When it comes to paediatric perioperative care, postoperative pain management is essential for improving patient comfort, speeding recovery, and lowering the risk of complications. Children whose pain is not well managed may experience heightened anxiety, disturbed sleep, postponed mobility, lengthened hospital stay, and adverse psychological effects that may last long after surgery has ended. Hence, in paediatric surgery, the use of an effective and safe analgesic method is crucial [1, 2].

Because of developmental disparities in pain perception, communication, and physiological reactions, assessing and managing pain in children is a challenging task. Nausea, vomiting, respiratory depression, sedation, and delayed recovery are some of the potential side effects of systemic analgesics such paracetamol, opioids, and nonsteroidal anti-inflammatory medications (NSAIDs) that are commonly used to control postoperative pain. As a result, multimodal analgesic treatments that use regional anaesthesia techniques have been gaining popularity for the purpose of enhancing postoperative outcomes with less systemic medication exposure [3-5].

When it comes to regional anaesthesia, the caudal epidural block is a popular choice for paediatric patients having procedures on their lower limbs, urogenital areas, perineal areas, or lower abdominals. By inserting a local anaesthetic into the sacral hiatus and into the caudal epidural region, this method blocks the roots of the sacral and lower lumbar nerves, thus relieving pain. It has been standard practice to use anatomical landmarks to perform caudal blocks; nevertheless, individual differences in anatomy can raise the likelihood of complications, failed or incomplete blocks, and other problems [6, 7].

For children experiencing pain after surgery, intravenous (IV) analgesia is still the go-to choice due to its quick start of effect and convenience of administration. Injections of paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioid pain relievers are common. Although effective, intravenous analgesia typically only alleviates pain for a shorter period of time and may necessitate additional doses or rescue drugs. In addition, respiratory depression, vomiting, nausea, pruritus, and urine retention are some of the side effects that may occur with opioid-based analgesics, especially in younger children [8, 9].

Elective lower limb and abdominal procedures in children necessitate pain management strategies, and this study aimed to assess the relative merits of intravenous analgesia, ultrasound-guided caudal epidural blocks, and other options. Finding the best method for controlling postoperative pain in children required measuring postoperative pain scores, duration of analgesia, rescue analgesic requirements, and side events linked to both approaches [10, 11].

This prospective randomized comparative study was conducted at the Department of Anesthesia, PSP Medical College Hospital and Research Institute, Kanchipuram Main Road, Oragadam, Panruti, Kancheepuram, Tamil Nadu between March 2024 to January 2025. A total of 30 pediatric patients scheduled for elective surgery under general anesthesia were enrolled in the study. The purpose of this study was to evaluate the relative merits of intravenous (IV) analgesia and ultrasound-guided caudal epidural blocks in alleviating postoperative pain in children having elective procedures on their lower limbs or abdomens. Before the study began, the researchers got approval from the Institutional Ethics Committee. All participants' parents or legal guardians gave their signed informed consent. Anesthetic Technique: Standardised general anaesthesia was administered to all patients in accordance with institutional protocols. After the anaesthesia was induced, participants in Group C were led to the sacral hiatus with a high-frequency linear transducer to guide the placement of the needle during the ultrasound-guided caudal epidural block. A dose of 1 mL/kg of 0.25% bupivacaine was given. As per the usual hospital practice, patients in Group I were given intravenous paracetamol (15 mg/kg) as a postoperative analgesic and at the conclusion of surgery. When necessary, intravenous tramadol (1 mg/kg) was given as a rescue analgesic. Outcome Measures: Postoperative pain intensity, as measured by FLACC scores, was the main outcome measure. The duration of analgesia, the incidence of adverse events, and the demand for rescue analgesic were included as secondary outcome measures. Inclusion Criteria: 1. Children aged 2–12 years. 2. American Society of Anesthesiologists (ASA) physical status I or II. 3. Scheduled for elective lower abdominal, inguinal, urological, perineal. 4. Patients undergoing surgery under general anesthesia. 5. Written informed consent obtained from parents or guardians. Exclusion Criteria: 1. Refusal of parental or guardian consent. 2. Known allergy or hypersensitivity to local anesthetics. 3. Coagulation disorders or ongoing anticoagulant therapy. 4. Infection at the site of caudal block injection. 5. Congenital spinal abnormalities or neurological disorders. 6. Severe systemic disease. 7. Developmental delay interfering with pain assessment. 8. Incomplete data collection or protocol violation. Statistical Analysis: Data were entered into Microsoft Excel and analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages.A p-value < 0.05 was considered statistically significant. The effectiveness of analgesic techniques was evaluated by comparing pain scores, duration of analgesia, rescue analgesic requirements, and incidence of adverse events between the two groups.

