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Original contribution
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.
⁎
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 2.3. Ultrasound-guided block: procedure
ultrasound-guided single-shot paravertebral block in children under-
going renal surgeries, namely pyeloplasties. 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. Materials & methods
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P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110
Fig. 1. Comparison between the heart rates of both the groups intraoperatively.
Fig. 2. Comparison between the mean arterial pressures of both the groups intraoperatively.
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P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110
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. Journal of Clinical Anesthesia 52 (2019) 105–110
Chalam and coworkers [12] noted that the time for rescue analgesic 5. Conclusion
demand after ultrasound-guided paravertebral block in children be-
tween aged 2–10 years undergoing thoracotomy was 8 to 10 h in over The present study was undertaken to find a better mode of analgesia
80% of the patients indicating an adequate duration of analgesia post- for children after pyeloplasty. We found that the analgesia following
operatively. They also emphasised on the use of ultrasound to enhance ultrasound-guided single-shot paravertebral block using ropivacaine
the efficacy and safety of the block, by determining the location and with adrenaline is better and efficacious in comparison to ultrasound-
depth of the transverse process and parietal pleura. However, im- guided single-shot caudal epidural block, with comparable adverse ef-
proving hands-on in the use of ultrasound in paediatrics is essential as it fects and hemodynamcis. Hence, it should be considered as an alter-
would help in faster and safer performance of paravertebral block. native modality of analgesia for pyeloplasty in children. However,
No complications were noted during the administration of the adequate practice and expertise is required for the performance of
blocks in our study. This may be due to a smaller sample size. Moawad paravertebral block under ultrasound guidance in children.
and coworkers [13], and Berta and coworkers [8] reported inadvertent
intravascular puncture as a complication with paravertebral block. The Conflict of interests
incidence of side-effects is higher with caudal block when compared to
non-caudal regional analgesic interventions (iliohypogastric nerve None.
block, local infiltration, or both). Shanthanna and coworkers [14]
found that motor block and urinary retention were significantly more Funding
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 None.
micturition was prolonged in the caudal group, but there was no ur-
inary retention in any of the children. No complications, apart from Ethical approval
mild local tenderness at the injection sites in three patients, were noted
in the paravertebral group by Naja and coworkers [11]. In the current Institute Ethics Committee approval was obtained in August 2014
study, the incidences of post-operative vomiting and urinary retention (Chairperson Prof. Shashi Wadwa) (Reg. No. CTRI/006688).
were statistically similar in both the groups. Post-operative vomiting in
the paravertebral group was recorded by Splinter and Thomson [16]. Acknowledgements
The incidence of vomiting reported by them was 11% in the para-
vertebral group against 23% in the control group. Dr. Kalaivani, Department of Bio-statistics, All India Institute of
Naja and coworkers [11], and Tug and coworkers [10] recorded Medical Sciences, New Delhi-110029.
93% and 74.3% parental satisfaction in the paravertebral group, re- Mr. Ashish, Department of Bio-statistics, All India Institute of
spectively, using a questionnaire. A questionnaire similar to the one Medical Sciences, New Delhi-110029.
used in their study was adopted in our study too (Appendix A).
The current study has a few limitations. Firstly, the sample size is Disclosures
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 No authors have any conflicts of interest or disclosures with regard
not yield results for a similar study, a minimum of 25 patients per group to this study. This research did not receive any specific grant from
was chosen. Secondly, an additive apart from adrenaline could have funding agencies in the public, commercial, or non-profit sectors.
been used. The addition of adrenaline to ropivacaine is of doubtful
benefit. Use of any other additive could have prolonged the duration of Appendix A. Parental satisfaction score
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 Was the pain relief after surgery the surgery adequate enough and
analgesia in some children in the paravertebral block. satisfactory in keeping the child comfortable?
• 1 - Not satisfied
• 2 - Good, satisfied
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P. Narasimhan et al. Journal of Clinical Anesthesia 52 (2019) 105–110
• 3 - Excellent, very satisfied. [8] Berta E, Spanhel J, Smakal O, et al. Single injection paravertebral block for renal
surgery in children. Paediatr Anaesth 2008;18:593–7.
[9] Lönnqvist PA, Olsson GL. Paravertebral vs epidural block in children. Effects on
Appendix B. Supplementary data postoperative morphine requirement after renal surgery. Acta Anaesthesiol Scand
1994;38:346–9.
Supplementary data to this article can be found online at https:// [10] Tug R, Ozcengiz D, Güneş Y. Single level paravertebral versus caudal block in
paediatric inguinal surgery. Anaesth Intensive Care 2011;39(5):909–13.
doi.org/10.1016/j.jclinane.2018.09.007. [11] Naja ZM, Raf M, El-Rajab M, Daoud N, Ziade FM, Al-Tannir MA, et al. A comparison
of nerve stimulator guided paravertebral block and ilio-inguinal nerve block for
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