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Caudal epidural block is a simple and safe technique with a low complication rate commonly used for pediatric anesthesia and treatment of chronic lumbosacral pain. However, it is not exempt from some risks that, although infrequent, should be known. We describe the case of a 48-year-old female with chronic lumbosacral radicular pain who underwent caudal epidural infiltration. During the withdrawal of the catheter, accidental breakage and retention of a fragment at the level of the anterior epidural space of the sacrum occurred. We choose to have an expectant management with regular controls and a radiological lumbosacral computed tomography (CT) scan. Since the catheter was placed under sterile conditions, no prophylactic antibiotic treatment was considered. The patient showed no adverse events during the 6 months following catheter rupture. To our knowledge, there are no reports of epidural catheter breakage at the caudal level in adults. This is why there is no standardized protocol on how to proceed in these cases, and the handling of this situation must be individualized. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal block provides good perioperative analgesia for pediatric infraumbilical surgeries but has a short duration of action after a single injection. To overcome this limitation, we evaluated the effect of magnesium sulfate added to caudal bupivacaine on postoperative analgesia in pediatric patients undergoing infraumbilical surgeries. Materials and Methods: In this prospective randomized double-blind comparative study, 60 American Society of Anesthesiologists Grade I, II children aged 1--5 years, of either gender, undergoing infraumbilical elective surgeries were randomly divided into 2 Groups (Group M [Magnesium sulfate] and Group C [control]) and received caudal block with magnesium sulfate 50 mg (upto 1 ml with saline) and 1 ml saline, respectively, added to 1 ml/kg of 0.25% bupivacaine. Hemodynamic parameters were recorded at predefined time intervals. Postoperative pain by Face, Legs, Activity, Cry and Consolability (FLACC) scale and level of sedation by Ramsay Sedation Score was assessed postoperatively. Duration of analgesia and number of rescue analgesic doses received in 24 h were recorded. Quantitative and qualitative variables were analyzed using Mann--Whitney U test, Chi-Square test, and Kruskal--Wallis test where deemed appropriate. P ≤ 0.05 was considered statistically significant. Results: The mean duration of analgesia was significantly higher in Group M with reduced requirement of rescue analgesic doses. FLACC scores were higher in control Group C at all time intervals. Patients in the magnesium group were sedated for a longer period. Both groups had comparable hemodynamic parameters throughout the study. Conclusion: Magnesium sulfate as an adjuvant to bupivacaine in caudal block prolongs the duration of analgesia with a reduction of postoperative rescue analgesic requirement in pediatric patients. [ABSTRACT FROM AUTHOR]

Background Caudal block is the most common regional anesthetic technique performed for analgesia for pediatric surgeries. The aim of this study was to evaluate dexamethasone through intravenous and caudal routes as adjuvants to caudal block for postoperative analgesia for pediatric patients who underwent lower abdominal surgeries. Patients and methods This prospective, randomized, double-blinded controlled study included 150 children who were divided into three equal groups. All patients received caudal analgesia with 0.125% hyperbaric bupivacaine 1 ml/kg. Group C received an intravenous injection of 10 ml normal saline, group D received 0.1 mg/kg dexamethasone added to the caudal analgesia, and 10 ml normal saline intravenous, while group IV received dexamethasone 0.1 mg/kg in 10 ml normal saline intravenous. The primary outcomes were the duration and severity of postoperative pain. The amount of rescue analgesic doses, residual motor block, and side effects such as nausea, vomiting, and hyperglycemia (secondary outcomes) were monitored. Results Dexamethasone groups (D, IV) showed a significantly prolonged duration of postoperative analgesia in comparison to the control group (C) and group D showed a longer duration of analgesia and delayed analgesic rescue when compared with the dexamethasone IV group. CHIPPS was the least in group D compared with group C and group IV at 3, 6, 12, and 24 h. Postoperative nausea and vomiting were significantly lower in group IV compared with the other two groups. Conclusions Dexamethasone either caudal or low-dose intravenous was effective for prolonging the duration of analgesia from caudal blockade with bupivacaine, while caudal dexamethasone was more effective. Intravenous dexamethasone had the upper hand in decreasing postoperative nausea and vomiting. [ABSTRACT FROM AUTHOR]

