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Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 360-365  

Caudal morphine in pediatric patients: A comparison of two different doses in children undergoing infraumbilical surgery – A prospective, randomized, double-blind study


Department of Anesthesiology and Pain Medicine, IMS and Sum Hospital, Bhubaneswar, Odisha, India

Date of Submission27-Jul-2022
Date of Decision01-Sep-2022
Date of Acceptance13-Sep-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Dr. Nupur Moda
301, Tower 2, Vipul Garden, Ghatikia, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.aer_120_22

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   Abstract 

Background: One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg−1 and 30 μg.kg−1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles. Materials and Methods: The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 μg.kg−1 of morphine was added to 0.2% ropivacaine 1 mL.kg−1 and the solution was made. Group B: 30 μg.kg−1 of morphine was added to 1 mL.kg−1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded. Results: The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting. Conclusion: From the above observations, it can be concluded that morphine of less dosage (20 μg.kg−1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg−1) as the duration of analgesia is similar with decreased incidence of side effects.

Keywords: Caudal epidural anesthesia, morphine, pain, pain score, rescue analgesia


How to cite this article:
Das S, Acharya R, Patro M, Moda N, Mounika G. Caudal morphine in pediatric patients: A comparison of two different doses in children undergoing infraumbilical surgery – A prospective, randomized, double-blind study. Anesth Essays Res 2022;16:360-5

How to cite this URL:
Das S, Acharya R, Patro M, Moda N, Mounika G. Caudal morphine in pediatric patients: A comparison of two different doses in children undergoing infraumbilical surgery – A prospective, randomized, double-blind study. Anesth Essays Res [serial online] 2022 [cited 2023 Feb 3];16:360-5. Available from: https://www.aeronline.org/text.asp?2022/16/3/360/363127


   Introduction Top


One of the most feared symptoms of any disease is PAIN, which is always being tried to conquer and alleviate. It is a complex phenomenal experience, especially in children because it is difficult to decide whether the cry of a child is due to pain or due to hunger or fear in the child.[1] Adequate pain therapy is one which cannot be taken for granted. Under treatment of the postoperative pain because of some the wrong notions like children would neither suffer/feel the pain nor respond to/remember the painful experiences like adults may trigger physiological and biochemical stress response which leads to impairment in cardiovascular, pulmonary, neuro-endocrinal, gastrointestinal, immunological, and metabolic functions. Pain memory will cause an exaggerated stress response and hormonal response which would lead to long term adverse effects including disturbed sleep, appetite, behavior changes, neuronal and endocrine responses, which would lead to the perception of more pain on subsequent exposures.[2]

Adequate and required intra- and postoperative analgesia will modify the stress response as well as it also reduces morbidity and mortality. A different and various practical approaches to postoperative pain management have been developed and used in recent years to recognize, minimize, prevent, bring rapidly under control, and continue even after the discharge from the hospital. Various methods and medications have been administered through different routes to provide better postoperative pain relief, but the side effect profile is higher than regional anesthesia. The different methods are the central neuraxial blockade (spinal block, epidural/caudal blocks, which in turn include caudal analgesia of single shot, epidural anesthesia such as continuous infusion of thoracic, lumbar, and caudal regions), peripheral nerve blocks, intravenous (i.v.) administration of medications, oral analgesia, per rectal administration. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children.[3] Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children because of its efficacy, simplicity, accessibility, and low failure rates.[3]

Various adjuncts are added to local anesthetic drugs while administered into caudal epidural space to prolong the duration of analgesia. The various adjuncts include norepinephrine, ketamine, tramadol, α2 agonists such as dexmetomidine and clonidine, and opioid analgesics such as morphine and fentanyl.[4],[5],[6],[7],[8] Local anesthetics alone have a relatively short duration of postoperative analgesic effect for which opioids conventionally have been added to increase the duration of analgesia. In this study, the local anesthetic used was 0.2% ropivacaine 1 mL.kg-1. Ropivacaine produces lesser motor blocks than the equivalent concentrations of bupivacaine. It is slowly absorbed from caudal epidural space compared to bupivacaine due to its intrinsic vasoconstrictor properties. It is as potent as bupivacaine and the toxicity threshold is much higher. Hence, ropivacaine has been chosen for the study.

The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Hence, morphine has been chosen for this study. Various articles use the various doses of morphine as adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg−1 and 30 μg.kg−1 of caudal epidural morphine (CEM) for infraumblical surgeries with regard to its efficacy and safety and side effect profiles.


