Comparison of caudal epidural block with paravertebral block for renal surgeries in pediatric patients: A prospective randomised, blinded clinical trial
Narasimhan et al report a single-blind RCT to compare the analgesic efficacy of ultrasound guided single-shot caudal and paravertebral blocks in children undergoing pyeloplasty. The study has an elegantly simple design and the methodology is well described. The same medication (0.2% ropivacaine with 1:200,000 adrenaline) is delivered by one of two different routes with all other factors unchanged between groups. The results convincingly indicate superiority of paravertebral block over caudal block. They show longer median duration of analgesia (11hrs vs 5.5hrs time to first rescue analgesia), and lower pain scores (starting from three hours post-op) and lower total analgesic requirements (0.6+/-0.8mcg/kg vs 1.8+/-1.2mcg/kg fentanyl) over 24 hours. The only detriment to paravertebral over caudal block was time to administer the block (5 mins vs 2 mins, respectively). While the study was powered to show a modest 20% increase in duration of analgesia, the difference shown was actually an increase of 100%! The shortcoming of this study is that it was a single centre study, with a single provider performing all cases. This therefore provides very strong evidence to support this particular provider to adopt paravertebral blocks routinely, however it is difficult to know how this translates more broadly for paediatric anaesthetists in Australia.
Take home message
Ultrasound guided single-shot paravertebral blocks can provide excellent analgesia for children undergoing pyeloplasty and take under five minutes in experienced hands. This paper suggests a paravertebral block may achieve better analgesia than a caudal block, whilst using lower drug doses. Unfortunately, this study cannot be directly translated to clinical practice in Australia without further evaluation.
Reviewed by: Dr Bae Corlette