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A COMPARATIVE STUDY OF CAUDAL BUPIVACAINE AND BUPIVACAINE TRAMADOL FOR ANALGESIA IN PAEDIATRIC INFRAUMBILICAL SURGERIES
Abstract
Background: Caudal analgesia using bupivacaine is commonly used for the relief of pain in
children. Paracetamol and/or non-steroidal anti-inflammatory drugs, commonly oral
ibuprofen, are used for postoperative control of pain, but their analgesic effect is often
insufficient. Opioids on the other hand, administered intravenously, provide effective
analgesia but the fear of their side-effects, especially respiratory depression, emesis and
sedation, have restricted their use. This study evaluated one modality of perioperative
analgesia in children for infra-umbilical surgeries using different drugs, comparing the effect
of addition of caudal tramadol to bupivacaine.
Methodology: This was a prospective, randomized, double-blind study. American Society of
Anesthesiologists (ASA) physical status classes I and II patients were recruited from the
Orthopaedic surgery and Plastic surgery units. The patients were of both sexes, aged between
1 year and 6 years scheduled for elective infra-umbilical surgeries.
Baseline heart rate (HR), non-invasive blood pressure (NIBP), arterial oxygen saturation
(SpO2), respiratory rate (RR), and temperature were measured and recorded. Inhalational
induction using halothane (0.5% increments up to 3%) in 100% oxygen was administered via
a face mask using the Jackson Rees’ modified Ayre’s T piece before intravenous (IV)
cannulation. Venous access was established and IV infusion of lactated Ringers’ solution
mixed with 50% dextrose in water commenced. Aseptic procedure was used in the caudal
administration of preservative-free plain bupivacaine, (National Agency for Food and Drug
Administration and Control (NAFDAC) registration number A4 – 9832) and preservative
free tramadol, NAFDAC approved, ( NAFDAC registration number A4 – 2539) to all the
children using 21-gauge to 23-gauge hypodermic needles. Surgery commenced 15 minutes
after the caudal injection. The patients were randomly assigned to receive 1 ml/kg of 0.25%
bupivacaine (group A) or 1ml/kg of 0.25% bupivacaine plus 1mg/kg of tramadol (group B).
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Intraoperatively, monitoring of the SpO2, HR, RR, NIBP was recorded every 5 minutes.
Postoperatively, these parameters were recorded every 15 minutes in the first hour and hourly
for another 3 hours. Postoperative pain assessment using Toddler pre-schooler postoperative
pain score (TPPPS), need for additional analgesia and the occurrence of adverse event(s) was
determined and recorded.
Results: One Hundred and Thirty Four patients participated in the study ( A, n = 66 and B,
n = 68). At the point of skin incision, 10 patients (4 in group A, and 6 in group B) recorded
≥15% rise in systolic arterial pressure (SAP) or HR from the baseline values. These patients
were regarded as having had failed caudal block, excluded from the study and their surgeries
concluded under general anaesthesia. The socio-demographic characteristics, ASA status and
duration of surgery were comparable in both groups. The proportion of patients with
significant postoperative TPPPS ≥3 at 3 hours was 20 (32.3%) patients in group A and none
in group B, p = 0.0012. Group B had significant mean duration of analgesia of 10.89 ± 1.10
hours compared with group A of 3.2 ± 1.0 hours, p = 0.0014. The proportion of patients with
incidence of vomiting was 2 (3.23%) in group A which was similar to group B of 3 (4.84%),
p = 0.4702. None of the patients in both groups had motor weakness, urinary retention in the
postoperative period.
Conclusion: The addition of tramadol to bupivacaine for caudal analgesia resulted in longer
analgesia in the postoperative period compared to bupivacaine alone, with acceptable side
effect profile.
