Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : UC11 - UC15 Full Version

Lumbar Epidural Anaesthesia versus Caudal Epidural Anaesthesia- Intraoperative and Postoperative Profile in Paediatric Surgical Patients


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51831.16095
Pareesa Rashid, Khairat Mohd Butt, Sargam Goel, Aamil Haameem, Showkat Ahmed Gurcoo

1. Senior Resident, Department of Anaesthesia, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 2. Head, Department of Anaesthesia, Hamdard Institute of Medical Sciences and Research and HAHC Hospital, Delhi, India. 3. Assistant Professor, Department of Anaesthesia, Hamdard Institute of Medical Sciences and Research and HAHC Hospital, Delhi, India. 4. Ex-senior Resident, Department of Anaesthesia, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. 5. Head, Department of Anaesthesia, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.

Correspondence Address :
Sargam Goel,
963-B, D Block, New Friends Colony, Delhi, India.
E-mail: drsargamgoel@gmail.com

Abstract

Introduction: Caudal and lumbar epidural are established techniques of central neuraxial blocks in paediatric anaesthesia. Learning them by landmark guidance is extremely important given the fact that they have a short learning curve and all centres may not be equipped with modern equipment like fluoroscopy and ultrasound.

Aim: To compare lumbar epidural anaesthesia with caudal epidural anaesthesia in terms of the ease of needle and catheter insertion, efficacy in providing intraoperative and postoperative analgesia, haemodynamics, patient satisfaction and complications.

Materials and Methods: This prospective observational study was done in the Department of Anaesthesiology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India between September 2016 and June 2018. Study included 60 patients, aged 2-15 years, of American Society of Anaesthesiology (ASA) grade I and II, undergoing elective infraumbilical surgeries. Patients were either administered General Anaesthesia (GA) and 0.2% ropivacaine 0.3 mL/kg through lumbar epidural catheter (Group L), or GA and 0.2% ropivacaine 1 mL/kg through caudal epidural catheter (Group C). Pain was measured postoperatively using Face, Legs, Activity, Cry, Consolability (FLACC) score and number of rescue top ups in the form of tramadol 1.5 mg/kg epidurally were noted. Student’s independent-test was employed for intergroup and, paired t-test and Fisher’s-exact test was used for intragroup analysis.

Results: Out of 60 patients, the mean age±Standard devation (SD) in lumbar technique group and caudal technique group was 8±3.42 years and 6.56±2.93 years, respectively. The age, gender distribution, intraoperative and postoperative vitals (heart rate, mean arterial pressure and oxygen saturation), number of rescue top ups, patient satisfaction were comparable between the two groups. On statistical comparison, needle insertion was easy in 21 patients in caudal epidural group (vs 13 in lumbar epidural group) and catheter insertion was difficult in 18 (vs 8 in lumbar epidural group) in caudal epidural block compared with lumbar epidural block (p-value=0.037 and 0.010 respectively). No complications were observed in any patient of either group except one patient in group C who had catheter occlusion in the postoperative period.

Conclusion: Needle insertion was easy and catheter insertion was difficult in caudal epidural block compared with lumbar epidural block in paediatrics. Both the techniques provided comparable quality of analgesia, stable haemodynamics with minimum complications.

Keywords

Endotracheal tube, Infraumbilical surgery, Regional anaesthesia, Tuohy needle

The history of paediatric anaesthesia and analgesia is fascinating, in terms of the enormous advancement that has taken place, from the days when block techniques and equipment for adults were adapted for use in children. Since then, significant developments have occurred regarding General Anaesthesia (GA), Regional Anaesthesia (RA) and perioperative pain management in the paediatric population.

The RA and analgesia techniques provide a combination of excellent anaesthesia and pain relief, minimal side-effects and high patient satisfaction. Caudal block and epidural block were first described in paediatrics by Campbell MF in 1933 and Roderie Sievers in 1936 respectively for cystoscopies. These techniques have now become the most commonly used RA techniques in paediatric practice (1),(2). They have a short learning curve, with an extensive safety record. The use of neuraxial catheters has circumvented the disadvantage of short duration of action after single injection (3).

