Anaesthesia, 1979, Volume 34, pages 552-554
Postoperative analgesia after circumcision A randomised comparison between caudal analgesia and intramuscular morphine in boys
J.N. LUNN
It is often asserted that caudal anaesthesia in boys who have just been circumcised causes the recovery period to be Retrospective inspection of 98 records of day-case anaesthesia revealed, to the author’s horror, that nine out of fifty patients who had received caudal injections had also required intramuscular morphine postoperatively. The explanation that poor selection of patients or poor technique were responsible was not acceptable and this comparative prospective study was therefore planned.
Method Boys selected for circumcision for surgical reasons were studied. Circumcision in normal children may result in less pain postoperatively because of the absence of chronic inflammation or adhesions so children having the operation for religious reasons were not studied. These operations are routinely performed in a day-case suite on children aged between 2 and 12 years; the anaesthetic management described below is not substantially different from usual. The boys were seen and examined in the presence of their parents preoperatively. Boys with palpably unfused sacral vertebrae were excluded from the study. An explanation was given to the boy of all that would happen to him whilst he was conscious. The boy was then brought, with his mother, to the anaesthetic room where, amongst suitable toys, books and pictures to distract him, general anaesthesia was induced. All the patients were treated in the
same manner by the same anaesthetist. Anaesthesia was induced with thiopentone ( 3 4 mg/kg intravenously), followed by atropine (0.01 mg/ kg). The child was then placed on the operating table and the mother escorted elsewhere. Anaesthesia was maintained with nitrous oxide (50%) oxygen and halothane. Electrocardiograph leads were on a back pad and an oesophageal stethoscope was passed. Random numbers were used to allocate patients into two groups. Both groups had their sacra, hips and surrounding areas sprayed with pink hibitane. Those who were to receive intramuscular morphine did so as surgery started: 0.15 mg/kg was given into the left deltoid muscle. Those who were to receive caudal analgesia were turned into the semi-prone position and received 1.5 mg/kg bupivacaine (0.5% without adrenaline). As soon as the injection was completed, a dressing was applied and the child was taken into theatre. The inspired concentration of halothane was reduced so that the child would be almost conscious at the end of the operation. The dressing was then applied and the child turned onto his left side; an oxygen mask applied and the child moved to a tipping trolley and transferred to the recovery room. Routine observations were then made. An independent experienced staff nurse made special notes of the child’s behaviour. These were made on a linear analogue which was 10 cm long with ‘asleep’ at one end and ‘violently restless’ at the other. A mark was made along
J.N. Lunn, MD, FFARCS, Senior Lecturer, Welsh National School of Medicine, Cardiff.
552
0003-2409/79/0600-0552$02.00
0 1979 Blackwell Scientific Publications
Postoperative analgesia ajier circumcision the line to indicate the state of the child at that time. This was done at 5-min intervals after admission to the recovery room until 30 min. No member of staff in the recovery room knew which technique of analgesia had been used. When the child was awake, or almost so, the mother was reunited with her child and then they returned to the bedded area. Observations about the need for supplementary morphine and the incidence of vomiting were also made. The duration of stay in the bedded area of the Day Unit until the boy could stand unaided was also recorded. Observations about later recovery at home were recorded by the Community Nurse who visited the patients twice in the next 24 hr. Final healing and overall results were noted at the subsequent visit to Surgical Outpatients one week later. Some months later measurement of the length of the analogue line were made by the author before the nature of the analgesia was again known. Results 40 boys were studied; 20 in each group. The mean age of the morphine group of boys was 5 months greater than that of the caudal group but this was not statistically different ( t = 0.69; P = 0.24). The mean weights in the two groups were identical (18.68 kg). The mean length of the analogue line (measured from asleep to violently restless) at each time is shown in Fig. 1. The differences at 5 and 30 min were not statistically significant. The line was longer for boys who received morphine than that for those who received a caudal injection and the difference (by unpaired t-test ;probability single-tailed) was highly significant at all other times. The average durations'of stay in the bedded area before the boys were able to stand were almost identical. (192 and 189 min for the morphine and caudal groups respectively.) Not all the records about vomiting were complete. Three out of 13 boys who received caudals (23%) and 8 out of 12 (80%) who received morphine, vomited (,yz 7.26: P
Postoperative analgesia after circumcision A randomised comparison between caudal analgesia and intramuscular morphine in boys
J.N. LUNN
It is often asserted that caudal anaesthesia in boys who have just been circumcised causes the recovery period to be Retrospective inspection of 98 records of day-case anaesthesia revealed, to the author’s horror, that nine out of fifty patients who had received caudal injections had also required intramuscular morphine postoperatively. The explanation that poor selection of patients or poor technique were responsible was not acceptable and this comparative prospective study was therefore planned.
