Nalbuphin as an Adjuvant to Levobupivacaine in Caudal Analgesia in Children
Authors: Reiad Mostafa Kamel , Elfawal Sanaa Mohamed , Razik Rehab Abdel Fattah Abdel , Soliman Mohamed Mahmoud 
Published: August 2023

Abstract

Background
Caudal anethesia is the single most important pediatric regional anethetic technique and is increasingly performed in pediatric regional anesthesia practices. It is preferred in order to relieve intraoperative and postoperative pain in children of all age groups undergoing pelvi-abdominal or lower limbs surgeries using levobupivacaine 0.25%.Various adjuvant have been added to levobupivacaine to prolong postoperative caudal analgesia. Nalbuphine as many opioids can be added in caudal analgesia. This prospective randomised double blind study was done to compare the effects of plain levobupivacaine 0.25% versus Levobupivacaine 0.25% plus nalbuphine 0.1 mg/kg single-shot for postoperative pain relief in children undergoing hypospadius repair surgery.

Materis and Methods
At total of 64 pediatric patient 1 to 3 years old with American society of Anethesiologist (ASA) status | to |‖, undergoing hypospadius repair surgery were prospectively randomized into two groups, Group 1 received levobupivacaine 0.25% only 1 ml/kg plus 1 ml normal saline and group 2 received levobupivacaine 0.25% 1 ml/kg plus 0.1 mg/kg in 1 ml normal saline. The primary outcome of the study were time to first analgesia request, total consumption of rescue analgesia and the FLACC scale (face, legs, activity, cry and consonlability). The secondary outcome were heart rate (HR), mean arterial blood pressure (MAP), Oxygen saturation, occurrence of complications (respiratory depression, pruritis, xerostomia and postoperative nausea and vomiting).

Results
During surgery adequate intraoperative analgesia was defined by hemodynamic stability. An increase in the HR or MAP within 15 minutes greater than 15% compared to the baseline values obtained before skin incision recieved a rescue opioid in the form of fentanyl 5 mcg /kg and was excluded from the study. The difference between the two groups regarding time to first analgesia request was highly significant, group 1 (7.28±1.07), group 2 (11.59±2.54) (p &lt; 0.01).The comparison between the two groups regarding the total consumption of rescue analgesia was also significant, group 1 (23.47±8.17), group 2 (19.23±7.31) (p &lt; 0.05). There was statistically significant increase in FLACC in group 1 than group 2 at 30 min and up to 8 hours. There was no significant decrease in HR or MAP in group 2 more than group 1 except between 20 min and 8 hours. There was no statistically significant difference found between two studied groups regarding oxygen saturation regarding intraoperative and postoperative follow up. No patients in both groups had respiratory depression, xerostomia or pruritis.Few patients (3 _4) had postoperative nausea and vomiting with no statistically significant difference between the two groups.

Conclusion
The combination between nalbuphine and Levobupivacaine was valuable as regarding efficacy and safety profiles in pediatric analgesia. The intensity and duration of analgesia were remarkable compared to levobupivacaine alone. Fortunately, there were no side effects of systemic hazards recorded from systemic absorption of nalbuphine. To recommend considering nalbuphine as one of the valuable adjuvants to levobupivacaine in epidural analgesia according to its efficacy and safety profile.