   Materials and Methods Top


A prospective, randomized, double-blinded comparative study was conducted in IMS and SUM hospital from January 2019 to August 2020. The Institute Ethical clearance has been taken with reference no: IMS.SH/SOA/180267. Children who were undergoing infraumbilical surgeries were included in the study. A valid informed written consent had been obtained from the parents of each child. The data collected were kept confidential.

Sample size

The sample size was calculated based on the pilot study:[7] Nafiu et al. reported the comparison of caudal ketamine with or without bupivacaine in pediatric subumbilical surgery. J Natl Med Assoc 2007;99:670-3 and it was found that there was 59% of the second reduction in Groups A and B. Taking this into account, the power of study is 80% and the confidence interval of 95%; the sample size is calculated as 27. To minimize any effect of data, we have taken 32 samples in each group, assuming approximately 10% as the dropout rate. A total of 68 patients were assessed for eligibility. Among them, four patients did not give consent to get enrolled in the study. The remaining 64 patients were allocated to both the groups for the study, 32 in Group A and 32 in Group B. Out of them, three children's parents did not respond to the questionnaire adequately and one was excluded from the study due to failed caudal block. Hence, we have 30 patients in Group A and 30 patients in Group B for the final analysis.

Inclusion criteria

The complete physical examination was done, and basic investigations were done. Children were selected based on these criteria (1) American Society of Anesthesiologists physical status (ASA PS) classes I and II, (2) 27 years of age, (3) Male or female sex, and (4) Children undergoing elective infra-umbilical surgeries.

Exclusion criteria

Children with the under-mentioned problems were excluded from the study: (1) Refusal by the parents of the children to participate in the study, (2) Children allergic to any of these drugs, (3) Children who presented with a local infection like abscess and fistula, (4) History of any congenital abnormalities such as sacral deformity, neural tube defects, cardiovascular defects, urinary bladder anomalies, neuro-muscular deformities, trachea-esophageal fistula, and others contributing to morphine-ropivacaine side effects, (5) Children having any respiratory illness such as asthma, allergic bronchitis, and other conditions, (6) Children suffering from any systemic illness or endocrine abnormalities, bleeding disorders, or coagulopathies, and (7) Children born to mother who is suffering from any of the infectious diseases such as HIV, HEPATITIS B, and RUBELLA.

The randomization was done by computer-generated random number chart into two groups, who received the assigned dose of ropivacaine and morphine accordingly. GROUP A: 20 μg.kg−1 of morphine was taken from morphine loaded in insulin syringe; as 1 mL of morphine contains 10,000 μg. Each unit of insulin syringe contained 250 μg of morphine. It was added to 0.2% ropivacaine 1 mL.kg−1 and the solution was made. Group B: 30 μg.kg−1 of morphine was added to 1 mL.kg−1 of 0.2% ropivacaine in a similar way as mentioned above. Children in the study received 1 mL.kg−1 of solution and it was not labeled. After the completion of all the 60 cases, the study blinding was broken and the data were sent for statistical analysis. Then, the two groups were compared prospectively using the observational data, and statistical analysis was made to derive conclusions. After screening for eligibility, written and informed consent was obtained from the parents of these children. Preprocedure children were kept fasting as per the ASA PS classification guidelines. All children were premedicated with oral midazolam 0.5 mg.kg−1 45 min before the surgery. The baseline vital parameters such as blood pressure, heart rate (HR), and saturation were recorded. Precordial stethoscope was attached, i.v., access was secured with 2022 G i.v. cannula and i.v. fluids were started.

