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Laryngomalacia is the most common cause of stridor in newborns. Pediatric difficult airway is a major challenge for anesthetists and one of the main causes of perioperative respiratory complications. In order to prevent respiratory complications of general anesthesia, especially apnea, in newborns, regional anesthesia techniques such as caudal or spinal anesthesia may be preferred. Caudal anesthesia can be used as the sole anesthesia method, especially for subumbilical surgeries, or as an adjunct to general anesthesia and is an effective way to provide perioperative analgesia. In this article, we presented our experience with caudal anesthesia for bilateral inguinal hernia surgery in a newborn with laryngomalacia. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of caudal block and penile block methods, in patients who underwent circumcision surgery in preventing postoperative pain. Materials and Methods: Patients who underwent elective circumcision surgery between January 2019 and May 2022 were retrospectively evaluated. After the exclusion criteria, 56 patients were included in the study. They were divided into two groups as penile block (group P, n=31) and caudal block (group C, n=25). Anesthesia technique applied, anesthesia duration, postoperative first micturition time, postoperative complications, time of first analgesia, analgesia need in the first six hours, observer pain score and Modified Pediatric Objective Pain Scale scores (MPOPS) were scanned. Results: When the first micturition time in the postoperative period was compared, it was found that group P took a significantly shorter time than group C (p=0.001). It was determined that group C needed analgesia in a shorter time than group P (p=0.028). When the MPOPS at 30th min (p=0.031), 90th min (p=0.043) and 6th hour (p=0.016) were compared, group C higher scores than group P. Conclusion: As a result, both methods can be used effectively and safely for appropriate pain control in patients who will undergo circumcision surgery. Both methods have advantages and disadvantages over each other. The choice of methods may vary with the experience of the surgeon and anesthetist.

Purpose: The evaluation of postoperative pain in pediatrics is a true challenge. We aimed to evaluate the immediate postoperative pain management using FLACC (Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain Scale) scale after caudal block. Material and Methods: The anesthesia records of children aged 0-8 years who underwent caudal block under general anesthesia prior to surgery were evaluated. The intraoperative and postoperative use of opioids were obtained, as well as, the FLACC scores. Results: Seventy-eight children were included and evaluated in two groups according to ages of 1-24 (n=37) and 24-96 months (n=41). Intraoperative requirement for opioid was observed in 7.7% (n=6) of patients. Nine patients (11.5%) required fentanyl in the immediate postoperative period with FLACC ≥4. Only 1 patient required opioids both intraoperatively and in the immediate postoperative period, suggesting a success rate of 98.7%. The patients were observed to receive single dose opioid, despite FLACC ≥4 in the following postoperative 1st, 2nd and 3rd hours. The subgroups of age were similar in terms of FLACC scores and the changes in these scores within the postoperative 3 hours. There were no urinary retention or motor block. However, paresthesia was recorded in 4 patients at age of 24-96 months, whereas, in none of the patients at age of 1-24 months. The uncomfortable numbness, which could not be described at age of 1-24 months may have caused the difference, as well as, leading to high FLACC scores without any opioid use. Conclusion: Our study supported that anesthetists consider FLACC scale as a part of pain assessment to administer opioid, not as a sole indicator. [ABSTRACT FROM AUTHOR]

Perioperative care of neonates/infants is a great challenge for anesthesiologists, regardless of the type of anesthesia chosen. Furthermore, providing regional anesthesia techniques as "surgical anesthesia" in this population is even more difficult. In this review, the merits and demerits of all available techniques of central neuraxial blocks (CNBs) are discussed in detail, and their recent advances are discussed. The "research gaps" on this topic are also highlighted. The author hopes it would be a valuable addition to the literature and lead to further research on this potential topic. [ABSTRACT FROM AUTHOR]

Introduction Necrotizing enterocolitis (NEC) is one of the most common serious acquired diseases of the gastrointestinal tract, both in full-term and premature infants, and is associated with a high risk of complications and high mortality. Anesthetic management for necrotizing enterocolitis in newborns during surgery is a complex task and is still relevant. Purpose of the study: Optimization of anesthesia during surgery in newborns for necrotizing enterocolitis. Material and methods The study was carried out at the Research Institute of Pediatrics named after. K. Farajeva. The paper presents the results of treatment of 118 patients based on the assessment of clinical indicators of preoperative preparation, anesthesiological care, and the study of central hemodynamics in newborns operated on for necrotizing enterocolitis. Newborns were divided into 2 groups depending on the method of anesthesia used: group I with general anesthesia and group II with general anesthesia using caudal anesthesia. Results Results showed that effective interruption of nociceptive impulses from the surgical site through caudal blockade and sufficient sedation can prevent pronounced activation of the body's neurohumoral reactions to surgical stress under conditions of balanced regional anesthesia, and it was also revealed that the modern muscle relaxant rocuronium bromide allows the concept of multicomponent anesthesia to be implemented, causing complete relaxation of the striated muscles during surgery, which helps to effectively block pathological reactions in response to surgical stress. [ABSTRACT FROM AUTHOR]

Background According to previous research, 20% of infants experience prolonged postsurgical pain 6–12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries. Methods Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia. Results The FLACC score 2 h post¬operatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups. Conclusions The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery.

Background: According to previous research, 20% of infants experience prolonged postsurgical pain 6-12 months after major surgery, which is linked to functional impairment and a lower quality of life. The aim of our study is to evaluate whether the analgesic effect of the erector spinae plane block (ESPB) is superior to that of caudal epidural anesthesia (CEA) in pediatric patients undergoing hip or proximal femoral surgeries. Methods: Seventy-six children ranging in age from 1 to 7 years scheduled for hip or proximal femur surgery were randomly assigned to receive either a unilateral ultrasound-guided ESPB or CEA with bupivacaine 0.25% at a dose of 0.5 ml/kg. The primary outcome was the Face, Legs, Activity, Cry, and Consolability (FLACC) scale 2 h postoperatively. The secondary outcomes were pain scores every 15 min for the first hour and then at 6, 12, and 24 h postoperatively; the block failure rate; time to perform a successful block; and time to first rescue analgesia. Results: The FLACC score 2 h postoperatively was not superior in the ESPB group compared to the CEA group; indeed, it was significantly higher in the ESPB group at 15 and 30 min post-operation (P = 0.005, 0.004, respectively). Additionally, the time to first rescue analgesia was prolonged in the CEA group (P < 0.001). The time to perform a successful block was comparable between the groups. Conclusions: The analgesic effect of the ESPB was not superior to that of CEA in pediatric patients undergoing hip and proximal femur surgery. [ABSTRACT FROM AUTHOR]

