Journal of Clinical Anesthesia 52 (2019) 105–110

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Journal of Clinical Anesthesia

journal homepage: www.elsevier.com/locate/jclinane

Original contribution

Comparison of caudal epidural block with paravertebral block for renal T

surgeries in pediatric patients: A prospective randomised, blinded clinical
trial
⁎
Purnima Narasimhana, Lokesh Kashyapa, , V.K. Mohana, Mahesh Kumar Arorab, Dilip Shendea,
Maddur Srinivasc, Seema Kashyapd, Sayan Natha, Puneet Khannaa
a
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
b
Department of Anaesthesia, Institute of Liver and Biliary Sciences, New Delhi, India
c
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
d
Department of Ocular Pathology, All India Institute of Medical Sciences, New Delhi, India

A R T I C LE I N FO A B S T R A C T

Keywords: Study objective: This study was undertaken to compare the analgesic efficacy of ultrasound-guided single-shot
Analgesia caudal block with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries.
Child Design: Randomised, interventional, blinded clinical trial.
Regional Setting: Operating rooms of All India Institute of Medical Sciences, New Delhi, India.
Ultrasound
Patients: 50 children aged 2–10 years, of ASA status I/II, posted for elective renal surgeries.
Single-shot
Interventions: The children were randomised into two groups (Group C-caudal block, Group P-paravertebral
Pyeloplasty
block). After induction of general anesthesia, single-shot caudal or paravertebral block was performed under
ultrasound guidance, with 0.2% ropivacaine with 1:200000 adrenaline.
Measurements: Time to first rescue analgesia, time to perform blocks, intraoperative and post-operative hemo-
dynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded.
Main results: Children in Group P had significantly longer duration of analgesia (p < 0.0004) than Group C.
Post-operative FLACC scores (p < 0.005) and analgesic requirements (p < 0.0004) were lower in Group P. The
mean fentanyl requirement over 24 h in group P was 0.56 ± 0.82 μg/kg, compared to 1.8 ± 1.2 μg/kg in group
C. Parents in Group P reported greater satisfaction (p < 0.02). No complications were seen in either of the
groups.
Conclusion: This study showed superior analgesia and parental satisfaction with single-shot paravertebral block
in comparison to single-shot caudal block for renal surgeries in children. However, the block performance in
children requires adequate expertise and practice.

1. Introduction advent of ultrasound and nerve stimulators, which assist in better

Renal surgeries, one of the common surgical procedures performed
in children, are associated with significant post-operative pain. Good
post-operative analgesia is essential to allow effective coughing and
early mobilisation to reduce the occurrence of post-operative re-
spiratory complications. In pediatric patients, caudal epidural block, via
landmark approach, remains the most commonly performed regional
anesthetic technique [1]. The use of ultrasound has facilitated the
correct placement of the block, even in children with sacral anomalies
[2]. The use of peripheral nerve blocks in children is on the rise with the
identification of fascial planes.
Paravertebral block has been used for post-operative analgesia in
children since 1992 [3]. The main advantages include localised pain
control and the ability to avoid large volumes of local anesthetic [4]. It
is a promising alternative to caudal analgesia [5]. The use of ultrasound
in pediatric regional analgesia has great utility because these are often
performed under deep sedation or general anesthesia. Ultrasound gui-
dance offers a qualitative anatomic end-point, provides the ability to
observe local anesthetic spread during injection, and can be used to
identify abnormal anatomy [6]. This study was undertaken to compare

⁎
Corresponding author at: Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar East, New Delhi
110029, India.
E-mail address: lokeshkashyap@yahoo.com (L. Kashyap).

https://doi.org/10.1016/j.jclinane.2018.09.007
Received 3 May 2018; Received in revised form 22 August 2018; Accepted 8 September 2018
0952-8180/ © 2018 Elsevier Inc. All rights reserved.
P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110

the analgesic efficacy of ultrasound-guided caudal epidural block with
ultrasound-guided single-shot paravertebral block in children under-
going renal surgeries, namely pyeloplasties.
2. Materials & methods
2.3. Ultrasound-guided block: procedure
The blocks were administered by an anesthesiologist who is familiar
with the use of ultrasound-guided blocks for post-operative analgesia,
both in adults and children.

