Summary Nerve blocks improve postoperative analgesia, but their benefits may be short-lived. This quantitative review examines whether perineural dexmedetomidine as a local anaesthetic (LA) adjuvant for neuraxial and peripheral nerve blocks can prolong the duration of analgesia compared with LA alone. All randomized controlled trials (RCTs) comparing the effect of dexmedetomidine as an LA adjuvant to LA alone on neuraxial and peripheral nerve blocks were reviewed. Sensory block duration, motor block duration, block onset times, analgesic consumption, time to first analgesic request, and side-effects were analysed. Results were combined using random-effects modelling. A total of 516 patients were analysed from nine RCTs. Five trials investigated dexmedetomidine as part of spinal anaesthesia and four as part of a brachial plexus (BP) block. Sensory block duration was prolonged by 150 min [95% confidence interval (CI): 96, 205, P

Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis

Despite lack of paediatric labelling, contributions to the literature on paediatric applications of dexmedetomidine have increased over recent years. Dexmedetomidine possesses many properties that are advantageous for a sedative and anaesthetic; it has been reported to provide sedation that parallels natural sleep, anxiolysis, analgesia, sympatholysis, and an anaesthetic-sparing effect with minimal respiratory depression. In addition, there is increasing evidence supporting its organ-protective effects against ischaemic and hypoxic injury. These favourable physiological effects combined with a limited adverse effect profile make dexmedetomidine an attractive adjunct to anaesthesia (general and regional) for a variety of procedures in paediatric operating rooms. A comprehensive understanding of the pharmacological, pharmacokinetic, and pharmacodynamic effects of dexmedetomidine is critical to maximize its safe, efficacious, and efficient paediatric perioperative applications. This review focuses on the current paediatric perioperative and periprocedural applications of dexmedetomidine and its limitations, with a consideration for the future.

Dexmedetomidine: review, update, and future considerations of paediatric perioperative and periprocedural applications and limitations

Background
The present study was designed to test the hypothesis that the increased duration of analgesia caused by adding dexmedetomidine to local anesthetic results from blockade of the hyperpolarization-activated cation (Ih)current.

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Perineural Dexmedetomidine Added to Ropivacaine for Sciatic Nerve Block in Rats Prolongs the Duration of Analgesia by Blocking the Hyperpolarization-activated Cation Current

Efforts to find a better adjuvant in regional anaesthesia are underway since long. Aims and objectives are to compare the efficacy and clinical profile of two α-2 adrenergic agonists, dexmedetomidine and clonidine, in epidural anaesthesia with special emphasis on their sedative properties and an ability to provide smooth intra-operative and post-operative analgesia. A prospective randomized study was carried out which included 50 adult female patients between the ages of 44 and 65 years of (American Society of Anaesthesiologists) ASAI/II grade who underwent vaginal hysterectomies. The patients were randomly allocated into two groups; ropivacaine + dexmedetomidine (RD) and ropivacaine + clonidine (RC), comprising of 25 patients each. Group RD was administered 17 ml of 0.75% epidural ropivacaine and 1.5 μg/kg of dexmedetomidine, while group RC received admixture of 17 ml of 0.75% ropivacaine and 2 μg/kg of clonidine. Onset of analgesia, sensory and motor block levels, sedation, duration of analgesia and side effects were observed. The data obtained was subjected to statistical computation with analysis of variance and chi-square test using statistical package for social science (SPSS) version 10.0 for windows and value of P 0.05). Dexmedetomidine is a better neuraxial adjuvant compared to clonidine for providing early onset of sensory analgesia, adequate sedation and a prolonged post-operative analgesia.

Dexmedetomidine and clonidine in epidural anaesthesia: A comparative evaluation

More than 200 studies and reports have been published regarding the use of dexmedetomidine in infants and children. We reviewed the English literature to summarize the current state of knowledge of this drug in children for the practicing anesthesiologist. Dexmedetomidine is an effective sedative for infants and children that only minimally depresses the respiratory system while maintaining a patent airway. However, dexmedetomidine does depress the cardiovascular system. Specifically, bradycardia, hypotension, and hypertension occur to varying degrees depending on the age of the child. Hypertension is more prevalent when larger doses of dexmedetomidine are given to infants. Consistent with its 2-hour elimination half-life, recovery after dexmedetomidine may be protracted in comparison with other sedatives. Dexmedetomidine provides and augments analgesia and diminishes shivering as well as agitation postoperatively. The safety record of dexmedetomidine suggests that it can be used effectively and safely in children, with appropriate monitoring and interventions to manage cardiovascular sequelae.