Background Different additives have been reported to prolong the duration of caudal anesthesia in pediatrics. Although these drugs successfully increased the duration of the block, ketamine has been found to effectively increase the duration of caudal block in pediatrics. Aim This study aimed to assess the clinical effectiveness of ketamine after caudal or intravenous administration in pediatric patients who underwent hypospadias repair to distinguish between local and systemic analgesia. Patients and methods After induction of general anesthesia 48 patients aged 1-6 years assigned to undergo hypospadias repair received a caudal injection of bupivacaine and were randomly blinded into two groups: K1 group received 1 mg/kg S-ketamine as the caudal group and K2 group received 1 mg/kg S-ketamine as the intravenous group. Postsurgical measurements included the effectiveness of postsurgical analgesia which was assessed by using observational pain scale duration of analgesia sedation score and hemodynamic and complications. Results The caudal block was successful in all the patients included in the study. None of the patients in either groups required intraoperative rescue analgesia. All patients remained vitally stable during the procedure and intraoperative hemodynamic parameters were comparable in the two groups. The time to the administration of first analgesia was statistically longer in K1 group (11.5±4.6 h) than in the K2 group (8.7±3.1 h). Time to spontaneous leg movement and time to first micturition were statistically nonsignificant between both groups. The number of patients requested for additional analgesic drugs (acetaminophen and ibuprofen) was statistically significant being higher in the K2 group than the K1 group. Conclusion This study demonstrates that ketamine if added to caudal epidural in a dose of 1 mg/kg provided prolonged postoperative analgesia with improved quality had longer duration of analgesia decreased the supplemental acetaminophen analgesia during the first 24 h postoperatively had stable hemodynamic changes and had comparable adverse effects and complications in comparison with systemic ketamine in a dose of 1 mg/kg. [ABSTRACT FROM AUTHOR]

Objective: Risk factors of cranial migration were investigated in patients with lumbar disc herniation (LDH) that migrated in the cranial direction and the long-term outcomes are discussed in this study. Materials and Methods: Patients who underwent surgery for LDH at four different centers between 2012 and 2017 were studied. Extraligamentous discs were located in the lateral part of the posterior longitudinal ligament (PLL) within the spinal canal of the axial plane, and subligamentous discs were located under the PLL. The extent of cranial migration was calculated as a percentage of the height of the migrated corpus. Based on the extent of cranial migration, partial hemilaminectomy or hemilaminectomy was performed at different rates in each patient and the amount of laminectomy performed was recorded. During surgery, all free fragments were attempted to be removed. The appropriate technique was decided intraoperatively, and the surgery was performed on an individual patient basis. Results: Of 1289 patients who underwent surgery for LDH, 654 (50.73%) had caudal migration, 576 (44.68%) had migration at the level of the disc, and 59 (4.57%) had cranial migration. Analysis of 59 patients with cranial migration according to the localization of the disc fragment revealed that 31 had extraligamentous and 28 had subligamentous fragments (P = 0.024). Conclusions: Extraligamentous intervertebral disc fragments migrate more cranially than subligamentous intervertebral fragments. The anatomy of the PLL that varies along the corpus is the main reason for the weakness of the resistance of the disc material to the dorsolateral region, direction of discrete force vectors, and orientation of the disc fragment due to torsional vertebral movements. [ABSTRACT FROM AUTHOR]

Background and Aims: Pre‑emptive analgesia using caudal epidural technique is an underutilized technique in lumbosacral spine surgery patients. We intend to study if pre‑emptive analgesia with a single caudal epidural injection of ropivacaine is an effective method of postoperative analgesia by assessing the quality and duration of pain relief and intraoperative opioid requirement. Material and Methods: Eighty patients undergoing lumbosacral spine surgeries by the posterior approach were randomized to ropivacaine (R) group (n = 40) and saline (S) group (n = 40). Patients in R group received caudal epidural injection of 20 ml of 0.2% ropivacaine for surgeries at or below L5 lumbar spine and 25 ml of 0.2% ropivacaine for surgeries between L2 and L5 lumbar spine. Patients in S group received similar amounts of normal saline. Patients were monitored in the immediate postoperative period and at 4, 8, 12, and 24 hours for pain using visual analogue scale (VAS) scale. Time to rescue analgesia and intraoperative fentanyl requirement were noted. Results: The demographics, duration of anesthesia, and hemodynamic variables were comparable in both groups. The mean intraoperative fentanyl requirement (P = 0.001) and mean VAS scores were significantly lower in the R group in the immediate postoperative period, (P < 0.001), 4 hours (P < 0.001), 8 hours (P = 0.009), 12 hours (P = 0.007), and 24 hours (P = 0.046) postoperatively. The mean time to rescue analgesia was significantly longer in the R group (P < 0.001) compared to S group. No hemodynamic or neurological side‑effects were observed in the groups. Conclusion: Pre‑emptive analgesia with caudal epidural injection of ropivacaine is a safe and effective method of postoperative analgesia. [ABSTRACT FROM AUTHOR]

