[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.

98]

Original Article

Effects of Low-Dose Intravenous Dexamethasone Combined

with Caudal Analgesia on Post‑herniotomy Pain
Omotayo Felicia Salami, Simbo Daisy Amanor‑Boadu1, Olayinka Ranti Eyelade1, Simeon Olugbade Olateju2
Department of Anaesthesia and Intensive Care, Ben Carson School of Medicine, Babcock University, Ogun State, 1Department of Anaesthesia and Intensive Care,
College of Medicine, University of Ibadan, Ibadan, Oyo State, 2Department of Anaesthesia and Intensive Care, Obafemi Awolowo University, Ile‑Ife, Osun State, Nigeria

Abstract
Background: Caudal analgesia for postoperative pain relief in paediatric day‑case surgery has been found to be of short duration, hence the
need for addition of adjuncts to prolong the analgesia. Objective: The objective of the study was to compare the analgesic effects of caudal
block with or without low‑dose intravenous dexamethasone in children undergoing day‑case herniotomy. Patients and Methods: This was
a prospective randomised controlled study conducted in male patients, aged between 1 and 7 years scheduled for herniotomy. A total of
94 patients were randomised into two groups. Group A received intravenous 0.25 mg/kg dexamethasone in 5 ml solution, whereas Group B
received equivalent volume of intravenous normal saline. All the patients had a caudal block. Post‑operative pain was assessed and recorded
in post‑anaesthesia care unit  (PACU) using objective pain scale. Time to first analgesia request  (TFA), pain scores and complications
were documented. Data were analysed using Statistical Package for the Social Sciences version 21.0. Results: A total of 94 patients were
analysed with a mean age of 3.30 ± 1.67 and 3.06 ± 1.50 years for Groups A and B, respectively. The TFA request was 654.18 ± 31.56 and
261.50 ± 10.82 min in Groups A and B, respectively, P = 0.0001. Postoperatively, in the PACU, there was statistically significant difference in
pain score between the two groups at 0, 30, 60, 120, 180 and 240 min (P = 0.0001) all through. Conclusion: The use of low‑dose intravenous
dexamethasone (0.25 mg/kg) in combination with caudal block prolonged duration of analgesia, reduced pain scores and analgesic consumption
postoperatively, in children undergoing day‑case herniotomy.

Keywords: Bupivacaine, caudal, dexamethasone, herniotomy

Introduction circumcision, inguinal hernia procedures, tonsillectomy and

Pain in the paediatric patient has become a major concern
worldwide, such that there has been introduction of new
analgesic agents and newer ways of application of old ones. In
2001, the Society of Paediatric Anaesthesia, at its 15th annual
meeting in New Orleans, Louisiana, clearly defined the
alleviation of pain as a ‘basic human right’, irrespective of
age, medical condition, treatment, or medical institution.[1]
Despite this, pain remains the most frequent complication
after day‑case surgery. In a study by Faponle and Usang in
Nigeria, it was observed that, in paediatric day‑case surgery,
post‑operative pain constituted 72% of symptoms recorded
by parents at home.[2‑4]
Day‑case or ambulatory surgery is one in which the patient
is admitted, operated and discharged that same day. Some
procedures performed on day‑case basis include orchidopexy,
Access this article online
Quick Response Code:
Website:
www.npmj.org
myringotomy. Minor surgery, like circumcision, has been
observed to cause significant pain in children.[3] Therefore, pain
relief in children is of paramount importance. Specifically, the
goal of post‑operative pain relief in day‑case procedures is to
reduce or eliminate pain with minimum side effects.
In current practice, a multimodal approach is employed in
pain management. Psychological methods, mild analgesics
such as paracetamol, non‑steroidal anti‑inflammatory drugs,
opioids and local and regional analgesia, are often combined
to achieve superior pain relief and to minimise the side effects
Address for correspondence: Dr. Omotayo Felicia Salami,
Department of Anaesthesia and Intensive Care, Babcock University,
Ogun State, Nigeria.
E‑mail: tsalami40@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Salami OF, Amanor-Boadu SD, Eyelade OR,
DOI: Olateju SO. Effects of low-dose intravenous dexamethasone combined
10.4103/npmj.npmj_120_17 with caudal analgesia on post-herniotomy pain. Niger Postgrad Med J
2017;24:230-5.