Anorectal malformations are among the most common congenital malformations in children, occurring at a fre- quency of 2-5 per 10,000 births. Surgical correction for anorectal malformations is a significant operation, ac- companied by severe pain. Of the 35 children included in the study, 10 children were assigned to group I (general anesthesia) and 25 children to group II (general anesthesia + caudal block). Hemodynamic parameters during surgery in the group of general anesthesia + caudal block were more stable than in group I (general anesthesia). There was no significant difference in the incidence of side effects (including laryngospasm, restlessness, nausea and vomiting) be- tween the two groups I (33%) vs II (24.2%,). When as- sessing postoperative pain using the FLACC scale, it was found that in the group of general anesthesia + caudal block, pain appeared only 6 hours after surgery than in the group of general anesthesia (1 hour after surgery), but there were significant differences between the two groups after 12 and 24 hours after the operation was absent. General anesthesia in combination with a caudal block is an effective, safe method of anesthesia for complex sur- gical interventions for anorectal malformations in new- borns and young children. This technique allows to reduce the duration of the operation and improves the postoperative period.

Pediatric inguinal hernia repair (IHR) is increasingly performed using minimally invasive surgery (MIS) but has only recently been described using caudal block without endotracheal intubation. We evaluated the surgical outcomes and resource utilization of infants undergoing hernia repair, comparing both the operative approach (open/MIS) and anesthetic technique (general anesthesia [GA]/caudal). All infants <1 year-of-age undergoing elective IHR without concomitant procedures from July 2016 to July 2021 at a single tertiary care teaching center were retrospectively reviewed. Eight surgeons and 25 anesthesiologists contributed patients, with approach dictated by practitioner preference. Data collected included patient demographics, surgical and anesthetic details, and operating room (OR) utilization metrics. Post-operative complications were evaluated and aggregated, including recurrent hernia, metachronous hernia, hematoma, hydrocele, testicular atrophy, and acquired cryptorchidism. Descriptive statistics were performed with R Studios (p < 0.05). Of the 338 patients included for analysis, most underwent an open procedure (n = 275) while anesthetic technique was evenly split between GA (n = 185) and caudal (n = 153). Most patients were male (87.6%) and born premature: mean gestational age of 31.4 ± 4.1 weeks. MIS-to-Open conversion was noted once (3.3%) in the GA MIS group, but none in caudal. Median follow up was 2.5 (1.4–3.8) years. No differences were noted in aggregate surgical complication rates (p = 0.4). The Caudal Open group had the shortest total OR time (p < 0.01); caudal anesthesia shortened post-procedure times (p < 0.01). MIS IHR performed under caudal block and sedation yields comparable complication rates compared to the open approach or GA. Open IHR with caudal blockade was the most efficient operative room utilization. Original Article, Clinical Research. Level III. • Variation exists in the surgical and anesthetic approach for inguinal hernia repair in infants. • Laparoscopy with caudal blockade is a safe and effective option. • Open surgery with caudal blockade is the most resource-efficient option. [ABSTRACT FROM AUTHOR]

Objectives: To compare the post-operative pain relief with Bupivacaine and Ropivacaine for caudal block in children in terms of mean duration of analgesia. Study design: Prospective comparative study. Place and duration: Department of Anesthesia, Combined Military Hospital Rawlakot from July 2021 till June 2022. Methodology: A total of 100 patients undergoing infra-umbilical Surgery as circumcision, herniotomy, orchidopexy and of age 1 to 10 years were included. After induction of general anesthesia, caudal block was given. Group B patients were given 1 ml/kg of 0.25% bupivacaine whereas group R patients were given 1 ml/kg of 0.25% ropivacaine. Modified Hnnallah Pain Score was used to observe the post-operative analgesic effects of the block. Score was noted every 30 minutes. Pain free duration was considered from time of caudal block till the modified Hannallah pain score of 4 or more. Injectable paracetamol 10 mg/kg was given as rescue analgesia as required. Results: Demographic data was comparable in both groups with no statistical significance. In our study, we have found duration of analgesia as 219.78 ± 35.42 minutes in the bupivacaine group compared with 198.24 ± 34.5 minutes in patients with ropivacaine group with p-value of 0.54 which is statistically significant. Conclusion: In this study, we concluded that the ropivacaine is as effective as bupivacaine in terms of post-operative pain relief for caudal block in children.

Airway and spine involvement in ankylosing spondylitis (AS) impose unique anesthetic challenges. Ankylosis and intervertebral space obliteration in AS make neuraxial anesthesia technically challenging and sometimes impossible. The anatomical variations of impalpable sacral cornu and complete or partially closed sacral hiatus in adults coupled with positioning difficulties, epidural space narrowing as well as an increased predilection for intraosseous or intravascular injection, and cauda equina syndrome complicate caudal anesthesia in AS. Combined ultrasound and fluoroscopic (ultrafluoro) guidance during caudal anesthesia improves accessibility and identifies and avoids any aberrant nonepidural injection. By providing a fluoroanatomical endpoint, i.e., local anesthetic (LA) contrast washout covering the concordant dermatomes, it reduces the amount of LA required and pressure build-up in already compromised epidural space. Ultrafluoro guidance improves accessibility, identifies, and avoids any nonepidural injection, and reduces the amount of LA required during caudal anesthesia in AS.

Anorectal abnormalities are among the most common congenital malformations in children requiring emergency surgical interventions.The objective is to analyze existing domestic and foreign publications on the features of anesthesia in anorectal abnormalities in children.Subjects and Methods. The search for publications was carried out in the abstract bases of Russian Scientific Citation Index, PubMed and Scopus according to the key words: anorectal abnormalities, anesthesia, regional anesthesia, children. 105 publications were found, 49 studies were selected for analysis.Results. For the purpose of anesthesia, both general and regional anesthesia are used to correct anorectal anomalies. Among regional techniques, spinal and caudal anesthesia is most often used. The most effective anesthesia option for anorectal surgery is saddle anesthesia since it is accompanied by a significant decrease in the tone of the anal sphincter. Combined use of general anesthesia and caudal analgesia contributes to the reduction of intraoperative blood loss and early restoration of bowel functions.Conclusion. Further research is needed to establish rapid post-operative recovery protocols for anorectal malformations in children.