Background: Desirable adjuvants to caudal ropivacaine are the one which prolongs analgesia and free of side effects. We compared nonopioid drugs dexmedetomidine, dexamethasone, and magnesium as adjuvants to ropivacaine caudal analgesia in pediatric patients undergoing infraumbilical surgeries. Materials and Methods: This study was done on 128 pediatric patients (3-12-year olds) undergoing infraumbilical surgeries; they were randomly allocated to four groups to receive normal saline, dexmedetomidine 1 μg/kg, dexamethasone 0.1 mg/kg, and magnesium sulfate 50 mg with injection ropivacaine 0.2% in the dose 0.5 ml/kg caudally. Modified Objective Pain Score and Ramsay Sedation Score, duration of analgesia, hemodynamic changes, and side effects were assessed. ANOVA test was used for numerical values as data were expressed in mean and standard deviation. Kruskal-Wallis test was used for postoperative pain and sedation score as data were expressed as median and range. Results: The demographic data and hemodynamics were comparable. There was a significant prolongation of duration of analgesia in all study groups, dexmedetomidine (406.2 ± 45.5 min), dexamethasone (450.0 ± 72.6 min), and magnesium (325.0 ± 45.8 min) as compared to ropivacaine (285.9 ± 52.7 min) group. None of the adjuvants resulted in either excess or prolonged sedation. No side effects were encountered. Conclusion: The adjuvants dexmedetomidine, dexamethasone, and magnesium added to ropivacaine prolong caudal analgesic duration without any sedation or side effect. [ABSTRACT FROM AUTHOR]

Background: The challenge in providing analgesia for spine surgeries is to provide extended postoperative pain relief and simultaneously allow early neurological assessment and mobilization. Our study aimed to evaluate the analgesic efficacy of intravenous versus caudal dexamethasone in lumbosacral spine surgeries. Materials and Methods: In this prospective double-blind study, a total of 96 patients undergoing lumbosacral spine surgery were randomized into three groups to receive 25 ml of preemptive caudal epidural injection of either injection ropivacaine 0.2% (Group A, n = 32), a 25 ml of injection ropivacaine 0.2%, and intravenous injection dexamethasone 8 mg (Group B, n = 32) or 25 ml mixture of injection ropivacaine 0.2% with injection dexamethasone 8 mg (Group C, n = 32) under general anesthesia. Visual analog scale (VAS), heart rate, blood pressures, blood sugar levels, and time to rescue analgesia were recorded at regular intervals for the first 24 h. Time to discharge was noted. Analysis of variance has been used to find the significance of study parameters between the groups of patients. Statistical software, namely, SAS 9.2 and SPSS 15.0, have been used for the analysis of the data. Results: The mean VAS was significantly lower in the Group C for up to 24 h following the caudal block. No significant hemodynamic changes were noted in any of the groups. The intravenous dexamethasone group showed higher blood glucose levels at 24 h but was not clinically relevant Conclusion: These results suggest that injection dexamethasone is a safe adjunct to caudal ropivacaine in lumbosacral spine surgeries. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal analgesia is a good, reliable, and easy method to provide intraoperative and postoperative analgesia for infra-umbilical surgeries in children. Many additives are being used in combination with local anesthetics in caudal block to prolong the postoperative analgesia (clonidine, midazolam, ketamine, fentanyl, and dexmedetomidine). The purpose of this study was to compare the intraoperative hemodynamics, postoperative analgesia, postoperative rescue analgesic requirement, postoperative sedation and side-effects of clonidine and midazolam used as adjuvants to bupivacaine for caudal analgesia. Material and Methods: Following approval from Institutional Ethical Research Committee, 75 American Society of Anesthesiologists I and II patients aged between 1 and 7 years undergoing various elective infra-umbilical surgical procedures were included in this study. The patients were randomly allocated into three groups of 25 patients each. Group B received 1 ml/kg 0.25% bupivacaine in normal saline, Group BC received 1 ml/kg 0.25% bupivacaine + 1 µg/kg clonidine in normal saline, and Group BM received 1ml/kg 0.25% bupivacaine + 30 µg/kg midazolam in normal saline. The various parameters studied were intraoperative hemodynamic changes, duration of postoperative analgesia, postoperative sedation, postoperative analgesic requirement, and incidence of side-effects. Results: All the groups were similar with respect to patient and block characteristics. The hemodynamic parameters before and after administering caudal analgesia were also comparable. The mean duration of analgesia was 724.80 ± 60.29 min in Group BC, 605.40 ± 82.37 min in Group BM and 295.00 ± 41.78 min in Group B. Thus, the duration of analgesia was significantly prolonged in Group BC compared to Groups BM and B. The FLACC pain score was higher in Group B at the end of 4th, 8th and 12th h compared with Group BC and Group BM. Furthermore at the end of 12th h, pain scores were significantly higher in Group BM compared to Group BC. Only 1 child in Group BC received three rescue medications compared to 15 (60%) children in Group B and 7 (28%) children in Group BM. None of the groups were treated for bradycardia or hypotension and no significant sedation was noted. Conclusion: This study showed that the addition of both clonidine (1 µg/kg) and midazolam (30 µg/kg) with bupivacaine administered caudally significantly increase the duration of postoperative analgesia with minimal side-effects in children. The use of clonidine as an additive to bupivacaine in caudal epidural is a superior choice to midazolam as it reduces the demand of postoperative rescue analgesics significantly. [ABSTRACT FROM AUTHOR]