Intra-operative period

Children were shifted to the operation theater and glycopyrrolate 10 μg.kg−1, fentanyl 1 μg.kg−1 were given. Preoxygenation with 100% oxygen was done through bag and mask ventilation. Induced with propofol 2 mg.kg−1 and atracurium 0.5 mg.kg−1 children were given proseal laryngeal mask airway (LMA)of appropriate size. The position of the proseal is confirmed and secured. Anesthesia is maintained with 50% O2 and 50% N2O mixture and isofluorane 1%. Maintenance dose of atracurium 0.1 mg.kg−1 i.v. was given accordingly. For the caudal block procedure, these children were placed in the left lateral position. Under all aseptic precautions, the lower back is painted and draped. Palpation of the posterior superior iliac spine and sacral hiatus was done, and the 23G hypodermic needle was introduced in 45° angle to the skin surface in the sacral to pierce the sacrococcygeal ligament and then directed to cephalad to enter the caudal epidural space. To detect and prevent accidental inadvertent intravascular or subarachnoid injection, drug has been injected slowly after aspiration negative for blood or cerebrospinal fluid. While injecting, vitals and electrocardiogram monitoring were done. Then, these children were placed in the supine position and the LMA position was reconfirmed. The surgeons were also asked to give incision 15 min after the caudal block procedure. HR, blood pressure, and oxygen saturation continuous monitoring were done every 5 min since then and the values were recorded. Any increase in vitals more than 20% of baseline was considered as inadequate analgesia and was treated with i.v. fentanyl 1 μg.kg−1. Significant bradycardia (that is heart rate fall by more than 20%) from the baseline was treated with injection atropine 20 μg.kg−1 and significant hypotension (>20% fall in systolic blood pressure (SBP)) was treated by vasopressors and then pt shifted to the recovery room for observation.

Postoperative period

In the postoperative period, the children were monitored carefully and closely for 2 h in the recovery room and then shifted to the postoperative ward for 24 h. Pulse, blood pressure, and saturation were monitored every 15 min in the 1st h and every hour later on. Postoperative complications such as nausea, vomiting, shivering, hypotension, and bradycardia were observed and treated accordingly. PONV was treated with ondansetron 0.06 mg.kg−1 i.v., shivering was controlled with warm, i.v., fluids, warm blankets, and bradycardia and hypotension were treated with atropine 0.02 mg.kg−1 i.v. and intravenous fluids. Apart from that, side effects of morphine such as urinary retention, itching, and respiratory depression which is considered as decreased oxygen saturation SpO2 < 93 were treated accordingly.

Quality of analgesia has been determined by pain scoring and sedation scale every 15 min in the 1st h and every hour later on. Objective pain scoring was done by a 5-point scale, a modification of the pain/discomfort scale. Patients with a pain score of 4 or 5 will be given supplemental rescue analgesia. Sedation scoring was done by a modified Wilson sedation score. Duration of analgesia definition is the time interval right from the administration of caudal block until the requirement of 1st rescue analgesia for the patient. Intraoperatively Fentanyl 1 μg.kg−1 was given as a rescue analgesic agent and postoperatively, paracetamol 15 mg.kg−1 were given. The number of times analgesic requirements required were noted within 24 h.

The patients name, age, sex, weight, type, and duration of surgery were noted preoperatively, baseline HR, SBP, diastolic blood pressure (DBP), SPO2, and RR were recorded. Intraoperative vital parameters HR, SBP, DBP, and SPO2 were recorded during intubation, immediately after caudal block, then every 5 min till the end of the surgical procedure. Postoperative HR, SBP, DBP, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h.

Parameters observed

(1) Duration of analgesia and efficacy of analgesic agent, (2) analgesia requirement in 24 h, (3) pain scoring and sedation scoring at regular intervals, (4) hemodynamic changes at regular intervals, and (5) incidence of side effects such as nausea and vomiting, urinary retention, constipation, and respiratory depression.

All procedures were followed according to the Institutional Ethical Standards and the Helsinki Declaration of 1975, as revised in 1983. The continuous variables were analyzed with the unpaired t-test and categorical variables were analyzed with the Chi-square Test and Fisher exact test. Statistical significance was taken as P < 0.05 and data were analyzed using the SPSS Statistics for Windows, version 16. 0 (SPSS Inc., Chicago, Ill., USA).


   Results Top


There was no significant difference between groups in terms of gender distribution. Among 30 children in Group A (20 μg.kg−1), 23 were male and 7 were female. Thirty children in Group B (30 μg.kg−1), 47 were male and 6 were female. The P value is insignificant (P = 0.754). Both groups were comparable in terms of age. The mean age was around four and half years in both groups. The weight and ASA physical status were comparable in both groups. There is no much difference between the mean duration of surgery in both the groups, which is 55 min in 20 μg.kg−1 and 53 min in 30 μg.kg−1. Hence, both groups are comparable in terms of the duration of surgery.

No significant changes in HR when both groups are compared. The magnitude of decrease in HR is more in Group B than in Group A. This could be possibly explained that the analgesic and sedation effects of morphine are more in Group B when compared to Group A. There is increase in HR at 24 h in Groups A and B. This could be possibly explained by the weaning of the analgesic effect of morphine in Groups A and B. The mean HR was between 71 and 87 bpm in Group A. Mean HR was between from 67 to 83 bpm in Group B. There is no significant difference between both groups. No intervention was required.