While the landmark guided approach to central neuraxial blocks is time tested, simple, and easy to perform, it is prone to block failure due to anatomical variations (4),(5),(6). The advent of fluoroscopy and ultrasound has markedly improved the first attempt success rates of these techniques with less complications, although few studies reported a longer block time with ultrasound compared to the conventional technique (7),(8). However, learning the central neuraxial blocks with landmark guided technique is extremely important given the fact that all centres may not be equipped with modern equipment like fluoroscopy and ultrasound.

Although there are studies comparing lumbar and thoracic epidural analgesia in paediatrics (9),(10),(11),(12), an extensive literature search revealed no study comparing the ease of needle and catheter insertion in lumbar and caudal epidural space in paediatric patients undergoing infraumbilical surgeries. Hence, the aim of the present study was to compare lumbar epidural anaesthesia with caudal epidural anaesthesia, in terms of the ease of needle and catheter insertion, efficacy in providing intraoperative and postoperative analgesia in terms of number of rescue analgesic requirements, haemodynamics, patient satisfaction and complications.

Material and Methods

The present prospective observational study was conducted in the Department of Anaesthesiology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India. Sixty patients posted for elective infraumbilical surgeries were included between September 2016 and June 2018. Institutional Human Ethics Committee approval was taken (SIMS1131/IEC-SKIMS/ 2018-315). Patient information sheet was provided and written informed consent was obtained from the parents of all patients. Assent of the patient was taken if he was seven years or more in age.

Sample size calculation: Using G*Power software (Version 3.0.10; Franz Faul, Kiel University, Kiel, Germany), it was estimated that the least number of patients required in each group with 80% power, effect size of 0.65 and 5% significance level was 30. Therefore a total of 60 patients were included in the present study.

Inclusion criteria: Children between age group of 2-15 years, undergoing elective infraumbilical surgeries with ASA I and II status were included in the study.

Exclusion criteria: Patient/guardian who did not give consent for study, patients with neurological deficits or psychiatric disorders, bleeding disorders or who were on antiplatelet and anticoagulant drugs were excluded from the study. Patients who had infection at local site, spine deformities, raised intracranial tension, hypersensitivity to local anaesthesia drugs and patients with chronic pain syndrome or who were on pain modifying drugs were excluded from the study.

All patients underwent routine preanaesthetic evaluation a day before surgery and were fasted as per the institutional preoperative fasting guidelines. In the preoperative holding area, premedication (oral midazolam 0.4 mg/kg given 40 min before the procedure) was administered. In the Operating Theatre (OT), monitors were attached and patients were induced by inhalational agent sevoflurane 8% to start with, and titrated down to 3-4%. An intravenous (i.v.) line was established with 22/24 G i.v. cannula and Ringer’s lactate solution was started according to Holiday Segar formula and the losses calculated and replaced intraoperatively. Fentanyl 1 micrograms (mcg)/kg i.v., Propofol 2 mg/kg i.v. and atracurium 0.6 mg/kg i.v. were administered. The patients were ventilated using Jackson Rees circuit and appropriate size Endotracheal Tube (ETT) was placed. Anaesthesia was maintained with nitrous oxide (50%) in oxygen and isoflurane with a target Minimum Alveolar Concentration (MAC) of 1-1.5. Ventilation was controlled with a tidal volume of 6-8 mL/kg and respiratory rate adjusted to maintain End-tidal Carbondioxide (EtCO2) between 30-35 mmHg.

Procedure

Drugs were prepared by the anaesthesiologist and equipment necessary for procedure and resuscitation were kept available. Under all aseptic precautions, all blocks were performed in lateral decubitus position with one or both hips flexed, using midline approach. All those blocks were included in the study which were performed by a single anaesthesiologist with >5 years of experience in paediatric anaesthesia. For performing these blocks, 18 G Touhy needles with 20 gauge catheters were used.

