|Year : 2018 | Volume
| Issue : 1 | Page : 87-91
Caudal versus spinal anesthesia in children undergoing lower abdominal operations
Abd-Elrahman Ahmed Ahmed, Amany S Ammar, Ahmed Hashem M. Ismail
Department of Anesthesia, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||21-Nov-2016|
|Date of Acceptance||03-Feb-2017|
|Date of Web Publication||14-Jun-2018|
Ahmed Hashem M. Ismail
Berket El-Sabae, Menoufia
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare spinal and caudal anesthesia in children undergoing lower abdominal surgeries, as regards efficacy of anesthesia, hemodynamics, and postoperative pain.
General anesthesia in pediatric patients, especially premature children, is one of the most important risk factors for postoperative apnea.
Patients and methods
The study was a randomized, double-blind, controlled trial. Totally, 40 children aged 3–12 years received either caudal or spinal anesthesia. The outcomes measured were hemodynamics, degree of motor block using Bromage score, pain assessment using Wong–Baker facial grimace scale, degree of sedation, total requirement of postoperative analgesia, complication rate, and parent satisfaction.
A total of 40 children were included for analysis. Of them, 20 children received caudal and 20 received spinal anesthesia. Heart rate was significantly higher in the caudal group than in the spinal group (P = 0.006). The mean score measured using the Wong–Baker facial grimace scale for postoperative pain assessment at 2 h in the caudal group was 0.30 ± 0.47, compared with 5.05 ± 3.72 in the spinal group; there was a highly significant statistical difference (P = 0.00). The mean score measured using Bromage score at 90 min in the caudal group was 3.0 ± 0.00, compared with 2.75 ± 0.44 in the spinal group; there was a significant statistical difference (P = 0.021). There was no significant statistical difference between the two groups as regards blood pressure changes, oxygen saturation readings, sedation, and complication rate.
Both caudal and spinal approaches are effective in pediatric patients as anesthesia for lower abdominal operations. However, caudal anesthesia has a relatively longer duration of postoperative analgesia and motor block.
Keywords: caudal, lower abdominal operations, spinal
|How to cite this article:|
Ahmed AEA, Ammar AS, M. Ismail AH. Caudal versus spinal anesthesia in children undergoing lower abdominal operations. Menoufia Med J 2018;31:87-91
|How to cite this URL:|
Ahmed AEA, Ammar AS, M. Ismail AH. Caudal versus spinal anesthesia in children undergoing lower abdominal operations. Menoufia Med J [serial online] 2018 [cited 2018 Aug 17];31:87-91. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/87/234241
| Introduction|| |
Regional anesthesia, alone or in combination with light general anesthesia, provides several advantages for the pediatric patients. The most significant advantage is intraoperative and postoperative pain relief ,.
Other advantages include suppression of undesirable reflexes such as laryngospasm during circumcision and perianal procedures, earlier ambulation, earlier hospital discharge, decreased need for non-narcotic analgesics following discharge, and a more rapid return to the child's usual bright and alert state .
In recent times, the use of regional anesthesia in pediatric surgery has become more frequent due to the growing number of premature infants who are discharged with chronic and acute morbidities that need to be operated on. These infants are at great risk of developing respiratory failure and postoperative apnea compared with term infants of the same age .
Regional anesthesia could also be indicated as an alternative to general anesthesia, especially in situ ations such as chronic respiratory disease, potentially difficult airway, and malignant hyperthermia ,.
Regional anesthesia in children was first studied by August Bier in 1899 . In 1900, Bainbridge reported a case of strangulated hernia repair under spinal anesthesia in an infant of 3 months of age .
In 1901, Sicard and Cathelin introduced the caudal approach in anesthetic practice. The first publication that mentioned this technique in children was written by Campbell in 1933 and the second one by Leigh and Belton in 1951 .
Spinal anesthesia produces complete analgesia with profound muscle relaxation, quiet respiration, and small contracted bowel .
Caudal anesthesia is a useful adjunct to general anesthesia for lower abdominal surgery in children as it provides intraoperative analgesia, smooth recovery period, and good postoperative pain control, which reduces postoperative narcotic requirement .
| Patients and Methods|| |
The study was conducted during the period from 2015 to 2016 at Menoufia University Hospitals (Egypt). The study protocol was approved by the local ethics committee of Anesthesia Department, Menoufia University. All participants provided written informed consent before inclusion into the study. The study involved 40 children undergoing lower abdominal operations.
Children of both sexes between 3 and 12 years of age of American Society of Anesthesiology I or II undergoing lower abdominal surgeries were included in the study.
Exclusion criteria were as follows: presence of significant spinal defect, infection of the skin or subcutaneous tissue in puncture area, coagulopathy, and refusal of parents.
All participants were subjected to full history taking and complete physical examination. They were divided into two groups: the spinal group and the caudal group.
Group 1 (the spinal group)  included 20 children who received spinal anesthesia with hyperbaric bupivacaine 0.5% at a dose of 0.4 mg/kg.
