Anda di halaman 1dari 6
<a href=Journal of Clinical Anesthesia 52 (2019) 105–110 Contents lists available at ScienceDirect Journal of Clinical Anesthesia journal homepage: www.elsevier.com/locate/jclinane Original contribution Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial T Purnima Narasimhan , Lokesh Kashyap , V.K. Mohan , Mahesh Kumar Arora , Dilip Shende , Maddur Srinivas , Seema Kashyap , Sayan Nath , Puneet Khanna Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India Department of Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi, India Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India Department of Ocular Pathology, All India Institute of Medical Sciences, New Delhi, India ARTICLE INFO Keywords: Analgesia Child Regional Ultrasound Single-shot Pyeloplasty ABSTRACT Study objective: This study was undertaken to compare the analgesic e ffi cacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries. Design: Randomised, interventional, blinded clinical trial. Setting: Operating rooms of All India Institute of Medical Sciences, New Delhi, India. Patients: 50 children aged 2 – 10 years, of ASA status I/II, posted for elective renal surgeries. Interventions: The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline. Measurements: Time to fi rst rescue analgesia, time to perform blocks, intraoperative and post-operative hemo- dynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded. Main results: Children in Group P had signi fi cantly longer duration of analgesia ( p < 0.0004) than Group C. Post-operative FLACC scores ( p < 0.005) and analgesic requirements ( p < 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μ g/kg, compared to 1.8 ± 1.2 μ g/kg in group C. Parents in Group P reported greater satisfaction ( p < 0.02). No complications were seen in either of the groups. Conclusion: This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice. 1. Introduction Renal surgeries, one of the common surgical procedures performed in children, are associated with signi fi cant post-operative pain. Good post-operative analgesia is essential to allow e ff ective coughing and early mobilisation to reduce the occurrence of post-operative re- spiratory complications. In pediatric patients, caudal epidural block, via landmark approach, remains the most commonly performed regional anesthetic technique [ 1 ]. The use of ultrasound has facilitated the correct placement of the block, even in children with sacral anomalies [ 2 ]. The use of peripheral nerve blocks in children is on the rise with the advent of ultrasound and nerve stimulators, which assist in better identi fi cation of fascial planes. Paravertebral block has been used for post-operative analgesia in children since 1992 [ 3 ]. The main advantages include localised pain control and the ability to avoid large volumes of local anesthetic [ 4 ]. It is a promising alternative to caudal analgesia [ 5 ]. The use of ultrasound in pediatric regional analgesia has great utility because these are often performed under deep sedation or general anesthesia. Ultrasound gui- dance o ff ers a qualitative anatomic end-point, provides the ability to observe local anesthetic spread during injection, and can be used to identify abnormal anatomy [ 6 ]. This study was undertaken to compare Corresponding author at: Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi 110029, India. E-mail address: lokeshkashyap@yahoo.com (L. Kashyap). https://doi.org/10.1016/j.jclinane.2018.09.007 Received 3 May 2018; Received in revised form 22 August 2018; Accepted 8 September 2018 0952-8180/ © 2018 Elsevier Inc. All rights reserved. " id="pdf-obj-0-5" src="pdf-obj-0-5.jpg">

