Caudal dexmedetomidine improves analgesia duration & reduces analgesia need without increasing complications, when compared to local anaesthesia alone in children.

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• Ushma Jitendra Shah, Derek Nguyen, Niveditha Karuppiaah, Janet Martin, and Herman Sehmbi.
• Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada.
• Reg Anesth Pain Med. 2021 May 1; 46 (5): 422-432.

BackgroundDexmedetomidine is used as a local-anesthetics adjuvant in caudal block to prolong analgesia in pediatric infra-umbilical surgery.ObjectiveWe evaluated the analgesic efficacy and safety of the addition of caudal dexmedetomidine to local anesthetics (vs local anesthetics alone) in pediatric infra-umbilical surgery.Evidence ReviewWe searched 10 databases for randomized controlled trials (RCTs) of pediatric patients undergoing infra-umbilical surgery, comparing caudal block with and without dexmedetomidine as local anesthetic adjuvant. We performed a frequentist random-effects meta-analysis (R statistical package). We analyzed continuous outcomes as a ratio of means (ROM) and dichotomous data as relative risk (RR), along with 95% CI. We included 19 RCTs (n=1190 pediatric patients) in the meta-analysis. The primary outcome was duration of analgesia (defined as 'the time from caudal injection to the time at which the study-specific pain score was greater than a cut-off threshold').FindingsData from 19 included RCTs (n=1190) suggested that compared with control (mean duration 346 min), the addition of caudal dexmedetomidine significantly prolonged the duration of analgesia (ratio of means 2.14, 95% CI 1.83 to 2.49, p<0.001; 'moderate' evidence). Trial-sequential analysis showed adequate 'information size' for the primary outcome. Caudal dexmedetomidine also reduced the number of analgesic administrations ('low' evidence), total acetaminophen dose ('moderate' evidence) and the risk of emergence delirium ('moderate' evidence). There were no significant differences in adverse effects such as hypotension, bradycardia, post-operative nausea and vomiting, urinary retention and respiratory depression.ConclusionsOur results suggest that the addition of dexmedetomidine to local anesthetic in caudal block significantly improves the duration of analgesia and reduces the analgesic requirements, while maintaining a similar risk-profile compared with local anesthetic alone. Further data on neurological safety are needed.© American Society of Regional Anesthesia & Pain Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.

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