230 © 2018 Nigerian Postgraduate Medical Journal | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.98]
Salami, et al.: Efficacy of low‑dose intravenous dexamethasone on caudal analgesia in the paediatric age group
of individual drugs. In a day‑case setting, opioids are often
avoided because of potential side effects such as sedation,
respiratory depression, nausea and vomiting which may delay
discharge.[5]
Caudal epidural block is a common regional technique used
to provide intra‑  and post‑operative analgesia for surgical
procedures below the umbilicus in paediatric patients. It is
usually a single shot technique. However, the relatively short
duration of single‑shot caudal injection with local anaesthetic
is amongst the limitations of the procedure.[3,6]
Several adjuncts which have been added to the local
anaesthetics to prolong analgesia of ‘single‑shot’ caudal
include clonidine, midazolam, ketamine, neostigmine and
tramadol, but their use has been limited by unacceptable
adverse effects or safety not being fully established, especially
in preservative‑containing agents.[7,8]
Dexamethasone is a corticosteroid with strong anti‑inflammatory
properties.[9] Traditionally, in anaesthetic practice, the use of
dexamethasone is to reduce the incidence of post‑operative
nausea and vomiting (PONV). It is usually given for
prophylaxis. Some side effects such as insomnia, increased
appetite, weight gain, impaired skin healing, dyspepsia and
hyperglycaemia, have been linked with chronic use.
Dexamethasone, when administered intravenously, has been
documented to provide prolonged post‑operative analgesia.
Intravenous dexamethasone, when combined with caudal block,
has been documented to increase postoperative analgesia. Hong
et  al. showed that it prolongs the duration of post‑operative
analgesia when 0.5 mg/kg was used intravenously in addition
to caudal block, the same was reported in the study by Bangash
et al.[10,11] Srinivasan et al. in a recent study utilising intravenous
1.5 mg/kg dexamethasone in addition to caudal block also showed
prolonged post‑operative analgesia.[12] However, there is a dearth
of data regarding the use of low‑dose (0.25 mg/kg) dexamethasone
in combination with a caudal block in our population.
Aim
The aim of the study was to compare the analgesic effects
of caudal block with or without low‑dose intravenous
dexamethasone in children undergoing day‑case unilateral
inguinal herniotomy.
Objectives
The objectives of the study were to determine the time to
first analgesic request when caudal block is given alone and
in combination with intravenous dexamethasone. Second,
to compare blood sugar levels in patients given single‑dose
intravenous dexamethasone in addition to caudal bupivacaine
and in those who had only caudal bupivacaine.
Patients and Methods
Ethical approval/informed consent
Institutional Ethics Committee approval was obtained from the
UI/UCH Ethics Board with informed consent from the parents/
Nigerian Postgraduate Medical Journal  ¦  Volume 24  ¦  Issue 4  ¦  October-December 2017
guardians of the children recruited in the study (UI/UCH Ethics
committee assigned number UI/SC/112/0129).
Exclusion criteria
Children planned for bilateral herniotomy, patients who had
failed caudal block and received intraoperative pentazocine,
those with infection at the site of caudal injection or sepsis,
pre‑existing neurological deficits or spinal deformity,
coagulopathy and patients with allergy or hypersensitivity to
local anaesthetic drug were excluded from the study.
Study design
This was a prospective randomised double‑blind controlled
study conducted in children aged between 1 and 7 years
undergoing unilateral inguinal herniotomy as a day‑case
procedure at the University College Hospital Ibadan, from
September to December 2013.
Sample size
Ninety‑four male patients, aged 1–7 years, American Society
of Anaesthesiologists I and II, were recruited into the study
after obtaining informed consent from the parents or guardians.
