Year : 2009 | Volume
: 53 | Issue : 4 | Page : 463--466
Postoperative Analgesia in Children- Comparative Study between Caudal Bupivacaine and Bupivacaine plus Tramadol
Meena Doda1, Sambrita Mukherjee2,
1 Specialist & HOD, Dept.of Anaesthesiology, ESIC Hospital, Noida - 201301, India
2 Anaesthesiologist, Dept.of Anaesthesiology, ESIC Hospital, Noida - 201301, India
Anaesthesiologist, Dept.of Anaesthesiology, ESIC Hospital, Noida - 201301
Thirty children, ASAI-II, aged between 2yrs-5yrs, undergoing sub umbilical operation (inguinal and penile surgery) were selected for this double blind study. They were randomly divided in two groups, group Aand group B. Group A(n15) received 0.25%bupivacaine 0.5ml.kg -1 and Group B (n=15) received 0.25% bupivaeaine 0.5ml.kg -1 and tramadol 2mg.kg -1 as single shot caudal block. Postoperative pain was assessed by a modified TPPPS (ToddlerPreschool Postoperative Pain Scale) and analgesic given only when the score was more than 3. In the first 24 hrs it was observed that the mean duration of time interval between the caudal block and first dose of analgesic was significantly long(9. lhrs) in Group B as compared to Group A (6.3hrs) which was much shorter(p<0.01).There was no significant haemodynamie changes, motor weakness or respiratory depression in both groups. This study concluded that addition of tramadol 2mg.kg -1 to caudal 0.25% bupivacaine 0.5ml.kg -1 significantly prolong the duration of postoperative analgesia in children withoutprodueing much adverse effects.
|How to cite this article:|
Doda M, Mukherjee S. Postoperative Analgesia in Children- Comparative Study between Caudal Bupivacaine and Bupivacaine plus Tramadol.Indian J Anaesth 2009;53:463-466
|How to cite this URL:|
Doda M, Mukherjee S. Postoperative Analgesia in Children- Comparative Study between Caudal Bupivacaine and Bupivacaine plus Tramadol. Indian J Anaesth [serial online] 2009 [cited 2020 Jun 3 ];53:463-466
Available from: http://www.ijaweb.org/text.asp?2009/53/4/463/60318
The society of Paediatric Anaesthesia  , on it's 15 th annual meeting at New Orleans, Louisiana (2001) clearly definedthe alleviation of pain as a"basic human right", irrespective ofage, medical condition, treatment, primary service response for the patient care or medical institution. Finely et al  observed that many types of so called "minor" surgery (e.g. circumcision) can cause significant pain in children.
The goal of post operative pain relief is to reduce orehminate pain with minimum side-effects and in our setup as cheaply as possible. Effective pain relief means asmooth postoperative period, increased patient compliance and an early discharge from hospital. Langlade et al  suggested thatthe postoperative pain treatment mustbe included in the anaesthetic planning even before induction of anaesthesia, adopting the idea of 'managing pain before it occurs'.
Over the years various regional anaesthetic procedures has gained popularity forpostoperative analgesia because in addition to providing effective postoperative pain relief, they also reduce the requirement of general anaesthesia intraoperatively without significant side-effects and maintaining a smooth intra and postoperative period. Caudalblockhas proved useful in a variety of subumbilical operations  in children for providing both intra operative and post operative analgesia. Objective ofpresent study was to compare the quality and duration of analgesia, after a single shot caudal blockwith bupivacaine alone and bupivacaine plus tramadol, and thereby try to find out whether tramadol can be an effective adjuvantto bupivacaine for providingpostoperative analgesia in children undergoing subumbilical surgeries.
After obtaining institutional approval and parental written unformed consent, thirty children aged between 2-5yrs, weighing between 10-18 Kg and of ASA I and II physiologic status were enrolled for the study. These patients were scheduled for sub-umbilical surgeries like herniotomy and penile surgery under general anaesthesiaby asingle surgeon. The patients were randomly allocated in two groups.
Group Areceived single shot caudal block with 0.25% bupivacaine 0.5ml.kg -1 and Group B received 0.25% bupivacaine 0. 5ml.kg -1 plus tramadol 2mg.kg -1 , after induction of anaesthesia. Any children having allergy to bupivacaine or any contraindication to neuraxial blockade were excluded from the study.
