Single injection paravertebral block for renal surgery in children

Background:  Continuous paravertebral block (PVB) has been successfully used for postoperative analgesia in children. However, data regarding the efficacy of a single injection technique for major renal surgery are still lacking.
Methods:  Following the ethics committee approval and parent informed consent, 24 children (median 10.3 months; range: 2.9–26.8) undergoing major renal surgery were included in a prospective observational pilot study. Following a standardized general anesthetic the patients were administered a single injection low thoracic PVB (loss-of-resistance technique; 0.5 ml·kg⁻¹ of levobupivacaine 2.5 mg·ml⁻¹ with epinephrine 5 μg·ml⁻¹) at the end of surgery. Postoperative pain was assessed by Face, Legs, Activity, Cry, Consolability (FLACC) score at predetermined time points and in case of apparent patients' discomfort during the first 12 postoperative hours. The duration of postoperative analgesia was defined as the interval between PVB and the first supplemental administration of a rescue opioid analgesic. The incidence of complications and postoperative vomiting (POV) was also recorded.
Results:  A successful PVB was achieved in 23/24 patients (95.8%). The median duration of the block was 600 min (range: 180–720 min) with 10 children not requiring any supplemental analgesia during the 12-h observation period. Vascular puncture was observed in 2/24 children (8.3%) and POV occurred in 4/24 children (16.7%). All complications were considered minor and did not influence recovery.
Conclusions:  Single injection PVB provided clinically relevant postoperative analgesia in children undergoing major renal surgery.     

Levobupivacaine–tramadol combination for caudal block in children: a randomized,double‐blinded,prospective study1

Background: The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg·kg⁻¹ and mixture of both in children undergoing day‐case surgery. Methods: Sixty‐three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg·kg⁻¹ (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml·kg⁻¹). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children’s and Infants’ Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was ≥4. Results: No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 ± 160 min vs 322 ± 183 min and 248 ± 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. Conclusion: Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.     

右美托咪定复合罗哌卡因骶管阻滞在小儿腹腔镜疝手术中的应用

目的 探讨右美托咪定(dexmedetomidine,Dex)复合罗哌卡因骶管阻滞在腹腔镜下小儿腹股沟疝手术中的作用. 方法采 用随机数字表法将52例斜疝患儿分为两组(每组26例):A组,Dex 1 μg/kg复合0.25％罗哌卡因1 ml/kg骶管阻滞;B组,0.25％罗哌卡因骶管阻滞组.记录两组患儿麻醉前(T0)、骶管阻滞后5 min(T1)、切皮时(T2)、手术结束时(T3)、拔气管导管时(T4)、苏醒后10 min时(T5)的MAP和HR,观察术后苏醒时间、苏醒时躁动发生率、躁动评分、术后镇痛评分、术后追加镇痛药的发生率及副作用. 结果 A组HR在T4时显著低于B组[(106±12)次/min比(117±12)次/min] (P＜0.05).与B组比较,A组苏醒期躁动发生率[3.8％比23.1％]、躁动评分[(1.9±0.6)分比(3.1±0.7)分]和术后4、8、12、16 h FLACC疼痛评分[(1.1±0.6)分比(2.2±0.7)分、(1.2±0.6)分比(3.8±0.9)分、(2.3±0.6)分比(4.2±0.7)分、(2.6±0.9)分比(3.8±0.8)分]均降低(P＜0.05);两组苏醒时及术后2、24 h的FLACC疼痛评分差异无统计学意义(P＞0.05).B组术后使用镇痛药曲马多为4例,A组无使用曲马多者(P＜0.05).两组均未发生明显的副作用. 结论 与单独使用罗哌卡因相比,Dex复合罗哌卡因骶管阻滞用于腹腔镜下小儿腹股沟疝手术能降低拔管时的应激反应,减少小儿苏醒期躁动,明显延长罗哌卡因骶管阻滞的术后镇痛时间.     

