|Year : 2015 | Volume
| Issue : 2 | Page : 208-212
Caudal-epidural bupivacaine versus ropivacaine with fentanyl for paediatric postoperative analgesia
Swapnadeep Sengupta1, Sudakshina Mukherji1, Jagabandhu Sheet2, Anamitra Mandal3, Sarbari Swaika4
1 Department of Anaesthesiology and Critical Care, Medical College and Hospital, Kolkata, India
2 Department of Anaesthesiology and Critical Care, IQ City Medical College, Durgapur, India
3 Department of Anaesthesiology and Critical Care, College of Medicine and JNM Hospital, Kalyani, India
4 Department of Anaesthesiology and Critical Care, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India
|Date of Web Publication||6-May-2015|
Department of Anaesthesiology and Critical Care, Medical College and Hospital, Kolkata - 700 073, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Aims : Caudal-epidural, the most commonly used regional analgesia technique, is virtually free of measurable hemodynamic effects, thus adding a new dimension to the evolving necessity of pediatric postoperative pain management. Though, bupivacaine is the most commonly used drug for this purpose, ropivacaine has emerged as a safer alternative, with the addition of opioids, like fentanyl, increasing the effective duration of analgesia. With this overview, our present study was designed to compare the postoperative analgesic efficacy of bupivacaine-fentanyl and ropivacaine-fentanyl combinations by caudal-epidural technique in pediatric infraumbilical surgeries.
Materials and Methods : Totally, 60 pediatric patients, of either sex, aged between 2 and 8 years, American Society of Anesthesiologists physical status I and II, undergoing elective infraumbilical surgeries were assigned into two groups, Group BF receiving bupivacaine 0.25%, 0.7 ml/kg and Group RF receiving ropivacaine 0.25%, 0.7 ml/kg with fentanyl 1 μg/kg added to each group. Assessment of pain was done using "Hannallah pain scale." Consumption of the total amount of rescue analgesic and time to requirement of the first dose, as also duration of motor blockade were noted. Perioperative hemodynamics and any adverse effects were monitored at regular intervals.
Results : The RF Group experienced significantly longer duration of effective postoperative analgesia, with significantly shorter duration of motor blockade and lesser total analgesic requirement in comparison to the BF Group. Hemodynamically, patients in both the groups, were equally stable.
Conclusion : Ropivacaine, with an equipotent analgesic efficacy and a lesser duration of motor block, can be used as an alternative to bupivacaine for pediatric postoperative pain care through the caudal route.
Keywords: Bupivacaine, caudal-epidural analgesia, fentanyl, pediatric postoperative pain management, ropivacaine
|How to cite this article:|
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
|How to cite this URL:|
Sengupta S, Mukherji S, Sheet J, Mandal A, Swaika S. Caudal-epidural bupivacaine versus ropivacaine with fentanyl for paediatric postoperative analgesia. Anesth Essays Res [serial online] 2015 [cited 2019 Dec 15];9:208-12. Available from: http://www.aeronline.org/text.asp?2015/9/2/208/154541
| Introduction|| |
Postoperative pain management in children has been a challenging issue since long past owing to various obstacles and misbelieves. However, this concept is gradually gaining importance as it has become clear with time that children not only feel pain of same intensity as adults  but also, pain is associated with serious consequences, including harmful neuroendocrine responses, disrupted eating and sleep cycle and increased pain perception in subsequent painful experiences. ,, In addition, the invention of different pain scales has improved pain assessment in pediatric patients and thereby, aiding in better pediatric pain management.
As in adults, regional analgesia has been an attractive choice for this purpose in children; and among the various techniques of regional analgesia, caudal-epidural analgesia is one of the most popular one, providing both intra- and post-operative analgesia in pediatric age group.  Caudal blocks are easy to perform, extensively safe when used in children, resulting in low pain scores and when combined with general anesthesia, it reduces the requirement for volatile agents and opioids, allowing rapid, pain-free recovery with minimal postoperative vomiting.
