BACKGROUND: Immune responses appear to be affected by anesthetics and analgesics. We investigated the effects of caudal tramadol on the postoperative immune response and pain management in pediatric patients. METHODS: Sixty ASA-I pediatric patients aged 3–10 years undergoing lower abdominal surgery. Patients were randomly assigned either to a caudal bupivacaine (0.25%) group (group B), or a group that received caudal tramadol (1 mg/kg) added to the bupivacaine (0.25%) (group T). Both were diluted in a 0.9% NaCl solution to a total volume of 1ml/kg. The systemic immune response was measured by collecting blood samples preoperatively, at the end of anesthesia, and at 24 and 72 hours postoperatively, and studied for interleukin IL-6, C-reactive proteins (CRP) cortisol levels, and leucocytes with its differential count. Postoperative pain was assessed along with sedation scales. RESULTS: Postoperative production of IL-6 was significantly higher in group B at the end of anesthesia, than at the 24th hour, and at the 72nd hour in group B and group T, respectively. The immune response showed leukocytosis with increased percentages of neutrophil and monocytes, and a decreased lymphocyte response rate within both groups with no significant differences between the groups. Cortisol and CRP were significantly higher in group B. CONCLUSIONS: Adding tramadol to a caudal bupivacaine block can attenuate the pro-inflammatory cytokine response, Cortisol, and CRP in children undergoing lower abdominal surgery.
Abdomen ; Analgesics ; Anesthesia ; Anesthesia, Caudal ; Anesthetics ; Bupivacaine ; C-Reactive Protein ; Child ; Humans ; Hydrocortisone ; Interleukin-6 ; Interleukins ; Leukocyte Count ; Leukocytes ; Leukocytosis ; Lymphocytes ; Monocytes ; Neutrophils ; Pain Management ; Pain, Postoperative ; Pediatrics ; Tramadol ; Weights and Measures

BACKGROUND: Caudal epidural anesthesia is commonly performed in conjunction with general anesthesia. Bupivacaine and Levobupivacaine are used in epidural blockade that provide anesthesia and analgesia intraoperative and post-operatively.

OBJECTIVES: To compare the intraoperative and postoperative efficacy and safety of Bupivacaine and Levobupivacaine in children undergoing elective sub-umbilical operations under general and caudal anesthesia.

METHODS: Randomized control trial done in Philippine Children's Medical Center. Sixty-one subjects aged 6-months -8 years old, ASA I-II, undergoing subumbilical operations were randomly grouped to receive Bupivacaine and Levobupivacaine during anesthesia induction. Hemodynamic parameters, Bromage, and CHIPPS were recorded.

RESULTS: Results suggest both drugs have a significant effect in lowering heart rate and MAP. Bromage scores for patients from both groups are consistent at 0. The number of patients with a CHIPPS classification of 4-10, is significantly higher for bupivacaine group than levobupivacaine group.

CONCLUSION: Both Bupivacaine and Levobupivacaine provide adequate analgesia intraoperatively with no reports of intraoperative movement, increased inhalational agent concentration and additional intravenous analgesics. Post-operatively, no adverse effects and motor block was noted however Levobupivacaine has a longer efficacy as it required lesser rescue does post-operatively compared to Bupivacaine. 

STUDY DESIGN: This was a prospective, randomized, controlled trial comprising 60 patients undergoing lumbosacral spine (noninstrumentation/nonfusion) surgery. PURPOSE: The purpose of this study was to evaluate the efficacy of 0.2% ropivacaine (20 mL) administered alone as a single, preoperative, caudal epidural block injection versus that of intravenous analgesics in providing effective postoperative analgesia to patients undergoing lumbosacral spine surgery. OVERVIEW OF LITERATURE: Various studies have shown the effectiveness of a caudal epidural injection (bupivacaine or ropivacaine) in providing postoperative analgesia in combination with steroids or other analgesics. This study uniquely analyzed the efficacy of a single injection of caudal epidural ropivacaine in providing postoperative pain relief. METHODS: Sixty patients who were scheduled to undergo surgery for degenerative lumbar spine disease (noninstrumentation/nonfusion) were consecutively divided into two groups, group R (Study) and group I (Control). 30 group R patients received a caudal epidural block with 20 mL of 0.2% ropivacaine after the administration of general anesthesia. 30 group I patients received no preoperative analgesia. Intravenous analgesics were administered during the postoperative period after a complaint of pain. Various parameters indicating analgesic effect were recorded. RESULTS: There was a significant delay in the average time to the first demand for rescue analgesia in the study group, suggesting significantly better postoperative pain relief than that in the control group. In comparison with the control group, the study group also showed earlier ambulation with minimal adverse effects. The requirement for intraoperative fentanyl was higher in the control group than that in the study group. CONCLUSIONS: Preemptive analgesia with a single epidural injection of ropivacaine is a safe, simple, and effective approach, providing better postoperative pain relief, facilitating early mobilization, and decreasing the intraoperative requirement for opioid administration.
Analgesia ; Analgesics ; Anesthesia, Caudal ; Anesthesia, General ; Early Ambulation ; Fentanyl ; Humans ; Injections, Epidural ; Pain, Postoperative ; Postoperative Period ; Prospective Studies ; Spine* ; Steroids ; Walking