For lumbar epidural anaesthesia (Group L): Tuohy needle was introduced at L3-L4 or L4-L5 space, epidural space identified by loss of resistance to air technique and catheter threaded upto 3-5 cm in the cephalad direction. Aspiration for the absence of cerebrospinal fluid and blood was done.

For caudal epidural anaesthesia (Group C): The sacral hiatus was palpated and Tuohy needle advanced at a 70o angle cephalad, until a pop was felt as the needle pierced the sacrococcygeal ligament. The angle of the needle was then flattened to 20°-30° and advanced. Loss of resistance to air was checked and epidural catheter was left 3-5 cm into the space. Aspiration for blood and cerebrospinal fluid was performed.

The catheters were labelled for the purpose of identification. Proper placement in both the groups was confirmed by a negative test dose (2% lignocaine with adrenaline 5 μg/mL in a dose of 0.1 mL/kg, maximum 3 mL) before administration of the drugs.

Group L (n=30): Received GA and 0.2% ropivacaine 0.3 mL/kg through lumbar epidural catheter.

Group C (n=30): Received GA and 0.2% ropivacaine 1 mL/kg through caudal epidural catheter at the sacral hiatus.

The drug doses were based on the desired dermatome blockade as T10 for infraumbilical surgeries and were inferred from a previous study (13). In order to differentiate between difficult and unsuccessful needle/catheter insertion, all those patients were excluded in whom the block administration was unsuccessful. Successful block injection was defined as no blood or cerebrospinal fluid on aspiration, injection into the caudal canal without any resistance, no dural tap and no subcutaneous swelling. Such blocks were further classified as easy and difficult. A difficult caudal/epidural block was defined as a procedure that lasted >100 seconds or required >10 needle passes (14).

Vital parameters were recorded at induction (baseline), then for every 20 minutes till the end of surgery. After 20 minutes of block administration, any increase in Heart Rate (HR) or Mean Arterial blood Pressure (MAP) >20% from baseline inspite of a MAC value of 1-1.5, was considered as pain, and hence block failure. Patients with unsuccessful/failed blocks were supplemented with injection fentanyl 1 mcg/kg i.v. and paracetamol 15 mg/kg i.v. as analgesia.

Hypotension and bradycardia, defined as 20% decrease from baseline levels, were treated with rapid infusion of i.v. fluids and atropine 0.02 mg/kg i.v., respectively. Hypotension persisting inspite of fluid administration was treated with ephedrine 0.1-0.2 mg/kg i.v. Desaturation was defined as SpO2 <94% in the perioperative period. After the completion of the surgical procedure, the patients were extubated and shifted to the Post Anaesthesia Care Unit (PACU). In the postoperative period the following parameters were evaluated for 24 hours of the study duration:

• Postoperative vitals were noted at the time of being shifted to PACU, then at 6 hours, 12 hours and 24 hours.
• Patient satisfaction score was inferred from Face, Legs, Activity, Cry, Consolability (FLACC) (15) score in PACU, at 6 hours, 12 hours and 24 hours postoperatively where,
0: meant a relaxed and comfortable patient, represented by “best”
1-3: meant mild discomfort, represented by “good”
4-6: meant moderate pain, represented by “satisfactory”
7-10: meant severe pain or discomfort or both, represented by “poor”
• Total number of top ups received- At a FLACC Score of ≥4 in the postoperative period, rescue analgesia of tramadol 1.5 mg/kg epidurally was given.
• Complications related to the procedure or the drugs, were noted in the intraoperative and postoperative period like Local Anaesthesia Systemic Toxicity (LAST), haemodynamic instability, pericatheter leak (identified by mild soakage of dressing applied at the site of insertion), catheter migration/blockage and catheter breakage during removal. Complications like dural puncture and subcutaneous swelling during epidural and caudal block respectively, were noted but not analysed.