Among the commonly used long-acting local anesthetics, ropivacaine, the S(−) enantiomer of bupivacaine analogue, is known to have lesser cardiotoxicity ,, and less motor blockade , with similar pain relief  at equivalent analgesic doses in comparison to bupivacaine, the more commonly used amide local anesthetic and is considered to be a better agent for caudal-epidural analgesia in children.  The main reason for ropivacaine, as having a lesser motor blocking potency with similar analgesic effect is that 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). 
The addition of an adjuvant, like fentanyl, by its primary action as a μ receptor agonist, prolongs and intensifies the sensory blockade produced by local anesthetics with reduction in dose of the latter, thereby reducing the adverse effects.
With this background, an endeavor was made to compare the intensity and duration of postoperative analgesia in the pediatric patients, undergoing infraumbilical surgeries, receiving caudal-epidural bupivacaine-fentanyl combination versus ropivacaine-fentanyl combination.
| Materials and methods|| |
After taking the Institutional Ethics Committee approval and written informed consent from parents of the patients, 60 children of either sex, aged between 2 and 8 years of American Society of Anesthesiologists physical status I and II, posted for infraumbilical surgeries were included in the study, which was conducted over a period of 1 year, from May 2012 to April 2013. Children with local infection in the caudal area, history of bleeding disorder, allergic reaction to local anesthetics, preexisting neurological, spinal or neuromuscular diseases and mental retardation were excluded from this randomized, prospective, double-blind study.
The patients were randomly allocated into two groups by opening sealed envelope. Group BF received bupivacaine 0.25% 0.7 ml/kg and fentanyl 1 μg/kg and Group RF received ropivacaine 0.25% 0.7 ml/kg and fentanyl 1 μg/kg. Ropivacaine 0.25% was prepared by diluting 0.75% ropivacaine with normal saline in the ratio of 1:2. The calculated dose fentanyl was appropriately measured and taken using the tuberculin syringe. The parents of the patients, anesthesiologists who conducted the anesthetic procedures, including monitoring of the patients postoperatively and the statistician who analyzed the results were unaware of the group allocation. The anesthesiologist who prepared the study agents following standard written instructions was excluded from further contact with the patient.
A thorough preanesthetic check-up was done, and body weight of each patient was obtained. With adequate fasting, all patients were premedicated with 0.2 mg/kg of midazolam, orally 30 min prior to expected time of surgery. Then, after receiving the patient at the operation theatre, all the monitors to record the vital parameters were attached, and the baseline hemodynamic parameters were recorded. General anesthesia was induced by O 2 , N 2 O (1:2) with increasing concentration of halothane up to 2% through a facemask, using Jackson-Rees modification of Ayre's T-piece. After the child had become calm and quiet, all monitors were rechecked, and intravenous (IV) access was secured with appropriate sized IV cannula. Injection glycopyrrolate 0.01 mg/kg was given IV and tracheal intubation was facilitated following administration of the injection atracurium besylate 0.5 mg/kg IV. After 3 min of bag and mask ventilation, endotracheal intubation was done with uncuffed PVC endotracheal tube of appropriate size. A moist oral throat pack was placed following confirmation of the tube position. Anesthesia was maintained by 60% N 2 O in O 2 with 0.5-1% halothane and using intermittent positive-pressure ventilation.
After the induction of general anesthesia, each child was turned to left lateral position; overlying skin was antiseptically prepared and draped. The sacral hiatus was identified by the position of the apex of an equilateral triangle whose base was formed by a line joining the two posterior superior iliac spines and confirmed by palpation of the sacral cornua. A 22 or 23-gauge, sterile, disposable hypodermic needle, used for the caudal injection, was inserted into the hiatus at 60° to the skin. Once the needle was felt to pass through the sacrococcygeal ligament with a characteristic "pop," the angle was decreased to 30° and advanced 0.5 cm further into the sacral canal. The syringe filled with the calculated dose of the study drug for each of Groups BF and RF was then attached to the hub of the needle, and a gentle aspiration was performed. If no blood or CSF was aspirated, then only either of the study drug combinations was injected. The anesthesiologist who prepared the study agents following standard written instructions was excluded from further contact with the patient. At the end of the procedure, the point of puncture was covered with antiseptic dressing and the patient was turned supine.