Introduction Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants. Methods Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications. Results A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant). Conclusion This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration. [ABSTRACT FROM AUTHOR]

Background and Aims: Caudal epidural block is one of the most popular, reliable, and safe techniques in pediatric analgesia that can be used with general anesthesia for intra and postoperative analgesia in patients undergoing infraumbilical surgeries. The aim of this study was to compare ropivacaine 0.25% versus levobupivacaine 0.25% with dexamethasone in caudal block for duration of analgesia. Methodology: Hundred patients, aged 6 months to 6 years of ASA physical status I and II were randomly allocated in two groups in this prospective randomized double-blind study. Group RD (n = 50) received caudal 0.25% ropivacaine 1 ml/kg + dexamethasone 0.1 mg/kg, while Group LD (n = 50) received 0.25% levobupivacaine 1 ml/kg + dexamethasone 0.1 mg/kg in caudal block. The duration of analgesia, total number of doses of rescue analgesia consumed in 24 h, hemodynamics, and side effects were noted. Results: Duration of analgesia was 584.42 ± 84.21 min in group RD and 602.84 ± 85.48 min in group LD, which was not significant (P-value = 0.280). No significant difference was found for total number of doses of rescue analgesic consumption in 24 hours in both groups (P-value = 0.481). Both groups were comparable with respect to hemodynamics and side effects (P-value > 0.05). Conclusion: Addition of dexamethasone 0.1 mg/kg with ropivacaine 0.25% and levobupivacaine 0.25% for caudal block in pediatric patients having a similar clinical profile in both groups prolongs the duration of analgesia and decreases the analgesic consumption in 24 hours with stable hemodynamics and minimal side effects. [ABSTRACT FROM AUTHOR]

Background Subanesthetic intravenous (IV) ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain; however, its effectiveness in children is understudied. The primary aim of this study was to evaluate the non-inferiority of subanesthetic IV ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgery. Methods Children aged < 6 years were enrolled in this single-blind study and randomized to receive either subanesthetic IV ketamine (0.3 mg/kg) or caudal 0.125% bupivacaine (1 ml/kg) along with general anesthesia. Postoperative pain was assessed using the FLACC scale at 30 minutes and 1, 2, 3, and 6 h post-operation. Intra- and postoperative opioid consumption, time to extubation, postoperative vomiting, agitation, sedation, and inflammatory markers were also assessed. Results Altogether, 141 children completed the study (ketamine group: n = 71, caudal group: n = 70) The cumulative proportion of children without significant postoperative pain (FLACC score < 4) in the first 6 h post-surgery was 45.1% in the ketamine group vs. 72.9% in the caudal group (P < 0.001). More children in the ketamine group required an additional dose of intraoperative fentanyl (33.8% vs. 5.7%, P < 0.001) and postoperative tramadol (54.9% vs. 27.1%, P < 0.001). However, postoperative agitation, sedation, and other secondary outcomes were similar between the groups. Conclusions Subanesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children aged < 6 years undergoing infra-umbilical surgeries; however, other postoperative outcomes are similar.

Objective: To compare levobupivacaine based caudal epidural anesthesia and spinal anesthesia in terms of Intraoperative hemodynamic changes and postoperative pain and patient comfort in subjects undergoing perianal surgery in outpatient setting. Material and methods: All consecutive patients who were scheduled for perianal surgery. The difference in intraoperative hemodynamic changes, sensory and motor block level, postoperative pain and patient comfort was the primary outcome measure of this study. Results: There were no significant differences between the groups in terms of mean arterial pressure and heart rate recorded. Subjects randomized to spinal anesthesia had a significantl extensive motor and sensory block compared to those randomized to caudal epidural anesthesia. Visual analogue scale scores for surgical pain at postoperative 12 hours was significantly higher in subjects receiving spinal anesthesia compared to those receiving caudal epidural anesthesia (p< 0.05). Time to first analgesic administration was significantly lower in subjects randomized to spinal anesthesia compared to those receiving caudal epidural anesthesia (p< 0.01). Conclusion: Spinal anesthesia is associated with more extensive sensory and motor block compared to caudal epidural anesthesia in patients undergoing perianal surgery. Both techniques lead to similar hemodynamic changes. Postoperative pain control is more favorable with caudal block than the spinal anesthesia.

Background: Caudal epidural block (CEB) is a commonly performed neuraxial block to provide effective pain relief and analgesia in pediatric patients undergoing infraumbilical surgery. Aims: This study aimed to compare the effectiveness of adding CEB to general anesthesia (GA) in terms of intra- and postoperative pain management. Design: Prospective, randomized case-controlled trial study. Setting: Operation theater, and postoperative recovery rooms at Salmaniya Medical Complex, Bahrain. Materials and Methods: A total of 74 patients aged 2 months to 6 years with American Society of Anesthesiologists physical status classification I were recruited over a 6-month period between December 2019 and May 2020. Patients were allocated into two groups (Group A, with CEB) or (Group B, without CEB). Both groups were compared based on hemodynamic stability, pain scores, level of sedation, analgesia need, and parental satisfaction. Statistical Analysis: Data were analyzed using SPSS program. Categorical and numerical variables of both the groups were compared. Results: Patients with CEB had better hemodynamic stability during the surgical procedure based on heart rate (P = 0.039). Pain intensity scores were less in patients with CEB than those without (P < 0.001). Fentanyl consumption was lower in Group A compared to Group B at the end of surgery (P = 0.002). They were also ambulated earlier and discharged sooner than those without CEB. Parental satisfaction was 92.1% in Group A compared to 63.9% in Group B (P = 0.012). Conclusions: Adding CEB to GA for intraoperative and perioperative pain control in pediatric patients undergoing infraumbilical surgery makes it more effective, safe, and with better parental satisfaction. [ABSTRACT FROM AUTHOR]

Background: Subanesthetic intravenous (IV) ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain; however, its effectiveness in children is understudied. The primary aim of this study was to evaluate the non-inferiority of subanesthetic IV ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgery. Methods: Children aged < 6 years were enrolled in this single-blind study and randomized to receive either subanesthetic IV ketamine (0.3 mg/kg) or caudal 0.125% bupivacaine (1 ml/kg) along with general anesthesia. Postoperative pain was assessed using the FLACC scale at 30 minutes and 1, 2, 3, and 6 h post-operation. Intra- and postoperative opioid consumption, time to extubation, postoperative vomiting, agitation, sedation, and inflammatory markers were also assessed. Results: Altogether, 141 children completed the study (ketamine group: n = 71, caudal group: n = 70) The cumulative proportion of children without significant postoperative pain (FLACC score < 4) in the first 6 h post-surgery was 45.1% in the ketamine group vs. 72.9% in the caudal group (P < 0.001). More children in the ketamine group required an additional dose of intraoperative fentanyl (33.8% vs. 5.7%, P < 0.001) and postoperative tramadol (54.9% vs. 27.1%, P < 0.001). However, postoperative agitation, sedation, and other secondary outcomes were similar between the groups. Conclusions: Subanesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children aged < 6 years undergoing infra-umbilical surgeries; however, other postoperative outcomes are similar. [ABSTRACT FROM AUTHOR]