Background: Multiple studies claim that caudal administration of ketamine causes effective postoperative analgesia. The aim of this study was to assess the clinical effectiveness of ketamine after caudal or topical administration in pediatric patients undergoing inguinal herniotomy. Patients and Methods: This randomized, comparative, double-blind study included eighty children (aged 6 months to 6 years) received either 1 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg for caudal analgesia (caudal group) or 0.3 ml/kg of 0.25% bupivacaine/ketamine 0.5 mg/kg sprayed by the surgeon around the spermatic cord and upon the ilioinguinal nerve before wound closure for topical analgesia (topical group). The duration of postoperative analgesia, pain scores, rescue analgesic consumption, sedation score, hemodynamic monitoring, and side-effects were evaluated 48 h postoperative. Results: Kaplan-Meier survival analysis of analgesia free time demonstrated a significant advantage of topical ketamine (TK) group over caudal ketamine (CK) group. The duration of postoperative analgesia was longer in TK group than in CK group (28.74 ± 2.88 vs. 21.43 ± 5.01 h, P = 0.000). Fewer children asked for oral analgesics in the topical group (24 of 36, 66.7%) than in the caudal one (28 of 32, 87.5%; P < 0.01). Postoperative pain scores at the 6th till 48th h were lower in topical group with comparable analgesic consumption between two groups. In the caudal group, four subjects suffered from retention of urine: Two presented with a residual motor block and two had photophobia. Conclusion: Wound instillation of bupivacaine/ketamine is a simple, noninvasive, and effective technique that could be a safe alternative to CK for postoperative analgesia in children undergoing inguinal hernia repair. [ABSTRACT FROM AUTHOR]

Context: Caudal analgesia is a reliable and an easy method to provide intraoperative and postoperative analgesia for infraumbilical surgeries in pediatric population but with the disadvantage of short duration of action after single injection. Many additives were used in combination with local anesthetics in the caudal block to prolong the postoperative analgesia. Aim: We compared the analgesic effects and side effects of dexmedetomidine added to ropivacaine in pediatric patients undergoing lower abdominal surgeries. Settings and Design: Double-blinded randomized controlled trial. Materials and Methods: Sixty patients (2-10 years) were evenly and randomly assigned into two groups in a double-blinded manner. After sevoflurane in oxygen anesthesia, each patient received a single caudal dose of ropivacaine 0.25% (1 ml/kg) combined with either dexmedetomidine 2 µg/kg in normal saline 0.5 ml, or corresponding volume of normal saline according to group assignment. Hemodynamic variables, end-tidal sevoflurane, and emergence time were monitored. Postoperative analgesia, requirement of additional analgesic, sedation, and side effects were assessed during the first 24 h. Results: The duration of postoperative analgesia was significantly longer (P = 0.001) and total consumption of rescue analgesic was significantly lower in Group RD compared with Group R (P < 0.05). Group RD have better quality of sleep and prolonged duration of sedation (P = 0.001). No significant difference was observed in the incidence of hemodynamic changes or side effects. Conclusion: Addition of dexmedetomidine to caudal ropivacaine significantly prolongs analgesia in children undergoing lower abdominal surgeries without an increase in the incidence of side effects. [ABSTRACT FROM AUTHOR]