Changes in hemodynamic parameters like systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and SpO 2 were monitored intraoperatively. Intensity and duration of postoperative analgesia were similarly monitored with regular monitoring of SBP, DBP, MAP, HR, respiratory rate, SpO 2 and any adverse effect. Assessment of pain was done using "Hannallah pain scale."  Requirement of the first dose of rescue analgesic (injection paracetamol 3-5 mg/kg intramuscularly given when pain score was >4) and consumption of the total dose of additional analgesic were noted. Duration of motor blockade, in terms of spontaneous movement of the leg by patient, was, also, noted.
Statistical analysis was performed by using Statistical Package for Social Sciences software version 20 (IBM). Sample size was calculated with PS Power and Sample Size Calculations Version 2.1.30 (William Dupont and Walton D Plummer), February 2003. The sample size required was calculated considering an α-error of 0.05, power 0.90 or 90%, assumed difference in the dose of the total amount of rescue analgesic as 5 with a standard deviation of 5.5, which resulted in a predicted sample size of 28.6, considering a 10% drop-out for each group. Thereby, rounding up, 60 patients were included in the present study. Hemodynamic variables were compared between groups by Mann-Whitney U-test making no assumption regarding the distribution of the variables in the population. Unpaired Student's t-test to compare normally distributed numerical variables and Chi-square test or Fisher's exact test for categorical variables were used, with P < 0.05 taken to be statistically significant.
| Results|| |
The two groups were comparable in terms of demography, distribution of the type and duration of surgeries performed in each group as shown in [Table 1].
Group RF had significantly lesser duration of motor block than Group BF; the time to first rescue analgesic was significantly longer and the total amount of the same required was also less in Group RF, however, the latter was not significant statistically [Table 2].
|Table 2: Comparison of the duration of motor block, time point at which rescue analgesic required (measured by "Hannallah pain scale") and total amount of rescue analgesic required in two groups|
Click here to view
There were no significant differences in the side-effect profile [Table 3] and the hemodynamic parameters [Figure 1] and [Figure 2] between the two groups.
|Figure 1: Comparison of heart rate (HR) in two groups. Abscissa represents the observation intervals in minutes and ordinate represents HR per minute in given interval|
Click here to view
|Figure 2: Comparison of mean arterial pressure (MAP) in two groups. Abscissa represents the observation intervals in minutes and ordinate represents MAP in given interval|
Click here to view
|Table 3: Comparison of group BF and group RF according to the incidence of side - effects|
Click here to view
| Discussion|| |
Postoperative pain in children, with several negative implications on the hemodynamic status, state of anxiety and the overall recovery after surgery, has been a topic of interest to medical researches and practitioners, specially, anesthesiologists. The advent of regional analgesia, specially caudal-epidural, has added new dimensions to the strategy of pediatric postoperative analgesia, with bupivacaine, being the most commonly used local anesthetic for this purpose. However, ropivacaine has emerged as a safer option than the mother drug and is, thus, gaining popularity. Hence, we tried to find out the comparative efficacy of these two drugs, with the addition of fentanyl to each, in order to intensify their effects.
Two of the main aims of our study were to compare postoperative intensity (as measured by total amount of rescue analgesic consumed) and the duration of analgesia (as measured by endpoint when patient needs rescue analgesic) between the two groups. As per the first parameter, the total amount of rescue analgesic required in Group BF, 83.33 ± 33.869 mg was more than that in Group RF, 75.17 ± 24.582 mg, although it was not statistically significant. Thus, it can be concluded that the intensity of postoperative analgesia produced by ropivacaine was equivalent, or even better, than bupivacaine. Da Conceicao and Coelho  studied the effectiveness and degree of motor block produced by ropivacaine in comparison to bupivacaine and found that ropivacaine, in caudal route, produced sensory block and analgesia, which were equivalent to bupivacaine. Similarly, Khalil et al.  undertook a double-blind trial to compare the analgesic efficacy of caudal bupivacaine to ropivacaine, 0.25%, 1 ml/kg each and concluded that ropivacaine provided adequate postoperative analgesia with no difference from bupivacaine in quality and duration of pain relief. Similar findings were also found in the studies by Brescham et al.  and Locatelli et al.,  thus corroborating the findings of the present study, which ropivacaine had equipotent analgesic activity as bupivacaine, when given caudally.