Background and Aims: Emergence agitation (EA) is an unpleasant problem encountered in children following anesthesia with Sevoflurane. We studied the effectiveness of caudal epidural block (CEB) with ropivacaine 0.2% and clonidine two microgram per kilogram (mcg/kg) on the incidence of EA, with respiratory depression and hemodynamic variables as secondary end points. Material and Methods: Ninety children aged one to eight years undergoing infra umbilical surgeries were randomly allocated into two groups: Group RS: Ropivacaine 0.2% one ml/kg + Saline one ml and Group RC: Ropivacaine 0.2% one ml/ kg + Clonidine two mcg/kg made to one ml. They were then administered general anesthesia with endotracheal intubation followed by CEB using test drugs. Post surgery, EA was evaluated by Modified Richmond Agitation Scale at 15‑minute intervals for one hour. The results were then analyzed using mean and standard deviation (SD), Chi square test, and Independent t test. Results: EA was significantly lower in group RC when compared to group RS (P < 0.0001).Group RC had 12 (28.5%) children with EA at 15 minutes compared to 35 (83.3%) children in Group RS. At 30 minutes, it was seen in five (11.3%) and 27 (64.2%) children in group RC and RS, respectively. No significant respiratory depression was noted in both groups. A significant decrease in heart rate was seen in Group RC (P < 0.001) but was not significant clinically. No adverse events were recorded in both the groups. Conclusion: Addition of clonidine (2mcg/kg) to ropivacaine 0.2% offers an advantage over 0.2% ropivacaine alone in decreasing the incidence of sevoflurane induced EA in children undergoing lower abdominal surgery without any adverse effects. [ABSTRACT FROM AUTHOR]

Airway and spine involvement in ankylosing spondylitis (AS) impose unique anesthetic challenges. Ankylosis and intervertebral space obliteration in AS make neuraxial anesthesia technically challenging and sometimes impossible. The anatomical variations of impalpable sacral cornu and complete or partially closed sacral hiatus in adults coupled with positioning difficulties, epidural space narrowing as well as an increased predilection for intraosseous or intravascular injection, and cauda equina syndrome complicate caudal anesthesia in AS. Combined ultrasound and fluoroscopic (ultrafluoro) guidance during caudal anesthesia improves accessibility and identifies and avoids any aberrant nonepidural injection. By providing a fluoroanatomical endpoint, i.e., local anesthetic (LA) contrast washout covering the concordant dermatomes, it reduces the amount of LA required and pressure build-up in already compromised epidural space. Ultrafluoro guidance improves accessibility, identifies, and avoids any nonepidural injection, and reduces the amount of LA required during caudal anesthesia in AS. [ABSTRACT FROM AUTHOR]

Objectives: To assess the frequency of pain relief, using FLACC scores, in pediatric patients undergoing thoracotomy for congenital heart diseases with caudal anesthesia. Study design: Descriptive study Setting: Department of Anesthesiology, National institute of Cardiovascular Diseases, Karachi Study duration: 26th August 2019 to 25th February 2020. Materials & Methods: A total of 74 patients undergoing Thoracotomy for Congenital Heart Diseases and of age 6 months-6 years were included. Patients with bleeding disorders and skin lesion at site of needle insertion were excluded. Anesthesia fitness was obtained and a local anesthetic injection (Bupivicaine; dosage 1.5ml/kg) was injected in to the caudal canal. Thoracotomy and surgery was performed by pediatric surgeon with minimum experience of five years. Patients were kept under observation and Face, Legs, Activity, Cry, Consolability (FLACC) score was evaluated and noted after six hours of the surgery by principal investigator. We administered our rescue analgesia in form of Nalbuphine if pain intensity found to be moderate to severe on FLACC scale. Results: Age range in this study was from 6 months to 6 years with mean age of 3.34 ± 1.51 years. Majority of the females i.e. 43 (58.11%) were between 6 months to 3 years of age. Out of these 74 patients, 45 (60.81%) were male and 29 (39.19%) were females with male to female ratio of 1.6:1. In my study, frequency of pain relief, using FLACC scores was found in 65 (87.84%) pediatric patients undergoing thoracotomy for congenital heart diseases with caudal anesthesia. Conclusion: This study concluded that the frequency of pain relief, using FLACC scores, in pediatric patients undergoing thoracotomy for congenital heart diseases with caudal anesthesia is very high. [ABSTRACT FROM AUTHOR]

Context: Pediatric pain management is always a challenge for the anesthesiologist as surgery and pain inflicted at a young age has a bearing on the response to pain in the future. Aims: The aim of the study was to compare the different regional anesthesia techniques adopted for the postoperative pain relief in children aged between 6 months and 6 years who underwent open pyeloplasty. Settings and Design: It was a retrospective study. Materials and Methods: Children were divided into three groups: caudal group (n = 18), epidural group (n = 23), and transversus abdominis plane (TAP) group (n = 32) based on the regional anesthesia technique used. The primary outcome measured was total duration of postoperative analgesia. The secondary outcomes measured were median Face, Legs, Activity, Cry, Consolability (FLACC) score, intraoperative and postoperative heart rate, and mean arterial pressure along with incidence of any complication. Statistical Analysis Used: One-way ANOVA and Kruskal–Wallis test were applied for comparison between the three groups. Results: Postoperative analgesia duration in minutes was highest in the epidural group (1117.3 ± 112.2), followed by TAP group (1070.0 ± 109.3) and caudal group (261.5 ± 18.2). Median FLACC pain scores achieved at 12 and 24 h were least in the epidural group, followed by the TAP and caudal groups. Conclusions: Epidural analgesia is best suited in terms of the duration as well as the quality of postoperative analgesia is concerned, but surgeon-assisted TAP block looks promising and a feasible option with comparable postoperative analgesia quality and duration.

