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EFFICACY OF CAUDAL S(+)-KETAMINE WITH BUPIVACAINE AND CAUDAL BUPIVACAINE ALONE FOR HERNIOTOMY
ABSTRACT
SUMMARY
Caudal anaesthesia is the most frequently used regional technique for subumbilical
procedure in children. However, most children who had subumbilical operations with
caudal bupivacaine anaesthesia required analgesia during postoperative period. This is
because of its short duration due to single administration. This therefore, influenced many
authors to search for means to prolong the duration of caudal bupivacaine analgesia.
To overcome this limitation, additives (opioids, clonidine, midazolam, tramadol and
neostigmine) were added to caudal bupivacaine. However, the side effects of such
mixtures make the use of alternative method imperative. Therefore, the combination of
caudal bupivacaine and low dose ketamine might provide superior postoperative analgesia
without side effects compared to the use of other caudal additives. This study therefore,
compared the quality of caudal analgesia in children scheduled for unilateral herniotomy
using a combination of caudal preservative-free S(+)-ketamine and plain bupivacaine and
caudal bupivacaine alone.
Following the institution’s Ethics Committee approval, sixty-six patients aged
between 2 and 6 years scheduled for unilateral herniotomy were recruited and randomised
into two groups (33 in each group). Baseline haemodynamic parameters were recorded and
anaesthesia was induced with halothane in 100% oxygen using facemask. Plain
bupivacaine (0.5ml/kg of 0.25%) with or without 0.25mg/kg preservative-free S(+)
ketamine was administered for caudal anaesthesia in group 2 or group 1 respectively.
Anaesthesia was maintained with halothane 0.5 to 1.5% in 100% oxygen and the
caudal block with patients breathing spontaneously. Intraoperative haemodynamic
parameters were monitored. Postoperative pain was assessed for 6 hours using the
Objective Pain Scale. The primary outcome was the proportion of pain-free patients at the
pain assessment intervals. Data were analysed using IBM SPSS Statistics 20. Continuous
data were compared using t-test while categorical data were compared using Fisher’s exact
test p < 0.05 were considered significant.
There was no difference in the proportion of pain-free patients in both groups in
the first 180 minutes (3 hours) observation period. However, difference was first
observed at 240 minutes (4 hours) with 21 patients (63.6%) in group 1 were pain free
compared to 33 (100%) in group 2 p < 0.0001. Seventeen patients (51.5%) in group 1
were pain free compared to 30 (90.9%) in group 2 (p < 0.0001) at 300 minutes (5 hours).
The difference continued to 360 minutes (6 hours) in both groups, with 14 patients
(42.4%) in group 1 compared to 28 (84.4%) in group 2 were pain free (p < 0.0001).
The time to first analgesic requirement was 240.24±75.52 minutes in group 1 and
300.70±99.66 minutes in group 2 and the difference was statistically significant (p <
0.0001). Mean oral paracetamol consumption at the 6th hour was higher in group 1
(280.45±72.18mg) compared to 274.09±66.06mg in group 2 and it was not statistically
significant (p=0.710). Twenty-three parents/guardians (70%) were excellently satisfied in
group 2 compared to 6 (18.1%) in group 1 and it was statistically significant (p < 0.0001).
This study showed that an improved quality and prolongation of postoperative
analgesia can be achieved with caudal block for herniotomy when a combination of 0.5
ml/kg of 0.25% plain bupivacaine and 0.25 mg/kg S(+)-ketamine are used compared to the
use of 0.5 ml/kg of 0.25% plain bupivacaine alone.
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