Group 2 (the caudal group)  included 20 children who received caudal anesthesia with bupivacaine (volume = 0.1 ml of anesthetic solution × body weight × number of segments to be blocked) at a dose of 3 mg/kg.
On admission, the enrolled children were assigned to one of the described interventions according to atrial sequence, which was prepared using random number table in a statistical text book and then the determined assignment sequence was hidden in sequentially numbered, opaque, sealed envelopes. The trial was double blinded; the caregivers and the participants were blinded to the type of intervention. Monitoring of blood pressure (BP), heart rate (HR), and oxygen saturation was carried out throughout operation. Bromage score was used to record the degree of motor block. The Wong–Baker facial grimace scale was used to record duration of postoperative analgesia.
At the end of the study, data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package of the social sciences (version 20, SPSS; SPSS Inc., Chicago, Illinois, USA) and Epi Info 2000 programs (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia (US)), where the following statistics were applied. The results were expressed by applying mean ± SD, c2-test, t-test, Mann–Whitney U-test, Fisher's exact test, and P values.
| Results|| |
The study showed that there was no significant statistical difference between the two groups as regards age and sex [Table 1]. There was a significant statistical difference between the two groups as regards HR (P = 0.006) [Table 2] and [Figure 1]. However, there was no significant statistical difference between the two groups as regards BP readings [Table 3]. There was a highly significant statistical difference between the two groups as regards the Wong–Baker facial grimace scale at 2 h postoperatively (P = 0.00) [Table 4] and [Figure 2]. There was a significant statistical difference between the two groups as regards Bromage score at 90 min postoperatively (P = 0.021) [Table 5] and [Figure 3].
|Table 4: Comparison between studied groups as regards the Wong.Baker facial Grimace scale|
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|Figure 2: Pain assessment score in both groups. VAS, visual analog scale.|
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|Table 5: Comparison between studied groups according to Bromage score at different stages|
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| Discussion|| |
In the present study we used bupivacaine alone at a dose and volume that was sufficient to create adequate anesthetic plane for lower abdominal surgeries. Lidocaine was believed to have neurotoxicity .
Ivani et al.  compared ropivacaine, l-bupivacaine, and bupivacaine for caudal block in children, showing that all three investigated local anesthetics were found to be effective and similar.
Kokki et al.  studied the difference between bupivacaine and l-bupivacaine in spinal anesthesia in 40 children undergoing lower abdominal operations. Both were effective and had a similar duration of analgesia.
In the present study, there were fewer changes in arterial pressure and HR.
Dohi and Seino  have shown hemodynamic stability in children up to 5 years of age with regional anesthesia. In children above 6 years of age there has been a mild decrease in BP, and in children between 8 and 15 years of age there has been a more marked BP change.
Factors involved in this hemodynamic stability with regional anesthesia in pediatric are still not totally defined. One theory is that the relative immaturity of the sympathetic nervous system, less vasomotor tone, and less capacitance veins in lower extremities. HR was kept at normal range because regional anesthesia eliminates the bradycardiac response to mesenteric or spermatic cord manipulation during urogenital surgery or lower abdominal surgery .
The present study revealed that oxygen saturation did not suffer significant changes; this is in agreement with the findings of Warner et al. . However, Wright et al.  have reported respiratory failure or apnea when sensory and motor block levels were above the first thoracic dermatome (T1), with the need for ventilatory assistance until block regression.
In the present study a comparison was made between caudal and spinal anesthesia as regards postoperative analgesia. We found that the duration of analgesia was longer with caudal than with spinal anesthesia, which is coincident with the findings of Blaise and Roy .
Local anesthetics alone provide analgesia for a few hours. Increasing the duration of local anesthetic action is often desirable because it prolongs surgical anesthesia and analgesia .
In agreement with the present study, Williams et al.  showed that the duration of analgesia after spinal anesthesia in children is for ~90 min, which limits its use for longer surgeries.
Moreover, in the present study, the duration of postoperative analgesia after caudal anesthesia was ~300 min. This is in agreement with the findings of Klimscha et al. , who found that the mean duration of analgesia in caudal anesthesia using bupivacaine only was 346 min, in caudal with epinephrine it was 300 min, and 360 min in children who received caudal anesthesia with clonidine.
However, Jamali et al.  studied the duration of postoperative analgesia in three groups aged 1–7 years: caudal anesthesia using 0.25% bupivacaine only, caudal anesthesia with epinephrine, and caudal anesthesia with clonidine. The mean duration of postoperative analgesia was 460 min in patients who received caudal anesthesia with bupivacaine only .
In the present study, there were no significant changes as regards sedation score in both groups. This may be as attributed to the fact that intraoperative sedation may not be required if neuroaxial anesthesia is successful because deafferentiation itself produces sedation. This has been proven using bispectral index in infants under spinal anesthesia by Hermanns et al. .
Melman et al.  showed that regional anesthesia using the spinal, epidural, or caudal approach was used to anesthetize 200 children, varying in age from 17 days to 15 years. Ketamine (1–2 mg/kg) was administered in the majority of cases to ensure a quiet patient before block. No major anesthetic complications or deaths were attributable to the anesthetic technique. The caudal approach has shown to be easy and safe .