A total of 30 pediatric patients were enrolled and completed the study, with 15 patients in the Ultrasound-Guided Caudal Epidural Block Group (Group C) and 15 patients in the Intravenous Analgesia Group (Group I). There was little difference between the two groups in terms of demographics and surgical features. In comparison to patients given intravenous analgesia, those who underwent an ultrasound-guided caudal epidural block reported far less postoperative pain, a longer duration of analgesia, and a decrease in the need for rescue analgesics.

Table 1: Demographic and Surgical Characteristics of the Study Population

Both groups had similar demographic and surgical baselines, as shown in Table 1. Age, weight, gender distribution, and surgery time were not significantly different across the groups (p > 0.05), suggesting that both groups were similar before.

Table 2: Comparison of Mean FLACC Pain Scores between Groups

The results of the FLACC pain scale after surgery are shown in Table 2. Compared to children given intravenous analgesia, those who underwent an ultrasound-guided caudal epidural block reported far less discomfort during all postoperative evaluations. It wasn't until the first twelve hours after surgery that the difference became apparent.

Table 3: Analgesic Outcomes in the Study Groups

The analgesic effects of the two groups are compared in Table 3. Analgesia after surgery was prolonged and rescue medicine was postponed with an ultrasound-guided caudal epidural block. In addition, compared to Group I, significantly fewer patients in Group C needed rescue analgesics.

Table 4. Postoperative Adverse Events

These are the unfavourable occurrences that occurred after the operation, as shown in Table 4. While both groups had a low incidence of problems, children given IV analgesia were more likely to experience nausea and vomiting. The safety of the procedure was supported by the fact that no block-related problems were observed in the group who underwent an ultrasound-guided caudal epidural block.

Inadequate analgesia can cause physiological stress, slowed recovery, extended hospitalisation, and severe behavioural repercussions; thus, effective surgical pain control is an essential part of paediatric perioperative treatment. In this study, researchers looked at the effectiveness and safety of two methods for managing postoperative pain [12], ultrasound-guided caudal epidural blocks and traditional intravenous (IV) analgesia, in children having elective procedures on their lower limbs or abdomens. Compared to intravenous analgesia, the results showed that an ultrasound-guided caudal epidural block gave far better postoperative analgesia, a longer pain-free period, and fewer rescue analgesic needs [13, 14]. Differences in postoperative outcomes were mainly caused by the analgesic strategy used, since both groups were similar in terms of age, weight, gender distribution, and length of operation in the current study. The validity of the observed results is strengthened and the influence of confounding variables is minimised by this comparison [15]. The group that received the caudal epidural block had far lower FLACC pain levels after the operation, which was a major finding. The duration of action of bupivacaine supplied thru the caudal route is projected to be 12 hours after surgery, which is consistent with the superior pain control that children experiencing ultrasound-guided caudal analgesia reported throughout the first 12 hours postoperatively. These results corroborate earlier research showing that local anaesthetics inhibit nociceptive transmission from the surgical site more effectively than systemic meds, leading to better analgesia [16-18]. The positive results seen in this investigation were probably helped along by the utilisation of ultrasound guidance. Because of differences in anatomy, traditional landmark-based caudal epidural methods could lead to improper needle placement, ineffective blocks, or insufficient analgesia. Procedure precision and block success rates are both enhanced by ultrasound's ability to show the sacral hiatus, needle path, and local anaesthetic dissemination in real time. Further demonstrating the safety benefits of ultrasound-guided regional anaesthesia, the current investigation found no block-related problems [19-21]. Consistent with other studies, this one found that caudal epidural analgesia was effective in alleviating pain in children. When compared to systemic analgesic regimens, patients who had caudal blocks had less complaints of pain, a longer duration of analgesic effects, and a decreased need for opioids following surgery. The technique's dependability and safety have been enhanced with the addition of ultrasound guidance, giving it a promising choice for the management of postoperative pain in paediatric patients [22-24].

In children having elective procedures on the lower limbs or abdomen, an ultrasound-guided caudal epidural block was found to be a safer and more effective alternative to intravenous analgesia for postoperative pain control. It prolonged analgesia, decreased the requirement for rescue analgesics, and considerably decreased postoperative pain scores. There were also few side effects and no block-related problems linked to the method. Consequently, compared to traditional intravenous analgesia, ultrasound-guided caudal epidural blocks provide better pain control and faster recovery for children undergoing surgery.