Sample size formula for randomised clinical trials was used.[13]
Where n = sample size per group, Zα = 1.96 at 10%, Zβ = 1.28
at 90%, α = type I error, β = type II error, б = pooled standard
deviation of time of first dose of oral analgesic calculated
from a similar study is 177.36 min (time of first dose of oral
analgesic given);[10] δ = 125 min smallest clinical important
difference to be detected with at least 90% difference in the
duration of analgesia assumed. Substituting,
2 (1.96 + 1.28) 177.362
2
1252
Therefore; n = 42 in each group;
Minimum sample size = 42 + 42 = 84
Sample size will be increased by 10% to provide for
non‑response (r = 0.1) = n/1 − r
42/1–0.1  =  46.66; Approximate sample size per group  47;
Total sample size = 94.
At the pre‑anaesthetic visit, a detailed history of presenting
complaint, developmental milestones, medical disease,
chronic drug use and allergy or complication following
previous surgery or blood transfusion was obtained. Physical
examination of the cardiorespiratory, gastrointestinal and
the genitourinary systems were performed and documented.
Routine investigations  (full blood count, genotype and
urinalysis) were done on all the eligible patients before
surgery. The parents/guardians were informed about routine
pre‑operative fasting of 6 h to solids and baby formula, 4 h
to breast milk and 2  h to clear fluids before surgery. Pain
was to be assessed at home in the 1st h, then 4 hourly, in the
231
[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.98]
Salami, et al.: Efficacy of low‑dose intravenous dexamethasone on caudal analgesia in the paediatric age group
pre‑verbal children until they were perceived to be in pain and
until complaint of pain in the verbal children. Premedication
was omitted in all the patients. The patients were randomised
into two Groups A and B. Group A received intravenous
0.25 mg/kg dexamethasone in 5 ml plain solution, whereas
Group B received equivalent volume of intravenous normal
saline. All the patients had caudal block with 1  ml/kg of
0.25% bupivacaine. Before induction of anaesthesia, 94
sealed envelopes containing slips of paper were prepared, with
Group A written on half of the slips of paper and Group B on the
other half. This was presented in a box to the parent/guardian
who randomly picked one slip each. The study drugs were
prepared under aseptic conditions by an anaesthetist and
administered by the researcher who was blinded to the identity
of the intravenous study drugs. Resuscitation drugs, which
included adrenaline and atropine, were made readily available.
In the theatre, a multiparameter monitor  (Marathon Z,
manufactured by Health Care Equipment and Suppliers Co.
Ltd., UK) to measure heart rate, blood pressure, respiratory
rate, electrocardiograph and pulse oximetry for arterial oxygen
saturation was attached to the patient, and baseline readings
were obtained and recorded. Patients were pre‑oxygenated
with 100% oxygen for 3–5 min and anaesthesia was induced
using a stepwise increment of halothane from 0.5% to 3%
in 100% oxygen, using a Mapleson F breathing system for
patients <25 kg or Bain Circuit for patients weighing >25 kg
with appropriate size face mask until the patient lost
consciousness. Pre‑operative capillary blood sugar sample
was taken, as a baseline using the glucometer. Intravenous
access was then secured with a 21‑ or 23‑gauge cannula on
the dorsum of the hand, when the depth of anaesthesia was
adequate. Normal saline was then infused at a rate of 4 ml/kg/h
for the first 10  kg, then 2  ml/kg/h for the next 10  kg and
1 ml/kg/h for subsequent kg (4:2:1 ml/kg/h). After induction of
general anaesthesia, patients in Group A received intravenous
0.25 mg/kg dexamethasone (Hubei Tianyao Pharmaceutical
Limited) in 5  ml plain solution, whereas those in Group  B
received intravenous normal saline made up to the same 5 ml
volume.
Caudal epidural block was administered following standard
procedure guideline. The sacral hiatus was identified as the