After 24 hours, epidural catheter was removed by confirming the blue tip in all patients under aseptic precautions and antiseptic dressing was applied. If case of block failure, catheter malposition, catheter occlusion, postoperative analgesia/rescue analgesia would be maintained by injection paracetamol i.v.

Statistical Analysis

Statistical Package for the Social Sciences (SPSS) version 20.0 was used to obtain the statistics of the data including the mean and standard deviation for numerical variables and the percentages for categorical variables. Student’s independent t-test was employed for intergroup analysis of the data. Intragroup analysis was carried out with the help of paired t-test and Fisher’s-exact test. Paired t-test or Fischer’s-exact test, whichever appropriate, was used for comparison of categorical variables. Graphically the data was presented by bar and line diagrams. A p-value of less than 0.05 was considered statistically significant. All p-values were two tailed.

Results

The two groups were similar in terms of demographic characteristics like age (p-value of 0.087) and gender (Table/Fig 1). All patients in both the groups were ASA grade I.

On statistical comparison, needle insertion was easy and catheter insertion was difficult in caudal epidural block compared with lumbar epidural block with a p-value of 0.037 and 0.010, respectively (Table/Fig 2).

There were no statistically significant differences in baseline HR (p-value=0.252), MAP (p-value=0.091) and oxygen saturation (p-value=0.165), between the two groups before performing the epidural block, intraoperatively and in the postoperative period (Table/Fig 3), (Table/Fig 4). Patient satisfaction based on the FLACC scores and the rescue analgesic requirements were comparable at all time intervals in both the groups (p-value >0.05) (Table/Fig 5), (Table/Fig 6). None of the patients reported bradycardia in the intraoperative or postoperative period.

Discussion

Caudal and lumbar epidural anaesthesia techniques are the gold standard for postoperative analgesia in children. Epidurals avoid the side effects associated with administration of i.v. opioids, with studies demonstrating fewer episodes of hypoxemia or respiratory depression and a reduced need for postoperative ventilation and intensive care (16). There is also better haemodynamic stability, improved gastrointestinal function, less nausea and vomiting and a reduced neurohumoral stress response (17). The epidural and caudal anaesthesia and analgesia has been used either as a single shot technique or a continuous catheter technique for infants and young children undergoing abdominal, urologic or orthopaedic surgeries.

A total of 65 patients were enrolled in the present study. The demographic characteristics of patients in both the groups were comparable. There was inability to insert catheter in the epidural space in one patient of Group C. This was considered as block failure and the patient was excluded from the study. Dural puncture was observed in one patient from Group L during needle insertion. Although excluded from the present study, this patient was followed-up in the postoperative period. The child did not develop postdural puncture headache. Three patients were excluded from Group C due to subcutaneous swelling. Thus, 60 patients were analysed.

In the present study, the ease of epidural needle insertion in Group C was easier than in Group L (Table/Fig 2). In accordance with these findings, Ponde VC discussed the recent developments in paediatric neuraxial blocks and stated that, the caudal epidural was technically much easier and safer to practice in intra-abdominal surgeries for intra and postoperative analgesia (18). However, Price CM et al., found that 93% of lumbar and 64% of caudal epidural injections were correctly placed (p-value <0.001), indicating the accuracy of needle placement by the two approaches (11). Auler Jr JO et al., delineated the ease of localising sacral hiatus in children younger than eight years of age or weight lower than 30 kg and observed that above this age, there is a relative difficulty in administering caudal epidural anaesthesia. This difficulty was attributed to progressive sacral ossification and obliteration of sacrococcygeal angle with age, leading to difficulty in identification of the sacral hiatus (19). This explains the finding of subcutaneous swelling in three patients in the present study. This difficulty can be mitigated by using ultrasound to locate the sacral hiatus and visualise the local anaesthesia deposition in the space.

