Padmanabhan, K R (2010) A Comparative Study to Evaluate the Efficacy of Paracetamol as Rectal Suppository in Paediatric Patients Undergoing Subumbilical Surgery with Caudal Bupivacaine. Masters thesis, Chengalpattu Medical College, Chengalpattu.
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Abstract
INTRODUCTION: The postoperative pain in pediatric patient is not adequately managed, though it causes morbidity and mortality at times. It is now accepted that pain should be anticipated, and safely and effectively controlled, in all children, whatever their age, maturity or severity of illness be. Because of the multiplicity of mechanisms involved in post operative pain, a multimodalanalgesia regimen, with a combination of opiod and non-opiod analgesic drugs is often used to augment the analgesic efficacy and reduce the polypharmacy and its side effects. Peripheral tissue injury provokes both peripheral sensitization and central sensitization. These changes contribute to the post traumatic pain hypersensitivity state which manifests as an increase in the responsiveness to noxious stimuli and a decrease in the pain threshold, both at the site of injury and in the surrounding uninjured tissue. Single shot caudal epidural analgesia is a widely used regional technique for intra and postoperative pain relief during lower abdominal, inguinal and penoscrotal surgeries in paediatric patients. It is technically simple, safe and reliable, and provides effective analgesia for surgery below the umbilicus. However, the analgesic effect of caudal bupivacaine lasts for 4-12 hours. Different additives are used to prolong the period of post operative analgesia. The use of caudal Morphine provides excellent analgesia with higher incidence of serious side effects like respiratory depression, nausea, vomiting and urinary retention. Other combination such as ketamine, clonidine, tramadol and midazolam have also been used as adjuvant to bupivacaine for caudal analgesia. All of them provide improved analgesia without any serious side effects. However, clonidine, ketamine, tramadol and midazolam do have potential risk of producing hypotension, behavioralchanges, vomiting and sedation respectively. Paracetamol is a good analgesic. It has high therapeutic range and safe and easy to administer in children especially in the form of suppository. Rectal paracetamol is devoid of complications of non steroidal anti-inflammatory drugs, such as coagulopathy, nephropathy, gastropathy and bronchial asthma. Studies have demonstrated that mechanical hyperalgesia surrounding the wound in post operative patients and experimentally, heat induced, secondary hyperalgesia share a common mechanism of central neuronal sensitization which contributes to post operative pain. Paracetamol by its central effect on the nociceptive process involving central sensitization provides excellent post operative analgesia. In my institution I choose to study the post operative analgesic effect of rectal paracetamol in addition to caudal bupivacaine in paediatric patients subjected to sub umbilical surgeries. AIM: To evaluate the efficacy and duration of post operative analgesia of paracetamol rectal suppository, in paediatric patients undergoing subumbilical surgeries. METHODS AND MATERIALS: The study was conducted in Chengalpattu Medical college Hospital during the period May 2009 - August 2009 .Sixty ASA I children were taken up for a Prospective randomized comparative double blind trial and were grouped into Group C (caudal bupivacaine) and Group S (caudal bupivacaine with paracetamol suppository). Inclusion Criteria: 1. ASA I, 2. Age 3- 8 years (< 20 Kg), 3. All subumbilical surgeries. Exclusion Criteria: 1. Children with h/o allergic to local anaesthetics, 2. Undiagnosed diarrhea, 3. Coagulopathies, 4. Local sepsis, 5. Recent respiratory infection, 6. Abnormalities of sacrum, vertebral column and spinal cord, 7. The Children with developemental delay. RESULTS: The study constituted of sixty children undergoing sub-umbilical surgeries. They were evaluated for post operative pain score using FLACC scale rescue analgesic time, the modified aldrete recovery score, rise in temperature, post operative nausea and vomiting, first post operative urine voiding time were compared between Group S (rectal paracetamol with caudal bupivacaine) and Group C ( caudal bupivacaine alone). The Mean Rescue Analgesic time in the Group S is 353 ± 6.0mins and in the control Group C is 253 ± 3.9 mins, ( p < 0.0001, t value 13.9). There is significant increase in the post operative analgesia time and quality and there is less pain score in the study Group S when compared to the control Group C. The incidence of fever and post operative nausea and vomiting is higher in the control Group C. Most of the children voided urine within 6-7 hours . There was no need for catheterization and no incidence of retention of urine in any of the children. The variables age, weight, Pain scores , rescue analgesic time, heart rate, respiratory rate, the modified adrete recovery score and urine voiding time were analysed using Levene' s test for equality of variences and t-test for equality of means . The distribution of sex and the incidence of fever and postoperative nausea and vomiting were analysed using Chisquare test. RESULTS: 1. The Comparision of Mean Rescue analgesic time in Rectal Paracetamol group S and the Caudal bupivacaine Group C, were statistically significant at 2.30 , 3.00, 3.30, 4.30, 5.00, 5.30 , 6.00, 6.30 &7.00 hrs of post operative time intervals and is significantly higher in rectal paracetamol Group S than the caudal bupivacaine only Group C. 2. The Comparison of Mean FLACC Pain score in both Groups S & C, were statistically significant at2.30, 3.00, 3.30, 4.30, 5.00, 5.30 , 6.00, 6.30, & 7.00 hrs of post operative intervals and is significantly lower in Rectal paracetamol Group S than the caudal bupivacaine only Group C. 3. The Comparision of Heart rate & Respiratory Rate in both Groups S & C, were statistically significant at 2.30, 3.00, 3.30, 4.30, 5.00, 5.30, 6.00, 6.30, & 7.00 hrs of post operative intervals and is significantly lower in the Rectal paracetamol Group S than the caudal bupivacaine only Group C. 4. The Aldrete recovery score is significantly lower in Rectal paracetamol group S than the caudal bupivacaine only group C but it is not statistically significant. 5. The incidence of PONV & Rise in temperature is significantly lower in the Rectal paracetamol Group S than the caudal bupivacaine only Group C. 6. The first urine voiding time post operatively is significantly prolonged in Rectal paracetamol Group S than the Caudal bupivacaine only Group C. CONCLUSION: I conclude from the above study that the addition of paracetamol suppository to caudal bupivacaine enhances the quality and extends the duration of post operative analgesia better than the caudal bupivacaine alone in paediatric patients undergoing subumbilical surgeries, in fulfilling the criteria's mentioned in the aim of study.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Efficacy of Paracetamol ; Rectal Suppository ; Paediatric Patients ; Undergoing Subumbilical Surgery ; Caudal Bupivacaine ; Comparative study. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 30 Apr 2018 03:35 |
| Last Modified: | 30 Apr 2018 03:35 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7354 |
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