Pain is a distressing feeling caused by intense or damaging stimuli. The International Association for the Study of Pain's widely defines pain as - "An Unpleasant Sensory and Emotional Experience Associated with Actual Or Potential Tissue Damage, Or Described In Terms Of Such Damage." (1)

   Pain is the way our body lets us know there is something wrong. It is not a disease or an injury; it is a symptom of a disease, illness or physical damage. Pain has physical, mental and physiological effect on individual. It is one of the most misunderstood, under-diagnosed and untreated medical problem.

Children suffer pain in the same way as adults. But a child’s pain not only influences the child, instead entire family is affected. Although children are unable to describe the pain or their subjective experience, but in response to pain they show behavioural, psychological and social changes. Therefore, because of their lack of ability to communicate verbally, it has become very challenging to assess their pain, (particularly in small children). Currently different pain scales are used for assessment of pain but they may be too abstract for them. This is why, in smaller children different face-scales have become popular.

Childs response to pain depends upon his cognitive   ability,   his   trust   on care givers   and   previous   painful experiences. And also the family response to the stress of a child’s pain will influence his response to pain.

It has been observed that there is increase in the number of minor surgeries in children, due to various indications. Surgical trauma during these surgeries leads to significant intra operative and post-operative pain.  This  painful stimulation without any ‘proper analgesia’ will not only cause unacceptable  pain at   the   time   of   the  intervention  but   will  produce   a  ‘pain  memory’ for long  period following  the  surgery.(2-4) Therefore, appropriate pain management is  of  great  importance  when  dealing with children, because the way the children are treated will influence how they deals the pain for rest of their life. Along with this optimal pain management (intra operative as well as post-operative) will improve outcome of surgical procedure, hasten the recovery, facilitate early mobilization and return to daily living of children.

The  relief  of  perioperative pain  has  been  the fundamental  aspect  of  the  practice  of  Anaesthesiology.  The  main  role  of the  Anaesthesiologist  is  to  enable  patients  to undergo  surgical  and other painful procedures without pain or distress. Various multimodal techniques for paediatric pain relief in intra operative period have been designed like systemic analgesia, peripheral nerve blocks, epidural analgesia and topical analgesia.

Post-operative pain differs from other types of pain, as it is iatrogenic and is usually transitory. The traditional management of post-operative pain namely that of prescribing a standard dose of intramuscular or intravenous opioids, or other analgesics on demand, when patient’s threshold has been exceeded leads to poor control of pain. To avoid this insignificant treatment in paediatric patient, various pharmacological agents and analgesic delivery systems have been employed.

 Among all regional analgesia, caudal epidural technique has come out as one of the most popular, reliable, safe and easy to administer technique. It is therefore the commonly performed procedure for intraoperative and postoperative analgesia especially for sub umbilical surgeries in young children.

Caudal block since its first description in 1933 for paediatric urological interventions has evolved to become the most popular regional anaesthetic technique for use in children.(5) Caudal block is performed in children undergoing surgery at the lumbosacral to midthoracic dermatome levels with anticipated moderate- to-severe perioperative and postoperative pain (6) .It suppresses neurohumoral response to surgery, accelerates recovery and enhances postoperative pain control. Because of decreased perioperative and postoperative analgesic requirements (which are the most important advantages of this technique) caudal anaesthesia is commonly used in paediatric surgery for urological and lower abdominal procedures. As lower abdominal, genito-urinary and lower limb surgeries are generally associated with considerable intraoperative and post-operative pain of long duration(7-8).

To assess Post-operative pain relief with caudal epidural block in paediatric age group by using injection bupivacaine 0.25% or injection ropivacaine 0.25%. The present study was carried out in 60 patients. Inclusion criteria: • Elective cases of ASA Grade I and II • Age group 1-8 years • Patients undergoing infraumbilical procedures. Exclusion criteria: • The patients with Cases of ASA Grade III or IV • Emergency procedures • Patients with congenital anomaly • Surgery above the umbilicus • Surgery which lasted for more than 60 minutes Group division: The children were allocated into two groups of 30 patients each by Systematic Samling method as patients come in Monday, Wednesday and Friday is “R” group and Tuesday ,Thursday ,and Saturday is “B” group. Where in group R inj. ropivacaine & group B inj. bupivacaine was given respectively Group B: Patients in this group received 1ml/kg 0.25% Bupivacaine caudally. Group R: Patients in this group received 1ml/kg of 0.25% Ropivacaine caudally. The patients had undergone pre-anaesthetic checkup as per the departmental protocol in relation to history and investigations. A written informed consent was obtained from the parents after they were informed about the procedure to be performed, to give post operative analgesia for their children. Anaesthetic procedure: All children were kept fasting for 6 hours. They were received by an anaesthesiologist inside the premedication room half an hour before surgery and the children were premedicated with i.v. Glycopyrrolate 0.01 mg/kg , i.v. Midazolam 0.05 mg/kg, and inj. ondansetron 0.08mg/kg after securing an i.v. line. After premedication, they were shifted inside the operating room for surgery where baseline cardio-respiratory parameters (NIBP, pulse rate and SpO2) were recorded. Statistical analysis Data obtained was compiled systematically and a master chart was prepared. Statistical analysis was done after consultation with statistician. The tests employed in my study are - Categorical variables were numerically coded and distributed in frequency and percentage. Difference of frequency distribution between two treatment groups was analyzed using Chi square.