Caudal 0.2% ropivacaine is less effective during surgery than 0.2% levobupivacaine and 0.2% bupivacaine: a double-blind, randomized, controlled trial

BACKGROUND: We hypothesized that without the analgesic effects of volatile anesthetics, caudal 0.20% ropivacaine would be less effective during surgical stimulation than 0.20% bupivacaine or 0.20% levobupivacaine. This trial was designed to examine whether the combination of a caudal block with 0.20% ropivacaine and i.v. anesthesia resulted in reduced analgesic efficacy during surgery compared with caudal 0.20% levobupivacaine or 0.20% bupivacaine in children. METHODS: Ninety ASA I-II children between 1 and 7 years old, scheduled for inguinal hernia repair or orchidopexy under propofol anesthesia were randomized to receive a caudal block with 1 ml x kg(-1) of 0.2% bupivacaine, 0.2% ropivacaine or 0.2% levobupivacaine. The primary outcome measure of the study was the clinical efficacy of the caudal block during surgery. Secondary outcome measures were postoperative pain relief and residual motor blockade. RESULTS: Four children were excluded and 86 were analyzed. The proportion of children with effective caudal block during surgery was significantly higher in children receiving levobupivacaine (26/28) or bupivacaine (27/29) compared with patients receiving ropivacaine (21/29) (P = 0.03). There were no significant differences among groups in the analgesic onset time (P = 0.1), incidence of residual motor blockade (P = 0.4), number of patients requiring analgesia after operation or in the time from caudal injection to the first administration of analgesic medication (P = 0.3). CONCLUSIONS: Combined with propofol anesthesia, 0.2% levobupivacaine and 0.2% bupivacaine are more effective than 0.2% ropivacaine for caudal use in children undergoing inguinal hernia repair or orchidopexy.     

A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade

BACKGROUND: The aim of our study was to compare postoperative analgesic efficacy, analgesic duration and motor blockade of levobupivacaine, ropivacaine and bupivacaine administered caudally in equal concentrations to children undergoing elective minor surgery. METHODS: In the study, 182 children, aged 1-7 years, undergoing either inguinal hernia repair or orchidopexy, were randomly allocated to one of the three groups. They received via a caudal extradural either 1 ml x kg(-1) levobupivacaine 0.2% (Group L) or 1 ml x kg(-1) ropivacaine 0.2% (Group R) or 1 ml x kg(-1) bupivacaine 0.2% (Group B). RESULTS: No statistically significant difference was noted in age, weight, duration of the operation or level of the caudal block between the groups. The onset of analgesia was significantly later after levobupivacaine. Postoperative pain scoring evaluated with Children's and Infant's Postoperative Pain Scale observational scale showed no statistical difference between groups. Median postoperative analgesia was 5.75 h (SEMed: +/- 0.65) in Group L, 5.7 h (SEMed: +/- 0.8) in Group R and 5.35 h (SEMed: +/- 1.3) in Group B the difference being statistically nonsignificant. CONCLUSIONS: The degree of motor block was significantly less after ropivacaine and levobupivacaine during the first 2 h postoperatively.     

A comparison of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for analgesia after inguinal herniorrhaphy in children

The aim of this study was to compare the efficacy of nerve stimulator guided paravertebral block with ilio-inguinal nerve block in children undergoing inguinal herniorrhaphy. Eighty children were randomly allocated to receive either paravertebral block or ilio-inguinal nerve block. Each block was evaluated in terms of intra-operative haemodynamic stability, postoperative pain scores at rest, on movement and during activity, requirement for supplemental analgesia and parental satisfaction. Haemodynamic stability was maintained significantly better during sac traction in the paravertebral block group (p < 0.005). Pain scores and analgesic consumption were significantly lower in the paravertebral block group during the postoperative follow-up period (p < 0.05). Parental satisfaction (93%vs 69%) and surgeon satisfaction (93%vs 64%) were significantly higher in the paravertebral block group (p < 0.05). Paravertebral blockade improved and prolonged postoperative analgesia, and was associated with greater parental and surgeon satisfaction when compared to ilio-inguinal nerve block.     

