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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 132-134

Continues caudal anesthesia using ropivacaine 0.125% in pediatric patients undergoing infraumbilical surgery


Department of Anesthesiology, Pain Management, and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali, Indonesia

Date of Submission18-Oct-2020
Date of Decision12-Jan-2021
Date of Acceptance15-Dec-2021
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Muhammad R L A Armyda
Department of Anesthesiology, Pain Management, and Intensive Care, Udayana University, Sanglah General Hospital, Denpasar, Bali
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjoa.bjoa_230_20

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  Abstract 


Caudal block technique remains as the most popular regional anesthetic choice for the pediatric population since its first description in 1933 for pediatric urological interventions. This technique could provide exquisite analgesia during surgery, likewise in the postoperative period after infraumbilical surgeries. Caudal continues to essentially reduce systemic anesthetic and analgesic requirements, thus conceive a better postoperative outcome. Ropivacaine is a safe and effective local anesthetic agent which provides prolonged postoperative analgesia with significantly minor motor blockade following caudal block in pediatric patients undergoing infraumbilical surgeries.

Keywords: Caudal continues, infraumbilical surgeries, ropivacaine


How to cite this article:
A Armyda MR, Sukrana Sidemen I G, Aryabiantara I W, Agung Senapathi TG. Continues caudal anesthesia using ropivacaine 0.125% in pediatric patients undergoing infraumbilical surgery. Bali J Anaesthesiol 2021;5:132-4

How to cite this URL:
A Armyda MR, Sukrana Sidemen I G, Aryabiantara I W, Agung Senapathi TG. Continues caudal anesthesia using ropivacaine 0.125% in pediatric patients undergoing infraumbilical surgery. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:132-4. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/132/313890




  Introduction Top


Understanding physiological, pharmacological, and psychological features are essential for pediatric anesthesia as it possesses a different characteristic than the adult. Regional anesthesia has become regularly used in pediatric and provides great results in balancing intraoperative and postoperative analgesia. Epidural block through a caudal approach is often used as a complement to general anesthesia. This technique could give advantages in post infraumbical surgery by reducing the requirement of inhalation and intravenous anesthetic agents, attenuate the stress response toward surgery, accelerate recovery, and provide prompt postoperative analgesia.[1]

The most advantageous and preferred pediatric regional block used today is single-shot caudal analgesia. Many local anesthetics in different concentrations are used in caudal analgesia such as ropivacaine. Ropivacaine produces long-lasting analgesia when given in caudal epidural space. It has been used for a lengthy period; however, due to prolonged motor blockade, higher incidence of cardiovascular side effects, and neurotoxicity, the safer local anesthetic agent starts to take over. Ropivacaine is another choice of amide introduced recently which could be used in a wide range of ages, even in younger age groups. It could provide an akin type of pain relief with minimal motor blockade and cardiotoxicity.[2],[3] It selectively blocks nerve fibers involved in pain transmission (A-delta and C fibers) to a greater degree than those controlling motor function (A-beta fibers). Ropivacaine is also less lipophilic; hence, it is less likely to penetrate large myelinated motor fibers, resulting in a relatively reduced motor blockade and longer postoperative analgesia, and has a greater degree of motorsensory differentiation, which could be useful when the motor blockade is not desired.[4]


  Case Report Top


Several pediatric patients underwent infraumbilical operative procedures. Preoperative preparations include patient identification, maintaining intravenous line (20G-24G) with Ringer's lactate solution as required. Premedication given was midazolam 0.05 mg/kg intravenous (IV). Routine monitoring during the operative procedure was performed, including blood pressure, electrocardiography, pulse oximetry, and temperature monitoring. All patients received general anesthesia using sevoflurane (2%–7%) with oxygen or propofol 2–5 mg/kg as an induction agent. Fentanyl 2 mcg/kg IV was used as an analgesic and atracurium 0.5 mg/kg was chosen to facilitate intubation.

Patients underwent caudal catheter insertion in a lateral decubitus position after the intubation. Aseptic techniques were performed in penetrating sacral hiatus with loss of resistance technique using Tuohy 20G or intravenous catheter 20–22G. An aspiration test was executed before injecting an adjusted dose of ropivacaine 0.2% to the epidural. Blood aspirate indicates redo the insertion; meanwhile, cerebrospinal fluid aspirate abrogates the procedure and excludes the patient. Subcutaneous bulging after ropivacaine injection requires reinsertion to the caudal compartment. A 3 cm catheter epidural 24G was set after ropivacaine administration. Tuohy or intravenous catheter was released and an aspiration test was performed.[5] A negative result of the aspiration test continued with the administration of test dose lidocaine 0.1 ml/kg and epinephrine 1:200.000. The epidural catheter was fixated using the gluteus technique and sterilize gauzes were used as a dressing.