apex of an equilateral triangle facing inferiorly with a line
joining the posterior superior iliac spine as the base, with the
patient in the left lateral position and the legs flexed. Under
sterile condition, the palpating finger was directed caudally
from the midpoint of the line joining the posterior superior
iliac spines or cranially from the coccyx until a depression
was felt. A 23‑gauge cannula was inserted into the sacral hiatus
at 45° to the skin until a click was felt then it was angulated
cephalad. A 2 ml syringe filled with normal saline as test dose
was then used to exclude subcutaneous placement before the
local anaesthetic agent  (bupivacaine 0.25% 1  ml/kg) was
injected slowly after negative aspiration test. Patients were
then positioned supine, and surgery allowed to commence
15–20 min later with patients breathing spontaneously through
232 Nigerian Postgraduate Medical Journal  ¦  Volume 24  ¦  Issue 4  ¦  October-December 2017
a facemask. Monitoring of vital signs continued at 5 min
interval until the end of surgery.
Anaesthesia was maintained with halothane 0.5%–1% in
oxygen, and adequate anaesthesia was judged by a lack of
movement and stable vital signs following skin incision.
Failed caudal block was judged by movement of the limbs
to surgical incision, and  >20% increase in haemodynamic
parameters compared to baseline values. Patients with failed
caudal block had their anaesthesia deepened with increased
halothane and intravenous pentazocine 0.5 mg/kg was given
were excluded from the study. At the end of surgery, halothane
was discontinued and oxygen administered until recovery.
After emergence from anaesthesia, patients were managed by
a nurse unaware of group allocation in the post‑anaesthesia
care unit (PACU).
Postoperative pain was assessed and recorded on arrival at
PACU, 0 (baseline), 30, 60, 120, 180 and 240 min after surgery
using the Objective Pain Score (OPS).[14,15]
The Objective Pain Scale (OPS; minimum score: 0 = no pain
and maximum score: 10 = extreme pain) is composed of five
parameters; systolic blood pressure, crying, movements,
agitation and complaints of pain. Each parameter has a score
of 0–2. The reliability of the OPS has been demonstrated by
Norden et al. to effectively assess pain in both the pre‑verbal
and verbal children with a minimum score of 0 and a maximum
score of 10 or 8 (in children too young to complain of pain).[14]
The observer scored pain based on points (none/insignificant
pain [1–3], moderate pain [4–6] and severe pain [7–10]). Pain
score of  ≥4 or complaints of pain had rescue analgesic of
intravenous 0.5 mg/kg pentazocine. Oxygen saturation, blood
pressure and pulse rate were documented in the recovery room
at 15 min interval. The time to first analgesic requirement was
the duration from the time of administration of study drugs to
the time of first request for analgesic (TFA). The time to first
micturition was also documented.
Patients were discharged to the ward from the PACU after 1 h
and according to hospital protocol and when they satisfied
the Aldrete score value of  ≥9. The Aldrete recovery score is
commonly used to evaluate discharge from the recovery room. It
consists of five parameters; activity level, respiration, circulation
(blood pressure), consciousness and oxygen saturation as
determined by pulse oximetry. Each score has a maximum of 2
and a minimum of 0 with the maximum score being 10.[16]
Blood sugar sample was taken again before discharge from the
recovery room. Patients were discharged home from the ward
on oral paracetamol at 20 mg/kg. After discharge, information
regarding the pain and any other complications at home were
obtained from parents through a phone call 24 h post‑surgery.
Both the investigator and patients were blinded to the study
drugs.
Data analysis
Demographic characteristics, blood sugar values, pain scores,
time to first analgesia request (TFA), time to first micturition
[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.98]