Comparison of continuous thoracic epidural and paravertebral blocks for postoperative analgesia after minimally invasive direct coronary artery bypass surgery

OBJECTIVE: To compare continuous thoracic epidural analgesia (TEA) and paravertebral block (PVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass (MIDCAB) surgery for quality of analgesia, complications, compliance to chest physiotherapy, hemodynamics, and respiratory effects. DESIGN: Prospective, randomized study. SETTING: Specialty research hospital. PARTICIPANTS: Forty-one consenting patients undergoing MIDCAB surgery. INTERVENTIONS: Patients in the TEA group had an epidural catheter inserted at the T4-5 interspace, whereas patients in the PVB group had a catheter inserted in the paravertebral space on the left side at the T4-5 level. MEASUREMENTS AND MAIN RESULTS: Parameters evaluated included visual analog scale pain scores at rest and while coughing, supplemental analgesic requirement, complications, hemodynamics, and respiratory parameters. Measurements were made at 2-hour intervals for 12 hours beginning at 10 minutes after endotracheal extubation. There was no statistically significant difference in visual analog scale scores and requirement of supplemental analgesia between the 2 groups. Cardiac index at 4 hours and 6 hours was significantly higher in the TEA group. Patients in the PVB group had significantly lower respiratory rates at 8, 10, and 12 hours. All other parameters were comparable. In 1 patient, the epidural space could not be catheterized. One patient in the TEA group had transient hypotension, and 1 patient complained of backache at the site of the epidural catheter insertion. CONCLUSION: PVB is as effective as TEA for postoperative analgesia after MIDCAB surgery. PVB is technically easier than TEA and may be safer than TEA because no complications were seen in the PVB group.     

Paravertebral vs epidural block in children. Effects on postoperative morphine requirement after renal surgery

Continuous thoracic paravertebral blockade (PVB) has only recently been reported in pediatric patients. The aim of the present study was to compare retrospectively the postoperative analgesic efficacy of PVB vs conventional lumbar epidural blockade (EDA) in children. Thirty–five consecutive pediatric patients undergoing renal surgery, receiving either PVB (n = 15) or EDA (n = 20), were reviewed. The need for supplemental morphine administration during the first 24 postoperative hours was used to assess the postoperative analgesic efficacy of the two different regional techniques. Both the total amount of supplemental morphine and the number of patients with no need for supplemental morphine administration, were compared between the two groups. The need for supplemental morphine administration was significantly lower ( P = 0.046) and the number of patients with no need for supplemental morphine administration postoperatively was significantly higher ( P = 0.019) in patients treated with PVB vs EDA. The present study indicates that PVB may possess a potential for postoperative analgesia equal to or maybe even superior to conventional lumbar EDA in pediatric patients undergoing renal surgery. Further prospective studies investigating the analgesic efficacy of this novel technique are warranted.     

超声引导下腹横肌平面阻滞在患儿腹腔镜下腹股沟疝手术中的应用

目的探讨超声引导下腹横肌平面(TAP)阻滞在腹腔镜下患儿腹股沟疝手术中的作用。方法 56例患儿斜疝患儿随机均分为两组:A组静脉全麻诱导后超声引导下双侧TAP阻滞,每侧注射0.25%盐酸罗哌卡因0.5ml/kg,B组注入等量生理盐水。术中盐酸瑞芬太尼及以2%~5%的七氟醚维持麻醉,观察两组患儿术后苏醒时间、苏醒时躁动发生率、躁动评分、术后镇痛评分、家长满意度及术后追加镇痛药的发生率。结果 A组在苏醒期躁动发生率和躁动评分、术后2、4、8h的FLACC评分均明显低于B组(P0.05),术后12h两组VAS疼痛评分差异无统计学意义。A组术后家长满意度明显高于B组(P0.05)。B组术后曲马多使用例数明显多于A组(P0.05)。结论超声引导下TAP用于腹腔镜下小儿疝气手术安全有效,可减少小儿苏醒期躁动,减轻术后疼痛,提高家长满意度。     

Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy

OBJECTIVES: We compared the quality and duration of analgesia, the effect on perioperative sevoflurane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efficacy of morphine administered caudally in children. METHODS: Patients were randomly divided into three groups to receive 2 mg.kg-1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mg.kg-1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mg.kg-1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia. RESULTS: There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevoflurane concentration was significantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications. CONCLUSION: Caudal tramadol (2 mg.kg-1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mg.kg-1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevoflurane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia.     