Contents lists available at ScienceDirect

Journal of Clinical Anesthesia

<a href=Journal of Clinical Anesthesia 52 (2019) 105–110 Contents lists available at ScienceDirect Journal of Clinical Anesthesia journal homepage: www.elsevier.com/locate/jclinane Original contribution Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial T Purnima Narasimhan , Lokesh Kashyap , V.K. Mohan , Mahesh Kumar Arora , Dilip Shende , Maddur Srinivas , Seema Kashyap , Sayan Nath , Puneet Khanna Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India Department of Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi, India Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India Department of Ocular Pathology, All India Institute of Medical Sciences, New Delhi, India ARTICLE INFO Keywords: Analgesia Child Regional Ultrasound Single-shot Pyeloplasty ABSTRACT Study objective: This study was undertaken to compare the analgesic e ffi cacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries. Design: Randomised, interventional, blinded clinical trial. Setting: Operating rooms of All India Institute of Medical Sciences, New Delhi, India. Patients: 50 children aged 2 – 10 years, of ASA status I/II, posted for elective renal surgeries. Interventions: The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline. Measurements: Time to fi rst rescue analgesia, time to perform blocks, intraoperative and post-operative hemo- dynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded. Main results: Children in Group P had signi fi cantly longer duration of analgesia ( p < 0.0004) than Group C. Post-operative FLACC scores ( p < 0.005) and analgesic requirements ( p < 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μ g/kg, compared to 1.8 ± 1.2 μ g/kg in group C. Parents in Group P reported greater satisfaction ( p < 0.02). No complications were seen in either of the groups. Conclusion: This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice. 1. Introduction Renal surgeries, one of the common surgical procedures performed in children, are associated with signi fi cant post-operative pain. Good post-operative analgesia is essential to allow e ff ective coughing and early mobilisation to reduce the occurrence of post-operative re- spiratory complications. In pediatric patients, caudal epidural block, via landmark approach, remains the most commonly performed regional anesthetic technique [ 1 ]. The use of ultrasound has facilitated the correct placement of the block, even in children with sacral anomalies [ 2 ]. The use of peripheral nerve blocks in children is on the rise with the advent of ultrasound and nerve stimulators, which assist in better identi fi cation of fascial planes. Paravertebral block has been used for post-operative analgesia in children since 1992 [ 3 ]. The main advantages include localised pain control and the ability to avoid large volumes of local anesthetic [ 4 ]. It is a promising alternative to caudal analgesia [ 5 ]. The use of ultrasound in pediatric regional analgesia has great utility because these are often performed under deep sedation or general anesthesia. Ultrasound gui- dance o ff ers a qualitative anatomic end-point, provides the ability to observe local anesthetic spread during injection, and can be used to identify abnormal anatomy [ 6 ]. This study was undertaken to compare Corresponding author at: Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi 110029, India. E-mail address: lokeshkashyap@yahoo.com (L. Kashyap). https://doi.org/10.1016/j.jclinane.2018.09.007 Received 3 May 2018; Received in revised form 22 August 2018; Accepted 8 September 2018 0952-8180/ © 2018 Elsevier Inc. All rights reserved. " id="pdf-obj-0-16" src="pdf-obj-0-16.jpg">

Original contribution

Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial

T
T

Purnima Narasimhan a , Lokesh Kashyap a , , V.K. Mohan a , Mahesh Kumar Arora b , Dilip Shende a , Maddur Srinivas c , Seema Kashyap d , Sayan Nath a , Puneet Khanna a

a Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India b Department of Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi, India c Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India d Department of Ocular Pathology, All India Institute of Medical Sciences, New Delhi, India

ARTICLE INFO

Keywords:

Analgesia

Child

Regional

Ultrasound

Single-shot

Pyeloplasty

ABSTRACT

Study objective: This study was undertaken to compare the analgesic ecacy of ultrasound-guided single-shot caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries. Design: Randomised, interventional, blinded clinical trial. Setting: Operating rooms of All India Institute of Medical Sciences, New Delhi, India. Patients: 50 children aged 210 years, of ASA status I/II, posted for elective renal surgeries. Interventions: The children were randomised into two groups (Group C-caudal block, Group P-paravertebral block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline. Measurements: Time to rst rescue analgesia, time to perform blocks, intraoperative and post-operative hemo- dynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded. Main results: Children in Group P had signicantly longer duration of analgesia (p < 0.0004) than Group C. Post-operative FLACC scores (p < 0.005) and analgesic requirements (p < 0.0004) were lower in Group P. The mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μg/kg, compared to 1.8 ± 1.2 μg/kg in group C. Parents in Group P reported greater satisfaction (p < 0.02). No complications were seen in either of the groups. Conclusion: This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in children requires adequate expertise and practice.

1. Introduction

Renal surgeries, one of the common surgical procedures performed in children, are associated with signicant post-operative pain. Good post-operative analgesia is essential to allow eective coughing and early mobilisation to reduce the occurrence of post-operative re- spiratory complications. In pediatric patients, caudal epidural block, via landmark approach, remains the most commonly performed regional anesthetic technique [1]. The use of ultrasound has facilitated the correct placement of the block, even in children with sacral anomalies [2]. The use of peripheral nerve blocks in children is on the rise with the

advent of ultrasound and nerve stimulators, which assist in better identication of fascial planes. Paravertebral block has been used for post-operative analgesia in children since 1992 [3]. The main advantages include localised pain control and the ability to avoid large volumes of local anesthetic [4]. It is a promising alternative to caudal analgesia [5]. The use of ultrasound in pediatric regional analgesia has great utility because these are often performed under deep sedation or general anesthesia. Ultrasound gui- dance oers a qualitative anatomic end-point, provides the ability to observe local anesthetic spread during injection, and can be used to identify abnormal anatomy [6]. This study was undertaken to compare

Corresponding author at: Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi 110029, India. E-mail address: lokeshkashyap@yahoo.com (L. Kashyap).

