الفهرس 
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Abstract
Regional anesthesia is mainly used to provide postoperative analgesia. Prophylactic analgesia with local anesthetics is an attractive concept, especially in pediatric practice, because the evaluation of pain can be very challenging in young children. In contrast to opioids, local anesthetics can be administered safely, and in recent guideline,regional anesthesia is accepted as the cornerstone of post-operative pain relief in the pediatric patient.
The current study was designed to compare between anesthesia with intrathecal bupivacaine, intrathecal bupivacaine plus dexmedetomidine and caudal bupivacaine in 63 children (ASA I) of age 1-5 years old undergoing lower abdominal, orthopedic and urologic surgeries. Patients were randomly assigned into one of threegroups with 21 patients in each. Patients in group I were given intrathecal bupivacaine only in a dose of 0.4mg/kg hyperbaric bupivacaine 0.5%, patients in group II were given anesthesia with intrathecal bupivacaine plus dexmedetomidine in a dose of 0.4mg/kg hyperbaric bupivacaine 0.5% with 0.25mcg dexmedetomidine for every 1 mg bupivacaine whereas group III were given caudal anesthesia with bupivacaine in a dose of 3 mg/kg hyperbaric bupivacaine 0.5% .
The primary outcome measures from this study were duration of analgesia postoperatively (the time from the block to the first dose of analgesia or Observed painScore (OPS) ≥12) and the total consumption of analgesics, whereas the secondary outcome measures wereonset of block(the time from performing theblock till recording sensory loss using pin prick method and motor loss was recorded by modified Bromage scale), level of block,the effect on hemodynamics and ocurrence of any complication.
The results were; the first time to require analgesia, and total analgesic consumption of paracetamol suppositories in 24 hours, group II showed a statistically significant increase in time to first analgesic dose and a statistically significant decrease in the total analgesic consumption than group I. Duration of analgesia was longer with caudal 118.57±8.38 minutes than intrathecal bupivacaine only (89.42 ± 7.09 minutes) &(102.67 ± 9.84 minutes) with bupivacaine+dexmedetomidine. onset of sensory block in caudal block(groupIII) was delayed than intrathecal blocks that was 8.41±1.19 minutes in caudal, 2.85±0.64 minutes in intrathecal block with bupivacaine only(group I) & 3.19±0.37 minutes in intrathecal block with bupivacaine +dexmedetomidine (group II), the onset of the sensory block was earlier in group IIcompared to group I and III, time to Bromage 3 showed no significant difference between group I and II but both showed statistically significant decrease in time than group III, the level of anesthesia in both intrathecal blocks reached T4 and the level of anesthesia in caudal block reached T6, with limited variations inside each group
The changes in systolic, diastolic and mean blood pressures were minimal. Heart rate was kept at normal range. Respiratory rate and pulse oximetry did not show significantchanges.
As regards complications, only one patient had post spinal headache, four patients experienced nausea and vomiting, and four patients had bradycardia treated with atropine 0.01 mg/Kg. Bradycardiaoccurred in 3 cases in group II compared to one of the study patients in the group I and none in group III. 3 (21.4%) patients developed hypotension starting from 20 minutes following the spinal injection in group I, versus 4(44.4%) in group II. Shivering occurred in 7 patients in the group I, and in no patients in group II or III. No local infections, no intraoperative apnea and no inadequate or failed block had ocurred.
We concluded that the described techniques were used very successfully. These techniques (intrathecal blocks and caudal block) were safe, cost-effective, technically feasible and had different indications depending on the type and duration of surgery or the need of short or long postoperative analgesia. They reduced the need for postoperative narcotics which is useful in some of the sickest and smallest children. If both techniques (intrathecal block and caudal block) were correctly used and the anatomy of the patient was normal, there would be minimal risk of perforation of the dura when using caudal anesthesia and/or risk of damage to the spinal cord when performing the spinal anesthesia.
Our study showed that the use of intrathecal dexmedetomidine as an adjuvant to bupivacaine provides earlier sensory and motor blockade, less postoperative analgesic requirements and less shivering among patients with no neurologic complications.
As anesthetist became more experienced, regional anesthesa became a preferred choice either alone or as a part of balanced technique in children undergoing elective surgeries, rather than just as an alternative in the high-risk pediatric patients.