Paravertebral blockade vs general anesthesia or spinal anesthesia for inguinal hernia repair

One hundred and fifty-five patients scheduled for inguinal hernia repair (IHR) were given the choice of either general anesthesia (GA) (n = 53) or spinal anesthesia (SP) (n = 47) or nerve stimulator guided paravertebral blockade (PVB) (n = 55). The incidence of postoperative nausea and vomiting (PONV), duration of hospital stay and need for postoperative analgesia were recorded. Apart from a difference in the age of patients in the GA group who were found to be slightly younger, all groups were found similar with regard to weight, height, duration of surgery, sex, type of hernia and ASA class. The incidence of PONV (0%) v/s 19% and 21% was significantly reduced in patients treated with the PVB compared to patients receiving SA and GA respectively. The length of hospital stay was also found to be shorter in the PVB group (mean 1.2 days) v/s SA (mean 2.4 days) and GA (mean 2.9 days). The need for supplemental postoperative analgesics was also found to be higher in both SA and GA when compared to PVB patients who were managed without any analgesics during the first 24 postoperative hours. The described technique appears to be an attractive alternative method to provide adequate anesthesia for IHR.     

Bilateral paravertebral somatic nerve block for ventral hernia repair

BACKGROUND AND OBJECTIVE: Unilateral paravertebral nerve blockade has been reported to produce excellent afferent nerve block, reduce the incidence of postoperative nausea and vomiting, and reduce hospital stay following inguinal hernia repair. The aim was to compare the use of bilateral paravertebral blocks to regular general anaesthesia for ventral hernia repair. METHODS: Sixty patients were prospectively allocated to receive either bilateral paravertebral nerve blockade (midazolam for block; supplemented with light intraoperative sedation if needed) or general anaesthesia for ventral hernia repair. The end-points of the study were length of hospital stay, postoperative analgesia (visual analogue scale, supplemental opioid requirement) and incidence of postoperative nausea and vomiting. RESULTS: The duration of hospital stay was observed to be shorter in patients handled with bilateral paravertebral nerve blockade (2.3 [SD 1.3] days) compared with patients receiving general anaesthesia (4.1 (3.0) days). Paravertebral analgesia resulted in both lower visual analogue scores and a significantly reduced need for supplemental opioid administration during the first 48 h postoperatively compared with general anaesthesia (P < 0.001). The rate of postoperative nausea and vomiting in the paravertebral nerve blockade group was only 3.3%, while 26.7% of patients in the general anaesthesia group suffered from postoperative nausea and vomiting (P < 0.05). Paravertebral nerve blockade was associated with good patient acceptance in 90% of patients. CONCLUSIONS: Bilateral paravertebral blockade combined with light intravenous sedation was superior to general anaesthesia for ventral hernia repair. Paravertebral blockade was associated with shorter hospital stay, improved analgesia and less postoperative nausea and vomiting. It is suggested that this technique deserves more widespread use in patients undergoing ventral hernia repair.     

Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children

Background. The rationale for replacing racemic bupivacainewith the s-enantiomers levobupivacaine and ropivacaine is toprovide a wider margin of safety with the same analgesic efficacyand less postoperative motor block. In a randomized, double-blind,phase III, controlled trial we compared the caudal administrationof levobupivacaine 0.25% and ropivacaine 0.25% with bupivacaine0.25% in children. Methods. Ninety-nine ASA I–II children less than 10 yrold scheduled for elective sub-umbilical surgery were randomizedto receive caudal block with bupivacaine 0.25%, ropivacaine0.25% or levobupivacaine 0.25%. The primary outcome of the studywas the clinical efficacy of the caudal block during the operation.Secondary outcome measures were analgesic onset time, pain reliefafter the operation and residual motor blockade. Results. The proportion of children with effective analgesiaduring the operation was similar among groups. There were nosignificant differences in the analgesic onset time of the caudalblock. Bupivacaine produced a significant incidence of residualmotor block compared with levobupivacaine or ropivacaine atwake-up (P<0.01). There were no significant differences inthe number of patients receiving rescue analgesia after surgery.However, analgesic block lasted significantly longer in patientsreceiving bupivacaine (P=0.03). Conclusion. During sub-umbilical surgery, caudal levobupivacaine,ropivacaine and bupivacaine provided comparable analgesic efficacy.Bupivacaine produced a higher incidence of residual motor blockadeand a longer analgesic block than ropivacaine and levobupivacaine.      

Levobupivacaine caudal anesthesia in children: a randomized double-blind comparison with bupivacaine

BACKGROUND: Levobupivacaine is the pure S-enantiomer of bupivacaine. Despite obvious benefits in the event of accidental intravascular injection there has been no studies demonstrating a clinically significant benefit to levobupivacaine over racemic bupivacaine for pediatric regional anesthesia. Given the similar pharmacokinetic profiles of both drugs the studies to date have been underpowered to demonstrate what is likely to be a small difference in clinical effectiveness. Our aim was to determine if there are significant differences in the clinical effectiveness of levobupivacaine compared with racemic bupivacaine for caudal anesthesia in children having lower abdominal surgery. A secondary aim was to determine if there are differences in the incidence of postoperative motor blockade between these agents. METHODS: Three hundred and ten children ranging in age from 1 month to 10.75 years in age having lower abdominal surgery were enrolled. Patients were randomized in a double blind manner to receive a caudal block with either 0.25% bupivacaine (n = 152) or 0.25% levobupivacaine (n = 155) to a total volume of 1 ml x kg(-1). Motor blockade (modified Bromage scale) and postoperative pain or distress (FLACC behavioral scale for postoperative pain) were measured at predetermined time points during the subsequent 120 min. RESULTS: There were no significant adverse effects attributable to levobupivacaine. Success rates were defined as a lack of hemodynamic response to first surgical incision and low postoperative pain scores. At a mean duration of 5 min between block completion and first incision success for 1 ml x kg(-1) of 0.25% bupivacaine was 91% and 94% for 0.25% levobupivacaine. Satisfactory postoperative analgesia was present in 98% of patients after bupivacaine caudal anesthesia and 97.5% for levobupivacaine. At 30 min following caudal anesthesia the incidence of postoperative motor block with racemic bupivacaine was 84% and decreased to 7% at 120 min. For levobupivacaine motor block at 30 min postcaudal was present in 85% and decreased to 11% at 120 min. CONCLUSIONS: Levobupivacaine is an effective agent for caudal anesthesia in children at a recommended dose of 2.5 mg x kg(-1). The rapidity of onset was suitable for establishment of surgical anesthesia and postoperative analgesia was achieved in greater than 97.5% of patients. It appears to be of equivalent potency to racemic bupivacaine in children requiring lower abdominal surgery.     

Awake caudal anesthesia for inguinal hernia operations

Neonates with inguinal hernia face a relatively high risk of incarcerated hernia and bowel obstruction and this therefore requires surgical treatment. Complications following general anesthesia even for minor surgery are more common in low birth weight neonates than in term neonates. Caudal epidural anesthesia without adjunct general anesthesia has been recommended for neonates to reduce the risk of postoperative complications. The successful application of awake caudal anesthesia with levobupivacaine for inguinal hernia repair in 15 low birth weight neonates is reported. Single dose caudal epidural anesthesia was administered for inguinal hernia surgery to avoid complications associated with general anesthesia. Caudal block was performed with 2.5?mg/kg body weight (BW) levobupivacaine. Caudal anesthesia can be recommended as an effective technique for avoiding postoperative anesthetic complications in low birth weight neonates.     

