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CLINICAL INVESTIGATION
Year : 2009  |  Volume : 53  |  Issue : 4  |  Page : 450-454 Table of Contents     

Caudal Clonidine in Day-Care Paediatric Surgery


1 Consultant, Deptt of Anaesthesiology, Pain and Perioperative medicine, Sir Gangaram Hospital, New Delhi, India
2 Asso. Consultant, Deptt of Anaesthesiology, Pain and Perioperative medicine, Sir Gangaram Hospital, New Delhi, India
3 Senior consultant and Chairperson, Deptt of Anaesthesiology, Pain and Perioperative medicine, Sir Gangaram Hospital, New Delhi, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Archna Koul
Deptt ofAnaesthesiology, Sir Gangaram Hospital, OldRajinderNagar, New Delhi - 110060
India
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Source of Support: None, Conflict of Interest: None


PMID: 20640207

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We evaluated the analgesic efficacy, hemodynamic and respiratory safety of Clonidine when added to bupivacaine for caudal block. Forty children undergoing inguinal hernia repair were randomly given caudal injection with 0.75 ml.kg -1 of bupivacaine (0.25%) and clonidine 2 µg.kg -1 in Group C or 0.75 ml.kg -1 of bupivacaine (0.25%) alone in Group B after induction of anaesthesia. Postoperatively duration of analgesia, OPS score (observational pain / dis­comfort scale), Sedation score, heart rate and blood pressure were recorded. Duration of analgesia was significantly longer (p< 0.001) in Group C (10.25 hours) as compared to 4.55 hours in Group B. Bradycardia, hypotension and sedation were not observed in Group C. The addition of Clonidine in caudal blocks prolongs postoperativepain relief in children and is safe alternative to bupivacaine alone in paediatric daycare surgeries.

Keywords: Caudal epidural, Clonidine, Bupivacaine


How to cite this article:
Koul A, Pant D, Sood J. Caudal Clonidine in Day-Care Paediatric Surgery. Indian J Anaesth 2009;53:450-4

How to cite this URL:
Koul A, Pant D, Sood J. Caudal Clonidine in Day-Care Paediatric Surgery. Indian J Anaesth [serial online] 2009 [cited 2019 Jun 24];53:450-4. Available from: http://www.ijaweb.org/text.asp?2009/53/4/450/60316


   Introduction Top


Caudal epidural analgesiais one of the most popular regionalblocks inpaediatric anaesthesia, but its main dis­advantage is short duration of action aftersingle injection (46hrs) even with a long acting local anaesthetic.

Prolongation ofcaudal block using asingle shot technique; can be achieved by addition of various adju­tants. Epmephrinewas the earliest adjuvant drug used, during second half of 1980's. Opioids were also used but their use carried risk of respiratory depressions [1] . Ketamine as an adjutant has potential for neurotoxic ef­fects if inadvertently injected intrathecally [2] and neostig­mine is accompanied by 30% incidence of vomiting [3] .

Clonidine, an á-2 adrenergic agonist, produces analgesia without significant respiratory depression. The analgesic action of epidurally administered Clonidine is due to stimulation of descending noradrenergic medullospinalpathways i inhibiting the release of noci­ceptive neurotransmitters in the dorsal horn of spinal cord [4] . The analgesic effect of Clonidine is more pro­nounced after neuraxial injection which suggests a spi­nal site of action and makes this route of administration preferable [5],[6] .

We designed a prospective randomized double blind study to examinethe haemodynamic and respira­tory effects ofclonidine as an adjunct to bupivacaine caudal epidural analgesia and compare its analgesic efficacy with control group in which only bupivacaine was used, in paediatric day care procedures.


   Methods Top


After informed parental consent, 40 ASAI chil­dren between 1-10 years of age weighing 5-20 kg, who were scheduled to undergo inguinalherniotomy as daycare cases were admitted in the study. Children with any contraindication to caudal block or having congenital heartdisease were excluded from the study. No premedication was given and all surgeries were performed under general anaesthesia. Inhalational in­duction was done with oxygen, nitrous oxide and 8% sevoflurane delivered through Jacks on Rees modifica­tion of Ayre's T -piece and face mask, with standard monitoring. After intravenous cannula insertion a PUMA (Proseal Laryngeal MaskAirway LMAcompany Ltd.) of appropriate size (between size 1- 1.5), depending on the weight of the patient, was introduced. Anaes­thesia was maintained with 33% oxygen, 67% nitrous oxide and sevoflurane (3-4%) with manual assistance and fresh gas flow of 2-3 litres /minute. After induction of anaesthesia, the children were assigned randomly to receive a caudal ep idural injection of either 0.75 mLkg -1 of 0.25% bupivacaine (Group B) or 0.75 ml.kg -1 of 0.25% bupivacaine with 2ìg.kg-1of clonidine (Group C). Clonidine was loaded in 1 ml syringe so as to keep the volume same in both the groups. Caudal block was performed with 23 gauge hypodermic needle under aseptic conditions in left lateralposition and the child was turned supine aftertheinjection of thedrug. Mean blood pressure and heart rate were recorded before induction of anaesthesia and every 5 minutes subse­quently. An intraoperative increase in heart rate and blood pressure by more than 10% after 15 minutes of caudal injection was defined as insufficient analgesia and treated with intravenous fentanyl lmcg.kg -1 .