Operative procedures which beyond 90 min were given top-up ropivacaine at a half dose of the initial dosage. During operation, sevoflurane (1%–2.5%), oxygen, air, caudal ropivacaine, and atracurium were given as indicated. Continued ropivacaine 0.125% at rate 0.1 ml/kg/h was given via caudal catheter and paracetamol 10 mg/kg IV every 8 h as analgesia postoperative. The first dose of paracetamol was given before the operation was about to end. All patients were assessed with the Face, Leg, Activity, Cry Consolability (FLACC) pain scale. Rescued analgesics administration was indicated if the patients showed FLACC >3 postoperative. The results are presented in [Table 1].
Table 1: Result face, leg, activity, cry consolability score of caudal continues ropivacaine

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  Discussion Top


Postoperative pain is unavoidable, and the clinician constantly strives to relieve it. The pediatric group may be in a worse situation, who have long been under medication for acute pain. Caudal block is one of the frequent regional anesthetic techniques used in pediatric patients undergoing infraumbilical surgeries as it is considered an easy and reliable procedure. It gives excellent analgesia during surgery, likewise during postoperative period.[6],[7]

The 0.125% preparation of ropivacaine can be used in all ages; however, pharmacodynamics responses may vary depending on age. It is proposed that the concentration of the medication used for the block should be escalated as the child gets older. The volume and concentration of the medicine used for the block are associated with the effectiveness of caudal analgesia. Both ropivacaine 0.125% and 0.2% show similar analgesia time and quality in the pediatric population, yet ropivacaine 0.125% may cause less motor blockade. In this study, ropivacaine having a concentration of 0.125% was used because it is believed to have less side effects and adequate analgesia.[8],[9]

One of the recognizable side effects is postoperative nausea and vomiting (PONV). There are four risks that might cause PONV, which are the duration of operation (≥30 min), history of previous nausea, vomiting, strabismus surgery, and age of the patient (≥3 years). In the early postoperative period, volatile anesthetic agents may have a PONV side effect. Hence, we considered observing PONV in this research since the surgery durations were >30 min, and volatile anesthetic was used. We found a urine retention condition in only one patient in the ropivacaine group. There was no apparent arrhythmia in all patients in this study. The subjects were observed for 24 h postoperative and discharged in a stable condition [Figure 1]. The brain and heart are organs that should be observed in the case of local anesthetic's toxic reactions. The side effects may be found in the overdose condition or technical mistake in the application.[2],[10]
Figure 1: Graphic 1. Mean face, leg, activity, cry consolability score of ropivacaine usage measurement every 6 h

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  Conclusion Top


This study concludes that 0.125% ropivacaine was safe and effective for caudal analgesia in pediatric patients who underwent infraumbilical surgeries. We conclude that caudal continues ropivacaine provides effective postoperative analgesia for daycare surgery. As our study group sample size was smaller, to confirm the observations, the study on larger sample size is recommended.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors certify that they have obtained all appropriate consent from the patient for possible future publication. The patients understand that their names and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma J, Gupta R, Kumari A, Mahajan L, Singh J. A comparative study of 0.25% levobupivacaine, 0.25% ropivacaine, and 0.25% bupivacaine in paediatric single shot caudal block. Anesthesiol Res Pract 2018;2018:1486261.  Back to cited text no. 1
    
2.
Cinar SO, Isil CT, Sahin SH, Paksoy I. Caudal ropivacaine and bupivacaine for postoperative analgesia in infants undergoing lower abdominal surgery. Pak J Med Sci 2015;31:903-8.  Back to cited text no. 2
    
3.
Jadhav PA, Malde AD. Comparison of levobupivacaine 0.25% and bupivacaine 0.25% for caudal analgesia in children undergoing herniotomy. Pediatr Anesth Crit Care J 2017;5:66-73.  Back to cited text no. 3
    
4.
Tambey R, Vaidya A, Ankalwar V, Tirpude NG, Arepallu DK. Caudal epidural ropivacaine versus bupivacaine in pediatric patients for infraumbilical surgeries. Int J Health Sci Res 2015;5:6.  Back to cited text no. 4
    
5.
Senapathi TG, Subagiartha IM, Widnyana IM, Kurniyanta IP, Ryalino C, Estrada R, et al. Continues caudal analgesia as a safe and effective method for pediatric post-chordectomy analgesia. Bali J Anaesthesiol 2019;3:23-6.  Back to cited text no. 5
    
6.
Ahmad S, Mohammad K, Ahmad M, Nazir I, Ommid M, Nabi V, et al. Caudal analgesia in pediatric patient: Comparasion between bupivacaine and ropivacaine. Internet J Anaesthesiol 2012;30:3.  Back to cited text no. 6
    
7.
Suresh S, Long J, Birmingham PK, de Oliveira GS Jr. Are caudal blocks for pain control safe in children? An analysis of 18,650 caudal blocks form the pediatric regional anesthesia network (PRAN) database. Anesth Analg 2015;120:151-6.  Back to cited text no. 7
    
8.
Sengupta S, Mukherji S, Sheet J, Mandal A, Swaika S. Caudal-epidural bupivacaine versus ropivacaine with fentanyl for paediatric postoperative analgesia. Anesth Essays Res 2015;9:208-12.  Back to cited text no. 8
  [Full text]  
9.
Praveen P, Remadevi R, Pratheeba N. Caudal epidural analgesia in pediatric patients: Comparison of 0.25% levobupivacaine and 0.25% ropivacaine in terms of motor blockade and postoperative analgesia. Anesth Essays Res 2017;11:223-7.  Back to cited text no. 9
    
10.
Li M, Wan L, Mei W, Tian Y. Update on the clinical utility and practical use of ropivacaine in Chinese patients. Drug Des Devel Ther 2014;8:1269-76.  Back to cited text no. 10
    


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