Caudal anesthesia for minor pediatric surgery: a prospective randomized comparison of ropivacaine 0.2% vs levobupivacaine 0.2%

BACKGROUND: Previous published data comparing ropivacaine 0.2% with levobupivacaine 0.25% have suggested that ropivacaine might be associated with less early postoperative motor blockade compared with levobupivacaine. The aim of the present study was to further investigate this issue comparing equal concentrations (0.2%) of ropivacaine and levobupivacaine in children undergoing minor subumbilical surgery. METHODS: Following induction of a standardized anesthetic, patients (1-7 years) were randomized in a double-blind manner to receive a caudal block with either ropivacaine 0.2% (group R, n=30) or levobupivacaine 0.2% (group L, n=30), total volume 1 ml.kg-1. Motor blockade (modified Bromage scale; primary end-point) and analgesia [Children and Infants Postoperative Pain Scale (CHIPPS) score] were assessed at predetermined time points during the first 24-postoperative hours. RESULTS: Motor blockade was only registered during the first postoperative hour with no significant differences between the groups (group R n=5, group L n=8). Postoperative CHIPPS scores were almost identical in both groups with only seven and six patients requiring supplemental analgesia (CHIPPS score>or=4) in the R and L groups, respectively. CONCLUSIONS: A 0.2% concentrations of ropivacaine or levobupivacaine are clinically very similar with regard to postoperative analgesia and unwanted postoperative motor blockade in children undergoing minor subumbilical surgery.     

Unilateral groin surgery in children: will the addition of an ultrasound‐guided ilioinguinal nerve block enhance the duration of analgesia of a single‐shot caudal block?

Background: Inguinal hernia repair, hydrocelectomy, and orchidopexy are commonly performed surgical procedures in children. Postoperative pain control is usually provided with a single‐shot caudal block. Blockade of the ilioinguinal nerve may lead to additional analgesia. The aim of this double‐blind, randomized controlled trial was to evaluate the efficacy of an adjuvant blockade of the ilioinguinal nerve using ultrasound (US) guidance at the end of the procedure with local anesthetic vs normal saline and to explore the potential for prolongation of analgesia with decreased need for postoperative pain medication. Methods: Fifty children ages 1–6 years scheduled for unilateral inguinal hernia repair, hydrocelectomy, orchidopexy, or orchiectomy were prospectively randomized into one of two groups: Group S that received an US‐guided ilioinguinal nerve block with 0.1 ml·kg^?1 of preservative‐free normal saline and Group B that received an US‐guided nerve block with 0.1 ml·kg^?1 of 0.25% bupivacaine with 1 : 200 000 epinephrine at the conclusion of the surgery. After induction of anesthesia but prior to surgical incision, all patients received caudal anesthesia with 0.7 ml·kg^?1 of 0.125% bupivacaine with 1 : 200 000 epinephrine. Patients were observed by a blinded observer for (i) pain scores using the Children and Infants Postoperative Pain Scale, (ii) need for rescue medication in the PACU, (iii) need for oral pain medications given by the parents at home. Results: Forty‐eight patients, consisting of 46 males and two females, with a mean age of 3.98 (sd ± 1.88) were enrolled in the study. Two patients were excluded from the study because of study protocol violation and/or alteration in surgical procedure. The average pain scores reported for the entire duration spent in the recovery room for the caudal and caudal/ilioinguinal block groups were 1.92 (sd ± 1.59) and 1.18 (sd ± 1.31), respectively. The average pain score difference was 0.72 (sd ± 0.58) and was statistically significant (P < 0.05). In addition, when examined by procedure type, it was found that the difference in the average pain scores between the caudal and caudal/ilioinguinal block groups was statistically significant for the inguinal hernia repair patients (P < 0.05) but not for the other groin surgery patients (P = 0.13). For all groin surgery patients, six of the 23 patients in the caudal group and eight of the 25 patients in the caudal/ilioinguinal block group required pain rescue medications throughout their entire hospital stay or at home (P = 0.76). Overall, the caudal group received an average of 0.54 (sd ± 1.14) pain rescue medication doses, while the caudal/ilioinguinal block group received an average of 0.77 (sd ± 1.70) pain rescue medication doses; this was, however, not statistically significant (P = 0.58). Conclusions: The addition of an US‐guided ilioinguinal nerve block to a single‐shot caudal block decreases the severity of pain experienced by pediatric groin surgery patients. The decrease in pain scores were particularly pronounced in inguinal hernia repair patients.     