Salami, et al.: Efficacy of low‑dose intravenous dexamethasone on caudal analgesia in the paediatric age group

and postoperative complications were documented. Numerical

Table  1: Demographic characteristics of the patients
data were expressed as a mean  ±  standard deviation and
categorical data as frequencies for both study groups. Variable Mean±SD P
Comparisons of means were done using the Student’s t‑test Group A (n=47) Group B (n=47)
and comparison of categorical data using the Chi‑square test. Age (years) 3.30±1.67 3.06±1.50 0.475
P  ≤  0.05 was considered statistically significant. Statistical Weight (kg) 14.87±2.46 13.74±3.29 0.063
analysis was done using Statistical Package for the Social Duration of surgery (min) 35.7±8.17 36±13.31 0.302
Sciences (SPSS 21.0 Inc., Chicago, Illinois, USA). SD: Standard deviation

Results Table  2: Comparison of time to first analgesia, total oral

Ninety‑four patients were analysed with 47 patients in each paracetamol and time to first micturition
group. The demographic characteristics (age and weight) of Variables Mean±SD P
the two groups were comparable, as shown in Table 1.
Group A (n=47) Group B (n=47)
Table 2 summarises that the time to first analgesic Time to first analgesia 654.18±31.56 261.50±10.82 0.0001
requirement (TFA) of 654.18 ± 31.56 min was longer in request (min)
Group A, compared to 261.50 ± 10.82 min in Group B. The Total oral paracetamol 38.30±17.95 55.30±20.15 0.0001
time to micturition was shorter in Group A compared to B; consumed at home
within 24 h (mg)
241.91 ± 86.24 and 326.00 ± 68.65 min, respectively. The mean
Time to first 241.91±86.24 326.00±68.65 0.0001
oral paracetamol dose given by parents at home was less in micturition (min)
Group A, 38.30 ± 17.95 mg compared with 55.30 ± 2015 mg SD: Standard deviation
in Group B (P = 0.0001). No patient reported PONV.
Pre‑induction blood glucose was 95.30 ± 7.91 mg/dl in Table  3: Comparison of pre‑  and post‑operative blood
Group A, compared to 91.21  ±  12.99  mg/dl in Group  B, glucose
P = 0.069. Postoperatively, blood glucose in Group A increased
to 101.91 ± 9.48 mg/dl and to 100.2 ± 14.94 mg/dl in Group B, Variable Mean±SD P
but the difference between the groups was also not statistically Group A (n=47) Group B (n=47)
significant (P = 0.495) as shown in Table 3. Pre‑induction blood 95.30±7.91 91.21±12.99 0.069
glucose (mg/dl)
Postoperative pain measurement in PACU showed a significant Post‑operative blood 101.91±9.48 100.2±14.94 0.495
difference in the mean baseline pain score between Group A glucose (mg/dl)
and B. At 60 min, pain score in Group A had reduced from SD: Standard deviation
1.5 ± 0.17 at 30 min to 1.00 ± 0.19, compared to an increase
in pain score from 2.2  ±  0.21 to 2.50  ±  0.19 at 60  min in
Group B (P = 0.0001). There was also a statistically significant Table  4: The objective pain scores
difference in pain score between the two groups at 120, 180 Time (min) Group Pain score (mean±SD) P
and 240 min, P = 0.0001, as shown in Table 4. 0 A 2.00±0.22 0.0001
B 3.00±0.17

Discussion 30 A
B
1.50±0.17
2.20±0.21
0.0001

This study revealed that a single dose of intravenous 60 A 1.00±0.19 0.0001

dexamethasone in combination with caudal epidural B 2.50±0.19
bupivacaine (0.25%) prolonged the TFA and decreased 120 A 0.80±0.09 0.0001
post‑operative analgesic consumption compared with caudal B 1.50±0.14
bupivacaine alone. 180 A 0.70±0.04 0.0001
B 1.50±0.14
The mean TFA was significantly longer in the dexamethasone
240 A 0.40±0.07 0.0001
group (654.18 ± 31.56 min), compared to the control group
B 1.30±0.14
(261.50 ± 10.82 min), P = 0.0001.
SD: Standard deviation
This finding is similar to that obtained by Hong
et al. (646 ± 149 min) in a comparative study of intravenous The time to first analgesic request in the control group of
dexamethasone 0.5 mg/kg combined with caudal ropivacaine this study (261.50 ± 10.82 min) is similar to that obtained
versus ropivacaine alone for post‑operative pain control by Srinivasan et al., who recorded 220 min,[12] while Hong
following orchidopexy.[10] Srinivasan et al. in a recent prospective et al. in their control group reported 430 ± 205 min.[10] This is
study also reported the prolonged duration of analgesia in their almost double the value in our control group; this difference
intravenous dexamethasone group of 720.0 min.[12] may be due to a higher volume of a different local anaesthetic