Background: Caudal block is a reliable regional analgesic technique for pediatric urogenital surgeries. Various adjuvants have been tried to enhance the duration of action of bupivicaine. Though clonidine is extensively used as an adjuvant in caudal anaesthesia, it can have troublesome adverse effects like bradycardia, hypotension and sedation. Lately dexamethasone has become popular as an adjuvant in paediatric caudals due to its safety profile. Aim: The aim of this study was to compare dexamethasone and clonidine coadministered with bupivicaine caudally in paediatric patients undergoing urogenital surgeries in terms of analgesia and adverse effects. Settings and Design: Prospective, double blinded randomised study. Subjects and Method: Sixty American Society of Anesthesiologists physical status I and II children, aged 1-6 years undergoing urogenital surgeries were allocated in 2 groups: Group I: 0.5 mL.kg-1 of 0.25% bupivicaine with dexamethasone 0.1 mg.kg-1 in 1 ml normal saline (NS) Group II: 0.5 mL.kg-1 of 0.25% bupivicaine with clonidine 1 µg.kg-1 diluted in 1 ml normal saline. The parameters studied included duration of analgesia, intraoperative and postoperative hemodynamics, sedation scores and incidence of adverse effects like wound dehiscence, bleeding, vomiting and respiratory depression. Statistical Analysis Used: Statistical analysis was carried out using Stata Version 10. After checking for the normality assumption, t-test for comparing means of two independent samples was used for comparing baseline continuous variables. P values <0.05 were considered significant. Results: Patients in Group II had longer duration of analgesia postoperatively. Patients in this group also had lower heart rate and more sedation scores. Conclusion: Our study shows that caudal dexamethasone is a good alternative to clonidine with more stable hemodynamics and lesser sedation scores in the immediate postoperative period. Both the drugs offer good analgesia postoperatively with the duration of analgesia more in clonidine. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal block (CB) with adjuvants is routinely used in children for anaesthesia. We evaluated the efficacy of the α2 adrenergic agonist, dexmedetomidine at two different doses as an adjuvant to bupivacaine in CB. Methods: This study was conducted on ninety children. Control group BD0 received 0.25% bupivacaine 1 ml/kg, whereas, the study groups BD1 and BD2 received 1 μg/kg and 2 μg/kg dexmedetomidine, respectively, with 0.25% bupivacaine 1 ml/kg as a single shot CB. Adequacy of the block, haemodynamic changes, duration of analgesia and side effects were compared. Analysis of Variance was used for between-group comparisons of numerical variables. Student's t-test and Mann-Whitney U-test were used for quantitative data. Results: The demography was comparable. Anal sphincter 5 min after administration of the CB was relaxed in 89.3%, 82.1% and 75% of cases in BD0, BD1 and BD2 groups, respectively. The sphincter was relaxed at the end of surgery in all the cases. Comparable haemodynamics was noted with significantly prolonged duration of analgesia in the groups BD1 (964.2 ± 309 min) and BD2 (1152.6 ± 380.4 min) compared to control (444.6 ± 179.4 min). While no complications were encountered in groups BD0 and BD1, bradycardia was observed in four cases of BD2 group with accompanied hypotension in one of them. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine improves the quality of CB, provides good operating conditions and increases the duration of post-operative analgesia. We conclude that 1 μg/kg is as effective as 2 µg/kg of dexmedetomidine and with a better safety profile. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal epidural block is the most commonly used neuraxial block in children. Morphine has been used as a caudal additive for more than three decades. The aim of our study was to evaluate the efficacy and duration of analgesia of three different doses of caudal epidural morphine (CEM), and to find out the incidence of side effects. Material and Methods: This study was conducted on 75 patients of American Society of Anesthesiologists grades I and II, aged 2-12 years, undergoing lower abdominal and urogenital surgeries. Patients were randomly allocated to one of the three groups according to the dose of morphine. Group I received 30 µg/kg, group II 50 µg/kg, and group III 70 µg/kg. Heart rate, blood pressure, oxygen saturation, electrocardiogram, pain score, sedation score, duration of analgesia, and side-effects were noted. Results: The mean duration of analgesia was 8.63 h in group I, 13.36 h in group II and 19.19 h in group III. Respiratory depression was noted in three patients in group III. One patient in group I had itching. One patient each in groups I, II, and III had nausea/vomiting. Conclusion: CEM significantly prolongs the duration of analgesia, though with a higher dose the risk of respiratory depression should always be kept in mind. [ABSTRACT FROM AUTHOR]

Background: The study was conducted to evaluate the perioperative analgesic efficacy of the two doses of caudally administered tramadol versus bupivacaine in adult hemorrhoidectomy. Patients and Methods: A total of 90 patients, aged 20-50 years, undergoing hemorrhoidectomy were randomly scheduled to receive bupivacaine 0.25% in 20 ml (Group B; n = 30), tramadol 1 mg/kg in 20 ml (Group T1; n = 30), tramadol 2 mg/kg in 20 ml (Group T2; n = 30) through caudal route after induction of general anesthesia. Postoperative pain was assessed every hour until the visual analog scale was 6, which is 1st time for rescue analgesia. Postoperative sedation, hemodynamic changes, serum cortisol, and epinephrine levels and incidence of side effects were also evaluated. Results: Duration of analgesia was longer in Group T2 (20 [1.14] h] compared with the Group B (7 [1.2] h) or Group T1 (12 [0.75] h); all P < 0.001. There were no significant hemodynamic changes. There were not incidences of side effects. Conclusion: Caudal tramadol 2 mg/kg provided a longer duration of postoperative analgesia with rapid onset and no incidence of complications or adverse effects in adult hemorrhoidectomy. [ABSTRACT FROM AUTHOR]

