European Journal of Cardiovascular Medicine

Modern paediatric anaesthesia is incomplete without the use of regional anaesthetic techniques¹. Inguinal hernia repair is a commonly performed surgery in children. Management of pain after hernia repair surgery in children may be achieved by intraoperative opioids, regional anaesthesia and postoperative systemic analgesics. Various regional techniques involving Caudal block^2-5, paravertebral block, lumbar epidural block, combined ilioinguinal iliohypogastric nerve block^5-8, wound infiltration^2,7,9with local anaesthetic agents have been used with varied success for postoperative analgesia after inguinal surgery.

We compared the analgesic effects of caudal and ilioinguinal iliohypogastric nerve block using bupivacaine clonidine performed in children undergoing inguinal surgery. The ilioinguinal iliohypogastric nerve block provides excellent pain relief for operations on the inguinal region, including emergency procedures (e.g. strangulated inguinal hernia with intestinal obstruction).

AIMS AND OBJECTIVES

AIM of The Study was designed to compare the analgesic effect of USG guided ilioinguinal iliohypogastric nerve block versus caudal block using bupivacaine-clonidine in inguinal surgeries in children. 

OBJECTIVES 

• To compare the duration of postoperative analgesia by using Wong and Backer Faces Pain scale
• To compare first request of analgesia and 24 hours analgesia requirement.
• To compare degree of sedation (Ramsay sedation score)
• Complication if any.

With the approval of Hospital research ethical committee and informed and written consent, this study was conducted in Department of Anaesthesia and Critical Care of S.N. Medical College, Agra.

INCLUSION CRITERIA- ASA I and II ,No other systemic diseases .No difficult airway  Age more than 02 years less than 08 years of either sex 

EXCLUSION CRITERIA -Patients of age below 02 years and above 08 years , ASA III and above,Patients with pre-existing infection at the block site,coagulopathy, allergy to local anaesthetics, decreased pulmonary reserve, major cardiac disorders,Patients having head injury and psychiatric illness.

SAMPLE SIZE CALCULATION -Based on  previous studies we presume that pre-operative block was reduce 24 hr post-operative analgesic by 35 % (type I error 0.05 & power of 0.8). Patients was randomly allocated into two groups using computer generated random numbers.

GROUP C (CAUDAL BLOCK) which was included 35 patients, received Caudal block with 1ml/kg 0.25% bupivacaine with 0.5microgram/kg clonidine [15-16-17-18]

GROUP I (ILIOINGUINAL ILIOHYPOGASTRIC NERVE BLOCK) which was also be included 35 patients, received USG guided ilioinguinal/ iliohypogastric nerve block with 0.3 ml/kg 0.25% bupivacaine with 0.5 microgram/kg clonidine. [12] 

This prospective randomized study was conducted after approval from  Institutional Review board approval. 70 ASA class I-II children of age group 2 to 7 years taken for elective inguinal hernia repair surgery from the study population. Written informed consent was taken from the parents of the children. 

A detailed pre anaesthetic check-up was carried out in all the cases. Patients were randomly allocated by computer generated random tables to one of the two groups comprising 35 patients each group. In Group I, combined ilioinguinal iliohypogastric block was performed and Group C patients received caudal block. All children were premedicated with intranasal midazolam (0.3 mg/kg). After 20 minutes, the patient was taken to the operative room and standard monitoring devices (electrocardiogram, pulse oximetry and non invasive arterial blood pressure) were attached to the patient. infusion of 20.5% dextrose in Ringer (10 mL/kg/h) was commenced. 

After taking the baseline values, induction of anaesthesia was done by using propofol 3 mg/kg, and Injection fentanyl (2 µg/kg) was given intravenously and maintained with 1-1.5 % Isoflurane in O2 /N2 O (1 : 1) spontaneous breathing was permitted via a laryngeal mask airway (LMA) of appropriate size. 

Patient with group C (CAUDAL BLOCK)- received caudal block. The caudal block was performed with the child in the left lateral decubitus position. After insertion of a 23 gauge needle into caudal epidural space and negative aspiration for blood and cerebrospinal fluid, 1 ml/kg of 0.25% bupivacaine combined with 0.5μg/kg of clonidine was injected.

Patients with group I (ILIOINGUINAL /ILIOHYPOGASTRIC NERVE BLOCK)- were given combined USG guided ilioinguinal/ iliohypogastric block. The ilioinguinal/iliohypogastric nerve block was performed by insertion of a short bevelled needle at the junction of lateral 1/4 and medial 3/4 on the line drawn between anterior superior iliac spine and umbilicus. The needle was initially inserted perpendicular to the skin, then declined to 45-60° directed to the middle of the inguinal ligament, then slowly advanced until the aponeurosis of the external oblique muscle was traversed, after which the drug was injected. Local anaesthetic solution was 0.3ml/kg of 0.25% bupivacaine combined with 0.5μg/kg clonidine. 

Heart rate, non-invasive blood pressure and peripheral oxygen saturation (Spo2) were recorded after induction of anaesthesia, every 5 minutes intra-operatively and every 5 minutes in recovery room for one hour. After the surgery patients were transferred to the recovery room when they were sufficiently awake and capable of maintaining an open airway. 

In the recovery room and the ward, the children were under constant supervision by experienced paediatric nurses. Any pain experienced by the patients was treated with 20 mg/kg of rectal acetaminophen. The duration of post-operative analgesia was defined as the time interval between the block and the first dose of rectal acetaminophen. Post-operative analgesia was assessed by Wong and Backer Faces Pain scale, and intensity of pain was scored between 0 and 10. When patients' pain score was above 4, they received rectal acetaminophen. 