Received 3 May 2018; Received in revised form 22 August 2018; Accepted 8 September 2018

0952-8180/ © 2018 Elsevier Inc. All rights reserved.

P. Narasimhan et al.

Journal of Clinical Anesthesia 52 (2019) 105–110

the analgesic ecacy of ultrasound-guided caudal epidural block with ultrasound-guided single-shot paravertebral block in children under- going renal surgeries, namely pyeloplasties.

2. Materials & methods

  • 2.1. Study design and participants

This prospective randomised single blind interventional study was conducted at the All India Institute of Medical Sciences after receiving Institutional Review Board approval (Reg. No. CTRI/006688), in ac- cordance with the CONSORT guidelines. Informed written consent was taken from the guardians of the children who were enrolled in the study. The routine anesthetic prac- tice at our institute for Anderson-Hynes pyeloplasty is the administra- tion of single-shot caudal block after induction of general anesthesia or local inltration of the surgical wound. In this study, single-shot caudal block was compared with single-shot paravertebral block. Fifty chil- dren, aged 210 years, of ASA physical status I/II planned for Anderson- Hynes pyeloplasty were randomised into two groups: Group C (caudal block) and Group P (paravertebral block), using sealed envelopes. Exclusion criteria included contraindications to regional analgesic procedures, neurological/cardiac disease, developmental delay, spine or chest wall deformity, history of previous renal surgeries and history of sensitivity to drugs used in the study. All the children were followed up for 24 h post-operatively, by an anesthesiologist who was blinded to the block given. The primary outcome was the time to rst analgesic requirement in the 24 h follow-up period. The secondary outcomes were the time required to perform the blocks, FLACC scores in the 24 h post-operative period, analgesic requirement in each group, incidence of block-related complications and the parental satisfaction scores. The primary outcome in our study was time to rst rescue analgesia. On the basis of previous available literature, the time to rst rescue analgesia after a caudal block in pyeloplasty was expected at 287.63 ± 68 min [7]. Assuming 20% increase in time to rst rescue analgesia in the paravertebral block group at the rate of 5% level of signicance to achieve 80% power of the study, we required 24 samples in each group.

  • 2.2. Study protocol

The perioperative anesthetic management was standardised. The children were induced either inhalationally or intravenously, along with fentanyl 2 μg/kg and atracurium 0.5 mg/kg. Airway was secured with an appropriate size endotracheal tube. Thereafter, anesthesia was maintained with O 2 /N 2 O (1:1) and isourane. The baseline hemody- namic parameters were noted and the children were positioned either for caudal block or paravertebral block. The time to perform the block was noted. Any change in the intra-operative hemodynamic parameters by > 20% was considered as inadequate analgesia and treated with 1 μg/kg fentanyl boluses. The hemodynamic parameters and the number of fentanyl boluses were recorded. Towards the end of the surgery, all the children received intravenous ondansetron 0.1 mg/kg as anti-emetic prophylaxis, and intravenous paracetamol 15 mg/kg, which was continued 6th hourly post-operatively. After the extubation of trachea, all the children were shifted to PACU where the hemodynamic parameters and FLACC scores were recorded at 0, ½, 1st, 2nd, 3rd, 6th, 12th and 24th hours. If FLACC score of > 3 was recorded, the child was rst managed by non-pharmacologic means (tactile stimulation, change of position, warming/cooling, etc.) in order to make the child com- fortable again. If the child did not settle down, rescue analgesia with fentanyl 1 μg/kg was administered. In cases where rescue analgesia was needed within rst 2 h, the block was considered a failure. The time to rst rescue analgesia, number of fentanyl boluses, total amount of fentanyl required and the parental satisfaction scores were recorded.

  • 2.3. Ultrasound-guided block: procedure

The blocks were administered by an anesthesiologist who is familiar with the use of ultrasound-guided blocks for post-operative analgesia, both in adults and children.

  • 2.3.1. Caudal block

Children in group C were turned to lateral decubitus position for ultrasound-guided caudal block. After cleaning and draping, a high- frequency 38 mm linear transducer was placed transversely over the sacral cornu to get the frog-eyeappearance. The probe was then turned longitudinally to obtain a sagittal view of the caudal space. Using 5 cm, 22 G needle, caudal block was given with 1.25 ml/kg of 0.2% ropivacaine with 1:200000 adrenaline, by in-plane approach.