Nigerian Postgraduate Medical Journal  ¦  Volume 24  ¦  Issue 4  ¦  October-December 2017 233
[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.98]
Salami, et al.: Efficacy of low‑dose intravenous dexamethasone on caudal analgesia in the paediatric age group
(1.5 ml/kg ropivacaine of 0.15%) utilised in the Hong’s study.
Edomwonyi and Egwakhide also observed similar time to first
analgesic request of 420 min using a lower volume (0.5 ml/kg)
of 0.25% bupivacaine in their caudal group compared to a
volume of 1 ml/kg (0.25%) utilised in this study.[17] This may
result from variations in population characteristics, the potency
and brand of local anaesthetic agent used.
The time to first analgesic (TFA) requirement in our
caudal only group is, however, longer compared to that of
Akinyemi and Soyannwo, who utilised 0.5 ml/kg of 0.25%
bupivacaine (TFA,170 min) for the caudal block compared to
1 ml/kg of 0.25% bupivacaine used in this study.[18] The shorter
duration in TFA in their study may be as a result of the low
volume of local anaesthetic (0.5 ml/kg) used, compared to the
1 ml/kg used in this study.
Although the exact mechanism of action is not known,
dexamethasone in prolongation of analgesia is said to act
through strongly mediated anti‑inflammatory process.[9]
The dose of dexamethasone (0.25 mg/kg), employed in this
study, was low compared to that used in some studies, but
similarly prolonged duration of analgesia was obtained. Hong
et al. and Srinivasan et al. utilised intravenous dexamethasone
dose of 0.5 mg/kg in their studies and obtained a TFA request
of about 646 and 620 min, respectively.[10,12] This may result
from a higher volume of ropivacaine (1.5 ml/kg) was used in
both studies compared to bupivacaine 1 ml/kg in our study.
Bangash, however, utilised a higher dose of dexamethasone,
1.5 mg/kg, but obtained a similar TFA request of 621.60 min
compared to the 654 min in our study[11] The similarity in time
to first analgesic request in ours and Bangash’s et al. study,
despite different dexamethasone dose may result from a higher
volume of bupivacaine utilised in our study (1 ml/kg of 0.25%)
compared to 0.5 ml/kg used in their study.
Although the caudal epidural administration of dexamethasone
in children is uncommon, Yousef et al. in a study of 105 children
scheduled for inguinal hernia repair under caudal block with
0.1 mg/kg dexamethasone and 1.5 ml/kg ropivacaine (1.5%),
reported more prolonged duration of analgesia of 12 h in their
dexamethasone group.[19] However, the slightly prolonged time
obtained in their dexamethasone group may be as a result of
the epidural administration of dexamethasone.
As advised by Desmet et  al., the intravenous routes for
dexamethasone may be safer as the drug has not been licensed
for the perineural or neuraxial routes. This advice has been
reiterated in an editorial review of the route of dexamethasone
administration during peripheral nerve block.[20,21]
The OPS, a validated pain scoring tool in children, was used
in the PACU to assess pain in the patients. On arrival at
the PACU, immediate pain scores  (baseline) for Groups A
and B were low (2.00 ± 0.22 and 3.00 ± 0.17, respectively)
but statistically significant (P = 0.0001). In a study of
100 children undergoing orchidopexy under caudal block
(0.5  ml/kg of 0.25% bupivacaine alone or in addition to
234 Nigerian Postgraduate Medical Journal  ¦  Volume 24  ¦  Issue 4  ¦  October-December 2017
intravenous dexamethasone [1.5 ml/kg]), Bangash et al.
reported similarly low and significant pain score differences
between the caudal and the caudal plus intravenous
dexamethasone (0.5 mg/kg) group of his study.[11]
Intravenous 0.5 mg/kg dexamethasone is considered to be a
high dose in children,[22] and blood sugar changes may result;
therefore, half this dose was investigated for any blood sugar
increase in our study.
Post‑operative increase in blood glucose was observed within
the group, in both groups, compared to the preoperative
levels, but there was no statistically significant difference