2.1. Study design and participants 2.3.1. Caudal block

Children in group C were turned to lateral decubitus position for
This prospective randomised single blind interventional study was ultrasound-guided caudal block. After cleaning and draping, a high-
conducted at the All India Institute of Medical Sciences after receiving frequency 38 mm linear transducer was placed transversely over the
Institutional Review Board approval (Reg. No. CTRI/006688), in ac- sacral cornu to get the ‘frog-eye’ appearance. The probe was then
cordance with the CONSORT guidelines. turned longitudinally to obtain a sagittal view of the caudal space.
Informed written consent was taken from the guardians of the Using 5 cm, 22 G needle, caudal block was given with 1.25 ml/kg of
children who were enrolled in the study. The routine anesthetic prac- 0.2% ropivacaine with 1:200000 adrenaline, by in-plane approach.
tice at our institute for Anderson-Hynes pyeloplasty is the administra-
tion of single-shot caudal block after induction of general anesthesia or 2.3.2. Paravertebral block
local infiltration of the surgical wound. In this study, single-shot caudal Children in group P were turned to lateral decubitus position for
block was compared with single-shot paravertebral block. Fifty chil- ultrasound-guided paravertebral block at T10 level. After cleaning and
dren, aged 2–10 years, of ASA physical status I/II planned for Anderson- draping, a high-frequency 38 mm linear transducer was placed long-
Hynes pyeloplasty were randomised into two groups: Group C (caudal itudinally to identify the spinous processes of T9-T10. The probe was
block) and Group P (paravertebral block), using sealed envelopes. then moved laterally till the respective transverse processes and the
Exclusion criteria included contraindications to regional analgesic corresponding paravertebral spaces were seen. The probe was then
procedures, neurological/cardiac disease, developmental delay, spine turned obliquely, and using in-plane approach, 0.5 ml/kg of 0.2% ro-
or chest wall deformity, history of previous renal surgeries and history pivacaine with 1:200000 adrenaline was injected at the T10 para-
of sensitivity to drugs used in the study. All the children were followed vertebral space with 19 G Touhy needle.
up for 24 h post-operatively, by an anesthesiologist who was blinded to
the block given. The primary outcome was the time to first analgesic 2.4. Statistical analysis
requirement in the 24 h follow-up period. The secondary outcomes
were the time required to perform the blocks, FLACC scores in the 24 h The data were analysed using STATA 14.0 and SPSS 20.0.
post-operative period, analgesic requirement in each group, incidence Continuous measurements were presented as mean ± SD, median
of block-related complications and the parental satisfaction scores. (IQR) and categorical variables were presented as numbers. Chi-square/
The primary outcome in our study was time to first rescue analgesia. Fisher exact test was used to find the significance of study parameters
On the basis of previous available literature, the time to first rescue on a categorical scale between the two groups. Unpaired sample t-test
analgesia after a caudal block in pyeloplasty was expected at was used to find the significance of study parameters on continuous
287.63 ± 68 min [7]. Assuming 20% increase in time to first rescue scale between two groups. The comparison between the two groups,
analgesia in the paravertebral block group at the rate of 5% level of when the variables were not normally distributed, was done by Mann-
significance to achieve 80% power of the study, we required 24 samples Whitney U test. p < 0.05 was considered significant.
in each group.
3. Results
2.2. Study protocol
As shown in Table 1, the baseline characteristics were comparable
The perioperative anesthetic management was standardised. The between both the groups, except for the time taken to perform the
children were induced either inhalationally or intravenously, along block. The time taken to administer the block was 288.1 ± 146 s (CI:
with fentanyl 2 μg/kg and atracurium 0.5 mg/kg. Airway was secured 227.8–348.4) in group P compared to 114.7 ± 68.1 s (CI: 86.6–142.8)
with an appropriate size endotracheal tube. Thereafter, anesthesia was in group C (p < 0.0001).
maintained with O2/N2O (1:1) and isoflurane. The baseline hemody- There was no statistically significant difference in the heart rate
namic parameters were noted and the children were positioned either (p = 0.34) and mean arterial pressures (p = 0.29) amongst the two
for caudal block or paravertebral block. The time to perform the block groups, recorded every 5 min intraoperatively (Figs. 1 & 2).
was noted. Any change in the intra-operative hemodynamic parameters The requirement of fentanyl boluses intraoperatively was compar-
by > 20% was considered as inadequate analgesia and treated with able between both the groups (p = 0.46). 12 children in group C and 9
1 μg/kg fentanyl boluses. The hemodynamic parameters and the
number of fentanyl boluses were recorded. Towards the end of the Table 1
surgery, all the children received intravenous ondansetron 0.1 mg/kg as Demography and patient characteristics (data expressed as mean ± SD,
median (IQR) or proportions as applicable).
anti-emetic prophylaxis, and intravenous paracetamol 15 mg/kg, which
was continued 6th hourly post-operatively. After the extubation of Variable Group C Group P p value
trachea, all the children were shifted to PACU where the hemodynamic (n = 25) (n = 25)
parameters and FLACC scores were recorded at 0, ½, 1st, 2nd, 3rd, 6th, Age (yrs) 5.1 ± 2.6 6.0 ± 2.6 0.23a
12th and 24th hours. If FLACC score of > 3 was recorded, the child was Weight (kg) 17.1 ± 6.0 19.5 ± 6.1 0.16a
first managed by non-pharmacologic means (tactile stimulation, change Sex (male/female) 20/5 19/6 0.99c
of position, warming/cooling, etc.) in order to make the child com- ASA I/II 22/3 25/0 0.23c
Time to give the block (s) 114.7 ± 68.1 288.1 ± 146 0.0001b
fortable again. If the child did not settle down, rescue analgesia with
Duration of surgery (min) 99.6 ± 20.7 98.2 ± 22.8 0.82a
fentanyl 1 μg/kg was administered. In cases where rescue analgesia was
needed within first 2 h, the block was considered a failure. The time to a
t-Test.
first rescue analgesia, number of fentanyl boluses, total amount of b
Mann-Whitney test.
c
fentanyl required and the parental satisfaction scores were recorded. Fisher's exact.