In the present study, the ease of epidural catheter placement was easier in Group L in comparison to Group C (p-value=0.010). Valairucha S et al., recommended that caudal catheters should be limited to patients younger than one year of age because development of the lumbar curve during infancy can prevent easy threading of the catheter and may cause catheter kinking (20). This explains the block failure due to inability to insert caudal catheter in the present study. Polaner DM et al., also reported that the main problems with epidural blocks were block failure and inability to place needle correctly in caudal space (4). The most common adverse effects in a study by Walker BJ et al., were catheter occlusion, dislodgement and disconnection that occurred in 4% of the patients (21). However, with the introduction of new equipment and techniques, caudal catheter advancement is even possible in older children using epidural stimulation. According to Gunter J malpositionings are known in caudal epidural catheters and they can be reduced by the use of large bore catheters (18 G) and catheters with a stylet (the stimulating catheters) (22).

In the present study, incidence of catheter occlusion postoperatively was 3.33% in each group (one patient each in Group C and Group L). The incidence of block failure, catheter occlusion and dural puncture observed in the present study was in accordance with those reported by previous studies (23),(24). In a review article by Patel D on epidural analgesia in children, serious or catastrophic complications after caudal block were described as rare (incidence of inadvertent IV injection as 1:10 000, incidence of epidural haematoma/abscess as 1:80 000). The reported failure rate was 2-10% in caudal block (attributed to abnormal anatomy, inexperienced operator or inappropriate choice of block) and 5% in lumbar epidural block. The incidence of catheter leakage/occlusion and dural tap after lumbar epidural were reported as 11-17% and 0.1–0.5%, respectively. Similarly, the incidence of serious or major complications after lumbar epidural (<1:100 000) in children was described as less than that in adults (16). Walker BJ et al., reported the risk of transient neurologic deficit was 2.4:10000 and did not report any permanent neurologic damage in any patient. They calculated the risk of severe (LAST) as 0.76:10000 and reported no haematomas due to neuraxial catheters. This study demonstrated a comparable efficacy of paediatric and adult RA techniques and confirmed the safety of performing the neuraxial blocks under GA (21).

In the present study, HR and MAP decreased from the baseline values after 20 minutes of block administration, indicating effective analgesia achieved by theropivacaine injections in both the groups. But when they were compared with the other group, the result was not significant (p-value >0.05) (Table/Fig 3), (Table/Fig 4). Therefore, indicating that both the techniques were comparable in providing effective analgesia and none was superior to the other. Also, both the techniques had insignificant effect on the haemodynamics of the patient. There was no incidence of hypotension, bradycardia and respiratory depression postoperatively in either group. Various studies support the present study findings (10),(25),(26),(27),(28). Comparison of the number of top ups in each group revealed statistically insignificant results (Table/Fig 6). These findings were in accordance with the findings of numerous studies (10),(29),(30),(31). Patient satisfaction inferred from FLACC scores was also comparable between the two groups (Table/Fig 5) at all the time intervals. This finding was similar to that observed by Schnabel A et al., (32).

After the surgery all children were calm and showed no signs of discomfort. This suggests effective immediate postoperative analgesia, similar in both lumbar and caudal epidural techniques. No patient in either group who received epidural tramadol had any complications like nausea, vomiting, sedation, respiratory depression and pruritus.

Although the literature finds caudal and epidural catheters to be extremely valuable for managing postoperative analgesia when administered as a continuous infusion (9),(33), authors in the present study, inserted them to observe the ease of catheter insertion and used it for intraoperative analgesia and postoperative rescue analgesia. We did not administer continuous analgesic infusions through them in the postoperative period.

Limitation(s)

Firstly, unsuccessful/failed block was defined separately from difficult block, hence not analysed for incidence. Secondly, the present study included a broad range of age i.e., 2-15 years, which makes reliable pain assessment a challenge in different age groups. Authors therefore suggest more prospective studies with larger sample sizes and with multicentre patient enrollments, to find out the incidence of complications associated with these procedures.