between the groups. This may be due to perioperative stress,
as documented in adults day‑case surgical patients.[23] In a
study on the effect of single‑dose intravenous administration
of dexamethasone (0.15 mg/kg) in obese and normal children,
elevated blood sugar documented within the group was within
normal limits.[24] Further studies to investigate the ideal or
appropriate dosage are required so that blood sugar remains
within normal limits.
Pain was to be assessed at home in the 1st h, then 4 hourly, in
the pre‑verbal children until they were perceived (behavioural
pattern) to be in pain and until complaint of pain in the verbal
children. From our study, patients in Group A consumed
less paracetamol  (38.30  ±  17.95  mg) compared to children
in Group B (55.30 ± 20.15 mg). This supports most studies
that low post‑operative pain scores result in less analgesic
consumption.[10,25]
Caudal bupivacaine has been associated with a delay in time to
first micturition and this has been an issue of concern regarding
its use in day‑case surgery.[26] The incidence is low with low
concentration of bupivacaine as used in this study. Furthermore,
time to first micturition was prolonged in both groups but
was significantly longer in the control compared to the
dexamethasone group (326 ± 168.65 vs. 241.91 ± 86.24 min).
Postoperative pain in addition to blockade of sacral nerve
fibres may be attributed to the slightly prolonged duration in
the control group. Edomwonyi and Egwakhide also reported
delay in time to first micturition (4.02 ± 1.69 h) in the caudal
group in a study comparing caudal versus local anaesthesia in
children undergoing unilateral inguinal herniotomy.[17]
The time to first micturition in the bupivacaine alone group in
this study was 5 h, compared with similar findings of 4 h plus
by Edomwonyi and Egwakhide in their study.[17] This may be
as a result of population variation and local anaesthetic potency.
However, there are other causes of delay in urination after
surgery which includes drugs such as anticholinergic agents,
opioids, β‑blockers and sympathomimetics in children, but
these should not cause delay on discharge.
Conclusion/Recommendation
This study has shown that the use of low‑dose intravenous
dexamethasone 0.25 mg/kg, in combination with caudal
bupivacaine prolonged the duration of analgesia and reduced
[Downloaded free from http://www.npmj.org on Sunday, July 21, 2019, IP: 180.243.166.98]
Salami, et al.: Efficacy of low‑dose intravenous dexamethasone on caudal analgesia in the paediatric age group
postoperative pain scores and analgesic consumptions in
children undergoing day‑case unilateral inguinal herniotomy.
It is recommended that low‑dose intravenous dexamethasone
could be considered as an adjunct to caudal bupivacaine in
day‑case herniotomy.
Limitation
The administration of oral paracetamol at home after discharge
was based on parents’ sole assessment of pain and discretion
to administer analgesics.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Frank HK. The society of paediatric anaesthesia: 15th annual meeting.
New Orleans, Louisiana, October 2001. Anesth Analg 2002;94:1661‑8.
2. Amanor‑Boadu SD, Soyannwo OA. Complications following day case
paediatric surgery. West Afr J Med 1997;16:223‑6.
3. Wolf AR. Tears at bedtime: A pitfall of extending paediatric day‑case
surgery without extending analgesia. Br J Anaesth 1999;82:319‑20.
4. Faponle AF, Usang UE. Post‑operative symptoms at home in children
following day case surgery. Middle East J Anaesthesiol 2007;19:185‑96.
5. Menezes MS, Gozzani JL. Postoperative analgesia in pediatric patients:
Comparative study among local anesthetics, opioids and non‑steroidal
anti‑inflammatory drugs. Rev Bras Anestesiol 2002;52:175‑84.
6. Silvani  P, Camporesi A, Agostino  MR, Salvo  I. Caudal anesthesia in
pediatrics: An update. Minerva Anestesiol 2006;72:453‑9.
7. NYSORA – The New York School of Regional Anaesthesia‑Paediatric
Epidural and Caudal Analgesia and Anesthesia in Children; 2008.
Available from: http://www.nysora.com/regional_anesthesia/