At the beginning of skin closure, sevoflurane and nitrous oxide were discontinued. When the children were sufficiently awake, PLMA was removed and they were shifted to the recovery room, breathing room air.

After arrivalmean blood pressure, heart rate and SpO 2 was documented hourly for 6 hours. Intraopera­tive orpostoperative decrease in mean blood pressure orheart rate more than 30% of the baseline values was defined as severe hypotension or bradycardia respec­tively. Respiratory depression was defined as a de­crease of SpO 2 less than 93% and required supple­mental oxygen viamask. Pain assessment in the post­operative period was done by an observer blinded to the therapeutic intervention using OPS score (at 30 minutes, 1 hour and 2 hours) and duration of analgesia. Each variable (crying, facial expression, verbal response, position of torso and motor restlessness) was scored between 0-2 (0: none, 1: moderate, 2: severe), to give a cumulative score of 0-10. Ifthe OPS score was more than 4 in 2 subsequent measurements or ifthe patient showed obvious signs of pain they were given oral paracetamol 10 mg.kg -1. The duration of postopera­tive analgesia was defined as time between caudal drug injection and the first complaint of pain. Assessment of sedation was done by sedation score at 30 minutes, lhourand 4hours afterthe operation. Patient sedation score was defined as 1: asleep, not arousable by ver­bal contact; 2: asleep, arous able by verbal contact; 3: drowsy not sleeping; 4: alert/aware. This helped in iden­tification of respiratory depression. Duration of motor blockwas assessed by notingthe time children began moving theirlegs. Time offirstmicturition was also noted. Children were discharged from the daycare ward after 6hours of arrival. Parents noted the total requirement of additional analgesia in first 24 hours after operation on a form and were contacted telephonically.

Parametric data was analysed using Student's t test.


   Results Top


Mean age, weight, surgical and recovery time were comparable between two groups (mean age of Group B: 3.3 years, mean age of Group C: 3.5 years, mean weight of Group B: 13.5 kg, mean weight of Group C: 14.6kg, mean surgical time ofGroup B: 39.7 min, mean surgicaltime of Group C:43.S min, as shown in [Table 1]. The duration of analgesia and the time for first postoperative analgesic requirement was signifi­cantly prolonged in Group C [Table 2] and [Figure 1]. There was a decrease from base line mean arterial pressure in Group C 5-15 minutes after the injection but it re­turned to normal in 30 minutes. The mean time for first analgesic requirement in Group C was 10.25 ± 6.03 hours, while it was 4.5 ± 0.87 hours in bupivacaine Group [Table 2] and [Figure 1].

The comparison of mean arterial pressure during intraoperative and post operative period [Figure 2] and [Figure 3], between both groups, using Student's t test, yielded p­values (0.86 for intraoperative MAP and 0.15 for post­operative MAP) which were not significant. The com­parison of heart rate during intraoperative and post operative period, between both groups showed insig­nificant p-value (p-value for intraoperative heart rate was 0.99 and forpostoperative heart rate itwas 0.54). With N as 20 in each group with a m can prolongation of analgesia by 5.75 hours in Group C as compared to Group B [Figure 6], the power of study was 94.2% and the p-value less than 0.05 (p< 0.001).

None of the children had urinary retention and the incidence of vomiting was comparable between the groups [Table 1] and [Table 2]. None of the children had SpO Z value less than 95%. None of the children had bradycardia. On awakening no motorblock was observed in any case in either group. There was no significant difference in either group in the mean postoperative sedation score (Group B was 2.8± 0.45 and Group C was 2.83, [Table 2] and [Figure 4]. The mean OPS score of Group B was 4.65 ± 0.25 and Group C was 4.55 f 0.25 [Table 2] and [Figure 5]. The mean time of firstmicturition in Group B was 4.8 hours and in Group C was 4.7 hours.


   Discussion Top


Our data indicates that for caudal blockade, the addition of clonidine 2 µg.kg -1 with 0.25%bupivacaine significantly prolongs the duration of analgesia [Table 2] and [Figure 1]. This reduces the need for both intraoperative and postoperative analgesia. These findings confirm with apreviousstudy 7 'which reported that 1-2µg of clonidine with bup ivacaine increases duration of analgesia in small children undergoing day care hemiarep air compared to bupivacaine alone or bupivacaine with epinephrine5µg.ml -1 .

Duration of analgesia inthis study is less than that observed in another study [8] where they used combina­tion ofketarnine 1 mg.kgl and clonidine 1-2 µg.kg -1 of caudal blockade in children.

Our experience with clonidine for caudal block­ade is consistent with the results obtained from other studies [9],[10],[11] , where clondine 1-2 µg.kg 1 was added to caudal bupivacaine for supraumbilical, urn logical or orthopaedic surgeries.