BACKGROUND: We investigated the value of using contrast as an additional aid to confirm the accuracy of needle placement for caudal epidural injections under intraoperative image intensifier guidance. METHODS: A total of 252 consecutive patients were included in this study. Their mean age was 46.7 years (range, 32 to 76 years). There were 133 males (53%) and 119 females (47%) over a 12-month period. RESULTS: Of the 252 consecutive procedures, the contrast enhanced image intensifier confirmed accurate needle placement on first attempt in 252 cases (100%). Needle resiting following the infiltration of contrast was required in 0 case. CONCLUSIONS: The results from this study demonstrate that a surgeon beyond the learning curve can accurately place caudal epidural injections using image intensification only, without the use of contrast.
Anesthesia, Caudal ; Female ; Fluoroscopy ; Humans ; Injections, Epidural* ; Learning Curve ; Male ; Needles ; Spine

BACKGROUND: Confirming a successful caudal block is challenging in the pediatric population. Pulse transit time (PTT) may reflect the decrease in arterial resistance and may act as a potential indicator for confirming successful peripheral nerve or axial block. Heart rate variability (HRV) is also a possible candidate because it may be influenced by variation in sympathetic tone. We expected an increasing PTT pattern and change in HRV parameters after caudal block. METHODS: We enrolled 27 male patients (range, 1–4 years old) who were scheduled for urological surgeries. Caudal block was performed with 1 ml/kg of 0.25% ropivacaine and 1 : 200,000 epinephrine under sevoflurane anesthesia after the surgery. Successful block was confirmed by auscultation and ultrasonography. PTT and HRV parameters, such as standard deviation of normal-to-normal intervals, root mean square of successive differences, very low-frequency power, low-frequency power (LF), high-frequency power (HF), LF/HF ratio, approximate entropy (ApEn) were calculated based on electrocardiography from 1 min before to 5 min after the block. Those variables were analyzed by repeated measures analysis of variance. RESULTS: No significant change was found in PTT with time interval after caudal block. Heart rate and ApEn of the R-R interval decreased with time interval (P = 0.001, 0.033, respectively). Some HRV parameters showed notable changes, although statistically insignificant. CONCLUSIONS: The PTT pattern may not be an indicator for successful caudal block. However, heart rate with parameters of HRV analysis may be alternatives.
Anesthesia ; Anesthesia, Caudal ; Anesthesia, General* ; Auscultation ; Child* ; Electrocardiography ; Entropy ; Epinephrine ; Heart Rate* ; Heart* ; Humans ; Male ; Peripheral Nerves ; Pulse Wave Analysis* ; Ultrasonography

BACKGROUND: Caudal block is a popular regional anesthesia in children undergoing infraumbilical surgeries including inguinal hernia repair and orchiopexy. We evaluated the efficacy of eutectic mixture of local anesthetic (EMLA) cream for reducing needle insertion pain during caudal block in pediatric patients. METHODS: Forty-one children between the ages of 13 months and 5 years undergoing infraumbilical surgery were randomized to receive either topical EMLA or placebo cream over the sacral hiatus one hour before caudal block. All children were assessed with the Multidimensional Assessment Pain Scale (MAPS) at the following time points. T0: arrival at the operation room; T1: just before needle insertion; T2: immediately after needle insertion into the sacral hiatus. The need for sevoflurane inhalation due to procedural pain response was also assessed at the same time as MAPS assessment. RESULTS: MAPS scores were significantly lower in the EMLA group compared with the placebo group at T2 (P = 0.001). Moreover, need for sevoflurane inhalation due to procedural pain response was significantly lower in the EMLA group compared with the control group at T2 (P < 0.001). CONCLUSIONS: We suggest that pretreatment with EMLA cream over the sacral hiatus before caudal block has significant advantages in alleviating procedure pain during caudal block in children.
Anesthesia, Caudal ; Anesthesia, Conduction ; Child* ; Hernia, Inguinal ; Humans ; Inhalation ; Needles ; Orchiopexy ; Pediatrics ; Punctures* ; Skin*