106
P. Narasimhan et al.
Fig. 1. Comparison between the heart rates of both the groups intraoperatively.
children in group P required fentanyl boluses in the intraoperative
period (Table 2). The mean analgesic requirement intraoperatively in
group C was 0.72 ± 1.1 μg/kg vs 0.52 ± 0.82 μg/kg in group P
(p = 0.46).
At 0, ½, 1, 2, 3, 6, 12 and 24 h post-operatively, there was no sta-
tistically significant difference in the heart rate (p = 0.13) and mean
arterial pressure (p = 0.68) between the two groups.
Median FLACC score was ≤2 in both the groups during the 24 h
follow up period. As shown in Fig. 3, the difference in the FLACC scores
were noted to be statistically significant from the 3rd post-operative
hour, with group C having higher scores than group P. The post-op-
erative FLACC scores did not show differences that were statistically
significant at 0 (p = 0.64), 0.5 (p = 0.46), 1 (p = 0.71), and 2 h
(p = 0.53). However, the FLACC scores were statistically different be-
tween the two groups at 3 (p < 0.001), 6 (p < 0.05), 12 (p < 0.002)
and 24 h (p < 0.002). The median FLACC scores are shown in Table 3.
One child in group P needed rescue analgesia after 30 min of
shifting to PACU and hence, the block was considered a failure. 20
children in Group C had an analgesic requirement in the follow-up
period compared to only 9 in Group P. Amongst those who required the
rescue analgesia, the mean time to first rescue analgesia in Group P was
664.4 ± 223.4 min (CI: 492.7–836.2) which was significantly longer
than 391.8 ± 217.4 min (CI: 290–493.5) in Group C (p < 0.002). The
median time to first analgesic rescue amongst children who had a de-
mand was 660 min in Group P compared to 322.5 min in Group C,
Fig. 2. Comparison between the mean arterial pressures of both the groups intraoperatively.
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Journal of Clinical Anesthesia 52 (2019) 105–110
Table 2
Intraoperative fentanyl bolus requirement (data are expressed as numbers (%)).
Number of fentanyl boluses Group C Group P
(n = 25) (n = 25)
0 13 (52) 16 (64)
1 9 (36) 6 (24)
2 2 (8) 2 (8)
3 0 (0) 1 (4)
5 1 (4) 0 (0)
(p = 0.78, Fisher's exact).
which was statistically significant (p < 0.004). Kaplan-Meier survival
estimate for all the children in both the groups, irrespective of analgesic
consumption (Fig. 4) shows that > 50% of children in group P did not
require rescue analgesia (p < 0.0004), which was statistically sig-
nificant.
The post-operative analgesic requirements were statistically sig-
nificantly different between the two groups. The median number of
analgesic dose requirement in group C was two, while it was nil in
group P (p < 0.0002). The mean fentanyl requirement over 24 h in
group C was 1.8 ± 1.2 μg/kg, compared to 0.56 ± 0.82 μg/kg in
group P, which was statistically significant (p < 0.0002). 15 children
in group P did not require rescue analgesia in the 24 h follow-up period
compared to 5 in group C (p < 0.0004). Amongst the children who
P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110