The undesirable side effects ofneur Gaxial clonidine are hypotension and bradycardia. Many studies [6],[12],[13] in adult patients have reported adecrease in MAP and HR within 15-30 minutes after ep idural injection which lasted for 3-4 his before returning to baseline. In our study decrease in blood pressure did occur in all pa­tients who were given clonidine with bupivacaine within 5-15 minutes but returned to normal within 30 minutes.

Some studies [12],[13] report a marked decrease in heart rate afler epidural clonidine while others do not. We did not observe any significant bradycardia in our study.

Dose dependent sedation usually accompanies the use of clonidine for regional anaesthesia [6],[14] however with 2µg.kg -l , we did notappreciate any excessive se­dation [Figure 2] and [Figure 6]. All the children were sleeping but arousable andthis was appreciated by the parents.

All children could move their legs at the end of 6 hourperiod and there was no case of retention ofurine. Except fort patients, there was no case ofpostopera­tive vomiting and therefore discharge of no child was delayed.

This study used patients undergoing the same sur­gical procedure, no premeditation and same pattern of induction so as to eliminate any factor that could have interfered with analgesia requirement or haemodynamic variables.

The use of parents to assess pain after discharge till 24 hours may introduce some sort of inconsistency in deciding to medicate the child but it is the parents who know their child best.

The main purpose of our study was to assess the suitability ofclonidine and bupivacaine in daycare pa­tients who are to go home the same day. Absence of any side effect like sedation, bradycardia, vomiting and respiratory depression with reduction in the need of analgesic goes in the favorof using clonidine as an ad­juvant with local anaesthetic in this set of patients. We chose dose of 2µg.kg -1 as compared to lµg.kg -l as used in many studies, as this dose provides benefit to the child with no additional risk of side ef­fects.

This combination of 2 µg.kg -l clonidine with bupivacaine 0.25% is a safe and effective alternative to bupivacaine alone for caudal block in peadiatric day care surgeries.



 
   References Top

1.Krane EJ.Delayed respiratory depression in a child after caudal morphine. AnesthAnaig 1988;67 :79-82.  Back to cited text no. 1      
2.Malinovsky JM, Lepage JY Cosian A, et al. Is ketarnine or its preservative responsible for neurotoxicity in rabbit? Anesthesiology) 993; 78:101-5.  Back to cited text no. 2      
3.Lonngvist PA. Additives to caudal block in children. Br JAnaesth 2005 ; 95 : 431-3.  Back to cited text no. 3      
4.Cook B, Dayle E. The use of additives to local anaes­thetic solutions for caudal epidural blockade. Paediatric anesthesia 1996; 6: 353-9.  Back to cited text no. 4      
5.Bonnet F, Boico O, Rostaing S, et al. Clonidine induced analgesia in post operative patients; epidural versus intramuscular administration. Anesthesiology 1990;72: 423-7.  Back to cited text no. 5      
6.Eisenach J, Detweiter D, Hood D. Haemodynamic and analgesic action of epidurally administered clonidine. Anesthesiology 1993;78: 277-87.  Back to cited text no. 6      
7.Klimscha W Chiari A, Michalek Sauberer, Wildling E, et al. The efficiecy and safety of clonidine/bupivacaine combination in caudal blockade for a paediatric hernia repair. Anesth Analg 1998; 86: 54-61.  Back to cited text no. 7      
8.Hemut Hager, Peter Marhofer, Christian Sitzwohl, et al Caudal clonidine prolongs analgesia of caudal ketamine in children. AnesthAnalg 2002; 94: 1169-72.  Back to cited text no. 8      
9.CookB, Grubb DllI, Aldridge LAandDoyle E, et al. Com­parison of effects of adrenaline, clonidine and ketamine on the duration of caudal analgesia produced by bupivacaine in children. Br J Anaesth 1995; 75: 698-701.  Back to cited text no. 9      
10.Jamali S,Monin S, Begaon C, et al. Clonidine in paediat­ric caudal anaesthesia. AnesthAnalg 1994; 78: 663-666.  Back to cited text no. 10      
11.Lee JJ, Rubin AP, et al. Comparison of bupivacaine­clonidine mixture with plainbupivacaine for caudal an­algesia inchildren. Br JAnaesth 1994; 72:258-262.  Back to cited text no. 11      
12.RaukRL,EisenachJC,Jackson K,etal.Epiduralclonidine treatment for refractory reflex sympathetic dystrophy. Anesthesiology 1993; 79: 1163-9.  Back to cited text no. 12      
13.Bernard SM, Kick O, Bonnet F. Comparison of intrave­nous and epidural clonidine for post operative patient controlled analgesia. AnesthAnalg 1995;81: 706-712.  Back to cited text no. 13      
14.Bonnet F, Boico O, Rostang S, et al. Post operative an­algesia with extradural clonidine.Br JAnaesth 1989;63: 465-9.  Back to cited text no. 14      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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