There was statistically significant difference in duration of analgesia among the two study groups, with patients in Group RF (286 ± 10.780 min) had significantly long duration before rescue analgesic was required than Group BF (252.67 ± 7.038 min). Similar study was done by Doctor et al.  showed duration of analgesia was also more in the ropivacaine-fentanyl group (6.1 h) in comparison to bupivacaine-fentanyl group (5.6 h), though it was statistically insignificant. However, the outcome corroborated with our findings. The duration to first rescue analgesic in the ropivacaine group was quite close to the findings of Shukla et al.  Again, the same for the bupivacaine group matched with the findings of Constant et al.,  where they studied the effects of addition of clonidine or fentanyl with local anesthetics in regards to prolongation of duration of surgical analgesia after single-shot caudal block and found that the first rescue analgesic required in the fentanyl group was longer than in the plain bupivacaine group, thus substantiating the fact that the duration of analgesia had been increased with the addition of fentanyl to the local anesthetics.
The findings of various previous studies also corroborated with the finding of the present study that ropivacaine provided a longer duration of postoperative analgesia as compared to bupivacaine. Ivani et al.,  reported a significantly increased duration of analgesia for ropivacaine in comparison to bupivacaine. While comparing ropivacaine with bupivacaine for pediatric caudal block in 245 children, Ivani et al.,  again in another study, found that the mean time to first analgesia after bupivacaine was earlier than that after ropivacaine. Similarly, Brescham et al.,  in a double-blind study among 42 children, found that the mean postoperative analgesia was slightly longer in the ropivacaine group compared to the bupivacaine group, though it was statistically nonsignificant.
This study also showed that in the two comparable groups, the duration of motor block in the RF Group (54.5 ± 22.103 min) was significantly less than the BF Group (216 ± 44.147 min), thereby allowing early ambulation. Study by Da Conceicao and and Coelho  similarly showed a significant difference in degree of motor block in their two study groups. Findings, alike in respect to duration of motor blockade was also shown in the study by Doctor et al.  Again, Da Conceicao et al.,  in another study comparing ropivacaine 0.25% with bupivacaine 0.25% by the caudal route, found that the ropivacaine group showed a shorter duration of motor block than the bupivacaine group. Though, Ivani et al.  did not find any motor block in either group in one of their studies, their subsequent study  was corroborating with our present study, as was the study by Khalil et al.,  where they found significant motor block initially, which almost recovered to normal power within 3 h in ropivacaine group, whereas motor recovery was significantly slow in bupivacaine group.
Per-operative mean arterial blood pressure (MAP), pulse rate was monitored to evaluate hemodynamic stability in intra- and post-operative period. The intraoperative hemodynamic profile, an indirect indicator of intra- and post-operative pain, was well maintained with both the groups. Likewise, the incidence of side-effects, like respiratory depression, hypotension or urinary retention was not significant in either of the groups. Other similar studies, like the one performed by Doctor et al.  also found no significant difference in hemodynamic or side-effect profiles between the two groups.
| Conclusion|| |
Hence, it can be concluded that ropivacaine has an equipotent analgesic efficacy with a lesser duration of motor block in comparison to bupivacaine, suggesting a greater degree of sensory and motor separation; however, a similar hemodynamic and side-effect profile. Thus, ropivacaine can be used as an alternative to bupivacaine for pediatric postoperative pain care through the caudal route as a safe and effective agent.
| References|| |
American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108:793-7.
Anand KJ, Brown MJ, Causon RC, Christofides ND, Bloom SR, Aynsley-Green A. Can the human neonate mount an endocrine and metabolic response to surgery? J Pediatr Surg 1985;20:41-8.
