Caudal block is a common method of regional anesthesia. In pediatrics, it works as a supplement to general anesthesia and is a good method for control postoperative pain. By offering superior analgesia, it decreases the use for intravenous opioids, thereby reducing related adverse reactions like nausea, vomiting, and respiratory impairment. Consequently, caudal block is a safe and appropriate method for managing pain in children undergoing different types of surgery. Usually, it is given following general anesthesia in children, making a some difficulty in evaluating the block's effectiveness The success of a caudal block is traditionally predicted by hemodynamic changes in blood pressure and heart rate, although these variables are thought to be unreliable, many tests, like 'swoosh' and 'whoosh' tests, and ultrasonography, can be used to guarantee precise needle placement and enhance the probability of block success.
Other variables are sometimes used, such as laxity of the anal sphincter tone and loss of the cremasteric reflex; however under general anesthesia, their dependability is doubtful and the latter can only be used for male children . Technological developments in pulse oximeters have improved their capacity to monitor other parameters, such as the surgical pleth index (SPI) and perfusion index (PI).
Perfusion index (PI) is a non-invasive numerical evaluation of the pulsatile strength at a monitoring site that offers helpful data regarding the patient's peripheral perfusion status .
Local vasoconstriction may induce a decrease in PI, whereas vasodilatation causes an increase in PI in the skin at the monitoring site Successful anesthesia onset is indicated by an increase in PI, but failure to do so may be indicated by a lack of increase.
Surgical pleth index (SPI) is another noninvasive, dimensionless score whose value is derived from pulse wave amplitude and heartbeat interval as measured by a pulse oximetry probe The sympathetic reaction of the patient to the surgical stimulus is reflected in SPI , research on SPI indicates that adults with values between 20 and 50 have good nociception, but its usefulness in children is unclear.
The aim of this study This study aims to determine the time to change of value of PI and SPI in assessing the effectiveness of a caudal block in pediatric patients during infraumbilical surgeries under general anesthesia
• Children aged 1 to 6 years of either sex
With American Society of Anesthesiologists (ASA) physical status I-II
undergoing elective infraumbilical surgery
• parental refusal
Patients with liver disease (e.g. elevated bilirubin >2mg/dL, albumin<3.0g/dL)
Patients with renal disease (e.g. serum creatinine >1.5-2mg/dL)
Cardiac disorders (low EF>50%, sever valvular heart disease)
study will be conducted in Fayoum University hospital after the local Institutional Ethics Committee and local institutional review board approval. Inclusion criteria * Children aged 1 to 6 years of either sex * With American Society of Anesthesiologists (ASA) physical status I-II * undergoing elective infraumbilical surgery. Exclusion criteria * parental refusal * Patients with liver disease (e.g. elevated bilirubin \>2mg/dL, albumin\<3.0g/dL) * Patients with renal disease (e.g. serum creatinine \>1.5-2mg/dL) * Cardiac disorders (low EF\>50%, sever valvular heart disease) * Recent respiratory tract infection within 1-2 weeks and bronchial asthma * Known organic brain disease (cerebral palsy, tumors) * patients with any contraindication to caudal anesthesia (local infection, coagulation abnormality e.g. INR \> 1.5, known structural abnormality e.g. kyphosis) * Known allergy to local anesthetics.
Other
Prospective
caudal block
Procedure/SurgeryThree minutes after anesthesia induction the patient will be positioned in the lateral decubitus position, a caudal block will be performed using the landmark technique under aseptic conditions. After carful preparing and cleaning the area using 10% povidone-iodine, the sacral hiatus will be identified, a 22G, 1 to 1.5 inch hypodermic needle will be inserted until the sacro-coccygeal ligament will be pierced a distinct "pop" indicated entry into the caudal space, a test dose of lidocaine 1% with epinephrine (1:200,000) will be administered at a dose of 0.5 mL/kg (maximum 3 mL) to exclude inadvertent intravascular or intrathecal injection. After confirming negative aspiration for blood or cerebrospinal fluid (CSF) then a 0.25% bupivacaine (1 mL/kg) will be injected at a rate of 1 mL per 3 seconds. The patient will be immediately repositioned supine; The surgical incision will be made approximately 10 min after caudal block administration.
Time to change of value of PI and SPI after caudal block
The primary outcome is the difference in time to change between the Perfusion Index (PI) and the Surgical Pleth Index (SPI) following caudal block
The recorded values of PI, SPI, HR and MAP
The recorded values of PI, SPI, HR and MAP in assessing the effectiveness of a caudal block in pediatric patients during infraumbilical surgeries under general anesthesia
ROC curve of PI, SPI, HR and MAP
ROC curve of PI, SPI, HR and MAP
AUC of PI, SPI, HR and MAP
AUC of PI, SPI, HR and MAP
Best cut of value of PI, SPI, HR and MAP
Best cut of value of PI, SPI, HR and MAP in assessing the effectiveness of a caudal block in pediatric patients during infraumbilical surgeries under general anesthesia
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