Restricted accessResearch articleFirst published online 2021-6
Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized,Prospective,Double-Blind Study
Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery?
Design:
Randomized, controlled, and double-blind study.
Setting:
Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India).
Participants:
A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders.
Interventions:
Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG.
Main Outcome Measure:
The primary end point was the incidence of emergence agitation.
Results:
There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed.
Conclusions:
The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.
AntonyAKSloanGM. Airway obstruction following palatoplasty: analysis of 247 consecutive operations. Cleft Palate Craniofac J. 2002;39(2):145–148.
2.
AugsornwanDPattangtanangPPikhunthodKSurakunpraphaP. Postoperative pain in patients with cleft lip and palate in Srinagarind Hospital. J Med Assoc Thai. 2011;94(suppl 6):S118–123.
3.
BajwaSACostiDCynaAM. A comparison of emergence delirium scales following general anesthesia in children. Paediatr Anaesth. 2010;20(8):704–711.
4.
BergendahlHTLonnqvistPAEksborgSRuthstromENordenbergLZetterqvistH. Clonidine vs. midazolam as premedication in children undergoing adenotonsillectomy: a prospective, randomized, controlled clinical trial. Acta Anaesthesiol Scand. 2004;48(10):1292–1300.
5.
BockMKunzPSchreckenbergerRGrafBMMartinEMotschJ. Comparison of caudal and intravenous clonidine in the prevention of agitation after sevoflurane in children. Br J Anaesth. 2002;88(6):790–796.
6.
BuckenmaierCCIIIBlecknerLL. Anaesthetic agents for advanced regional anaesthesia: a North American perspective. Drugs. 2005;65(6):745–759.
7.
ButterworthJFStrichartzGR. The alpha 2-adrenergic agonists clonidine and guanfacine produce tonic and phasic block of conduction in rat sciatic nerve fibers. Anesth Analg. 1993;76(2):295–301.
8.
CarlsonLHatcherKTombergLKabetuCAyalaRVander BurgR. Inequitable access to timely cleft palate surgery in low- and middle-income countries. World J Surg. 2016;40(5):1047–1052.
9.
ChionoJRauxOBringuierSSolaCBigorreMCapdevilaX.Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children a prospective, randomized, double-blind study versus placebo. Anesthesiol. 2014;120(6):1362–1369.
10.
CubittJHodgesAVan LierdeKSwanM. Global variation in cleft palate repairs: an analysis of 352,191 primary cleft repairs in low- to higher-middle-income countries. Cleft Palate Craniofac J. 2014;51(5):553–556.
11.
CucchiaroGGaneshA. The effects of clonidine on postoperative analgesia after peripheral nerve blockade in children. Anesth Analg. 2007;104(3):532–537.
12.
EchanizGDe MiguelMMerrittGSierraPBoraPBorahNCiaralloCde NadalMIngRJBosenbergA. Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair: a double-blind prospective, randomised study. Eur J Anaesthesiol. 2019;36(1):40–47.
13.
EisenachJCDe KockMKlimschaW.Alpha(2)-adrenergic agonists for regional anesthesia. A clinical review of clonidine (1984-1995). Anesthesiol. 1996;85(3):655–674.
14.
GhaiBRamJChauhanSWigJ. Effects of clonidine on recovery after sevoflurane anaesthesia in children undergoing cataract surgery. Anaesth Intensive Care. 2010;38(3):530–537.
15.
GulerGAkinATosunZOrsSEsmaogluABoyaciA. Single-dose dexmedetomidine reduces agitation and provides smooth extubation after pediatric adenotonsillectomy. Paediatr Anaesth. 2005;15(9):762–766.
16.
HuKSKwakHHSongWCKangHJKimHCFontaineC. Branching patterns of the infraorbital nerve and topography within the infraorbital space. J Craniofac Surg. 2006;17(6):1111–1115.
17.
HuKSKwakJKohKSAbeSFontaineCKimHJ. Topographic distribution area of the infraorbital nerve. Surg Radiol Anat. 2007;29(5):383–388.
18.
IbacacheMEMunozHRBrandesVMoralesAL. Single-dose dexmedetomidine reduces agitation after sevoflurane anesthesia in children. Anesth Analg. 2004;98(1):60–63, table of contents.
19.
IsikBArslanMTungaADKurtipekO. Dexmedetomidine decreases emergence agitation in pediatric patients after sevoflurane anesthesia without surgery. Paediatr Anaesth. 2006;16(7):748–753.
20.
JindalPKhuranaGDvivediSSharmaJP. Intra and postoperative outcome of adding clonidine to bupivacaine in infraorbital nerve block for young children undergoing cleft lip surgery. Saudi J Anaesth. 2011;5(3):289–294.
21.