Levobupivacaine 0.25% compared with ropivacaine 0.25% by the caudal route in children

BACKGROUND AND OBJECTIVE: Levobupivacaine is the most recently introduced local anaesthetic into clinical practice. In a randomized double-blinded study, the onset, intraoperative tolerance, postoperative analgesic effect, motor blockade and any adverse reactions produced by levobupivacaine were compared with ropivacaine. METHODS: Sixty children, ASA I-II, 2-6 yr old, undergoing elective minor surgery, received a single caudal injection of 1 mL kg(-1) of either levobupivacaine 0.25% or ropivacaine 0.25%. Caudal blocks were performed after induction of inhalation general anaesthesia using sevoflurane; anaesthesia was maintained via a laryngeal mask airway using a mixture of sevoflurane, oxygen and air. RESULTS: Onset time, intraoperative tolerance, postoperative analgesic effect and motor blockade were comparable between the two groups. The mean onset of the block was 8.2 +/- 2.2 min for levobupivacaine and 8.5 +/- 3.0 min for ropivacaine (P = 0.66). Additional analgesics during operation were not required in any of the children. No significant difference was found for mean time to requirement of additional analgesia with rectal acetaminophen (paracetamol) (302 +/- 29 min for the levobupivacaine group and 230 +/- 38 min for the ropivacaine group (P = 0.32)). During the first 4 h after placement of caudal block, the pain assessment score (according to the Children Hospital Eastern Ontario Pain Scale) was comparable for the two groups. No motor block was observed in any group on awakening, nor during the observation period. CONCLUSIONS: We conclude that levobupivacaine 0.25% 1 mL kg(-1) provides caudal block of comparable onset and duration, as produced by the same volume and concentration of ropivacaine.     

Nerve Stimulator-guided Paravertebral Blockade Combined with Sevoflurane Sedation versus General Anesthesia with Systemic Analgesia for Postherniorrhaphy Pain Relief in Children: A Prospective Randomized Trial

Background: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair.

Methods: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair.

Results: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05).     

Nerve stimulator-guided paravertebral blockade combined with sevoflurane sedation versus general anesthesia with systemic analgesia for postherniorrhaphy pain relief in children: a prospective randomized trial

BACKGROUND: Improvement of the duration of postoperative analgesia is desirable in children undergoing inguinal hernia repair. METHODS: Fifty children aged 5-12 yr were prospectively randomized to receive either paravertebral nerve blockade or general anesthesia (sevoflurane-fentanyl-nitrous oxide-oxygen) combined with standardized postoperative systemic analgesia, both combined with light sevoflurane anesthesia, for inguinal hernia repair. RESULTS: Mean pain scores were significantly lower in paravertebral nerve blockade patients compared with patients treated with systemic analgesia during the entire 48-h observational period (P < 0.05). Analgesic consumption was significantly higher in the systemic analgesia group (88%) compared with the paravertebral nerve blockade group (32%) (P < 0.001). Parental satisfaction was significantly higher (80 vs. 48%; P < 0.05) and same-day discharge was possible in a higher proportion of patients in the paravertebral blockade group (80% vs. 52%; P < 0.05). CONCLUSIONS: Paravertebral nerve blockade was associated with improved postoperative pain relief; reduced analgesic consumption, and faster hospital discharge compared with a systemic analgesia protocol in children undergoing herniorrhaphy.