Review article: Dexmedetomidine in children: current knowledge and future applications.

Background Caudal block is a common technique for paediatric analgesia but with the disadvantage of short duration of action after single injection. Caudal dexmedetomidine and clonidine could offer significant analgesic benefits. We compared the analgesic effects and side-effects of dexmedetomidine and clonidine added to bupivacaine in paediatric patients undergoing lower abdominal surgeries. Methods Sixty patients (6 months to 6 yr) were evenly and randomly assigned into three groups in a double-blinded manner. After sevoflurane in oxygen anaesthesia, each patient received a single caudal dose of bupivacaine 0.25% (1 ml kg−1) combined with either dexmedetomidine 2 µg kg−1 in normal saline 1 ml, clonidine 2 µg kg−1 in normal saline 1 ml, or corresponding volume of normal saline according to group assignment. Haemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, use of analgesics, and side-effects were assessed during the first 24 h. Results Addition of dexmedetomidine or clonidine to caudal bupivacaine significantly promoted analgesia time [median (95% confidence interval, CI): 16 (14–18) and 12 (3–21) h, respectively] than the use of bupivacaine alone [median (95% CI): 5 (4–6) h] with P Conclusions Addition of dexmedetomidine or clonidine to caudal bupivacaine significantly promoted analgesia in children undergoing lower abdominal surgeries with no significant advantage of dexmedetomidine over clonidine and without an increase in incidence of side-effects.

Addition of clonidine or dexmedetomidine to bupivacaine prolongs caudal analgesia in children

BACKGROUND Intraoperative bleeding during functional endoscopic sinus surgery (FESS) poses a challenge to both surgeon and anesthetist. The primary aim of this study was to evaluate the effectiveness of local, intravenous and combined use of tranexamic acid (TA) in improving the surgical field quality during FESS. METHODS We conducted a randomized controlled double-blinded prospective trial on 120 patients scheduled for elective FESS. After induction of general anesthesia, patients were randomly and evenly assigned to one of four groups; IV TA, local TA, both IV and local TA, and placebo. Surgical field was assessed using five-point Boezaart scale. Total fentanyl and esmolol consumption, operative time, recovery time, and postoperative complications were recorded. RESULTS Surgical field quality score was the best in IV and local TA group compared to others (p < 0.001). Mean operative time was found significantly shorter in IV and local TA group than placebo one. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others (p = 0.025). Mean recovery time was significantly shorter for IV and local TA group compared to others. Total fentanyl consumption was significantly lower in IV and local TA group comparing to others. No significant differences were found of mean arterial pressure and heart rate decline in four groups. None of the patients in four groups required esmolol administration. No statistically significant differences were found in change of hemoglobin, hematocrit, prothrombin time, and partial thromboplastin time over time in all groups. CONCLUSION The combined use of topical and intravenous TA provided the best surgical field in FESS, less fentanyl consumption, and less recovery time without causing significant side effects.

Outcomes of combined use of topical and intravenous tranexamic acid on surgical field quality during functional endoscopic sinus surgery: Randomized controlled trial.

Background: it’s considered that post-operative pain management in children is essential as it reduce the pain as well as anxiety of the parents regarding post-operative pain There are some options which are found and being used currently by pediatric anesthetists However there is no consensus over a single best method Post- operative pain management had always been a major concern of parents as well as pediatric anesthetists Contrary to the ancient notion that children don’t feel pain, many studies have focused on the importance of good pain management in children According to the studies, children in surgical ward feel more pain than children in medical ward and prevalence was found to be 44% and 13% respectively and it was found that about 64% of pediatric patients after surgery experience moderate to severe pain while 29% experience mild pain
Objectives: the aim of this study was to compare pain scores in patients undergoing inguinal herniotomy after caudal block and intravenous nalbuphine
Patients and Methods: this comparative double blind study was conducted at Paediatric Surgery Department We included patients with age range of 3-12 years The children were randomly divided into two groups Group C included Caudal Block; and Group N included patients who received Nalbuphine In group C patients, after herniotomy and before extubating the patient, caudal block was introduced by giving Bupivacaine 025% according to body weight In patients in group N, immediately after herniotomy, nalbuphine was given intravenously 018 mg/kg according to body weight Patients were shifted to post-operative ICU where pain scores were measured at 0,1,2,4 and 8 hours Also any side effect of the drugs was noted and taken care of For pain measurement Faces Pain scale was used If any patient developed pain score 8 or more, patient was given paracetamol10 mg/kg
Results: we have used FACES pain scale in our study which is a verified scale for pain assessment in children with the age range of 3-12 years There was no significant difference between the two study groups as regard side effects, as 148% of group 2 (Caudal Group) cases had side effects compared to 36% for group 1 (Nalbuphine cases(p=0052) As regard the need for rescue analgesia, no significant difference was found between the two study groups Regarding our study, there was no significant difference between the two study groups as regard pain scale at 1 hour However, a highly significant difference was found between the two study groups as regard pain score at 2, 4, and 8 hours with higher pain among caudal block group
Conclusion: nalbuphine is better than caudal block for post-operative pain management after inguinal herniotomy in children