The wide implementation of different regional anesthesia techniques is also actual in pediatric anesthesiology. Using modern methods of regional anesthesia (RA) and modern local anesthetics is a new level in development of pediatric anesthesiology. This article is about advantages of regional pediatric anesthesia in intra- and post-surgery pain management and analgesia. We analyse the techniques of spinal and epidural anesthesia, as well as their varieties such as unipolar spinal block and caudal anesthesia, compare their advantages and disadvantages. Some more techniques such as paravertebral block, TAP-block are considered as an alternative to epidural anesthesia. Methods and possibilities of ilioinguinal, iliohypogastric and TAP-blocks are also mentioned here. The use of the above-mentioned methods allows to reduce the use of narcotic analgesics and hypnotics and, as a consequence, reduces their systemic effects on the child’s body. These methods are safer for use, since they allow you to plan a safe anesthetic for each child and minimize complications.

Inguinal hernia is more common in premature male babies. Using General Anesthesia (GA) for the repair operation may cause apnea in them. Caudal anesthesia on the other hand provides effective anesthesia and analgesia without the complication of GA. Here we discuss different methods of anesthesia in inguinal herniorrhaphy and their merits and downfalls.

Background Pain experienced after abdominal surgery is derived from abdominal wall incision. Transversus abdominis plane (TAP) block is a novel approach for blocking abdominal wall neural afferents. Aim of study To evaluate the analgesic effects of ultrasound-guided TAP block and caudal block in lower abdominal surgeries in pediatrics compared with general anesthesia (GA). Patients and methods This prospective, randomized, controlled, single-blinded study was conducted on 60 pediatric patients of the American Society of Anesthesiologists physical status I and II, aged 2–6 years. Patients were randomized into three equal groups. Groups I and II received ultrasound-guided TAP and caudal block, respectively, whereas group III received GA and opioid analgesia. The primary outcome was intraoperative analgesic effects manifested by changes in hemodynamics and catecholamines. Secondary outcomes included postoperative analgesia and complications. Results There was a highly significant decrease in heart rate 5 min after skin incision in both TAP and caudal groups compared with the GA group. However, there were nonsignificant differences between groups as regards systolic and diastolic blood pressures at baseline and 5 min after skin incision. There was a highly significant decrease in both norepinephrine and epinephrine in TAP and caudal groups compared with the GA group at 5 min after skin incision. Similar findings were reported 60 min after recovery. Postoperatively, Face, Legs, Activity, Cry, Consolability values were significantly higher in the caudal group compared with the GA and TAP groups. The side effects were statistically higher in the GA group. Till 12 postoperative hours the patients who received the TAP block did not require analgesic medication compared to the seven patients who received the caudal block. Patients who received GA significantly required analgesia after 4 h postoperatively. Conclusion Ultrasound-guided TAP block is a good option for providing intra- and postoperative analgesia with no side effects in children undergoing lower abdominal surgeries.

Abstract Pregnancy in Ebstein anomaly could cause acute decompensated heart failure. Therefore, medical termination of pregnancy is the next course of action in such cases. We present a case of 25-year-old primigravida with Ebstein anomaly posted for termination of pregnancy at 8 weeks of gestation. The patient had dyspnea on minimal exertion with a recent episode of upper respiratory tract infection. Caudal epidural in place of lumbar epidural or general anesthesia was chosen in view of the recent episode of respiratory infection and minimal hemodynamic changes and early recovery of motor blockade associated with the former. Pregnancy was terminated successfully with minimal intraoperative hemodynamics variation. Hence, for minor gynecological procedure like termination of pregnancy, caudal epidural anesthesia provides an alternative option especially in cases where hemodynamic variation is least desired like decompensating congenital heart condition.

Anticipated difficult endotracheal intubation and impossibility of conventional methods of neuraxial blocks in Ankylosing Spondylitis (AS) led to our search for an alternative technique of regional anesthesia for total hip replacement surgery in such a patient. The approach undertaken was, after infiltration of the area with a local anesthetic drug, an orthopedic surgeon drilled the posterior wall of sacral hiatus and surgically created a small opening on it. A nerve stimulator needle was then introduced through this opening to get muscle twitches of the great toe, which helped in identification of the sacral epidural space. 30 ml of 0.5% injection ropivacaine was then deposited in this extradural space. Motor and sensory blocks developed within 10 minutes. The novel approach of surgically assisted drilling of the posterior wall of sacral hiatus may be established as an alternative approach to the classical caudal anesthesia when other alternatives fail.

Background: Caudal epidural anesthesia is a common technique providing intra and postoperative analgesia in pediatric infraumbilical surgical procedures. Objectives: The aim of this study was to compare the effect of adding Dexmedetomidine or Magnesium Sulfate as an adjuvant to Bupivacaine for caudal anesthesia in pediatric infraumbilical surgeries. Patients and Methods: This randomized controlled prospective study was done at Sohag University Hospital on sixty pediatric patients with American Society of Anesthesiologists (ASA) Classes I or II or III, weighted up to 20 kg scheduled for infraumbilical surgeries using caudal block in the period between January 2019 and January 2020. The included subjects were divided into three groups, twenty patients each: Group C (control), Group D (Dexmedetomidine group) and Group M (Magnesium group). Results: In our study, the caudal block mainly used to relieve pain after Sevoflurane anesthesia with less incidence of emergence agitation. On comparing (Group D) and (Group M), Face, Legs, Activity, Cry, Consolability scale (FLACC) score was lower in (Group D: 0,1,1,2) than (Group M: 1,1,2,2) without significant difference at postoperative set times (30 minutes, 1,2,3 hours), respectively. At the 6th hour postoperatively, (Group M) patients achieved higher FLACC scores (3) compared with (Group D) patients (2.5) with statistically significant difference with P value of 0.05. During the first 3 hours post-operative, there were higher sedation scores in (Group D: 4,4,3,3) and (Group M: 4,4,3,2.5) more than (Control group: 3,2.5,2,2) with highly statistical significant difference with (P value < 0.001) at (30 minutes,1h, 2h, 3 hours), respectively. At the 6th hour postoperatively, there were higher sedation scores with (Group D) (3) more than (Group M) (2) with highly statistical significant difference with (P value < 0.001). Conclusion: Administration of Dexmedetomidine as adjuvant with Bupivacaine enhances caudal block, prolongs duration of postoperative analgesia, reduces postoperative EA and provides preferred postoperative sedation in pediatric patient undergoing infraumbilical surgeries with minimum adverse effects compared to Magnesium Sulfate as adjuvant. [ABSTRACT FROM AUTHOR]