There is no significant difference in SBP, DBP, and MAP postoperatively in both Groups A and B. There is a mild increase in SBP at 24 h. This could be explained by weaning of the analgesic effect of morphine in Group A more than in Group B and the need for rescue analgesia [Table 1].
Table 1: Comparison of postoperative systolic blood pressure at different interval

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The mean duration of analgesia is 20.517 ± 1.9143 h in Group A, whereas 22.233 ± 1.6853 h in Group B. There is a significant difference, but both the groups had a similar analgesia profile with 2 h apart [Table 2]. 5-POINT PAIN SCALE SCORING immediate postoperative period: In Group A, 36.7% of children with score 2 and 63.3% of children with score 3. While in Group B, 6.7% of children with score 2 and 93.3% of children with score 3. None of them required rescue analgesia. 5-Point Pain Scale after 15 min: In Group A, 33.3% of children with score 2 and 66.7% of children with score 3. In Group B, 6.7% of children with score 2 and 93.3% of children with score 3. None of them required rescue analgesia. Similarly, 5-Point Pain Scale after 30, 1, 4, 6, 12, and 16 h, none of the patients required rescue analgesia.
Table 2: Comparison of duration of analgesia

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5-Point Pain Scale at 18 h: In Group A, 20% of children with score 2, 66.7% of children with score 3 and 13.3% of children with score 4. In Group B, 100% of children with score 3. The patients who had pain score 4 and complained of pain were given rescue analgesia paracetamol 15 mg.kg−1 i.v. 5-Point Pain Scale at 24 h: Group A had 76.7% with score 3; 16.7% with score 2 and 6.7% with score 4 who required rescue analgesia at this point. While most of them had already received one dose of rescue analgesia previously. Group B had 81.7% with score 3; 8.3% with score 2; 8.3% with score 4 and 1.7% with score 5. The patients with scores 4 and 5 received rescue analgesia at this point, while most of them have received rescue analgesia before this time.

On complying with all 5-point pain scores, we observed that none of the patients in both Groups A and B had received any rescue analgesia until 16 h as the pain scores were <4. At 18 h postoperatively, four patients received rescue analgesia in Group A and none in Group B. At 24 h, two patients received rescue analgesia in Group A and four patients received rescue analgesia in Group B at the 24th h, while most of them except few have received rescue analgesia before this, i.e. between 18 and 24 h postoperatively [Table 3].
Table 3: Comparison of pain score in both groups

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The number of patients who required one dose of rescue analgesia in Group A was 83.3% which was higher than Group B which is 66.7%, whereas 16.7% in Group A and 33.3% in Group B did not require any rescue analgesia until 24 h. Group B had high sedation scores when compared to Group A. While the sedation effect weaned off in both the groups by the 8th h postoperatively [Table 4].
Table 4: Comparison of sedation score in both groups

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Most of the patients in Groups A and B did not have any side effects except few of them. The frequency of nausea and vomiting is more in Group B (8 patients [26.7%]) compared to Group A (two patients [6.6%]). One patient in Group B had urinary retention [Table 5].
Table 5: Comparison of side effect

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   Discussion Top


Perception of pain in children is actually a complex phenomenon because of difficulty in assessment (underestimation and improper detection) and difficulty in optimization in various healthcare settings. The principles of pain management would be applied all across the human lifespan, but there are unique challenges, especially in infants and children, which would consider the age, development level, cognitive and communication skills, and previous painful experiences associated with beliefs that would alter the physiological, psychological, behavioral, and developmental responses in children and causes long-term detrimental effects such as increased sensitivity and heightened disproportional stress response leading to morbidity. Hence, the goal is to reduce the pain as much as possible at the right moment with patient's safety to be kept in mind.

Among the above-mentioned modalities, the caudal block is the most preferable modality and has been in used for decades because of its reliability, safety, efficacy, and relatively ease to perform with very less side effects. It provides far better postoperative pain relief and early ambulation apart from perioperative hemodynamic stability.

In our study, we compared the efficacy of ropivacaine 0.2% with two different doses of morphine 20 μg.kg−1 and 30 μg.kg−1 caudally in terms of duration of analgesia, sedation levels, total rescue analgesic requirement, and incidence of side effects.