TABLE 1:  SHOWING TYPES OF SURGICAL PROCEDURES

TABLE 2:  SHOWING DURATION OF ANALGESIA

Duration of analgesia in group B (0.25%  Bupivacaine) ranged from 180-540 min with mean duration of 328.2 min and in group R (0.25% Ropivacaine) ranged from 180-480 min with a mean duration of 343.8 min. The p value between the two groups is <0.05 i.e. 0.429 which indicates a significant difference in post-operative analgesia duration between the two groups.

TABLE 3: SHOWING DURATION OF MOTOR BLOCKADE

Duration of motor block in group B (0.25% Bupivacaine) ranged from 120 – 180  minutes with mean duration of  158±25.8 minutes and in group R (0.25%Ropivacaine) ranged from 90 – 180 minutes with a mean duration of 99±21minutes. The p value between the two groups is <0.0001 which indicates highly significant difference between the two groups regarding duration of motor block.

TABLE 4: SHOWING DURATION OF SENSORY BLOCKADE

Duration of sensory block in group B ( Bupivacaine) ranged from 60-120 min with mean duration of  82.2±21 min and in group R (Ropivacaine) ranged from 60–90 min with a mean duration of 78±22.8min. The p value between the two groups is >0.05 which indicates there is no significant difference between the two groups regarding duration of motor block.

TABLE 5:  SHOWING POST OPERATIVE FLACC SCORING CHART

Our study has demonstrated significant difference in duration of motor blockade between the two groups (having significant P-value i.e < 0.05) with mean duration of motor blockade for Group B is 158±25.8min, which is statistically significantly higher if we compare it to group R i.e 99±21min.

Study also showed statistically non-significant difference in duration of sensory blockade between two groups with mean duration of 82.2±21min and 78±22.8min for group B and group R respectively.

Post operative analgesia time for group B is 328.2±82.8min and for group R analgesic time is 343.8±72min, which is statistically insignificant.

Pain is consistent and predominant complain of most individuals in post-operative period. “Failure to relieve pain is morally and ethically unacceptable.” Postoperative pain is commonly acute in nature and that should be treated adequately to decrease morbidity as well as hospital stay. The problem of post-operative pain receives attention of anaesthesiologist in last few years (9). The past decade has witnessed many advances in the understanding and treatment of pain in children. Regional anaesthetic technique such as caudal block has proven effective in controlling postoperative pain. Local anaesthetic agents like bupivacaine, ropivacaine & lignocaine have been extensively used for regional anaesthesia in adults and children(10). In our prospective study we had taken 60 paediatric patients posted for below umbilical surgery who comes under inclusion criteria. They were divided into two groups (30 patients each) and after taking written informed consent, group B and group R were given caudal block by using inj. bupivacaine 0.25% and inj. ropivacaine 0.25% respectively(11). A double blind study over 30 patients of ASA grade I and II. Patient was randomly divided in two groups (15 each), one group received 0.25% bupivacine and another group received 0.25% ropivacaine via caudal route. Study showed there was no statistically significant difference in quality and duration of analgesia between them. However degree of motor block was statistically less significant in ropivacaine group. Result correlate with our study but we used high dose (i.e.1ml/kg), compare to them (i.e. 0.75 ml/kg )(12). A randomised prospective controlled study over 60 patients of age between 1-12 years by single shot caudal block using 1ml/kg of bupivacaine 0.25% or ropivacaine 0.2% and compare duration of analgesia, motor and sensory block. They concluded ropivacaine provides better postoperative analgesia and provide significantly less motor blockade which is similar to our study(13). A prospective randomized controlled study over 50 patients of age group between 1-10 years. They compare Caudal bupivacaine 1ml/kg 0.25% and ropivacaine 1ml/kg 0.25% in paediatric patient along with general anaesthesia for below umbilical surgeries and concluded duration of analgesia is more to bupivacaine group compare to ropivacaine also motor block by ropivacaine was significantly less compare to bupivacaine which is similar to our study however general anaesthesia was not given in our study and intaoperative spontaneous ventilation was maintained to prevent any airway complications(14).

The incidence of post-operative pain in paediatric age group not only associated with major surgeries but also in minor surgeries. Postoperative pain is an acute pain and should be treated adequately to decrease morbidity and hospital stay so it is the duty of anesthesiologist to relief not only intra operative pain but also postoperative pain in paediatric patients. There for we conducted this study and found that postoperative pain relief is better with ropivacaine than Bupivacaine in caudal epidural block.

In future, further studies can be done by using different local anaesthetic agents in regional analgesia for better post-operative pain relief not only in paediatric age group but also in neonates and infants.

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