Background: Caudal anesthesia has emerged as a reliable and effective anesthetic technique in the pediatric age group. However, the limited duration of action of the local anesthetic drugs proves to one of the major hindrances in the complete utilization of caudal block as an effective analgesic technique. To overcome this shortcoming, adjuvant drugs were introduced into clinical practice. Aim: Our aim was to determine which of the two drugs – dexamethasone and tramadol – serves as a better adjuvant for caudal analgesia in pediatric patients. Settings and Design: This was a prospective, randomized, double-blind study that comprised 90 American Society of Anesthesiologist (ASA) physical status I and II pediatric patients posted for lower abdominal surgeries. Materials and Methods: Ninety ASA physical status I and II children aged 5–12 years posted for lower abdominal surgeries were chosen. They were randomly divided into three groups – Group R received 0.5 ml.kg−1 of 0.2% ropivacaine plus 0.9% normal saline; Group T received 0.5 ml.kg−1 of 0.2% ropivacaine plus 2 mg.kg−1 tramadol; and Group D received 0.5 ml.kg−1 of 0.2% ropivacaine plus 0.1 mg.kg−1 dexamethasone. Postoperative pain was assessed using a modified objective pain score and time to first rescue analgesia (duration of sensory block) was recorded. Postoperative sedation and any other postoperative adverse effects were noted. Statistical Analysis: Student's independent t-test was employed for comparing continuous variables and Chi-square test for categorical variables. Kruskal–Wallis test was used for postoperative pain and sedation score data. Results: The duration of sensory block was significantly longer with dexamethasone than tramadol. No significant postoperative sedation or any other adverse effect was noted in any patient. Conclusion: Dexamethasone is superior to tramadol as an adjuvant to ropivacaine for pediatric lower abdominal surgeries. [ABSTRACT FROM AUTHOR]

Introduction Optimization of anesthesiology benefits by conducting an internal medical audit based on the registration of critical incidents. Material and Methods An internal medical audit was applied to different versions of the anesthesiological aid carried out during surgical interventions in the conditions of one-day surgery. The age of patients ranged from 0 to 16 years. In most cases, operations were performed as planned. Results In our study, 498 critical incidents were recorded in patients, so the frequency of critical incidents (CHI) was 0.63 ± 0.03 incidents per operation. When analyzing critical incidents at the stages of various options for anesthesia, we found that their greatest number occurs at the stages of induction anesthesia and in the postoperative period (184 and 139, respectively). At the stage of maintaining anesthesia, the number of critical incidents is two times less than at the previous stage and does not significantly differ from that at the stage of awakening the patient. The most common critical incident at the stage of induction of anesthesia in children is laryngospasm caused by insufficient depth of anesthesia. Our study results showed that CI associated with the cardiovascular system were recorded at all stages of the anesthesiological aid, including the postoperative period. However, they were more often observed during induction of anesthesia (57) and maintenance of general anesthesia (38). So, all patients of this group, bypassing the wake-up chamber, were immediately transferred to the surgical ward immediately after the operation. Since complete awakening occurred in patients of this group on the operating table and hemodynamic parameters remained stable. Conclusion Reasonable inclusion of patients in the fast track group significantly saved their costs operated in the conditions of one-day surgery. [ABSTRACT FROM AUTHOR]

Study DesignThis was a prospective, randomized, controlled trial comprising 60 patients undergoing lumbosacral spine (noninstrumentation/nonfusion) surgery.PurposeThe purpose of this study was to evaluate the efficacy of 0.2% ropivacaine (20 mL) administered alone as a single, preoperative, caudal epidural block injection versus that of intravenous analgesics in providing effective postoperative analgesia to patients undergoing lumbosacral spine surgery.Overview of LiteratureVarious studies have shown the effectiveness of a caudal epidural injection (bupivacaine or ropivacaine) in providing postoperative analgesia in combination with steroids or other analgesics. This study uniquely analyzed the efficacy of a single injection of caudal epidural ropivacaine in providing postoperative pain relief.MethodsSixty patients who were scheduled to undergo surgery for degenerative lumbar spine disease (noninstrumentation/nonfusion) were consecutively divided into two groups, group R (Study) and group I (Control). 30 group R patients received a caudal epidural block with 20 mL of 0.2% ropivacaine after the administration of general anesthesia. 30 group I patients received no preoperative analgesia. Intravenous analgesics were administered during the postoperative period after a complaint of pain. Various parameters indicating analgesic effect were recorded.ResultsThere was a significant delay in the average time to the first demand for rescue analgesia in the study group, suggesting significantly better postoperative pain relief than that in the control group. In comparison with the control group, the study group also showed earlier ambulation with minimal adverse effects. The requirement for intraoperative fentanyl was higher in the control group than that in the study group.ConclusionsPreemptive analgesia with a single epidural injection of ropivacaine is a safe, simple, and effective approach, providing better postoperative pain relief, facilitating early mobilization, and decreasing the intraoperative requirement for opioid administration.

Background and Aims: Provision of adequate perioperative analgesia in children is important to attenuate the stress response to surgery. Caudal analgesia using local anesthetics is a traditionally used technique but provides a limited duration of analgesia. Several adjuvants can be added to local anesthetics to increase the duration of action. This study was undertaken to evaluate the efficacy of dexamethasone added to bupivacaine for caudal block in children. Material and Methods: This was a prospective, double-blinded trial on 130 children aged between 6 months and 6 years of age allocated randomly into one of two groups for elective subumbilical surgeries. Children in Group C received caudal bupivacaine and those in Group D received caudal bupivacaine with 0.1 mg/kg of dexamethasone. Results: The mean duration of analgesia when dexamethasone was added to caudal bupivacaine was 1044.92 (±48.66) min, while it was 435.85 (±17.95) min with plain bupivacaine. The number of doses of rescue analgesics required and the mean pain score was also lesser in this group. Conclusion: The addition of 0.1 mg/kg of dexamethasone to caudal bupivacaine increases the duration of analgesia of caudal bupivacaine without any side effects in children undergoing subumbilical surgeries.