Background: Inguinal hernia is a common disease in preterm infants necessitating surgical repair. Despite the increased risk of postoperative apnea in preterm infants, the procedure was conventionally performed under general anesthesia. Recently, regional anesthesia approaches, including spinal and caudal blocks have been proposed as safe and efficient alternative anesthesia methods in this group of patients. The current study evaluates awake caudal and spinal blocks in preterm infants undergoing inguinal hernia repair. Materials and Methods: In a randomized clinical trial, 66 neonates and infants (weight <5 kg) undergoing inguinal hernia repair were recruited in Tabriz Teaching Children Hospital during a 12-month period. They were randomly divided into two equal groups; receiving either caudal block by 1 ml/kg of 0.25% bupivacaine plus 20 µg adrenaline (group C) or spinal block by 1 mg/kg of 0.5% bupivacaine plus 20 µg adrenaline (group S). Vital signs and pain scores were documented during operation and thereafter up to 24 h after operation. Results: Decrease in heart rate and systolic blood pressure was significantly higher in group C throughout the study period (P < 0.05). The mean recovery time was significantly higher in group S (27.3 ± 5.5 min vs. 21.8 ± 9.3 min; P = 0.03). Postoperative need for analgesia was significantly more frequent in group S (75.8% vs. 36.4%; P = 0.001). Failure in anesthesia was significantly higher in group S (24.4% vs. 6.1%; P = 0.04). Conclusion: More appropriate success rate, duration of recovery and postoperative need of analgesics could contribute to caudal block being a superior anesthesia technique compared to spinal anesthesia in awaked preterm infants undergoing inguinal hernia repair. [ABSTRACT FROM AUTHOR]

Caudal epidural block is one of the most commonly performed neuraxial block techniques with reliable peri-operative and post-operative analgesia in pediatric patients. In our randomized, prospective, double-blinded, open level, parallel group study, we have established the effect of caudal epidural block on maintenance requirement of intravenous (IV) propofol in targeted bispectral (BIS) monitored patients. Context: Neuraxial anesthesia exhibits sedative properties that may reduce the requirement for general anesthesia. TIVA with propofol has been administered as an established method of maintaining general anesthesia in children. Caudal analgesia being a type of neuraxial block, also seems to reduce the requirement of sedative hypnotics in pediatric patients. Numerous studies show that for patients, administered with caudal epidural block, they require reduced intra-operative volatile inhalation anesthetics. In the present study, we have established the anesthetic sparing effect of Caudal Epidural Analgesia in children undergoing infra-umbilical surgical procedure and calculated the efficacy of propofol-infusion in maintaining adequate depth of anesthesia. Aims: (1) To study and compare the dose requirements of propofol using caudal epidural analgesia. (2) To calculate the efficacy of propofol as maintenance anesthetic agent in both groups and to compare hemodynamic stability of patients in both the techniques. Settings and Design: In our study, after administering general anesthesia to pediatric patients, we have administered caudal analgesia and IV analgesia to monitor the requirement of intra-operative propofol infusion using BIS monitor with a target value of 40-60 in both groups. Materials and Methods: 82 patients (aged between 3 and 6 years) have been selected undergoing infra-umbilical surgery and randomly allocated into two groups containing 41 patients in each group. Both the groups group B and group A then intubated with glycopyrrolate, 2 mg/kg injection fentanyl, propofol till loss of verbal contact and atracurium at the rate of 0.5 mg/kg and group B has been administered caudal epidural blockade with 1 ml/kg 0.2% ropivacaine. Propofol infusion at the rate of 10 mg/kg/h is given as maintenance. BIS value has been recorded throughout and propofol requirement at the end of surgery has been calculated. Statistical Analysis Used: Numerical variables between groups have been analyzed using the Student’s t-test and the Mann-Whitney U-test as applicable. Categorical variables have been analyzed using the Pearson’s Chi-square test. P < 0.05 is considered statistically significant. Results: Consumption of propofol at the start of operation in the group A is 2.9 ± 0.17 and group B is 2.91 ± 0.17, which is not statistically significant (P > 0.05), whereas at the end of the operation in the group A is 11.33 ± 0.17 and group B is 7.83 ± 0.63, which is statistically significant (P < 0.05). Incidence of adverse effects is statistically insignificant between the two groups. The time for administration of rescue analgesic is 2.1 ± 0.88 in group A and 6.5 ± 0.17 in group B, which is statistically significant due to caudal analgesia. Conclusions: We conclude that in BIS-monitored patients (3-6 years) with infra-umbilical surgeries have shown a reduction in consumption of IV propofol due to caudal epidural blockade. [ABSTRACT FROM AUTHOR]