KayyalTAWolfswinkelEMWeathersWMCapehartSJMonsonLABuchananEP. Treatment effects of dexmedetomidine and ketamine on postoperative analgesia after cleft palate repair. Craniomaxillofac Trauma Reconstr. 2014;7(2):131–138.
KlimschaWChiariAMichalek-SaubererAWildlingELercheALorberC. The efficacy and safety of a clonidine/bupivacaine combination in caudal blockade for pediatric hernia repair. Anesth Analg. 1998;86(1):54–61.
KulkarniKRPatilMRShirkeAMJadhavSB. Perioperative respiratory complications in cleft lip and palate repairs: an audit of 1000 cases under ‘Smile Train Project’. Indian J Anaesth. 2013;57(6):562–568.
26.
LiauJYSadoveAMvan AalstJA. An evidence-based approach to cleft palate repair. Plast Reconstr Surg. 2010;126(6):2216–2221.
27.
MalviyaSVoepel-LewisTRamamurthiRJBurkeCTaitAR. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Paediatr Anaesth. 2006;16(5):554–559.
28.
MasukiSDinennoFAJoynerMJEisenachJH. Selective alpha2-adrenergic properties of dexmedetomidine over clonidine in the human forearm. J Appl Physiol (1985). 2005;99(2):587–592.
29.
MuthukumarMAryaVKMathewPJSharmaRK. Comparison of haemodynamic responses following different concentrations of adrenaline with and without lignocaine for surgical field infiltration during cleft lip and cleft palate surgery in children. Anaesth Intensive Care. 2012;40(1):114–119.
30.
NicodemusHFFerrerMJCristobalVCde CastroL. Bilateral infraorbital block with 0.5% bupivacaine as post-operative analgesia following cheiloplasty in children. Scand J Plast Reconstr Surg Hand Surg. 1991;25(3):253–257.
31.
ObayahGMRefaieAAboushanabOIbraheemNAbdelazeesM. Addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair. Eur J Anaesthesiol. 2010;27(3):280–284.
32.
PengWZhangT. Dexmedetomidine decreases the emergence agitation in infant patients undergoing cleft palate repair surgery after general anesthesia. BMC Anesthesiol. 2015;15:145.
33.
PrabhuKPWigJGrewalS. Bilateral infraorbital nerve block is superior to peri incisional infiltration for analgesia after repair of cleft lip. Scand J Plast Reconstr Surg Hand Surg. 1999;33(1):83–87.
34.
ReenaKHBAbhijitP. Postoperative analgesia for cleft lip and palate repair in children. J Anaesthesiol Clin Pharmacol. 2016;32(1):5–11.
35.
ReubenSSSteinbergRBKlattJLKlattML. Intravenous regional anesthesia using lidocaine and clonidine. Anesthesiol. 1999;91(3):654–658.
36.
RoulleauPGallODesjeuxLDagherCMuratI. Remifentanil infusion for cleft palate surgery in young infants. Paediatr Anaesth. 2003;13(8):701–707.
37.
SharpePKleinJRThompsonJPRushmanSCSherwinJWandlessJG. Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine. Paediatr Anaesth. 2001;11(6):695–700.
38.
SilvaLMBrazLGModoloNS. Emergence agitation in pediatric anesthesia: current features. J Pediatr (Rio J). 2008;84(2):107–113.
39.
SomayajiKSRaoMK. Anatomy and clinical applications of the maxillary nerve in dentistry: a literature review. Dent Update. 2012;39(10):727–730, 33–35.
40.
SuranaPParikhDAPatkarGATendolkarBA. A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery. Korean J Anesthesiol. 2017;70(6):633–641.
41.
TakemuraHYasumotoKToiTHosoyamadaA. Correlation of cleft type with incidence of perioperative respiratory complications in infants with cleft lip and palate. Paediatr Anaesth. 2002;12(7):585–588.
42.
TobiasJDBerkenboschJWRussoP. Additional experience with dexmedetomidine in pediatric patients. South Med J. 2003;96(9):871–875.
43.
VlajkovicGPSindjelicRP. Emergence delirium in children: many questions, few answers. Anesth Analg. 2007;104(1):84–91.
44.
Voepel-LewisTZanottiJDammeyerJAMerkelS. Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care. 2010;19(1):55–61; quiz 2.
45.
WelbornLGHannallahRSNordenJMRuttimannUECallanCM. Comparison of emergence and recovery characteristics of sevoflurane, desflurane, and halothane in pediatric ambulatory patients. Anesth Analg. 1996;83(5):917–920.
46.
XuYYSongXRLinZMZhangGQZhangN. Effect of dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing cleft lip and palate repair [in Chinese]. Zhonghua Yi Xue Za Zhi. 2012;92(13):878–881.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