Caudal Bupivacaine versus Systemic Nalbuphine for Post-Operative Pain Management in Children undergoing Inguinal Hernia Repair

Abstract 
Background: Laparoscopic bariatric surgery has become a regular procedure, and it has largely replaced traditional open surgery. Patients experience postoperative pain even after laparoscopic surgery, although the intensity is low compared to open surgery. We compared the effectiveness of intravenous (IV) vs. intraperitoneal (IP) magnesium sulphate (MgSO4) injection in pain management in laparoscopic mini-gastric bypass surgery.  
Methodology: We selected 100 patients based on convenient sampling and randomly divided into two groups; the IV group (50 patients) received MgSO4 50 mg/kg in 250 ml normal intravenously, and the IP group (50 patients) received MgSO4 50 mg/kg in 30 ml normal saline intraperitoneally. Nalbuphine was used as rescue analgesic and its total postoperative consumption during the first 24 h was recorded based on VAS score. Postoperative nausea and vomiting (PONV), sedation score and hemodynamic changes with pneumoperitoneum were also assessed. 
Results: Total nalbuphine consumption postoperatively was more in IV group than IP group (12 ± 3.03 mg vs. 8.3 ± 2.8 mg; P < 0.001). Postoperative pain score was significantly lower in IP group in comparison to IV group (P < 0.001). Intraoperative hypotension and bradycardia were significantly more (P = 0.03) in IV group (21% and 17% respectively) compared to IP group (10% and 7% respectively). Postoperative sedation and nausea and vomiting scores were reduced in IP group compared to IV group, the difference being highly significant (P < 0.001). 
Conclusion: Intraperitoneal MgSO4 instillation has better results than intravenous infusion in attenuation of postoperative pain and hemodynamic response associated with pneumoperitoneum, and results in less PONV when used in laparoscopic minigastric bypass patients. 
Key words: Analgesics / administration & dosage; Analgesics / pharmacology; Analgesics / therapeutic use; Bariatric; Magnesium Sulfate / administration & dosage; Magnesium Sulfate / pharmacokinetics; Magnesium Sulfate / therapeutic use; Mini-gastric bypass; Pain management; Pneumoperitoneum 
Citation: El-Sesy MG, Abdel Hameed AE, Abdelaziz AA, Ahmed IM, Elhennawy AM. A comparative study between intravenous and intraperitoneal magnesium sulphate for pain management in laparoscopic mini gastric bypass: a randomized clinical trial. Anaesth. pain intensive care 2022;26(4):450-457; DOI: 10.35975/apic.v26i4.1947 
Received: April 18, 2022; Reviewed: June 16, 2022; Accepted: July 10, 2022

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A comparative study between intravenous and intraperitoneal magnesium sulphate for pain management in laparoscopic mini gastric bypass: a randomized clinical trial

Ahmed Mohamed Elhennawy

Papers

Addition of clonidine or dexmedetomidine to bupivacaine prolongs caudal analgesia in children

Outcomes of combined use of topical and intravenous tranexamic acid on surgical field quality during functional endoscopic sinus surgery: Randomized controlled trial.

Caudal Bupivacaine versus Systemic Nalbuphine for Post-Operative Pain Management in Children undergoing Inguinal Hernia Repair

A comparative study between intravenous and intraperitoneal magnesium sulphate for pain management in laparoscopic mini gastric bypass: a randomized clinical trial