  • 2.3.2. Paravertebral block

Children in group P were turned to lateral decubitus position for ultrasound-guided paravertebral block at T10 level. After cleaning and draping, a high-frequency 38 mm linear transducer was placed long- itudinally to identify the spinous processes of T9-T10. The probe was then moved laterally till the respective transverse processes and the corresponding paravertebral spaces were seen. The probe was then turned obliquely, and using in-plane approach, 0.5 ml/kg of 0.2% ro-

pivacaine with 1:200000 adrenaline was injected at the T10 para- vertebral space with 19 G Touhy needle.

  • 2.4. Statistical analysis

The data were analysed using STATA 14.0 and SPSS 20.0. Continuous measurements were presented as mean ± SD, median (IQR) and categorical variables were presented as numbers. Chi-square/ Fisher exact test was used to nd the signicance of study parameters on a categorical scale between the two groups. Unpaired sample t-test was used to nd the signicance of study parameters on continuous scale between two groups. The comparison between the two groups, when the variables were not normally distributed, was done by Mann- Whitney U test. p < 0.05 was considered signicant.

3. Results

As shown in Table 1, the baseline characteristics were comparable between both the groups, except for the time taken to perform the block. The time taken to administer the block was 288.1 ± 146 s (CI:

227.8348.4) in group P compared to 114.7 ± 68.1 s (CI: 86.6142.8) in group C (p < 0.0001). There was no statistically signicant dierence in the heart rate (p = 0.34) and mean arterial pressures (p = 0.29) amongst the two groups, recorded every 5 min intraoperatively (Figs. 1 & 2). The requirement of fentanyl boluses intraoperatively was compar- able between both the groups (p = 0.46). 12 children in group C and 9

Table 1

Demography and patient characteristics (data expressed as mean ± SD, median (IQR) or proportions as applicable).

Variable

Group C (n = 25)

Group P (n = 25)

p value

Age (yrs) Weight (kg) Sex (male/female) ASA I/II Time to give the block (s) Duration of surgery (min)

5.1 ± 2.6 17.1 ± 6.0

20/5

22/3

114.7 ± 68.1 99.6 ± 20.7

6.0 ± 2.6 19.5 ± 6.1

19/6

25/0

288.1 ± 146 98.2 ± 22.8

0.23

a

0.16

a

0.99

c

0.23

c

0.0001 b

0.82 a

a t-Test. b Mann-Whitney test. c Fisher's exact.

106

P. Narasimhan et al.

Journal of Clinical Anesthesia 52 (2019) 105–110

P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110 Fig. 1. Comparison between the

Fig. 1. Comparison between the heart rates of both the groups intraoperatively.

children in group P required fentanyl boluses in the intraoperative period (Table 2). The mean analgesic requirement intraoperatively in group C was 0.72 ± 1.1 μg/kg vs 0.52 ± 0.82 μg/kg in group P (p = 0.46). At 0, ½, 1, 2, 3, 6, 12 and 24 h post-operatively, there was no sta- tistically signicant dierence in the heart rate (p = 0.13) and mean arterial pressure (p = 0.68) between the two groups. Median FLACC score was 2 in both the groups during the 24 h follow up period. As shown in Fig. 3, the dierence in the FLACC scores were noted to be statistically signicant from the 3rd post-operative hour, with group C having higher scores than group P. The post-op- erative FLACC scores did not show dierences that were statistically signicant at 0 (p = 0.64), 0.5 (p = 0.46), 1 (p = 0.71), and 2 h (p = 0.53). However, the FLACC scores were statistically dierent be- tween the two groups at 3 (p < 0.001), 6 (p < 0.05), 12 (p < 0.002) and 24 h (p < 0.002). The median FLACC scores are shown in Table 3. One child in group P needed rescue analgesia after 30 min of shifting to PACU and hence, the block was considered a failure. 20 children in Group C had an analgesic requirement in the follow-up period compared to only 9 in Group P. Amongst those who required the rescue analgesia, the mean time to rst rescue analgesia in Group P was 664.4 ± 223.4 min (CI: 492.7836.2) which was signicantly longer than 391.8 ± 217.4 min (CI: 290493.5) in Group C (p < 0.002). The median time to rst analgesic rescue amongst children who had a de- mand was 660 min in Group P compared to 322.5 min in Group C,

Table 2

Intraoperative fentanyl bolus requirement (data are expressed as numbers (%)).

