Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects?

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, Dec 2010

Purpose The purpose of this evidence-based clinical update is to identify the best evidence when selecting a long-acting local anesthetic agent for single-shot pediatric caudal anesthesia in children. Methods A structured literature search was conducted using PubMed and Medline (OVID) using the terms “caudal” and combinations of at least two of “bupivacaine”, “ropivacaine”, and “levobupivacaine”. The search limits included “randomized controlled trials” (RCTs), “meta-analysis”, “evidence-based reviews” or “reviews”, “human”, and “all child: 0-18 yr”. Seventeen RCTs were identified that concerned single-shot pediatric caudal anesthesia with at least two of the three drugs in question. Data were extracted for the areas of clinical efficacy and side effects. Study findings were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria. Results The three drugs investigated were found to be equivalent in terms of efficacy. Evidence showed bupivacaine with the highest incidence of motor block and ropivacaine with the lowest. Adverse effects were rare and unrelated to the choice of drug. There were no serious adverse events. Conclusion None of the three agents was shown to be superior in terms of efficacy. Bupivacaine is preferred if motor block is desired, ropivacaine is preferred if motor block is to be minimized. Adverse effects in human studies are rare, mild, and unrelated to the choice of drug. Despite encountering the absence of serious adverse events in each of the studies reviewed, it is noted that animal studies suggest a safer profile with ropivacaine or levobupivacaine than with bupivacaine.

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Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects?

Elisabeth F. A. Dobereiner 0 Robin G. Cox 0 MBBS 0 Alastair Ewen 0 MB ChB 0 David R. Lardner 0 MB ChB 0 0 E. F. A. Dobereiner, MD R. G. Cox, MBBS (&) A. Ewen, MB ChB D. R. Lardner, MB ChB Department of Anesthesiology, Alberta Children's Hospital, University of Calgary , 2888 Shaganappi Trail N.W, Calgary, AB T3B 6A8, Canada Purpose The purpose of this evidence-based clinical update is to identify the best evidence when selecting a long-acting local anesthetic agent for single-shot pediatric caudal anesthesia in children. Methods A structured literature search was conducted using PubMed and Medline (OVID) using the terms ''caudal'' and combinations of at least two of ''bupivacaine'', ''ropivacaine'', and ''levobupivacaine''. The search limits included ''randomized controlled trials'' (RCTs), ''metaanalysis'', ''evidence-based reviews'' or ''reviews'', ''human'', and ''all child: 0-18 yr''. Seventeen RCTs were identified that concerned single-shot pediatric caudal anesthesia with at least two of the three drugs in question. Data were extracted for the areas of clinical efficacy and side effects. Study findings were assigned levels of evidence, and grades of recommendation were made according to Centre for Evidence-Based Medicine criteria. Results The three drugs investigated were found to be equivalent in terms of efficacy. Evidence showed bupivacaine with the highest incidence of motor block and ropivacaine with the lowest. Adverse effects were rare and unrelated to the choice of drug. There were no serious adverse events. - Clinical question Methods Relative efficacy Side effects Motor block Others Onset time Intraoperative quality Duration of postoperative analgesia Comment on relative potency Table 1 Summary of study characteristics Bup % Lev % Review of current best evidence Age (yr) hernia, orchidopexy hernia, orchidopexy, penile hernia, orchidopexy, penile hernia, orchidopexy, penile hernia, orchidopexy, penile hernia, orchidopexy, penile unilateral hernia hernia, orchidopexy, penile orchidopexy hernia, orchidopexy, penile hernia, orchidopexy hernia, orchidopexy, penile hernia, orchidopexy, penile hernia, circumcision lower abdominal, urology, lower extremity Rop % Relative efficacy Side effects w a to S e R g ce llh . o ex n a n M fl a m re .A ck t e th p ro e k lo in R if c b o d reo tsoo d f B d lo f P n b o 0 a m p o rfo re jb . q ia c r .l r . t .t th to om u R rs c s r ho n fi je re po B r b o r d A O o L o B M F D A N ( ( N ( N t y b , n s a l n te s ts ac s iso re uo d lo itie .iff teopn ,iad ,tison lrenv iaenm feco ticox d hy r a a 1 re n c on (s acy icn trn V ts ied im V E ad llu ec )s N en ev tse N A r a r E PO ti b h o A a o sy O o Conclusions Recommendations 1. The choice of a long-acting local anesthetic for singleshot pediatric anesthesia in children includes bupivacaine, levobupivacaine, and ropivacaine, with no agent being clearly superior in terms of efficacy or side effects. (Grade B recommendation); 2. Bupivacaine is preferred if motor block is desirable; ropivacaine if motor block is to be minimized. (Grade B recommendation); 3. Levobupivacaine and ropivacaine show less toxicity in animal studies compared with bupivacaine. This finding might be considered when making the choice of agent. (Grade D recommendation). Appendix 1 Jadad score Please read the article and try to answer the following questions: 1. Was the study described as randomized (this includes the use of words such as randomly, random, and randomization)? 2. Was the study described as double-blind? 3. Was there a description of withdrawals and dropouts? Scoring the items: Give a score of either 1 point for each yes or 0 points for each no. There are no in-between marks. Give 1 additional point: If for question 1, the method to generate the randomization sequence was described and appropriate (e.g., table of random numbers, computer-generated, etc.) and/or; If for question 2, the method of double-blinding was described and appropriate (e.g., identical placebo, active placebo, dummy, etc.). Deduct 1 point: If for question 1, the method to generate the randomization sequence was described but was inappropriate (e.g., patients were allocated alternately or according to date of birth, hospital number, etc.) and/or; If for question 2, the study was described as double-blind but the method of blinding was inappropriate (e.g., comparison of tablet vs injection with no double dummy). Appendix 2 Centre for Evidence-Based Medicine criteria Levels of evidence for studies concerning therapy or harm Systematic Review of randomized controlled trials (RCTs) (with homogeneity) 1b Individual RCT (with narrow confidence intervals) 1c All or none study 2a Systematic review of cohort studies (with homogeneity) 2b Individual cohort study or poor quality RCT 2c Outcomes research or ecological survey 3a Systematic review of case control studies (with homogeneity) 3b Individual case-control study 4 Case-seri (...truncated)


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Elisabeth F. A. Dobereiner MD, Robin G. Cox MBBS, Alastair Ewen MB ChB, David R. Lardner MB ChB. Evidence-based clinical update: Which local anesthetic drug for pediatric caudal block provides optimal efficacy with the fewest side effects?, Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2010, pp. 1102-1110, Volume 57, Issue 12, DOI: 10.1007/s12630-010-9386-1