COMPARISON OF POSTOPERATIVE ANALGESIC EFFICACY BETWEEN CAUDAL BLOCK AND DORSAL PENILE NERVE BLOCK WITH PLAIN BUPIVACAINE IN PAEDIATRIC DAY- CASE CIRCUMCISION

COMPARISON OF POSTOPERATIVE ANALGESIC EFFICACY BETWEEN CAUDAL BLOCK AND DORSAL PENILE NERVE BLOCK WITH PLAIN BUPIVACAINE IN PAEDIATRIC DAY- CASE CIRCUMCISION

Abstract

Background: Postoperative pain in children following circumcision frequently result in crying,
restlessness and agitation which often leads to an increase incidence of bleeding, therefore, pain
needs to be anticipated and effectively relieved. Painful experiences in circumcision of infants
and children without the benefit of anaesthesia may lead to life-long behavioural changes.
Parenteral analgesia such as paracetamol and non- steroidal anti-inflammatory drugs (NSAIDS)
may be inadequate, while opioids are associated with serious side effects especially respiratory
depression, nausea and vomiting. Regional anaesthetic techniques such as caudal block and
dorsal penile nerve block are safe and provide effective postoperative pain relief. Hence, the aim
of this study was to compare the efficacy of caudal block and dorsal penile nerve block (DPNB)
with plain bupivacaine in paediatric circumcision for day-case surgery.
Method: This was a prospective randomized double blind study of paediatric patients aged 1-5
years with American Society of Anaesthesiologists (ASA) classification I and II. They
underwent day-case circumcision at Federal Teaching Hospital, Gombe. After an institutional
ethical approval, an informed written consent was obtained from the parent/guardian of each
patient. The patients were randomly allocated by balloting into group A which had caudal block
with 0.5% plain bupivacaine and group B who had dorsal penile nerve block (DPNB) with 0.5%
plain bupivacaine. Post-operative pain was assessed hourly using the Children’s Hospital of
Eastern Ontario Pain Scale (CHEOPS) in the PACU and four hourly at home by phone call to the
parent / care giver for 24 hours. The time for the first postoperative analgesic demand was
recorded. Patient’s age, pulse rate, blood pressure, weight, success rate of each block,
complications, average pain score, time for the first postoperative analgesia demand and total
analgesics consumed in 24 hours were recorded and analyzed.
Results: A total of 218 patients were recruited for this study however, only two hundred
and nine (209) patients completed the study, made up of 107 and 102 in group A and B
respectively. Group A had 98.17%, while group B had 95.41% successful blocks. There was no
significant difference in block success rate between the two groups (p = 0.34).
The mean postoperative increase in the pulse rate was 14.29 ± 2.42 beats/minute for group A and
38.18 ± 5.45 beats /minute for group B (p = 0.03) in the first 5 minutes. It was16.19 ± 2.29
beats/minute for group A and 36.08 ± 3.15 beats/minute for group B (p = 0.01), 14.27 ± 3.49
beats/minute for group A and 36.20 ±5.15 beats/minute for group B (p = 0.02), 12.29 ± 2.09
beats/minute for group A and 33.58 ± 1.35 beats /minute for group B (p = 0.05) in the in the 5th,
10th, 15th and 30th minutes respectively with significant difference between the two groups in
different periods.
There were also significant differences in the mean increase in the postoperative mean arterial
pressure (MAP) was 10.39 ±3.31 mmHg for group A and 28.82 ±5.47 mmHg for group B (p =
0.03), 11.04 ± 4.81 mmHg for group A and 29.81 ± 6.27mmHg for group B (p = 0.04), 11.36 ±
3.01 mmHg for group A and 29.73 ±5.07 mmHg for group B (p = 0.01), 12.34 ± 3.22 mmHg for
group A and 30.10 ± 7.42 mmHg for group B (p = 0.04) in the in the 5th, 10th, 15th and 30th
minutes respectively.
The mean time interval between the time the blocks were given to the time the first dose of
analgesics were given was significantly longer in the caudal block group 335.82 ± 16.17 minutes
compared to the 91.19 ± 14.10 minutes in the DPNB group (p = 0.02). Group A had significantly
lower average CHEOPS pain score in the immediate postoperative period of 4.17 ± 0.38 than the
Group B with 9.08 ± 0.86 (p = 0.02). Fewer patients in Group A compared to the Group B
needed postoperative analgesia in the PACU; 8 (7.5%) and 101(99%) respectively (p = 0.01).
Group A consumed 2.10 ± 0.31 number of paracetamol doses which was significantly lower than
3.04 ± 0.52 number of paracetamol doses consumed by group B (p = 0.05). Group A consumed
mean paracetamol doses of 371.59 ± 70.27 mg while group B consumed 516.07 ± 95.31 mg of
Paracetamol in 24 hours (p = 0.03).
There was no significant difference in the incidence of postoperative vomiting between the two
groups. The caudal block group had 5(4.67%) of the patients with postoperative vomiting and
dorsal penile nerve block group had 8(6.67%) of the patients with postoperative vomiting (p =
0.46). In the caudal group there was a higher incidence of delayed micturition 17(15.89%)
compared to 11(10.28%) in the DPNB group but it was not statistically significant (p = 0.16).
Conclusion: The results of this study, has shown that caudal block has a higher success rate,
better postoperative analgesia, less postoperative haemodynamic changes and less incidence of
vomiting. However, delayed micturition was more in the caudal block group compared to dorsal
penile nerve block in children aged 1- 5 years for day case circumcision.

COMPARISON OF POSTOPERATIVE ANALGESIC EFFICACY BETWEEN CAUDAL BLOCK AND DORSAL PENILE NERVE BLOCK WITH PLAIN BUPIVACAINE IN PAEDIATRIC DAY- CASE CIRCUMCISION

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