Method Boys selected for circumcision for surgical reasons were studied. Circumcision in normal children may result in less pain postoperatively because of the absence of chronic inflammation or adhesions so children having the operation for religious reasons were not studied. These operations are routinely performed in a day-case suite on children aged between 2 and 12 years; the anaesthetic management described below is not substantially different from usual. The boys were seen and examined in the presence of their parents preoperatively. Boys with palpably unfused sacral vertebrae were excluded from the study. An explanation was given to the boy of all that would happen to him whilst he was conscious. The boy was then brought, with his mother, to the anaesthetic room where, amongst suitable toys, books and pictures to distract him, general anaesthesia was induced. All the patients were treated in the
same manner by the same anaesthetist. Anaesthesia was induced with thiopentone ( 3 4 mg/kg intravenously), followed by atropine (0.01 mg/ kg). The child was then placed on the operating table and the mother escorted elsewhere. Anaesthesia was maintained with nitrous oxide (50%) oxygen and halothane. Electrocardiograph leads were on a back pad and an oesophageal stethoscope was passed. Random numbers were used to allocate patients into two groups. Both groups had their sacra, hips and surrounding areas sprayed with pink hibitane. Those who were to receive intramuscular morphine did so as surgery started: 0.15 mg/kg was given into the left deltoid muscle. Those who were to receive caudal analgesia were turned into the semi-prone position and received 1.5 mg/kg bupivacaine (0.5% without adrenaline). As soon as the injection was completed, a dressing was applied and the child was taken into theatre. The inspired concentration of halothane was reduced so that the child would be almost conscious at the end of the operation. The dressing was then applied and the child turned onto his left side; an oxygen mask applied and the child moved to a tipping trolley and transferred to the recovery room. Routine observations were then made. An independent experienced staff nurse made special notes of the child’s behaviour. These were made on a linear analogue which was 10 cm long with ‘asleep’ at one end and ‘violently restless’ at the other. A mark was made along
J.N. Lunn, MD, FFARCS, Senior Lecturer, Welsh National School of Medicine, Cardiff.
552
0003-2409/79/0600-0552$02.00
0 1979 Blackwell Scientific Publications
Postoperative analgesia ajier circumcision the line to indicate the state of the child at that time. This was done at 5-min intervals after admission to the recovery room until 30 min. No member of staff in the recovery room knew which technique of analgesia had been used. When the child was awake, or almost so, the mother was reunited with her child and then they returned to the bedded area. Observations about the need for supplementary morphine and the incidence of vomiting were also made. The duration of stay in the bedded area of the Day Unit until the boy could stand unaided was also recorded. Observations about later recovery at home were recorded by the Community Nurse who visited the patients twice in the next 24 hr. Final healing and overall results were noted at the subsequent visit to Surgical Outpatients one week later. Some months later measurement of the length of the analogue line were made by the author before the nature of the analgesia was again known. Results 40 boys were studied; 20 in each group. The mean age of the morphine group of boys was 5 months greater than that of the caudal group but this was not statistically different ( t = 0.69; P = 0.24). The mean weights in the two groups were identical (18.68 kg). The mean length of the analogue line (measured from asleep to violently restless) at each time is shown in Fig. 1. The differences at 5 and 30 min were not statistically significant. The line was longer for boys who received morphine than that for those who received a caudal injection and the difference (by unpaired t-test ;probability single-tailed) was highly significant at all other times. The average durations'of stay in the bedded area before the boys were able to stand were almost identical. (192 and 189 min for the morphine and caudal groups respectively.) Not all the records about vomiting were complete. Three out of 13 boys who received caudals (23%) and 8 out of 12 (80%) who received morphine, vomited (,yz 7.26: P