Background and Aims: It is well-known that neuroendocrine stress response (NESR) occurs in children and it can be modified by caudal block. However, there is paucity of literature comparing caudal fentanyl and ketamine on NESR. The present study was aimed to compare the analgesic efficacy of these caudal adjuvants and their effect on (NESR) in children undergoing infraumbilical and perineal surgery. Materials and Methods: A total of 60 children undergoing infraumbilical surgery were included in this randomized, double-blind study. Three groups of 20 each were assigned to receive caudal block with bupivacaine 0.25% 1 ml/kg along with either 0.9% normal saline (Group I) 1 µg/kg fentanyl (Group II) or 0.5 mg/kg ketamine (Group III). Modified visual analogue scale (VAS) was used for assessment of post-operative pain, and stress response was assessed by blood glucose, serum cortisol and insulin levels at various time intervals Results: VAS scores were significantly lower in the ketamine group at all-time intervals upto 4 h (P < 0.05). Patients in ketamine group required rescue analgesia significantly later (8.23 h) when compared to fentanyl (5.95 h) and bupivacaine group (4.10 h). Caudal block led to significant decrease in cortisol and insulin levels within the groups however this significance was not achieved between groups. Conclusion: Caudal ketamine in a dose of 0.5 mg/kg provides prolonged analgesia when compared to fentanyl 1 µg/kg. Blunting of the NESR was observed in all the groups though the indicators of the response were lowest with ketamine. [ABSTRACT FROM AUTHOR]

Background: Emergence delirium (ED) although a short-lived and self-limiting phenomenon, makes a child prone to injury in the immediate postoperative period and hence is a cause of concern not only to the pediatric anesthesiologist, surgeons, and post anesthesia care unit staff but also amongst parents. Additional medication to quieten the child offsets the potential benefits of rapid emergence and delays recovery in day care settings. There is conflicting evidence of influence of analgesia and sedation following anesthesia on emergence agitation. We hypothesized that an anesthetic technique which improves analgesia and prolongs emergence time will reduce the incidence of ED. We selected ketamine as adjuvant to caudal block for this purpose. Methods: This randomized, double blind prospective study was performed in 150 premedicated children ASA I, II, aged 2 to 8 years who were randomly assigned to either group B (caudal with bupivacaine), BK (bupivacaine and ketamine), or NC (no caudal), soon after LMA placement. Recovery characteristics and complications were recorded. Results: Emergence time, duration of pain relief, and Pediatric Anesthesia Emergence Delirium (PAED) scores were significantly higher in the NC group (P<0.05). Duration of analgesia and emergence time were significantly more in group BK than groups B and NC. However, the discharge readiness was comparable between all groups. No patient in BK group required to be given any medication to treat ED. Conclusion: Emergence time as well as duration of analgesia have significant influence on incidence of emergence delirium. Ketamine, as caudal adjuvant is a promising agent to protect against ED in children, following sevoflurane anesthesia. [ABSTRACT FROM AUTHOR]

Background: Addition of clonidine to ropivacaine (0.2%) can potentially enhance analgesia without producing prolonged motor blockade. The aim of the present study was to compare the post-operative pain relieving quality of ropivacaine 0.2% and clonidine mixture to that of plain ropivacaine 0.2% following caudal administration in children. Methods: In a prospective, double-blinded, randomized controlled trial, 30 ASA 1 pediatric patients undergoing infraumbilical surgery were randomly allocated to receive a caudal injection of either plain ropivacaine 0.2% (1 ml/kg) (group A ) or a mixture of ropivacaine 0.2% (1 ml/kg) with clonidine 2 μg/kg (group B). Objective pain score and need for supplemental analgesics were compared during the 1st 24 hours postoperatively. Residual post-operative sedation and motor blockade were also assessed. Results: Significantly prolonged duration of post-operative analgesia was observed in group B (P<0.0001). Heart rate and blood pressure were not different in 2 groups. Neither motor blockade nor post-operative sedation varied significantly between the groups. Conclusion: The combination of clonidine (2 μg/kg) and ropivacaine 0.2% was associated with an improved quality of post-operative analgesia compared to plain 0.2% ropivacaine. The improved analgesic quality of the clonidine-ropivacaine mixture was achieved without causing any significant degree of post-operative sedation or prolongation of motor blockade. [ABSTRACT FROM AUTHOR]