Number of fentanyl boluses

Group C (n = 25)

Group P (n = 25)

  • 0 13 (52)

16 (64)

  • 1 9 (36)

6 (24)

  • 2 2 (8)

2 (8)

  • 3 0 (0)

1 (4)

  • 5 1 (4)

0 (0)

(p = 0.78, Fisher's exact).

which was statistically signicant (p < 0.004). Kaplan-Meier survival estimate for all the children in both the groups, irrespective of analgesic consumption (Fig. 4) shows that > 50% of children in group P did not require rescue analgesia (p < 0.0004), which was statistically sig- nicant. The post-operative analgesic requirements were statistically sig- nicantly dierent between the two groups. The median number of analgesic dose requirement in group C was two, while it was nil in group P (p < 0.0002). The mean fentanyl requirement over 24 h in group C was 1.8 ± 1.2 μg/kg, compared to 0.56 ± 0.82 μg/kg in group P, which was statistically signicant (p < 0.0002). 15 children in group P did not require rescue analgesia in the 24 h follow-up period compared to 5 in group C (p < 0.0004). Amongst the children who

P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110 Fig. 1. Comparison between the

Fig. 2. Comparison between the mean arterial pressures of both the groups intraoperatively.

107

P. Narasimhan et al.

Journal of Clinical Anesthesia 52 (2019) 105–110

P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110 Fig. 3. Post-operative FLACC scores.

Fig. 3. Post-operative FLACC scores.

Table 3

Comparison of post-operative FLACC scores between the two groups (data ex-

pressed as median (range)).

FLACC

Group C

Group P

p value

 

Time

0

0 (01)

0 (01)

0.64

0.5

0 (02)

0 (04)

0.46

  • 1 0 (02)

0 (02)

0.71

  • 2 1 (02)

1 (05)

0.53

  • 3 1 (02)

2 (04)

0.001

 
  • 6 1(05)

2 (05)

0.05

  • 12 1(04)

2 (18)

0.002

  • 24 1(03)

2 (05)

0.002

p < 0.05. p < 0.005 (Mann Whitney test).

P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110 Fig. 3. Post-operative FLACC scores.

Fig. 4. Kaplan Meier survival curve for both the groups of the rescue analgesic requirement.

required rescue analgesic, the requirement in group P was 1.4 ± 0.7 μg/kg (CI: 0.91.9) vs 2.25 ± 0.85 μg/kg (CI: 1.852.64) in group C, which was a statistically signicant reduction in the analgesic consumption children in group P (p < 0.006). None of the patients in either of the groups had any complications during block performance. The incidence of complications was

comparable in both the groups. Post-operative nausea and vomiting was noted in one child in group C against none in group P. Though not statistically signicant (p = 0.35), three children in group C had ur- inary retention compared to one child in group P.

There was a statistically signicant dierence in the parental sa- tisfaction score (Appendix A) between the two groups, as shown in the Fig. 5, with parents of 18 children belonging to group P reporting ex- cellent satisfaction with regard to pain relief (p < 0.02).

4. Discussion

Caudal block is routinely performed at our institute for providing post-operative analgesia after Anderson-Hynes pyeloplasty. Paravertebral block in children is used occasionally, by anesthesiolo- gists familiar with use of ultrasound-guided blocks. It is used less fre- quently as it requires better skill and also due to the risk of complica- tions, especially pneumothorax, associated with it. This study was undertaken at our institute to compare the analgesic ecacy of caudal block and paravertebral block. Both the blocks were performed by the same anesthesiologist, who is familiar with ultra- sound-guided blocks. Our study showed that single-shot paravertebral block provided better analgesia than caudal block in children after pyeloplasty. 15 of the 24 children in group P did not have rescue an- algesic requirement in the 24 h follow-up period. Berta and co-workers [8], in their prospective observational pilot study in 24 children un- dergoing major renal surgery, found that the median duration of post- operative analgesia achieved with single-shot paravertebral block was 10 h. Ten of the 24 children did not require rescue analgesia in the 12 h follow up period. Similar results were also reported in a retrospective study comparing continuous thoracic paravertebral blockade with continuous lumbar epidural blockade, by Lönnqvist and coworkers [9], in 35 children undergoing renal surgery. They also concluded that the analgesia provided by PVB is superior as the children in PVB group had signicantly lower morphine consumption (81 μg/kg (0297) vs 143 μg/kg (0362), p < 0.05) than the children in lumbar epidural group in the post-operative period. Tug and coworkers [10] postulated that the longer duration of analgesia with paravertebral block com- pared to caudal block was probably due to the increased vascularity of the epidural space, leading to more systemic absorption of the local anesthetic agent and hence shorter duration of epidural analgesia. The superior analgesic ecacy of paravertebral block has also been attrib- uted to the block of nerves as close to the roots as possible, as well as its ability to ablate the visceral innervation [11].

