Preemptive and Postoperative Timing of Real-Time Sonar Guided Caudal Anesthesia for Pediatric Infra-Umbilical Procedures Analgesia

Adequate postoperative analgesia is essential for optimal recovery in children undergoing surgical procedures, yet it remains challenging due to their limited ability to self-report pain effectively.

Multimodal analgesia has become the standard approach to balance efficacy and safety in pediatric patients, incorporating non-opioid agents, regional techniques, and judicious use of opioids.

The caudal epidural block is a well-established and reliable regional anesthesia technique for providing both intra- and postoperative analgesia in pediatric patients undergoing infra-umbilical procedures.

The incorporation of real-time ultrasound (sonar) guidance has significantly enhanced the accuracy, safety, and success rate of caudal blocks by allowing direct visualization of anatomical structures, needle placement, and local anesthetic spread.

• Caudal block immediately following induction of general anesthesia (Drug), also known as 0.25% bupivacaine: Patients will receive the caudal block immediately following induction of general anesthesia.
• Caudal block at the end of surgery (Drug), also known as 0.25% bupivacaine: Patients will receive the caudal block at the end of surgery.

Primary outcomes

• Duration of effective postoperative analgesia [24 hours postoperatively]: The total duration of effective postoperative analgesia, defined as the time elapsed from the end of surgery to the first FLACC score ≥4 necessitating rescue analgesia.

Secondary outcomes

• Total consumption of rescue analgesics [24 hours postoperatively]: Rescue analgesia with intravenous fentanyl (0.5-1 μg/kg) was administered when FLACC scores reached or exceeded 4, with dosing governed by institutional protocol.
• Heart rate [Till the end of surgery (Up to 2 hours)]: Heart rate was documented at the time of induction, at the moment of skin incision, and at 10-minute intervals throughout the surgical procedure.
• Mean arterial blood pressure [Till the end of surgery (Up to 2 hours)]: Mean arterial blood pressure was documented at the time of induction, at the moment of skin incision, and at 10-minute intervals throughout the surgical procedure.
• Peripheral oxygen saturation [Till the end of surgery (Up to 2 hours)]: Peripheral oxygen saturation was documented at the time of induction, at the moment of skin incision, and at 10-minute intervals throughout the surgical procedure.
• End-Tidal Carbon Dioxide [Till the end of surgery (Up to 2 hours)]: End-Tidal Carbon Dioxide was documented at the time of induction, at the moment of skin incision, and at 10-minute intervals throughout the surgical procedure.
• Incidence of adverse events [24 hours postoperatively]: Incidence of adverse events such as postoperative nausea and vomiting (PONV), hematoma, hypotension, urinary retention requiring urinary catheterization, respiratory depression, bradycardia, and local anesthetic systemic toxicity (LAST), was recorded.

Sex: All, ages: 1 Year to 7 Years

Inclusion Criteria:

* Pediatric patients (aged 1-7 years).
* Both sexes.
* American Society of Anesthesiologists (ASA) physical status I or II.
* Scheduled for elective infra-umbilical surgical procedures, including inguinal hernia repair, orchidopexy, and hypospadias repair.

Exclusion Criteria:

* Parental refusal to provide written informed consent.
* Known sacral or spinal anatomical abnormalities (e.g., spina bifida).
* Infection at the proposed site of needle insertion.
* Coagulopathy or bleeding disorders.
* History of allergy to local anesthetic agents, including bupivacaine or ropivacaine.