Fig. 3. Post-operative FLACC scores.

Table 3 comparable in both the groups. Post-operative nausea and vomiting was
Comparison of post-operative FLACC scores between the two groups (data ex- noted in one child in group C against none in group P. Though not
pressed as median (range)). statistically significant (p = 0.35), three children in group C had ur-
FLACC Group C Group P p value inary retention compared to one child in group P.
There was a statistically significant difference in the parental sa-
Time tisfaction score (Appendix A) between the two groups, as shown in the
Fig. 5, with parents of 18 children belonging to group P reporting ex-
0 0 (0–1) 0 (0–1) 0.64
0.5 0 (0–2) 0 (0–4) 0.46 cellent satisfaction with regard to pain relief (p < 0.02).
1 0 (0–2) 0 (0–2) 0.71
2 1 (0–5) 1 (0–2) 0.53
3 2 (0–4) 1 (0–2) 0.001⁎⁎ 4. Discussion
6 2 (0–5) 1(0–5) 0.05⁎
12 2 (1–8) 1(0–4) 0.002⁎⁎
24 2 (0–5) 1(0–3) 0.002⁎⁎
Caudal block is routinely performed at our institute for providing
post-operative analgesia after Anderson-Hynes pyeloplasty.
⁎
p < 0.05. Paravertebral block in children is used occasionally, by anesthesiolo-
⁎⁎
p < 0.005 (Mann Whitney test). gists familiar with use of ultrasound-guided blocks. It is used less fre-
quently as it requires better skill and also due to the risk of complica-
tions, especially pneumothorax, associated with it.
This study was undertaken at our institute to compare the analgesic
efficacy of caudal block and paravertebral block. Both the blocks were
performed by the same anesthesiologist, who is familiar with ultra-
sound-guided blocks. Our study showed that single-shot paravertebral
block provided better analgesia than caudal block in children after
pyeloplasty. 15 of the 24 children in group P did not have rescue an-
algesic requirement in the 24 h follow-up period. Berta and co-workers
[8], in their prospective observational pilot study in 24 children un-
dergoing major renal surgery, found that the median duration of post-
operative analgesia achieved with single-shot paravertebral block was
10 h. Ten of the 24 children did not require rescue analgesia in the 12 h
follow up period. Similar results were also reported in a retrospective
study comparing continuous thoracic paravertebral blockade with
continuous lumbar epidural blockade, by Lönnqvist and coworkers [9],
in 35 children undergoing renal surgery. They also concluded that the
analgesia provided by PVB is superior as the children in PVB group had
Fig. 4. Kaplan Meier survival curve for both the groups of the rescue analgesic
significantly lower morphine consumption (81 μg/kg (0–297) vs
requirement. 143 μg/kg (0–362), p < 0.05) than the children in lumbar epidural
group in the post-operative period. Tug and coworkers [10] postulated
that the longer duration of analgesia with paravertebral block com-
required rescue analgesic, the requirement in group P was
pared to caudal block was probably due to the increased vascularity of
1.4 ± 0.7 μg/kg (CI: 0.9–1.9) vs 2.25 ± 0.85 μg/kg (CI: 1.85–2.64) in
the epidural space, leading to more systemic absorption of the local
group C, which was a statistically significant reduction in the analgesic
anesthetic agent and hence shorter duration of epidural analgesia. The
consumption children in group P (p < 0.006).
superior analgesic efficacy of paravertebral block has also been attrib-
None of the patients in either of the groups had any complications
uted to the block of nerves as close to the roots as possible, as well as its
during block performance. The incidence of complications was
ability to ablate the visceral innervation [11].