We observed that none of the patients in both the Groups A and B had received any rescue analgesia until 16 h as the pain scores were <4. The mean duration of analgesia postoperatively was 20.517 ± 1.9143 h in Group A, whereas 22.233 ± 1.6853 h in Group B. There is a significant difference of P = 0.011. The rescue analgesia given was i.v. paracetamol (15 mg.kg−1). 83.3% of children in Group A and 66.7% of children in Group B had received one dose of rescue analgesia by the end of 24 h. Whereas 16.7% of children in Group A and 33.3% of children in Group B has not received any dose until 24 h. More number of children have received rescue analgesia in Group A than in Group B.

Krane et al.[9] compared different doses of CEM (33, 67, and 100 μg.kg−1) in children and reported that the mean duration of analgesia was significantly prolonged with 100 μg.kg−1 (13.3 ± 4.7 h) than with 33 μg.kg−1 (10.33 ± 3.3 h) or 67 μg.kg−1 (10.4 ± 4.2 h).

Némethy M et al.[10] (Journal of Anaesthesiology and Clinical pharmacology 2016) in a prospective double-blind study conducted on 75 pediatric patients aged between 2 and 12 years of age belonging to ASA PS classes I and II undergoing lower abdominal and urogenital surgeries were allocated randomly into three groups 1, 2, and 3 and were given 30 μg.kg−1,50 μg.kg−1, and 70 μg.kg−1 of preservative-free morphine caudally along with 0.75 mL.kg−1 of 0.25% bupivacaine. This study concluded that the mean duration of analgesia was 8.63 h in Group 1, 13.36 h in Group 2, and 19.9 h in Group 3.

In our study, when it comes to sedation scoring postoperatively, at the 4th h postoperative period, all patients were awake in Group A, whereas 43.3% of patients were awake and 56.7% of patients were drowsy in Group B. By the end of 8 h, all children in both the Groups A and B were awake. Neha Baduni et al. have compared three different doses of morphine 30, 50, and 70 μg.kg−1 of Group I, II, and III with 0.25% bupivacaine caudally in 75 children of 2-12 years' age undergoing lower abdominal and urogenital surgeries. In this study, the sedation was prolonged in Group III. By 16 h, almost all patients in Groups I and II were alert and awake, whereas 11 out of 25 patients in Group III were sedated, although easily arousable.

Cesur et al.[11] studied the efficacy and adverse effects of three low doses of morphine 10, 15, and 30 μg.kg−1 of morphine combined with 0.5 mL.kg−1 1% lignocaine with adrenaline 5 μg.mL−1 given caudally in 135 boys aged 7-12 years who were undergoing Discussion Department of Anesthesiology, Pain, Palliative And Critical Care 2018-2021 102 outpatient circumcision procedure. This study revealed that nausea-vomiting occurred in 13.3%, 20% and 46.7% of the patients in the 10, 15 and 30 μg.kg−1 groups (P = 0.002 for 10 vs. 30 and 0.044 for 15 vs. 30) A Dostbil et al.[12] studied the effect of three different doses of morphine 7.5, 10, 15 μg.kg−1 morphine combined with 0.125% levobupivacaine among 240 children of age 5-12 years divided into three different groups who were undergoing circumcision and found out that the postoperative incidence of vomiting was 5%, 12.5% and 17.5% in the groups 7.5, 10 and 15 μg.kg−1 morphine, respectively (P = 0.012,7.5 vs. 15 μg.kg−1 group) [Figure 1]. Nurgul Isikay et al.[13] (British Journal of Medicine and Medical Research 2016) in a prospective double-blind study among 60 patients aged between 1 and 9 years who have undergone a Salter operation for congenital hip dislocation, with ASA classifications 1 and 2 were randomly allocated into three groups and were given 15, 20, or 25 μg.kg−1 of CEM, respectively combined with 0.25% bupivacaine 0.75 mL.kg−1 Postoperative nausea and vomiting in the first 24 h was reported in 1 (5%), 2 (10%), and 8 (40%) cases in 15, 20, and 25 μg.kg−1 groups, respectively. Although the difference between groups 15 and 20 was not statistically significant (P = 0.548), the number of patients with nausea and vomiting in Group 25 was statistically significantly higher than that of Group 15 and Group 20 (P = 0.009 and P = 0.025, respectively). None of the other patients in our study had complications such as respiratory depression, pruritus, and constipation. One patient had urinary retention in Group B and had been treated with urinary catheterization. In the first 24 h postoperatively when it comes to hemodynamic changes, both intraoperative and postoperative hemodynamic parameters remained stable and comparable between the groups. Intraoperatively, there was a mild increase in BP and HR during intubation and immediately after the procedure, which decreased after 10-15 min of caudal block in both Groups A and B. There were never any episodes of increase or decrease in the vital parameters more than or less than 20% of its baseline value. Hence, none of the children required any intervention.
Figure 1: Consort flow chart