Background and Objectives: This study was conducted to investigate the influence of an ultrasound-guided technique using a catheter-over-needle when an intravascular injection occurs in patients undergoing a caudal block. Material and Methods: We retrospectively investigated 41 cases of an ultrasound-guided technique using an angiocatheter for caudal block. These had been performed between November 2019 through August 2020 to manage pain of lumbosacral origin. Under ultrasound guidance, after advancing the introducer needle through the sacrococcygeal ligament and then slowly withdrawing it, the outer catheter was continuously advanced into the sacral hiatus. We confirmed proper needle placement under fluoroscopic imaging, using 5 mL of contrast media. We assessed the contrast spread pattern with fluoroscopic imaging and checked it for the presence of intravascular injection. Results: In all recruited cases, the catheter-over-needle was guided successfully to the sacral hiatus and into the caudal epidural space. There was 100% accuracy under ultrasound guidance, without intravascular uptake, as confirmed by contrast media fluoroscopy. The incidence of ventral spread was 84.2% above the S1 with 5 mL of contrast. Conclusions: The technique of using a catheter-over-needle under ultrasound induced successful block without intravascular injection. Thus, this technique is a reliable option for conventional caudal block.

Objectives: In pediatric cardiac surgery, does caudal anesthesia promote early extubation, reduce pain scores, reduce stress responses, and length of stay (LOS)?Design: A systematic review.Participants: Inclusion criteria included cardiac surgical procedures (with or without cardiopulmonary bypass) in any subject between the ages of full-term newborn and 18 years receiving caudal anesthesia of any medication combination. Searches were conducted with assistance of an Academic librarian from 1947 to July 2017.Methods: Relevant studies selected were randomized trials or cohort studies.Results: The total number of patients was 2159 in 17 studies. There were 8 prospective randomized clinical trials and 9 cohort studies. Caudal medications included dexmedetomidine, bupivacaine, sufentanil, morphine, fentanyl, and neostigmine. Nine studies reported earlier extubation in patients with caudal anesthesia. Cardiopulmonary bypass and surgical duration mitigated early extubation anesthetic strategies. Three of 5 studies showed reduced pain scores and need for opiates, 2 studies showed no difference. Two of 3 studies showed a reduction in stress response. Hemodynamic assessments were improved in 2 studies and unchanged in 3 studies. Four studies showed reduced hospital LOS. Studies are difficult to interpret because of the comparative techniques used.Conclusions: The data quality in this review is too poor to make recommendations regarding incorporation of caudal anesthesia into clinical practice. Caudal anesthesia may be favorable for early extubation, improved pain, and hemodynamics and reduced LOS. There are many other anesthetic alternatives to facilitate early extubation. Our review is limited by heterogeneous populations, variable pain measurement scales, and absent definitions of extubation indicators. [ABSTRACT FROM AUTHOR]

Summary Background The surgical anorectal diseases are common and distressful pathologies and their management mostly needs surgical intervention. Caudal anesthesia is effective in doing surgical procedures whenever the surgical area is mainly innervated by the sacral and lower lumbar nerve roots. It is used to give the local anesthesia by surgeons, in the present study the surgeon is the person who also gives the caudal anesthesia. Methods 202 patients (118 males vs. 84 females) were enrolled in this study with different surgical anorectal diseases. All of them were planned to be treated surgically under the effect of caudal anesthesia that was given by injection 10 ml of 2% lidocaine through sacral hiatus. All caudal anesthesia attempts were performed by the author surgeon. Results The total success rate of caudal anesthesia performed by the surgeon was 72.2% (divided into ≅67.7% in the first year of the study, ≅72 in the second and ≅76.4% in the third year). The failed attempts were in 18.81% males vs. 8.91 females. The morbidity rate was 0.99% and the mortality rate was zero. Conclusions The surgeon can perform the caudal anesthesia effectively and safely. This success improved with gaining more experience. This can help partly in solving the shortage in no. of anesthetists in some developing countries. [ABSTRACT FROM AUTHOR]

Summary: Dr. Estela Melman (1939‐present), Professor in the Department of Anesthesiology, the American British Cowdray Medical Center, Mexico, is an influential pioneer who has shaped the scope and practice of pediatric anesthesia in Mexico and throughout the world. Her early work to reintroduce neural blockade into routine pediatric anesthetic care, particularly the caudal approach to the epidural space, helped to transform current anesthesia practice. Based on a series of interviews held with Dr. Melman between 2016 and 2017, this article reviews the remarkable career of a pioneering pediatric anesthesiologist. [ABSTRACT FROM AUTHOR]

BackgroundCaudal block is a popular regional anesthesia in children undergoing infraumbilical surgeries including inguinal hernia repair and orchiopexy. We evaluated the efficacy of eutectic mixture of local anesthetic (EMLA) cream for reducing needle insertion pain during caudal block in pediatric patients.MethodsForty-one children between the ages of 13 months and 5 years undergoing infraumbilical surgery were randomized to receive either topical EMLA or placebo cream over the sacral hiatus one hour before caudal block. All children were assessed with the Multidimensional Assessment Pain Scale (MAPS) at the following time points. T0: arrival at the operation room; T1: just before needle insertion; T2: immediately after needle insertion into the sacral hiatus. The need for sevoflurane inhalation due to procedural pain response was also assessed at the same time as MAPS assessment.ResultsMAPS scores were significantly lower in the EMLA group compared with the placebo group at T2 (P = 0.001). Moreover, need for sevoflurane inhalation due to procedural pain response was significantly lower in the EMLA group compared with the control group at T2 (P < 0.001).ConclusionsWe suggest that pretreatment with EMLA cream over the sacral hiatus before caudal block has significant advantages in alleviating procedure pain during caudal block in children.

Neuraxial anesthesia combined with general anesthesia has become a widely accepted method of providing effective postoperative analgesia and decreasing intraoperative anesthetic needs in the pediatric population. In clinical practice, there still appears to be hesitancy for the use of a neuraxial technique (spinal or epidural) in patients at risk for bacteremia or with an on-going systemic infection. However, evidence-based medicine lacks any data to support an increase in the risk of infectious complications following neuraxial anesthesia. We present two pediatric patients with intra-abdominal infectious processes who received caudal epidural blockade for postoperative operative analgesia. The use of neuraxial techniques in patients at risk for bacteremia is reviewed, evidence-based medicine regarding the risks of infection discussed, and the potential favorable effects of neuraxial blockade on the neurohumoral response to sepsis and the systemic inflammatory responses presented.