subspecialties/pediatric_ane.tric_epidural_and_caudal_analgesia_and_
anesthesia_in_childr.html-37. [Last accessed on 2014 Jan 12].
8. Taheri R, Shayeghi S, Razavi SS, Sadeghi A, Ghabili K, Ghojazadeh M,
et al. Efficacy of bupivacaine‑neostigmine and bupivacaine‑tramadol
in caudal block in pediatric inguinal herniorrhaphy. Paediatr Anaesth
2010;20:866‑72.
9. Bartko J, Stiebellehner L, Derhaschnig U, Schoergenhofer C,
Schwameis M, Prosch H, et al. Dissociation between systemic and
pulmonary anti‑inflammatory effects of dexamethasone in humans. Br J
Clin Pharmacol 2016;81:865‑77.
10. Hong JY, Han SW, Kim WO, Kim EJ, Kil HK. Effect of dexamethasone
in combination with caudal analgesia on postoperative pain control in
day‑case paediatric orchiopexy. Br J Anaesth 2010;105:506‑10.
11. Bangash  LR, Afzal  F, Hussain  S, Ali  K. Comparison of caudal
Nigerian Postgraduate Medical Journal  ¦  Volume 24  ¦  Issue 4  ¦  October-December 2017
block alone with caudal block plus intravenous dexamethasone for
postoperative analgesia in children undergoing orchidopexy under
general anaesthesia. Biomedica 2014;30:267‑71.
12. Srinivasan B, Karnawat R, Mohammed S, Chaudhary B, Ratnawat A,
Kothari SK, et al. Comparison of caudal and intravenous dexamethasone
as adjuvants for caudal epidural block: A  double blinded randomised
controlled trial. Indian J Anaesth 2016;60:948‑54.
13. Dhulkhed  VK, Dhorigol  MG, Mane  R, Gogate  V, Dhulkhed  P. Basic
statistical concepts for sample size estimation. Indian J Anaesth
2008;52:788‑93.
14. Norden J, Hanallah R, Getson P. Reliability of an objective pain scale in
children. J Pain Symptom Manage 1991;6:196.
15. Hasani  A, Soljakova  M, Ustalar‑Ozgen  S. The management of
postoperative pain in children with caudal block. South Afr J Anaesth
Analg 2011;17:376‑9.
16. Phillips NM, Haesler E, Street M, Kent B. Post‑anaesthetic discharge
scoring criteria: A systematic review. JBI Libr Syst Rev 2011;9:1679‑713.
17. Edomwonyi  NP, Egwakhide  EO. Postoperative analgesia in children:
Caudal versus local. Afr J Anaesth Int Care 2005;6:1‑4.
18. Akinyemi OA, Soyannwo OA. Evaluation of the perioperative analgesic
effects of caudal block for herniotomy in children at the university
college hospital Ibadan, Nigeria. Afr J Med Med Sci 2013;42:73‑9.
19. Yousef  GT, Ibrahim  TH, Khder  A, Ibrahim  M. Enhancement of
ropivacaine caudal analgesia using dexamethasone or magnesium
in children undergoing inguinal hernia repair. Anesth Essays Res
2014;8:13‑9.
20. Desmet M, Braems H, Reynvoet M, Plasschaert S, Van Cauwelaert J,
Pottel H, et al. I.V. And perineural dexamethasone are equivalent in
increasing the analgesic duration of a single‑shot interscalene block
with ropivacaine for shoulder surgery: A  prospective, randomized,
placebo‑controlled study. Br J Anaesth 2013;111:445‑52.
21. Martinez V, Fletcher  D. Dexamethasone and peripheral nerve blocks:
On the nerve or intravenous? Br J Anaesth 2014;113:338‑40.
22. Cooper  NS. Intravenous dexamethasone and caudal analgesia. Br J
Anaesth 2011;106:145.
23. Murphy  GS, Szokol  JW, Avram  MJ, Greenberg  SB, Shear  T,
Vender JS, et al. The effect of single low‑dose dexamethasone on blood
glucose concentrations in the perioperative period: A  randomized,
placebo‑controlled investigation in gynecologic surgical patients.
Anesth Analg 2014;118:1204‑12.
24. Gnatzy R, Hempel G, Kaisers UX, Höhne C. The effect of intraoperative
administration of dexamethasone for PONV prophylaxis on
perioperative blood glucose level in obese and normal weight children.
J Pediatr Endocrinol Metab 2015;28:1287‑92.
25. Aroso BK, Menkiti ID, Akintimoye MA, Dada OI, Desalu I. Comparison
of caudal analgesia and intravenous diclofenac for postoperative pain
relief in paediatric patients undergoing day case herniotomy. Afr J
Anaesth Intensive Care 2012;1:21‑5.
26. Mohan SK, Selvakumar R, Suresh M, Chandran K. A randomized
double‑blinded comparative study of 0.25% ropivacaine and 0.25%
bupivacaine by caudal epidural for paediatric sub‑umbilical surgeries.
Indian J Clin Anaesth 2016;3:593‑8.
235