Conclusion

Needle insertion was easy and catheter insertion was difficult in caudal epidural block compared with lumbar epidural block in paediatrics. Both the techniques provided comparable quality of analgesia, stable haemodynamics with minimum complications. In settings where ultrasound is available, the safety of needle and catheter insertion under anaesthesia may be further improved.

References

1.
Campbell MF. Caudal anesthesia in children. The Journal of Urology. 1933;30(2):245-50. [crossref]
2.
Kil HK. Caudal and epidural blocks in infants and small children: Historical perspective and ultrasound-guided approaches. Korean Journal of Anesthesiology. 2018;71(6):430. [crossref] [PubMed]
3.
Srinivasan B, Karnawat R, Mohammed S, Chaudhary B, Ratnawat A, Kothari SK. Comparison of caudal and intravenous dexamethasone as adjuvants for caudal epidural block: A double blinded randomised controlled trial. Indian J Anaesth. 2016;60:948-54. [crossref] [PubMed]
4.
Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, et al. Pediatric Regional Anesthesia Network (PRAN): A multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesthesia & Analgesia. 2012;115(6):1353-64. [crossref] [PubMed]
5.
Mirjalili SA, Taghavi K, Frawley G, Craw S. Should we abandon landmark-based technique for caudal anesthesia in neonates and infants? Pediatric Anesthesia. 2015;25(5):511-16. [crossref] [PubMed]
6.
Boretsky KR, Camelo C, Waisel DB, Falciola V, Sullivan C, Brusseau E, et al. Confirmation of success rate of landmark-based caudal blockade in children using ultrasound: A prospective analysis. Pediatric Anesthesia. 2020;30(6):671-75. [crossref] [PubMed]
7.
Riaz A, Shah AR, Jafri SA. Comparison of pediatric caudal block with ultrasound guidance or landmark technique. Anaesthesia, Pain & Intensive Care. 2019;23(1):18-22.
8.
Kollipara N, Kodali VR, Parameswari A. A randomized double-blinded controlled trial comparing ultrasound-guided versus conventional injection for caudal block in children undergoing infra-umbilical surgeries. J Anaesthesiol Clin Pharmacol. 2021;37:249-54. [crossref] [PubMed]
9.
Rasch DK, Webster DE, Pollard TG, Gurkowski MA. Lumbar and thoracic epidural analgesia via the caudal approach for postoperative pain relief in infants and children. Canadian Journal of Anaesthesia. 1990;37(3):359-62. [crossref] [PubMed]
10.
Ecoffey C, Dubousset AM, Samii K. Lumbar and thoracic epidural anesthesia for urologic and upper abdominal surgery in infants and children. The Journal of the American Society of Anesthesiologists. 1986;65(1):87-89. [crossref] [PubMed]
11.
Price CM, Rogers PD, Prosser AS, Arden NK. Comparison of the caudal and lumbar approaches to the epidural space. Annals of the Rheumatic Diseases. 2000;59(11):879-82. [crossref] [PubMed]
12.
Tsui BC, Wagner A, Cave D, Kearney R. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: A review of 289 patients. The Journal of the American Society of Anesthesiologists. 2004;100(3):683-89. [crossref] [PubMed]
13.
Narasimhamurthy GC, Patel MD, Menezes Y, Gurushanth KN. Optimum concentration of caudal ropivacaine & clonidine-a satisfactory analgesic solution for paediatric infraumbilical surgery pain. Journal of Clinical and Diagnostic Research: JCDR. 2016;10(4):UC14.
14.
Kim YH, Park HJ, Cho S, Moon DE. Assessment of factors affecting the difficulty of caudal epidural injections in adults using ultrasound. Pain Research and Management. 2014;19(5):275-79. [crossref] [PubMed]
15.
Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293-97.