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P. Narasimhan et al.
Fig. 5. Parental satisfaction scores.
Chalam and coworkers [12] noted that the time for rescue analgesic
demand after ultrasound-guided paravertebral block in children be-
tween aged 2–10 years undergoing thoracotomy was 8 to 10 h in over
80% of the patients indicating an adequate duration of analgesia post-
operatively. They also emphasised on the use of ultrasound to enhance
the efficacy and safety of the block, by determining the location and
depth of the transverse process and parietal pleura. However, im-
proving hands-on in the use of ultrasound in paediatrics is essential as it
would help in faster and safer performance of paravertebral block.
No complications were noted during the administration of the
blocks in our study. This may be due to a smaller sample size. Moawad
and coworkers [13], and Berta and coworkers [8] reported inadvertent
intravascular puncture as a complication with paravertebral block. The
incidence of side-effects is higher with caudal block when compared to
non-caudal regional analgesic interventions (iliohypogastric nerve
block, local infiltration, or both). Shanthanna and coworkers [14]
found that motor block and urinary retention were significantly more
common in the caudal group with an ARR of 7.44 and 8.42, respec-
tively. Bengisun and coworkers [15] also noted that the time to first
micturition was prolonged in the caudal group, but there was no ur-
inary retention in any of the children. No complications, apart from
mild local tenderness at the injection sites in three patients, were noted
in the paravertebral group by Naja and coworkers [11]. In the current
study, the incidences of post-operative vomiting and urinary retention
were statistically similar in both the groups. Post-operative vomiting in
the paravertebral group was recorded by Splinter and Thomson [16].
The incidence of vomiting reported by them was 11% in the para-
vertebral group against 23% in the control group.
Naja and coworkers [11], and Tug and coworkers [10] recorded
93% and 74.3% parental satisfaction in the paravertebral group, re-
spectively, using a questionnaire. A questionnaire similar to the one
used in their study was adopted in our study too (Appendix A).
The current study has a few limitations. Firstly, the sample size is
small to bring out the incidence of side-effects or complication of the
blocks. Since our literature review at the time of planning the study did
not yield results for a similar study, a minimum of 25 patients per group
was chosen. Secondly, an additive apart from adrenaline could have
been used. The addition of adrenaline to ropivacaine is of doubtful
benefit. Use of any other additive could have prolonged the duration of
both the blocks further. Thirdly, there was no assessment of pain at
18th hour. An assessment at this time may have showed wearing off of
analgesia in some children in the paravertebral block.
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Journal of Clinical Anesthesia 52 (2019) 105–110
5. Conclusion
The present study was undertaken to find a better mode of analgesia
for children after pyeloplasty. We found that the analgesia following
ultrasound-guided single-shot paravertebral block using ropivacaine
with adrenaline is better and efficacious in comparison to ultrasound-
guided single-shot caudal epidural block, with comparable adverse ef-
fects and hemodynamcis. Hence, it should be considered as an alter-
native modality of analgesia for pyeloplasty in children. However,
adequate practice and expertise is required for the performance of
paravertebral block under ultrasound guidance in children.
Conflict of interests
None.
Funding
None.
Ethical approval
Institute Ethics Committee approval was obtained in August 2014
(Chairperson Prof. Shashi Wadwa) (Reg. No. CTRI/006688).
Acknowledgements
Dr. Kalaivani, Department of Bio-statistics, All India Institute of
Medical Sciences, New Delhi-110029.
Mr. Ashish, Department of Bio-statistics, All India Institute of
Medical Sciences, New Delhi-110029.
Disclosures
No authors have any conflicts of interest or disclosures with regard
to this study. This research did not receive any specific grant from
funding agencies in the public, commercial, or non-profit sectors.
Appendix A. Parental satisfaction score
Was the pain relief after surgery the surgery adequate enough and
satisfactory in keeping the child comfortable?
• 1 - Not satisfied
• 2 - Good, satisfied
P. Narasimhan et al.
• 3 - Excellent, very satisfied.
Appendix B. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jclinane.2018.09.007.
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