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From the above observations and comparisons, we conclude that the analgesic profile is similar in both Groups A and B with hemodynamic stability which was comparable in both groups. While Group B had increased sedation levels with increased incidence of side effects such as nausea and vomiting and urinary retention.


   Conclusion Top


From the above observations, it can be concluded that morphine of less dosage (20 μg.kg−1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg−1) as the duration of analgesia is similar with decreased incidence of side effects.

Limitation of the study

The duration of analgesia was extending beyond 24 h postoperatively in 16.7% children in Group A and 33.3% children in Group B. As this study was limited for monitoring up to 24 h postoperatively, further evaluation regarding the duration of analgesia and the requirement of rescue analgesia were not done.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bisonette B, Anderson BJ, Bosenberg A, Engelhardt T, Mason LJ, Tobias JD. Pediatric Anesthesia. In: Regional Anaesthesia: Central Neuraxial Blocks. Ch. 49. USA: People's Medical Publishing House. 2011. p. 811.  Back to cited text no. 1
    
2.
Barrett KE, Barman SM, Boitano S, Heddwen L. Ganong's Review of Medical Physiology. 25th ed. Lange Medical Publications; 1977.  Back to cited text no. 2
    
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GREGORY'S Pediatric Anaesthesia. In: Pediatric Regional Anaesthesia. 5th ed., Ch. 18. Wiley; 2020. p. 427.  Back to cited text no. 3
    
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Cohen NH, Eriksson LI, Fleisher LA, Leslie K, Wiener-kronish JP. Miller's Anesthesia Ninth Edition by Michael A Gropper. Spinal, Epidural, Caudal Anaesthesia. Ch. 45. Elsevier; 2019.  Back to cited text no. 4
    
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Parameswari A, Dhev AM, Vakamudi M. Efficacy of clonidine as an adjuvant to bupivacaine for caudal analgesia in children undergoing sub-umbilical surgery. Indian J Anaesth 2010;54:458-63.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pradhan B, Bajracharya GR. Midazolam for caudal analgesia in children: Comparison with caudal bupivacaine. Kathmandu Univ Med J (KUMJ) 2008;6:166-72.  Back to cited text no. 6
    
7.
Nafiu OO, Kolawole IK, Salam RA, Elegbe EO. Comparison of caudal ketamine with or without bupivacaine in pediatric subumbilical surgery. J Natl Med Assoc 2007;99:670-3.  Back to cited text no. 7
    
8.
Khan S, Memon MI. Comparison of caudal bupivacaine and bupivacaine-tramadol for postoperative analgesia in children with hypospadias repair. J Coll Physicians Surg Pak 2008;18:601-4.  Back to cited text no. 8
    
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Krane EJ, Jacobson LE, Lynn AM, Parrot C, Tyler DC. Caudal morphine for postoperative analgesia in children: A comparison with caudal bupivacaine and intravenous morphine. Anesth Analg 1987;66:647-53.  Back to cited text no. 9
    
10.
Némethy M, Paroli L, Williams-Russo PG, Blanck TJ. Assessing sedation with regional anesthesia: Inter-rater agreement on a modified Wilson sedation scale. Anesth Analg 2002;94:723-8.  Back to cited text no. 10
    
11.
Cesur M, Alici HA, Erdem AF, Yapanoglu T, Silbir F. Effects of reduction of the caudal morphine dose in paediatric circumcision on quality of postoperative analgesia and morphine-related side-effects. Anaesth Intensive Care 2007;35:743-7.  Back to cited text no. 11
    
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Dostbil A, Celik MG, Aksoy M, Ahiskalioglu A, Celik EC, Alici HA, Ozbey I. Paedriatric pain. Anaesthesia Intensive Care 2014:334-50.  Back to cited text no. 12
    
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Isikay N, Cesur M, Kılıc E, Çelik MM. Comparing three different doses of caudal morphine for analgesia after salter innominate osteotomy. British J Med Med Res 2016;16:1-7.  Back to cited text no. 13
    


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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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