الفهرس 
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Abstract
A better knowledge of the pharmacokinetics and pharmacodynamics of local anaesthetic substances in infants and children, the development of regional anaesthetic techniques, as well the availability of better equipment specifically designed for children, have all allowed the implementation of regional anaesthesia in paediatric surgery.
In recent years, the use of regional anaesthesia in paediatric surgery is more frequent due to the growing number of premature infants who are discharged with chronic and acute morbidities that need to be operated upon. These infants are at a greater risk of developing respiratory failure and postoperative apnea compared to full term infants of the same age.
When regional anaesthesia is given to older children, some variables such as the intervention site, age, and presence of chronic disease, cooperativeness and parental preferences should be considered.
Among the regional anaesthetic techniques, spinal (subarachnoid), epidural and caudal block, we chose preferentially the caudal approach because of the ease and safety of reaching the epidural space through this route in children. If all these techniques are correctly used and the anatomy of the patient is normal, there is minimal risk of perforation of the dura when using caudal or epidural anaesthesia and/or risk of damage to the spinal cord when performing the spinal anaesthesia. This is also true for newborns that have a more caudal extension of the dura compared to adults.
Caudal anaesthesia is the oldest and still most commonly used technique of epidural blockade in children. It is performed via the sacral hiatus, through the sacrococcygeal membrane. Caudal anaesthesia considerably decreases stress hormone response to surgery.
The reason for the widespread use of this block both by the fulltime paediatricanaesthetist, as well as those undertaking occasional paediatric cases, is that caudal neuroaxial block can be used for most of the operations that make up the large bulk of every day paediatricanaesthesia (e.g. inguinal hernia repair, hydrocoele, orchidopexy, circumcision, orthopedic interventions on the lower limb, anorectal procedures) and can also be used for certain types of abdominal surgery.
Multiple studies showing DPNB to be effective in reducing behavioral and physiologic markers of pain and stress following circumcision were published.Nowadays DPNB became one of the most popular methods used for reducing pain in children undergoing circumcision, because it can be easily learned and performed by health care providers.
EMLA Cream 5% (lidocaine 2.5% and prilocaine 2.5%) is an emulsion in which the oil phase is a eutectic mixture of lidocaine and prilocaine in a ratio 1:1 by weight. This eutectic mixture has a melting point below room temperature and therefore both local anaesthetics exist as liquid oil rather than as crystals. It is packaged in 5 gram and 30 gram tubes.
EMLA Cream should be applied to intact skin under occlusive dressing for at least an hour to provide dermal analgesia, which is achieved by release of lidocaine and prilocaine from the cream into epidermal and dermal layers of the skin and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings. Lidocaine and prilocaine are amide-type local anaesthetic agents. Both lidocaine and prilocaine stabilize neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anaesthetic action.
The aim of this work was to compare the efficacy of caudal analgesia, dorsal penile nerve block and EMLA cream for postoperative analgesia in children undergoing circumcision.
The present study was carried out on ninety children aged between 2-5 years old ASA physical status I and II in Elshatby University children Hospital scheduled for circumcision surgery under general anaesthesia. Postoperative pain was assessed using an objective pain score. This score uses five criteria: systolic blood pressure, crying, movement, agitation and localization of pain. Each criterion scores from 0–2 to give a possible total score of 0–10. By the use of closed envelop technique; they were randomly categorized into three equal groups (thirty each): Group I: Children received a caudal injection of 0.25% bupivacaine 0.75 mL/kg.
Group II: DPNB using 0.2 mL/kg patients received 0.5% plain bupivacaine without adrenaline. Group III: 2–4 g of EMLA cream was administered with a syringe to the distal half of the penile skin.
Patients with a history of allergic reactions to local anaesthetics, bleeding diathesis, neurological or spinal diseases, recent ingestion of sulfonamides or nitrites, congenital or idiopathic methemoglobinemia, and atopic dermatitis were excluded from the study.
Heart rate, mean arterial blood pressure and arterial oxygen saturation was recorded at the following times: pre-induction, post-induction, at starting surgical manipulation every 10 minutes interval for 30 min and then every 30 min in the post operative period for 4 hours.
There was no statistically significant difference among the three groups as regard the patients’ age in years and their weights.
As regards heart rate, there was no statistically significant difference between the three groups at the pre induction period and the post induction period.
But with the start of surgical manipulation and throughout the surgery as well as postoperatively; the heart rate among group I showed a statistically significant difference with group II, as well as with group III. Also the heart rate among group II showed a statistically significant difference with group III.
As regards the mean arterial blood pressure, there was no statistically significant difference between the three groups at the pre induction period and the post induction period.
But with the start of surgical manipulation and throughout the surgery as well as postoperatively; the mean arterial blood pressure among group I showed a statistically significant difference with group II, as well as with group III. Also the mean arterial blood pressure among group II showed a statistically significant difference with group III.
The comparison of arterial oxygen saturation readings between the three studied groups showed no statistically significant difference. Clinically none of the patients in the three groups developed significant change.
Pain scoring using Objective Pain Scale (OPS) in the three studied groups reveals:Thirty minutes postoperatively, the recorded OPS in the three studied groups was zero. One hour postoperatively, OPS in the three studied groups showed no statistically significant difference. Starting from one and half hour postoperatively up till 210 minutes postoperatively, OPS in group I showed a statistically significant difference versus group II, as well as versus group III. But at the time of four hours group I showed no statistically significant difference versus group II or group III.Group II showed a statistically significant difference against group III Starting from one and half hour postoperatively up till four hours.
By comparing the number of doses of paracetamol used there was a statistically significant difference between the three groups.
Group I showed a statistically significant difference as regard the number of doses of paracetamol when compared to group II, as well as when compared to group III.Also there was a statistically significant difference between group II and group III in the number of doses of paracetamol used.
By comparing the three groups, a statistically significant difference was found among them as regard the duration of analgesia.Group I showed a statistically significant difference as regard the duration of analgesia when compared to group II, as well as when compared to group III.Also there was a statistically significant difference between group II and group III in the duration of analgesia.
There was no statistically significant difference among the three groups as regards the duration of the operation.
In all three groups, no technical difficulties, no major complication after any procedure was noted. No edema, hematoma, postoperative agitation, motor block, or urinary retention were seen in either group. Only minor bleeding occurred in one patient after performing penile block and it resolved with simple compression. As regards the surgical technique no sever bleeding occurred during surgery.