Funding

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Conflict of Interest:

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1. Polaner DM, Taenzer AH, Walker BJ, Bosenberg AT, 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. Anesth Analg. 2012;115(6):1353–1364.
2. Suresh S, Ecoffey C, Bosenberg A, Lonnqvist PA, de Oliveira GS Jr, de Leon Casasola O, et al. The European Society of Regional Anaesthesia and Pain Therapy/American Society of Regional Anesthesia and Pain Medicine recommendations on local anesthetics and adjuvants dosage in pediatric regional anesthesia. Reg Anesth Pain Med. 2018;43(2):211–216.
3. Tsui BCH, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and adolescents: a review of current literature and its application in the practice of extremity and truncal blocks. Anesthesiology. 2010;112(2):473–492.
4. Ivani G, Suresh S, Ecoffey C, Bosenberg A, Lonnqvist PA, Krane E, et al. The European Society of Regional Anaesthesia and Pain Therapy and the American Society of Regional Anesthesia and Pain Medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia. Reg Anesth Pain Med. 2015;40(5):526–532.
5. 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):721–732.
6. Beyaz SG, Tokgöz O, Tüfek A. Ultrasound-guided caudal epidural block in pediatric patients: a prospective randomized study. J Clin Anesth. 2011;23(5):357–362.
7. Willschke H, Bösenberg A, Marhofer P, Johnston S, Kettner SC, Wanzel O, et al. Ultrasonography-guided caudal epidural blocks in children. Br J Anaesth. 2005;95(2):226–230.
8. Marhofer P, Willschke H, Kettner SC. Ultrasound-guided upper and lower extremity blocks in children. Paediatr Anaesth. 2005;15(11):937–942.
9. Lonnqvist PA. Adjuncts to caudal block in children—quo vadis? Br J Anaesth. 2005;95(4):431–433.
10. Suresh S, Wheeler M. Practical pediatric pain management. Anesthesiol Clin. 2014;32(1):1–19.
11. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293–297.
12. Voepel-Lewis T, Zanotti J, Dammeyer JA, Merkel S. Reliability and validity of the FLACC behavioral tool in assessing acute pain in children. Pediatr Nurs. 2010;36(2):55–61.
13. Splinter WM, Bass J, Komocar L. Regional anesthesia and postoperative analgesia in children. Can J Anaesth. 1999;46(11):1064–1068.
14. Kokki H. Current management of pediatric postoperative pain. Expert Rev Neurother. 2004;4(2):295–306.
15. Howard RF. Current status of pain management in children. JAMA. 2003;290(18):2464–2469.
16. Tobias JD. Postoperative analgesia in children. Curr Opin Anaesthesiol. 2005;18(3):293–299.
17. Wolf AR. Tears at bedtime: a pitfall of extending paediatric day-case surgery without extending analgesia. Br J Anaesth. 1999;82(3):319–320.
18. Giaufré E, Dalens B, Gombert A. Epidemiology and morbidity of regional anesthesia in children. Anesth Analg. 1996;83(5):904–912.
19. Dalens B, Hasnaoui A. Caudal anesthesia in pediatric surgery: success rate and adverse effects in 750 consecutive patients. Anesth Analg. 1989;68(2):83–89.
20. Ivani G, Conio A, De Negri P, Lonnqvist PA. Spinal versus caudal anesthesia for minor pediatric surgery. Paediatr Anaesth. 2002;12(8):680–683.
21. Bosenberg AT, Kimble FW. Pediatric regional anesthesia and postoperative pain management. Anesthesiol Clin North America. 2000;18(4):859–882.
22. Willschke H, Marhofer P, Bösenberg A, Johnston S, Kettner SC, Wanzel O, et al. Epidural catheter placement in children: comparing ultrasound and landmark techniques. Anesthesiology. 2006;104(5):1001–1006.
23. Suresh S, Schaldenbrand K, Wallis B, De Oliveira GS Jr. Regional anesthesia to improve pain outcomes in pediatric surgical patients. Anesth Analg. 2014;119(3):702–708.
24. Chiaretti A, Pierri F, Valentini P, Russo I, Gargiullo L, Riccardi R. Current practice and recent advances in pediatric pain management. Eur Rev Med Pharmacol Sci. 2013;17(Suppl 1):112–126.