16.
Patel D. Epidural analgesia for children. Continuing Education in Anaesthesia, Critical Care & Pain. 2006;6(2):63-66. [crossref]
17.
Marhofer P, Keplinger M, Klug W, Metzelder M. Awake caudals and epidurals should be used more frequently in neonates and infants. Pediatric Anesthesia. 2015;25(1):93-99. [crossref] [PubMed]
18.
Ponde VC. Recent developments in paediatric neuraxial blocks. Indian Journal of Anaesthesia. 2012;56(5):470. [crossref] [PubMed]
19.
Auler Jr JO, Teruya SB, Jacob RS. Anesthesia Pediátrica. São Paulo. Atheneu. 2008:208-14.
20.
Valairucha S, Seefelder C, Houck CS. Thoracic epidural catheters placed by the caudal route in infants: The importance of radiographic confirmation. Paediatr Anaesth. 2002;12:424-28. [crossref] [PubMed]
21.
Walker BJ, Long JB, Sathyamoorthy M, Birstler J, Wolf C, Bosenberg AT, et al. Complications in pediatric regional anesthesia: An analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology. 2018;129(4):721-32. [crossref] [PubMed]
22.
Gunter J. Caudal anesthesia in children: A survey. Anesthesiology. 1991;75:A936. [crossref]
23.
Giaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children: A one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists. Anesthesia & Analgesia. 1996;83(5):904-12. [crossref]
24.
Wood CE, Goresky GV, Klassen KA, Kuwahara B, Neil SG. Complications of continuous epidural infusions for postoperative analgesia in children. Canadian Journal of Anaesthesia. 1994;41(7):613-20. [crossref] [PubMed]
25.
Murat I, Delleur MM, Esteve C, Egu JF, Raynaud P, Saint-Maurice C. Continuous extradural anaesthesia in children: Clinical and haemodynamic implications. British Journal of Anaesthesia. 1987;59(11):1441-50. [crossref] [PubMed]
26.
Fortuna A. Caudal analgesia; A simple and safe technique in pediatric surgery. Br J Anesth. 1967;39:156-59. [crossref] [PubMed]
27.
Melman E, Penuelas JA. Regional anesthesia in children. Anesth Analg. 1975;54:387-98. [crossref] [PubMed]
28.
Glenski JA, Warner MA, Dawson B, Kaufman R. Postoperative use of epidurally administered morphine in children and adolescents. Mayo Clin Proc. 1984;59:530-33. [crossref]
29.
Meignier M, Souron R, Le Neel JC. Postoperative dorsal epidural analgesia in the child with respiratory disabilities. Anesthesiology (Philadelphia). 1983;59(5):473-75. [crossref] [PubMed]
30.
Soliman MG, Ansara S, Laberge R. Caudal anaesthesia in paediatric patients. Canadian Anaesthetists' Society Journal. 1978;25(3):226-30. [crossref] [PubMed]
31.
Krane EJ, Jacobson LE, Lynn AM, Parrot C, Tyler DC. Caudal morphine for postoperative analgesia in children: A comparison with caudal bupivacaine and intravenous morphine. Anesthesia and Analgesia. 1987;66(7):647-53. [crossref] [PubMed]
32.
Schnabel A, Thyssen NM, Goeters C, Zheng H, Zahn PK, Van Aken H, et al. Age-and procedure-specific differences of epidural analgesia in children-a database analysis. Pain Medicine. 2015;16(3):544-53. [crossref] [PubMed]
33.
Taenzer AH, Clark C. Efficacy of postoperative epidural analgesia in adolescent scoliosis surgery: A meta-analysis. Pediatric Anesthesia. 2010;20(2):135-43. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/51831.16095

Date of Submission: Aug 17, 2021
Date of Peer Review: Nov 02, 2021
Date of Acceptance: Dec 02, 2021
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
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• iThenticate Software: Jan 03, 2022 (12%)

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