The patients were induced with halothane and 50% nitrous oxide in oxygen inhalation via face mask. Intravenous cannulation was done using 22G cannula, then atropine 0.02mg.kg -1 , ondansetron 0.lmg.kg - l and midazolam 0. lmg.kg -1 were given i.v as premedication. After induction, caudal block was then given in right lateral position by a 22G needle under aseptic condition. Syringes containing an equal volume of either 0.25% bupivacaine 0.5m1.kg 1 or 0.25% bupivacaine 0.5ml.kg -1 plus tramadol 2mg.kg -1 wereprepared and given to the investigator who was blinded to the identity of drug(s).He gave the caudal blocks. Then the surgery was continued under inhalational anaesthesia via mask. Intraoperative heartrate, respiratory rate, blood pressure (NIBP) and oxygen saturation (SpO2) was monitored. After recovery from general anaesthesiathe patient was shifted to PACU and his vitals and pain was assessed by a 10-point TPPS score  [Table 1] by a blinded investigator .The child's motor power, any side-effects and sedation score(0=Eyes open, l= Eyes open to speech, 2=Eyes open when shaken, 3= unrousable) was also noted. Assessment was done every 5-min for the first 30-min, then every 15-min for next lhr, then hrly fornext 2 his andthen at 4, 6, 8, 10, 14, 18 and 24hr by the same blinded investigator.
ANOVAiwith multiple comparisons was used for comparisons between the groups. Using Chi squared (X2)test compared the non-parametric data. p -1 . Significant pain is described as one that has apain score of more than 3 [Table 3].
When pain score was plotted against time in a graph, it was seen thatthe score was 0 upto 2 his and then started to increase and reached a score of 3 only after 9 hrs in Group B ,where as in Group Athe pain score started to attain 3 after 6 hrs.[Figure 1].
It was also seen that the children in Group A needed more doses of paracetamol syrup in fast 24 hrs than Group B [Table 4].
The vitals of patients in both groups remain stable during operation and the incidences of emergence agitation were much less in both groups ratherthan the patients undergoing surgery under general anaesthesia without caudal block.
There was no major difference m sedation score between the two groups after recovery. 13.3% patients in Group A and 6.6% in Group B developed motor weakness. It was also observed that incidences of postoperative urinary retention was 20% in Group A and 13.3% in Group B. Nausea and vomiting was slightly more in Group B (26.67%)than Group A(20%), [Table 5].
Ease of p erformance and reliability makes caudal blockthe most commonly performed block in children. Caudal administration ofbupivacaine is a widespread regional anaesthetic technique for ultra- and postoperative analgesia during lower limb, anoperineal, penos crotal and abdominal surgical procedures in children ,, . Tramadol is a centrally acting opioid analgesic, used for treatingmoderate to severe pain. It is a synthetic agent, made of racemic mixture of two enantiomers- (+)tramadol and (-) tramadol and it appears to have actions at the µ opioid receptor as well as the noradrenergic and serotonergic systems  . Tramadolwas developed by the German pharmaceutical company GrunenthalGmbH in the late 1970s andmarketed underthe trade name Tramal. As an analgesic it's equipotent to meperidine without any respiratory depressant action. The most commonly reported adverse drug reactions are nausea, vomiting, sweating and constipation. Drowsiness is reported, although it is less of an issue than for opioids.
