SURVEY OF PENILE AND CAUDAL BLOCK USE IN PAEDIATRIC PENILE SURGERY WITHIN A TERTIARY CHILDREN’S HOSPITAL.
Introduction
A recent Cochrane review concluded that penile and caudal blocks both provide effective analgesia for circumcision surgery. An increased incidence of motor block associated with caudals suggests they should be reserved for younger boys who are non-ambulatory1. For hypospadias repair, caudal block is commonly recommended although penile blocks are also effective2. We sought to establish anaesthetist preference in our institution.
Methods
A survey was distributed to all consultant anaesthetists at Birmingham Children’s Hospital. Respondents were asked to describe the regional technique they would use in both circumcision and hypospadias surgery in 1, 2, 4 and 6 year-olds. Data on preferred pharmacy was also collected.
Results
Twenty three out of 27 consultant anaesthetists replied. All used regional anaesthesia routinely during penile surgery. Penile block was favoured in older boys having circumcision surgery (age 6: 17/23) . However, in younger boys, caudal blocks were preferred (age 1: 17/23) with the cited reason penile blocks are unreliable due to difficulty in identifying Buck’s fascia. In hypospadias surgery, caudal blocks were preferred for all ages (age 1: 22/23; age 6: 17/23).
Penile block was universally performed using 0.25% levobupivacaine and a volume of 0.43 ml/kg [0.2-1]. Caudal block was commonly performed using 0.25% levobupivacaine and a volume of 0.65 ml/kg [0.5-1]. A variety of adjuncts were used: ketamine 9/23, adrenaline 1/23, clonidine 1/23. There was no variation in choice of pharmacy with age.
Conclusions
These results suggest that paediatric anaesthetists are not confident in the efficacy of penile blocks both for hypospadias repair and younger boys undergoing circumcision; caudals instead are favoured. There is a paucity of evidence and studies are needed in these two patient groups. If a future study demonstrated that penile block is effective then this would potentially be a safer alternative to invading the caudal (extradural) space. Neuraxial adjunctive agents are widely used despite insufficient evidence to compare benefits with risks2.
References
1. Cyna AM, Middleton P. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Cochrane Database Syst Rev. 2008 8;(4):CD003005.
2. Howard R et al. Good Practice in Postoperative and Procedural Pain. London: Association of Paediatric Anaesthetists. 2008; 105-111.
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