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.
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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
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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)