108

P. Narasimhan et al.

Journal of Clinical Anesthesia 52 (2019) 105–110

P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110 Fig. 5. Parental satisfaction scores.

Fig. 5. Parental satisfaction scores.

Chalam and coworkers [12] noted that the time for rescue analgesic

5. Conclusion

demand after ultrasound-guided paravertebral block in children be- tween aged 210 years undergoing thoracotomy was 8 to 10 h in over 80% of the patients indicating an adequate duration of analgesia post- operatively. They also emphasised on the use of ultrasound to enhance the ecacy and safety of the block, by determining the location and depth of the transverse process and parietal pleura. However, im- proving hands-on in the use of ultrasound in paediatrics is essential as it would help in faster and safer performance of paravertebral block. No complications were noted during the administration of the blocks in our study. This may be due to a smaller sample size. Moawad

The present study was undertaken to nd a better mode of analgesia for children after pyeloplasty. We found that the analgesia following ultrasound-guided single-shot paravertebral block using ropivacaine with adrenaline is better and ecacious in comparison to ultrasound- guided single-shot caudal epidural block, with comparable adverse ef- fects and hemodynamcis. Hence, it should be considered as an alter- native modality of analgesia for pyeloplasty in children. However, adequate practice and expertise is required for the performance of paravertebral block under ultrasound guidance in children.

and coworkers [13], and Berta and coworkers [8] reported inadvertent intravascular puncture as a complication with paravertebral block. The

Conict of interests

incidence of side-eects is higher with caudal block when compared to non-caudal regional analgesic interventions (iliohypogastric nerve

None.

block, local inltration, or both). Shanthanna and coworkers [14] found that motor block and urinary retention were signicantly more

Funding

common in the caudal group with an ARR of 7.44 and 8.42, respec- tively. Bengisun and coworkers [15] also noted that the time to rst

None.

micturition was prolonged in the caudal group, but there was no ur- inary retention in any of the children. No complications, apart from

Ethical approval

mild local tenderness at the injection sites in three patients, were noted in the paravertebral group by Naja and coworkers [11]. In the current study, the incidences of post-operative vomiting and urinary retention

Institute Ethics Committee approval was obtained in August 2014 (Chairperson Prof. Shashi Wadwa) (Reg. No. CTRI/006688).

were statistically similar in both the groups. Post-operative vomiting in the paravertebral group was recorded by Splinter and Thomson [16].

Acknowledgements

The incidence of vomiting reported by them was 11% in the para- vertebral group against 23% in the control group. Naja and coworkers [11], and Tug and coworkers [10] recorded 93% and 74.3% parental satisfaction in the paravertebral group, re- spectively, using a questionnaire. A questionnaire similar to the one

Dr. Kalaivani, Department of Bio-statistics, All India Institute of Medical Sciences, New Delhi-110029. Mr. Ashish, Department of Bio-statistics, All India Institute of Medical Sciences, New Delhi-110029.

used in their study was adopted in our study too (Appendix A). The current study has a few limitations. Firstly, the sample size is

Disclosures

small to bring out the incidence of side-eects or complication of the blocks. Since our literature review at the time of planning the study did not yield results for a similar study, a minimum of 25 patients per group was chosen. Secondly, an additive apart from adrenaline could have

No authors have any conicts of interest or disclosures with regard to this study. This research did not receive any specic grant from funding agencies in the public, commercial, or non-prot sectors.

been used. The addition of adrenaline to ropivacaine is of doubtful benet. Use of any other additive could have prolonged the duration of

Appendix A. Parental satisfaction score

both the blocks further. Thirdly, there was no assessment of pain at 18th hour. An assessment at this time may have showed wearing oof analgesia in some children in the paravertebral block.

Was the pain relief after surgery the surgery adequate enough and satisfactory in keeping the child comfortable?

1 - Not satised 2 - Good, satised

109

P. Narasimhan et al.

3 - Excellent, very satised.

Appendix B. Supplementary data

Supplementary data to this article can be found online at https:// doi.org/10.1016/j.jclinane.2018.09.007 .

References

Journal of Clinical Anesthesia 52 (2019) 105–110

[11]

110