In our study, we found that by adding tramadol 2mg.kg -1 to caudalbupivacaine (0.025%) 0.5ml.kg -1 in children undergoing sub-umbilical operation, significantly increased the duration ofpain free period postoperatively. Similar results were reported by Gune et al  during a study ofchildren undergoing hypospadias repair showedthat caudaltramadol provides betterand longerlasting postoperative analgesiathan i.v tramadol Sendl et al  in a study on children undergoing herniorrhaphy showed that, caudal administration of bupivacaine with the addition of tramadol resulted in superior analgesiawith alonger period without demand for additional analgesics compared with caudal bupivacaine and tramadol alone without an increase of side effects. The incidence of emergence agitation, which is frequently seen during recovery from inhalational anaesthesia in children, were much less in children with preoperative caudal block in both groups and it was more less in Croup B and this is supported by a previous study of Weldon et al  who reported that effective postoperative analgesia may reduce the incidence of emergence agitation with sevoflurane anaesthesia. The degree of sedation was comparable m two groups. The potency of single shot caudal bupivacaine was increased by addition oftramadol because in our set up it was neithertechnically possible norcost effective to use caudal ep idural catheter and maintain postoperative analgesia with bup ivacaine alone. A prolong and effective postoperative analgesia to children means a cooperative child with less emotional and haemodynamic stress and rapid recovery with less hospital stay. Mean duration of postoperative analgesia with caudal bupivacaine was 6.3 his whereas with addition of tramadol it increased up to 9.1 his, without increasingthe dose as wellas the side effects of bupivacaine as it was shown in various studies , . A higher dose of tramadol could have caused nausea and vomiting whereas increasingthe dose of bupivacaine could have caused more motor weakness and urinary retention. 
Our study concluded that caudal administration oftramadol 2mg.kgi along with 0.25% bupivacaine 0.5ml.kg -l significantly increased the duration and quality ofpostoperative analgesia in children undergoing subumbilical operation, without producing significant adverse effects.
|1||Frank HK. The society of Paediatric Anaesthesia: 15 th annual meeting, New Orleans, Louisiana. Anaesthesia. Aanalgesia 2002;94: 1661-1668.|
|2||Finley GA, Mc Granth PJ, Forward SP, et al. Parents management of children pain following "minor" surgery.Painl 996;64:83-87.|
|3||Langlade A, Kriegel I Treatment of acute postoperativepainAnn Chir 1997 51:1013-1021.|
|4||Morgan GE, Mikhail MS. Pediatric Anaesthesia. In: Morgan GE, Mikhail MS, ed. Clinical Anaesthesiology Appleton&Large 1996; 726-742.|
|5||Prosser DP, Davis A, Booker PD, Hurray A. Caudal tramadol for postoperative analgesia in paediatric hypospadias surgery. Br JAnaesth 1997; 79:293-296.|
|6||Dalens B, Hasnaoui A Caudal anesthesia in paediatric surgery: success rate and adverse effects in 750 consecutive patients. AnesthAnalg 1989; 68:83-89.|
|7||Yasterlvi, Maxwell LG Paediatric regional anaesthesia. Anesthesiology 1989; 70:324-338.|
|8||Wolf AR, Valley RD, Fear DW, Roy WI, Lerman J. Bupivacainefor caudal analgesia in infants and children : The optimal effective concentration. Anesthesiology 1988;69:102-106.|
|9||RaffaRB, Friderichs E, ReimannV et al. Complementary and synergistic antinociceptive interaction between the enantiomers of Tramadol. J Pharmaco 1 Exp Ther 1993; 267;331-310.|
|10||Gune Y Gunduz M Unlugene H, et al . Comparison of caudal vs intravenous tram adol administered either preoperatively or postoperatively for pain relief in boys. Paediatric Anaesthesia 2004;14:324-328.|
|11||Sendl AC, AkyolA, Dohman D, etal. Caudal bupivacaintramadol combination for postoperative analgesia in paediatric herniorrhaphy. Acta Anaesthesi o logi ca Scandinavica 2001;45 :786-789.|
|12||Weldon BC, Bell M, Craddock T. The effect of caudal analgesia on emergence agitation in children. Anesth Ana1g 2004 98 :321-326.|
|13||GunduzM, OzcengizD, OzbekH. Acomptarisonof single dose caudal tramadol, tramadol plus bupivacaine and bupivacaine administration for postoperative analgesia in children Paediatric anaesthesia 2001;11:323-32.|
|14||Ozkan S ,Pocan S, BaharA, et al .The effect of caudal bupivacaine vs tramadol in posoperative analgesia in paediatric patients. The Journal of International Medical Research2003; 31:497-502.|
|15||Nagiub M, SharifAM, Seraj Iv1 ElGammal lv1, Dawlatly AA Ketamine for caudal analgesia in children: comparison with caudal bupivacaine. Br J Anaesth 1991; 67:559-564.|