Purpose: The objectives of this study were to compare the effects of caudal dexmedetomidine combined with ropivacaine to provide postoperative analgesia in children and also to establish its safety in the paediatric population. Methods: In a randomised, prospective, parallel group, double-blinded study, 60 children were recruited and allocated into two groups: Group RD (n=30) received 0.25% ropivacaine 1 ml/kg with dexmedetomidine 2 μg/kg, making the volume to 0.5 ml and Group R (n=30) received 0.25% ropivacaine 1 ml/kg + 0.5 ml normal saline. Induction of anaesthesia was achieved with 50% N2O and 8% sevoflurane in oxygen in spontaneous ventilation. An appropriate-sized LMA was then inserted and a caudal block performed in all patients. Behaviour during emergence was rated with a 4-point scale, sedation with Ramsay's sedation scale, and pain assessed with face, legs, activity, cry, consolability (FLACC) pain score. Results: The duration of postoperative analgesia recorded a median of 5.5 hours in Group R compared with 14.5 hours in Group RD, with a P value of <0.001. Group R patients achieved a statistically significant higher FLACC score compared with Group RD patients. The difference between the means of mean sedation score, emergence behaviour score, mean emergence time was statistically highly significant (P<0.001). The peri-operative haemodynamics were stable among both the groups. Conclusion: Caudal dexmedetomidine (2 μg/kg) with 0.25% ropivacaine (1 ml/kg) for paediatric lower abdominal surgeries achieved significant postoperative pain relief that resulted in a better quality of sleep and a prolonged duration of arousable sedation and produced less incidence of emergence agitation following sevoflurane anaesthesia. [ABSTRACT FROM AUTHOR]

Surgery and anaesthesia are known to cause stress response. Attenuation of stress response can decrease morbidity, postoperative hospital length of stay and, thus, cost. Intrathecal and epidural techniques produce reliable analgesia in patients undergoing surgery along with stress response attenuation. The present study was undertaken to evaluate the efficacy of caudal sufentanil and bupivacaine combination on perioperative stress response in paediatric patients undergoing open heart surgery. Thirty patients (ASA grade II-III) undergoing elective corrective cardiac surgery for acyanotic congenital heart disease, were randomly allocated to two groups. In group GA (n = 15), patients received balanced general anaesthesia. In group GC (n = 15), in addition to general anaesthesia, caudal block with bupivacaine and sufentanil combination was given after endotracheal intubation. Monitoring included electrocardiography, invasive arterial pressure, end-tidal carbon dioxide, pulse oximetry, arterial blood gases including serum electrolytes, blood glucose, serum cortisol, urine output, central venous pressure and temperature. Haemodynamic responses in both groups were statistically similar. Serum cortisol levels were significantly lower in GC group than GA group (P < 0.05) after sternotomy (9.8±7.5 vs. 34.74±27.35), on cardiopulmonary bypass (CPB) (12.17 ± 6.2 vs. 35.36 ± 24.15), after sternal closure (14.03 ± 5.1 vs. 37.62 ± 20.69), 4 hours (26.64 ± 14.61 vs. 37.62 ± 9.13) and 24 hours (14.30 ± 8.11 vs. 28.12 ± 16.31) after intubation. Blood glucose levels were significantly higher in GA group as compared to GC group at sternal closure (277.46 ± 77.25 vs.197.73 ± 42.17) and 4 hours (255.26 ± 73.73 vs. 185.26 ± 57.41) after intubation (P < 0.05). To conclude, supplementation of caudal epidural bupivacaine and sufentanil could effectively attenuate the stress response in paediatric patients undergoing cardiac surgery under CPB in acyanotic congenital heart anomaly. [ABSTRACT FROM AUTHOR]

Context: Neostigmine extends the duration of analgesia produced by caudal bupivacaine in children. Aims: To study the effect of different doses of caudal neostigmine on the duration of postoperative analgesia. Settings and Design: A randomized, double-blind study was conducted in 120 boys aged 1-12 years undergoing urethroplasty under combined general and caudal anesthesia. Materials and Methods: Children were administered 1.875 mg/kg bupivacaine alone (Group B), or with 2, 3 or 4 μg/kg of neostigmine (groups BN2, BN3 or BN4 respectively) as caudal drug (0.75 ml/kg). Children with a pain score of 4 or more (OPS and NRS) postoperatively were administered rescue analgesic. Time to first analgesic and the number of analgesic doses administered in the 24h were recorded. Statistical Analysis: Parametric data were analyzed using ANOVA. Kaplan-Meier survival curves for the time to first analgesic administration were plotted and compared using log rank analysis. Chi-square test was used to analyze the incidence data. Results: The median [IQR] time to first analgesic in Group B (540 [240–1441] min) was similar to that in Groups BN2 (450 [240–720]), BN3 (600 [360–1020]) and BN4 (990 [420-1441]). Significantly more patients in Groups B (9 [34.6%]) and BN4 (13 [44.8%]) required no supplemental analgesic for 24h than those in Groups BN2 and BN3 (4 [13.8%] and 4 [13.3%]). The number of analgesic doses required in 24h in the four groups was similar. Conclusion: Addition of neostigmine to 1.875 mg/kg of caudal bupivacaine did not prolong the analgesia following urethroplasty in children. [ABSTRACT FROM AUTHOR]