BACKGROUND: Caudal epidural injections have been commonly performed in patients with low back pain and radiculopathy. Although caudal injection has generally been accepted as a safe procedure, serious complications such as inadvertent intravascular injection and dural puncture can occur. The present prospective study was designed to investigate the influence of the depth of the inserted needle on the success rate of caudal epidural blocks. METHODS: A total of 49 adults scheduled to receive caudal epidural injections were randomly divided into 2 groups: Group 1 to receive the caudal injection through a conventional method, i.e., caudal injection after advancement of the needle 1 cm into the sacral canal (n = 25), and Group 2 to receive the injection through a new method, i.e., injection right after penetrating the sacrococcygeal ligament (n = 24). Ultrasound was used to identify the sacral hiatus and to achieve accurate needle placement according to the allocated groups. Contrast dyed fluoroscopy was obtained to evaluate the epidural spread of injected materials and to monitor the possible complications. RESULTS: The success rates of the caudal injections were 68.0% in Group 1 and 95.8% in Group 2 (P = 0.023). The incidences of intravascular injections were 24.0% in Group 1 and 0% in Group 2 (P = 0.022). No intrathecal injection was found in either of the two groups. CONCLUSIONS: The new caudal epidural injection technique tested in this study is a reliable alternative, with a higher success rate and lower risk of accidental intravascular injection than the conventional technique.
Adult ; Anesthesia, Caudal ; Fluoroscopy ; Humans ; Incidence ; Injections, Epidural ; Injections, Spinal ; Ligaments ; Low Back Pain ; Needles* ; Prospective Studies ; Punctures ; Radiculopathy ; Ultrasonography

Caudal epidural injection is a common intervention in patients with low back pain and sciatica. Even though the complications of fluoroscopically directed epidural injections are less frequent than in blind epidural injections, complications due to contrast media can occur. We report a case of anaphylactic shock immediately after injection of an intravenous nonionic contrast medium (iohexol) during the caudal epidural injection for low back pain and sciatica in a patient without a previous allergic history to ionic contrast media (ioxitalamate). Five minutes after the dye was injected, the patient began to experience dizziness, and the systolic blood pressure dropped to 60 mmHg. Subsequently, the patient exhibited a mild drowsy mental state. About 30 minutes after the subcutaneous injection of 0.2 mg epinephrine, the systolic blood pressure increased to 90 mmHg. The patient recovered without any sequela. Life-threatening complications after injection of intravenous contrast medium require immediate treatment.
Analgesia, Epidural ; Anaphylaxis* ; Anesthesia, Caudal ; Blood Pressure ; Contrast Media ; Dizziness ; Epinephrine ; Humans ; Hypotension ; Injections, Epidural* ; Injections, Subcutaneous ; Low Back Pain ; Sciatica ; Shock

BACKGROUND: Caudal block is a common technique in children for reducing postoperative pain, and there have been several reports on the variations of the sacral canal in children. However, previous studies have mainly focused on the needle trajectory for caudal block, and there is limited information on the structural variations of the sacrum in children. The purpose of this study was to analyze the anatomic variations of sacral canals in children. METHODS: Three-dimensional computed tomographic images were analyzed. The data from the images included fusion of the sacral vertebral laminae and the sacral intervertebral space existence of the sacral cornua and the types of sacral hiatus. The types of sacral hiatus were classified into 3 groups: group I (fusion of S3 or S4 vertebral laminae), group II (unfused vertebral arch with the distance of the S3 and S4 vertebral laminae < 50% of the distance between the cornua), and group III (unfused vertebral arch with the distance of the S3 or S4 vertebral laminae > or = 50% of the distance between the cornua). RESULTS: A total of 143 children were included in this study. All of the sacral vertebral arches were not fused in 22 children (15.4%). Cornua were not identified bilaterally in 5 (3.5%) and unilaterally in 6 (4.2%) children. In the sacral hiatus, group II and group III were identified in 22 (15.4%) and 31 (21.7%) children, respectively. CONCLUSIONS: The sacral canal has various anatomical variations in children. Careful attention must be paid to identify the correct anatomic landmark.
Anatomic Landmarks ; Anatomic Variation ; Anesthesia, Caudal ; Child* ; Humans ; Imaging, Three-Dimensional ; Needles ; Pain, Postoperative ; Sacrum

No abstract available.
Anesthesia, Caudal* ; Hernia, Inguinal* ; Humans ; Infant* ; Masks* ; Ventilation*