Objectives: Caudal analgesia is widely used in children; the aim of this trial was to evaluate the efficacy of adding nalbuphine to local anesthetic in pediatric patients undergoing hernia repair. Patients and methods: This randomized double-blind controlled trial was done in department of anesthesia, Cairo University hospitals, and 40 patients with ASA physical status classification I–II, aged 2–7 years were enrolled in this study and randomly assigned into 2 groups; group L received caudal levobupivacaine 1 ml/kg with concentration of 0.25% and group LN received caudal 0.125% levobupivacaine with volume of 1 ml/kg plus 0.2 mg/kg nalbuphine. Pain was evaluated immediately after emergence (FLACC 0 h), after 1 h in the PACU, after 2, 3, 4, 5, 6 and 12 h by the FLACC pain score (Face, Leg, Activity, Crying, Consolability). First time of rescue analgesic, total dose of rescue analgesic and side effects were observed for 12 h. Results: FLACC pain scores were much less in LN group compared to L group (p value 0.001). The total dose of postoperative supplementary analgesia (intravenous paracetamol infusion) in the first 12 h was significantly lower in LN group (200.5 ± 65.5 mg) in comparison with L group (355.25 ± 69.9 mg) (P

Abstract Background Neonatal encephalopathy with seizures after general anesthesia not occurring in infants undergoing cardiac or major neurosurgery is very uncommon. An ischemic origin due to cerebral hypoperfusion from perioperative hypotension has been suggested, but there is a lack of a consensus definition for intraoperatory hypotension in neonates. Case Report We report the first case of neonatal encephalopathy with seizures in a neonate with anorectal malformation. He underwent a colostomy with caudal anesthesia combined with light general anesthesia. Intraoperative systolic blood pressure and mean blood pressure values were considered normal. Thirty-two hours after the intervention, the patient presented electroclinical seizures. Diffusion-weighted imaging showed bilateral involvement with reduced diffusivity in the watershed areas of the middle cerebral artery and posterior cerebral artery. Conclusion Perioperative monitoring of blood pressure is not enough in neonatal surgery. Cerebral magnetic resonance imaging should be considered in infants with noncardiac congenital anomalies after neonatal surgery and long-term follow-up is required.

Introduction: Hypospadias repair is a common pediatric surgery. While caudal block (CB) is the most widely used procedure for analgesia, pudendal nerve block (PNB) can be utilized as an alternative. We evaluated the postoperative analgesic efficacy of CB and PNB in children undergoing hypospadias repair., Methods: In this prospective observational study, we evaluated 101 patients who received standard general anesthesia along with CB or PNB. Postoperative pain score (Face, Legs, Activity, Cry, and Consolability {FLACC} score) along with the total number of analgesic doses and the total amount of analgesic drugs consumed within 24 hours were noted. Time to first rescue analgesia, post-block penile length and midshaft circumference, surgeon satisfaction score, and postoperative complications were also evaluated., Results: Out of 101 patients observed, 50 received CB, and 51 received PNB. At 24-hour interval, the median FLACC score in CB was 6, while in the PNB, it was 4 (p<0.001). None of the patients who were given PNB received more than three doses (p<0.001), and the average consumption of analgesic drugs within 24 hours was significantly higher in CB (38.4±4.28) compared to PNB (21.7±6.33) (p<0.0001). The median time to first rescue analgesia in CB was four hours, while in patients receiving PNB, it was eight hours (p<0.001). The increase in penile volume was significantly higher with CB as compared to PNB (p<0.001). Surgeon satisfaction score was found to be better with PNB (p<0.002)., Conclusion: Patients who received PNB had significantly reduced pain scores and analgesic consumption in the first 24 hours post surgery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Hayaran et al.)

Key Clinical Message: Urethral steinstrasse is rare. Only a few cases of spontaneous or postinterventional urethral steinstrasse have been reported in pediatric and adult patients. We report a case of a 52‐year‐old Nigerian man with a secondary urethral steinstrasse, and the treatment options possible, as day case procedures, under caudal anesthesia. [ABSTRACT FROM AUTHOR]

Background: Immune responses appear to be affected by anesthetics and analgesics. We investigated the effects of caudal tramadol on the postoperative immune response and pain management in pediatric patients. Methods: Sixty ASA-I pediatric patients aged 3-10 years undergoing lower abdominal surgery. Patients were randomly assigned either to a caudal bupivacaine (0.25%) group (group B), or a group that received caudal tramadol (1 mg/kg) added to the bupivacaine (0.25%) (group T). Both were diluted in a 0.9% NaCl solution to a total volume of 1ml/kg. The systemic immune response was measured by collecting blood samples preoperatively, at the end of anesthesia, and at 24 and 72 hours postoperatively, and studied for interleukin IL-6, C-reactive proteins (CRP) cortisol levels, and leucocytes with its differential count. Postoperative pain was assessed along with sedation scales. Results: Postoperative production of IL-6 was significantly higher in group B at the end of anesthesia, than at the 24th hour, and at the 72nd hour in group B and group T, respectively. The immune response showed leukocytosis with increased percentages of neutrophil and monocytes, and a decreased lymphocyte response rate within both groups with no significant differences between the groups. Cortisol and CRP were significantly higher in group B. Conclusions: Adding tramadol to a caudal bupivacaine block can attenuate the pro-inflammatory cytokine response, Cortisol, and CRP in children undergoing lower abdominal surgery. [ABSTRACT FROM AUTHOR]

Background: Dexamethasone has anti-inflammatory properties that can affect postoperative analgesia when added to caudal bupivacaine. Methods: Seventy-two geriatric patients scheduled for elective total hip replacement under ultrasound guided caudal anesthesia were randomized blindly into two groups: Group BD received caudal isobaric bupivacaine 0.25% (20 ml) and dexamethasone 8 mg (2 ml) and Group BS received caudal isobaric bupivacaine 0.25% (20 ml) and normal saline (2 ml). Postoperative analgesia was assessed by recording time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively as a primary outcome. Secondary outcomes were the time taken to the onset of sensory analgesia at T10, time to the onset of complete motor block, VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12 and 24 h, and postoperative adverse events. Results: Group BD had a significantly longer time to first rescue analgesia [402 (63) vs 213 (53)] min and significantly lower doses of paracetamol [3389 (728) vs 2833 (697)] mg meperidine hydrochloride [78 (30) vs 142 (28)] mg than Group BS. VAS scores were significantly lower in Group BD than Group BS both at rest and on movement respectively at 4, 6, 8, 12 and 24 h. Conclusion: Adding dexamethasone with isobaric bupivacaine caudal anesthesia prolongs the duration of postoperative analgesia and decreased postoperative analgesic requirement in geriatric patients undergoing total hip replacement surgery in comparison isobaric bupivacaine alone.