purposive sampling). Children with hypersensitivity to any local anaesthetic based on history bleeding diathesis by doing PT/APTT and bleeding time and infections at the puncture site or neurological deficit were not included. Patients were allocated to group A and B using a random number table.
Data Collection Procedure: After arrival in the operation theatre standard monitors such as pulse oximeter electrocardiogram (ECG) and noninvasive blood pressure monitor (NIBP) were applied. Inhalational induction with halothane in oxygen was carried out. Intravenous (I/V) line was then secured. After giving inj. suxamethonium 1.5 mg/kg intubation was done using appropriate sized endotracheal tube. Anaesthesia was maintained with isoflurane 2% and 50% nitrous oxide in oxygen. Patients were placed in lateral position and caudal block was performed by the anaesthetist using short beveled 22 gauge needle. After aseptic measures and identifying the space by loss of resistance method with normal saline and negative aspiration for blood and cerebrospinal fluid patients received injection bupivacaine plain 0.25% 0.5 ml/kg body weight.
After performing caudal block the patients in group A were given intravenous dexamethasone 1.5 mg/kg in 5ml while patients in group B received same volume of normal saline. Surgery was allowed to start 10 minutes after the block. At the end of surgery patients were given 100% O2 and were extubated when awake. Pain was assessed 5 minutes after extubation and then every 30 minutes till the FLACC score became 5 at which point first dose of acetaminophen was given to the patients and time noted starting from 5 minutes after extubation to the first dose of oral analgesic. Both researchers who administered I/V injection
Table 1: The FLACC Pain Scale.
###Occasional gramise or frown###Frequent to constant frown
Face###No particular expression or smile
###withdrawn disinterested###clenched jaw quivering chin
Leg###Normal position or relaxed###Uneasy restless tense###Kicking or legs drawn up
###Ly ing quietly normal position###Squirming shifting back n forth
Activity###Arched rigid or jerking
###m oves easily###tense
###Moans or whim pers occasional###Cry steadily scream s or sobs
Cry###No cry (awake or asleep)
###com plaints###frequent com plaints
###Reassured by occasional touching
Consolability###Content relaxed###Difficulty to console or com fort
###hugging or talking to distractible
and those who recorded FLACC score and time were not aware of the group of the patients thus ensuring blindness.
Data Analysis: All data was entered and analyzed in SPSS version 16.0. Time to first rescue analgesia in two groups was noted in terms of minutes mean and standard deviation calculated and compared using independent sample t test. Pvalue = 0.05 was considered significant with confidence level of 95%.
The demographic profile of the patients in both groups with regards to age was comparable in both groups. Each group had patients with age ranging from 1 to 5 years. The mean age of patients in group A turned out to be 3.14 1.702 years while that in group B it was 3.24 1.546.The analgesia due to caudal block lasted for a minimum and maximum period of 570 and 660 minutes respectively in group A while the figures turned out to be 320 and 420 minutes for group B. Comparison of mean duration of analgesia was 621.60 25.743 and 402.40 34.792 minutes in group A and group B respectively with a P value of less than 0.0001.
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.10 Children with significant postoperative pain may demonstrate anxiety fright insomnia which often exacerbate their pain perception rendering the postoperative recovery period an unpleasant and traumatic experience. Other deleterious consequences of pain include sleep disturbance nausea vomiting prolonged hospital stay and parental dissatisfaction.1113 So providing them comfort in postoperative period is a highly desirable yet challenging task. Oral analgesics cannot be given to the children in immediate postoperative period. Also there are side effects of opioids such as nausea vomiting itching and above all respiratory depression. Similarly nonsteroid antiinflammatory drugs are at times contraindicated because the renal function is not fully mature in the early years of life.1416
Regional anaesthesia not only provides an extended pain free period but also reduces the stress responses of surgery.14 Caudal block has been found to be an excellent and safe technique for providing postoperative analgesia in paediatric population with a high success rate. However the single shot of caudal block provides analgesia for a limited period of time. To increase this duration various methods have been utilized.
Table 2: Distribution of cases by age.
Groups###Group A###Group B
Total Number of Cases###50###50
Maximum Age (Years)###5###5
Minimum Age (Years)###1###1
Table 3: Comparison of minimum and maximum duration of analgesia in two study groups.
###Minimum duration of Maximum duration of
###analgesia (minutes)###analgesia (minutes)
Caudal + I/V###570###660
Caudal block alone
Table 4: Comparison of mean duration of analgesia in two study groups.
###Mean duration of
Caudal plus I/V###621.60###25.743
Caudal block alone
P Value###less than 0.0001
The use of catheter technique did not gain popularity because of risk of infections.141718 Various additives have been tried successfully till now to increase the duration of caudal block including epinephrine clonidine dexmedetomidine neostigmine ketamine morphine tramadol and fentanyl. However they do have their share of undesirable side effects.171920
Our study shows that intravenous dexamethasone significantly prolongs the duration of caudal block (P less than 0.0001). Thus those patients who were given intravenous dexamethasone along with caudal block (group A) enjoyed a much longer period of postoperative analgesia than those in group B who received caudal block alone. Patients were given analgesia at a FLACC score of 5 or more. There were no failed blocks in our study and all patients had effective caudal block for a minimum duration of 5 hours approximately.
The results in our study were comparable to those of Hong et al who showed that the mean duration of analgesia after caudal block reaches up to 646 minutes if intravenous dexamethasone is administered to the patients.12
The proposed mechanism of this prolongation in duration of caudal block is the strong antiinflammatory property of dexamethasone.8921
Use of dexamethasone for prolonging the caudal block is a new concept. However Bigat et al showed in their study that addition of 8 mg of dexamethasone to lignocaine (3 mg/kg) for intravenous regional anaesthesia significantly lowers the pain score and hence the need for analgesia in first 24 hour after surgery. The number of patients who requested for analgesia in postoperative period were significantly lower in lingocaine plus dexamethasone group (P = 0.033).21
Jokela et al concluded in their study that intravenous dexamethasone in a dose of 15 mg administered before induction of anaesthesia decreased the consumption of oxycodone in the first 24 hours of laparoscopic hysterectomy.8
Dexamethasone unlike other intravenous adjuncts or additives to caudal block does not cause problems like prolonged sedation vomiting or urinary retention rather dexamethasone has anti emetic properties and is used for prevention of postoperative nausea and vomiting.2224 Also as dexamethasone in our study is used intravenously and not in caudal space concerns regarding its neurotoxicity are not valid.
Dexamethasone in high doses or in continuous use can produce side effects like hyperglycemia and adrenocortical suppression but single dose of 1.5 mg/kg used in our study is not likely to produce such harmful effects. Therefore in the absence of any contraindications to its use intravenous dexamethasone can be used as an effective safe and economical adjunct to caudal block. Further studies to investigate effect of dexamethasone on onset of block and duration of motor block can also be carried out.
It is concluded that dexamethasone when given intravenously just after caudal block is administered effectively prolongs the duration of caudal block in pediatrics patients undergoing orchidopexy.
We are thankful to the administration of King Edward Medical University / Mayo Hospital Lahore all the respected faculty of Department of Anaesthesiology and medical paramedical staff working in the Paediatrics Operation theatre and Ward for the help support and facilitation to complete this study.
CONFLICT OF INTEREST
There is no conflict of interest among the authors of this article.
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