Perioperative effects of caudal and transversus abdominis plane (TAP) blocks for children undergoing urologic robot-assisted laparoscopic surgery.
BACKGROUND
Regional anesthesia is often used in combination with general anesthesia for pediatric surgery, however, it is unknown if adjunctive regional blocks are beneficial to children undergoing urologic laparoscopic or robot-assisted laparoscopic (RAL) procedures.


OBJECTIVE
To compare perioperative outcomes in children with adjunctive caudal blocks, transversus abdominis plane (TAP) blocks, or no regional anesthesia for common RAL surgical procedures in pediatric urology.


METHODS
Inclusion in this retrospective study was limited to children who underwent RAL renal or ureteral/bladder procedures and received a standardized regimen of scheduled intravenous ketorolac and oral acetaminophen for acute postoperative pain control, with opioids as needed (PRN). Perioperative outcomes were compared between patients with an adjunctive caudal block (n = 25), bilateral TAP blocks (n = 44), or no regional anesthesia (n = 51).


RESULTS
Children with a preoperative caudal block received less intraoperative opioids than children with TAP blocks or no regional anesthesia (p < 0.001). This difference was observed both for renal procedures (p < 0.01) and ureteral/bladder procedures (p = 0.01). Patients with caudal blocks were also the least likely to require postoperative antiemetics (p = 0.03). There were no significant differences between groups in postoperative opioid use, maximum pain scores within 6 and 24 hours postoperatively, or length of hospital stay (LOS). No complications attributable to regional blocks were identified by chart review.


CONCLUSIONS
Use of adjunctive caudal blocks for pediatric RAL renal or ureteral/bladder surgical procedures may reduce need for alternate analgesic and/or anesthetic agents intraoperatively, as well as decrease postoperative nausea and vomiting. These findings may be related, since nausea and vomiting are common side effects of opioids and inhalational anesthetics. Consideration of the potential impact of caudal blocks on general anesthetic requirements is timely in light of concerns regarding the risk of anesthetic neurotoxicity in young patients. There was no evidence of improved postoperative pain control or shorter LOS for children who received regional anesthesia. It is unknown if regional blocks would have a greater impact in the absence of scheduled pain medications, which all patients in our study received. Limitations of this study include its retrospective nature and moderate sample size. Future randomized controlled trials are necessary to provide a more definitive understanding of regional anesthesia's role in minimizing pediatric surgical and anesthetic morbidity.


CONCLUSIONS
Administration of caudal blocks should be considered for children of suitable age undergoing RAL surgery involving either the upper or lower urinary tract.
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: mfaasse@sbcglobal.net.
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Faasse
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: blindgren@luriechildrens.org.
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Lindgren
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: brendo338@gmail.com.
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Frainey
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: cmarcus@luriechildrens.org.
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Marcus
Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 19, Chicago, IL 60611, USA. Electronic address: szczodryd@gmail.com.
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Szczodry
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: apglaser@northwestern.edu.
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Glaser
Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 19, Chicago, IL 60611, USA. Electronic address: ssuresh@luriechildrens.org.
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Suresh
Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA. Electronic address: egong@luriechildrens.org.
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Gong
D000293:Adolescent; D000700:Analgesics / Q000627:therapeutic use; D000765:Anesthesia, Conduction; D000779:Anesthetics, Local / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D010535:Laparoscopy; D008297:Male; D009407:Nerve Block; D010149:Postoperative Pain / Q000517:prevention & control*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome; D013520:Urologic Surgical Procedures
D000700:Analgesics; D000779:Anesthetics, Local
Caudal anesthesia; Laparoscopy; Pediatrics; Regional anesthesia; Robotics; Transversus abdominis plane blocks