In the present study, there were more complications in the spinal group: one case, headache; one case, backache; and three cases, hypotension. In the caudal group, complications were related mainly to procedure: one case, inadequate block; one case, vascular puncture; and one case, postoperative urine retention. Our patients were treated symptomatically with simple analgesia for headache and backache, ephedrine for hypotension, urinary catheterization for urine retention, and general anesthesia for inadequate block. We did not reported postoperative nausea and vomiting in contrast with Charu et al. , who showed that three of 60 children had developed postoperative nausea and vomiting.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rahim V, Maryam A, Amirhosein H, Mansureh A. Pain management in children with collaborative parents and healthcare team. Int J Pediatr 2015; 29
Dalens B, Tanguy A, Haberer JP. Lumbar epidural anaesthesia for operative and postoperative pain relief in infants and young children. Anaesth Analg 1986; 65
Hatch DJ, Hulse MG, Lindahl SGF. Caudal analgesia in children: influence on ventilatory efficiency during halothane – anaesthesia. Anaesthesia 1994; 39
Kurt C, Spitzer A, Broenni A. Postoperative apnea in preterm infants. Anesthesiology 1987; 66
Verma D, Naithani U, Gokula C, Harsha D. Spinal anesthesia in infants and children: a one year prospective audit. Anesth Essays Res 2014; 8
Sacrista S, Kern D, Fourcade O, Izard P, Galinier P. Spinal anesthesia in a child with hypoplastic left heart syndrome. Paediatr Anaesth 2003; 13
Fortuna A. Caudal Analgesia: a simple and safe technique in pediatric surgery. Br J Anaesth 1967; 39
Gingrich B. Spinal anesthesia for a premature infant undergoing upper abdominal surgery. Anesthesiology 1993; 79
Ecoffey C, Lacroix F, Orliaguit G. Bupivacaine in children: pharmacokinetics following caudal anesthesia. Anesthesiology 1985; 63
William JM, Stoddart PA, Williams SA. Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. Br J Anaesth 2001; 86
Pandya M, Tailor K, Vachhrajani P. Caudal block using ropivacaine with or without tramadol in children for lower abdominal and lower limb surgery. Int J Med Sci Public Health 2014; 3
Seow LT, Lips FJ, Cousins MJ, Mather LE. Lidocaine and bupivacaine mixtures for epidural blockade. Anesthesiology 1982; 56
Ivani G, DeNegri P, Conio A, Grossetti R, Vitale P, Vercellino C. Comparison of racemic bupivacaine, ropivacaine, and levo-bupivacaine for pediatric caudal anesthesia: effects on postoperative analgesia and motor block. Reg Anesth Pain Med 2002; 27
Kokki H, Paula Y, Marja H. Levobupivacaine for pediatric spinal anesthesia. Anesth Analg 2004; 98
Dohi S, Seino H. Spinal anesthesia in premature infants: dosage and effects of sympathectomy. Anesthesiology 1986; 65
Oberlander TF, Berde CB, Lam KH, Rappaport LA, Saul JP. Infants tolerate spinal anesthesia with minimal overall autonomic changes: analysis of heart rate variability in former premature infants undergoing hernia repair. Anesth Analg 1995; 80
Warner MA, Kunkel SE, Offord KO, Atchison SR, Dawson B. The effects of age, and operative site on duration of caudal analgesia in pediatric patients. Anesth Analg 1987; 66
Wright TH, Orr RJ, Haberkern CM. Complications during spinal anesthesia in infants: high spinal blockade. Anesthesiology 1990; 73
Blaise G, Roy L. Spinal anesthesia in pediatric surgery. Anesth Analg 1985; 64
Mamdouh LE, Ghada HA, Sherief ZI, Alaa Eldin AA, Tarek EA. Effect of addition of dexamethasone to low volumes of local anaesthetics for ultrasound-guided supraclavicular brachial plexus block. Menoufia Med J 2015; 28
Williams RK, Adams DC, Aladjem EV, Kreutz JM, Sartorelli KH, Vane DW. The safety and efficacy of spinal anesthesia for surgery in infants. Anesth Analg 2006; 102
Klimscha W, Chiari A, Michalek S, Wildling E, Lerche A. The efficacy and safety of a clonidine/bupivacaine combination in caudal blockade for pediatric hernia repair. Anesth Analg 1998; 86
Jamali S, Samir M, Sylvaine C, Christian D. Clonidine in pediatric caudal anesthesia. Anesth Analg 1994; 78
Hermanns H, Stevens MF, Werdehausen R, Braun S, Lipfert P, Jetzek-Zader M. Sedation during spinal anaesthesia in infants. Br J Anaesth 2006; 97
Melman E, Penuelas JA, Marrufo J. Regional anesthesia in children. Anesth Analg 1975; 54
Charu P, Kamala M, Kirti P, Khyati P. A comparison between pediatric spinal and caudal anesthesia. J Med Sci 2014; 3
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]