Anand KJ. Pain, plasticity, and premature birth: A prescription for permanent suffering? Nat Med 2000;6:971-3.
Peters JW, Schouw R, Anand KJ, van Dijk M, Duivenvoorden HJ, Tibboel D. Does neonatal surgery lead to increased pain sensitivity in later childhood? Pain 2005;114:444-54.
Dutta Gupta S, Mandal S, Naskar C, Mukherjee S, Kundu KK, Sah SK. Caudal epidural bupivacaine alone versus bupivacaine-low dose morphine combination in paediatric infraumbilical surgeries for postoperative analgesia. J Anaesthesiol Clin Pharmacol 2009;25:183-6.
Reiz S, Häggmark S, Johansson G, Nath S. Cardiotoxicity of ropivacaine - A new amide local anaesthetic agent. Acta Anaesthesiol Scand 1989;33:93-8.
Knudsen K, Beckman Suurküla M, Blomberg S, Sjövall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997;78:507-14.
Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg 1989;69:563-9.
McClure JH. Ropivacaine. Br J Anaesth 1996;76:300-7.
Da Conceicao MJ, Coelho L. Caudal anaesthesia with 0.375% ropivacaine or 0.375% bupivacaine in paediatric patients. Br J Anaesth 1998;80:507-8.
Markham A, Faulds D. Ropivacaine. A review of its pharmacology and therapeutic use in regional anaesthesia. Drugs 1996;52:429-49.
Hannallah RS, Broadman LM, Belman AB, Abramowitz MD, Epstein BS. Comparison of caudal and ilioinguinal/iliohypogastric nerve blocks for control of post-orchiopexy pain in pediatric ambulatory surgery. Anesthesiology 1987;66:832-4.
Doctor TP, Dalwadi DB, Abraham L, Shah N, Chadha A, Shah BJ. Comparison of ropivacaine and bupivacaine with fentanyl for caudal epidural in pediatric surgery. Anesth Essays Res 2013;7:212-5.
Shukla U, Prabhakar T, Malhotra K. Postoperative analgesia in children when using clonidine or fentanyl with ropivacaine given caudally. J Anaesthesiol Clin Pharmacol 2011;27:205-10.
Khalil S, Campos C, Farag AM, Vije H, Ritchey M, Chuang A. Caudal block in children: Ropivacaine compared with bupivacaine. Anesthesiology 1999;91:1279-84.
Brescham C, Krumpholz R, Schaumberger F, Likar R. Ropivacaine vs. bupivacaine in paediatric caudal blocks. Eur J Anesthesiol 2000;17:150.
Locatelli B, Ingelmo P, Sonzogni V, Zanella A, Gatti V, Spotti A, et al.
Randomized, double-blind, phase III, controlled trial comparing levobupivacaine 0.25%, ropivacaine 0.25% and bupivacaine 0.25% by the caudal route in children. Br J Anaesth 2005;94:366-71.
Constant I, Gall O, Gouyet L, Chauvin M, Murat I. Addition of clonidine or fentanyl to local anaesthetics prolongs the duration of surgical analgesia after single shot caudal block in children. Br J Anaesth 1998;80:294-8.
Ivani G, Mereto N, Lampugnani E, Negri PD, Torre M, Mattioli G, et al.
Ropivacaine in paediatric surgery: Preliminary results. Paediatr Anaesth 1998;8:127-9.
Ivani G, Lampugnani E, Torre M, Calevo Maria G, DeNegri P, Borrometi F, et al.
Comparison of ropivacaine with bupivacaine for paediatric caudal block. Br J Anaesth 1998;81:247-8.
Da Conceicao MJ, Coelho L, Khalil M. Ropivacaine 0.25% compared with bupivacaine 0.25% by the caudal route. Paediatr Anaesth 1999;9:229-33.
Ivani G, Negri PD, Conio A, Grossetti R, Vitale P, Vercellino C, et al
. Comparison of racemic bupivacaine, ropivacaine and levobupivacaine for paediatric caudal anesthesia: Effect on postoperative analgesia and motor block. Reg Anesth Pain Med 2002;27:157-61.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]