Statistical analysis Based on previous studies we presume that pre-operative block was reduce 24 hr post operative analgesic by 35 % (type I error 0.05 & power of 0.8) on this basis we was include 70 patients.  Patients were randomly allocated into two groups using computer generated random numbers. After counting the required information the data was classified tabulated and analyzed by using the various statistical method. SSPS version 23 was used for analysing the data.  The percentage, mean±SD standard deviation was used to express quantitative data Frequency and percentage were used to express Quantitative data. When comparing two means, the independent-sample t -test of significance was utilized. Applying chi-square (x²) test or Fishers exact test of significance was done to compare proportions between qualitative parameters. The confidence interval was set as 95%, while the acceptable margin of error was set at 5%.p value <0.05 were considered significant, p value <.001 were regarded as very significant, and p values >0.05 were considered as not significant.

70 patients were randomized into two with 35 patients in each group, Group C received Caudal Block, Group -I received IL & IH Block techniques. No Statistically significant difference was detected between two Group according to demographic data Age, Sex, Weight, ASA respectively as indication for surgery shown in TABLE 1,2,3. There was no difference in intraoperative Heart-Rate or Respiratory Rate between two Groups.  To compare the analgesic effect in both group in different time interval assess by wong and baker faces pain scale at 0,2,6,8,12,24 hours found group I was higher analgesic effect then group C shown in TABLE 4.

TABLE-1 :AGE DISTRIBUTION IN GROUP C AND GROUP I

TABLE-2: SEX DISTRIBUTION IN GROUP-C AND GROUP-I

TABLE 3: WEIGHT DISTRIBUTION IN GROUP -C AND GROUP-I

TABLE-4: COMPARISON OF ANALGESIC EFFECT IN GROUP C AND GROUP I BY WONG AND BAKER FACES PAIN SCALE AT DIFFERENT TIME INTERVAL

TABLE-5 : DURATION OF ANALGESIA, IN HOURS

The mean duration of Analgesia for the Group C was (13.26 ± 4.28) hours and Group I was (17.77 ± 4.92) hours, which was significant difference (p <0.05). Duration of analgesia significant higher in Group I then Group C shown in TABLE 5. 

The time for postoperative first request of analgesia was comparable between Group C where it was (8.63 ± 3.05) hours and Group I where it was (10.74 ± 5.04) hours, which was statistically significant (p <0.05).Time for first request of rescue analgesia much later in Group I as compared to Group C and this was statistically significant (P<0.05) shown in TABLE 6. 

Total dose of postoperative drug Rectal Acetaminophen 20 mg/kg was used in Caudal Block Group C was (459.26 ± 129.42) mg and USG II/IH Block was (336.57 ± 110.84) mg. Total dose of postoperative Rectal Acetaminophen in Group C was more than Group I  and this difference was statically significant(p<0.05) shown in TABLE7.

There was no difference found between two groups in terms of Degree of Sedation and Postoperative Nausea and Vomiting shown in TABLE 8,9.

TABLE-6: TIME REQUIRED FOR POST OPERATIVE FIRST REQUEST OF ANALGESIA IN GROUP C & GROUP I (HOURS) [USING RECTAL ACETAMINOPHEN 20 mg/kg]

TABLE-7:  TOTAL DOSE OF POSTOPERATIVE DRUGS REQUIRED IN GROUP C & GROUP I (IN MILLIGRAM)

TABLE-8: DEGREE OF SEDATION IN GROUP C& GROUP I BY RAMSAY SEDATION SCALE

TABLE-9 :  COMPLICATION IN GROUP C & GROUP I

Our study aimed to compare the postoperative analgesic efficacy of both groups undergoing inguinal surgeries in children 2-7 years under general anaesthesia.. Analgesia provided in both groups lasted for about 12-18 hours. In our study we found duration of analgesia by using Wong and Backer Faces Pain Scale was in Group I- (17.77±4.92) hours and Group-C (13.26±4.28) hours duration of analgesia was longer in theUSG-guided II/IH block with17.77±4.92 hours compared to 13.26±4.28 hours in the caudal block, this difference was statistically significant p<0.05.  A previous study compared analgesia provided by Caudal block to USG-guided II/IH block using 0.25% bupivacaine and found that the mean duration of analgesia for the caudal group was 4.8 hours and II/IH block was 5 hours, which was not statistically significant^[19]. The results of our study are supported by this study, although the duration of analgesia was significantly longer in both groups in our study. Our results are also supported by the study of Seyedhejazi et al^[10] in which they have compared the analgesic effect of caudal and II/ IH nerve blockade using bupivacaine-clonidine in inguinal surgeries in children and found the quality and duration of analgesia slightly more with ilioinguinal group when compared to caudal block group. In the study done by Abualhassan A. A.bdellatif^[13] in 2012, similar results were found as in our study in which duration of analgesia was higher with USG II/IH Block then Caudal block.  However in the study done by Caetano et al^[9] it was seen that the duration of postoperative analgesia in caudal epidural and II/IH blocks were comparable in children undergoing inguinal herniorrhaphy.^[34] Also in the study done by Fisher et al where they randomly assigned children who underwent orchiopexy to one of three groups at the end of surgery as follows: Caudal block with bupivacaine and 1:200,000 epinephrine (group I); bupivacaine alone (group II) andthe USG-guided II/IH nerve block with bupivacaine administered through the wound by the surgeon (group III). They reported no differences in the number of patients without pain for more than 4 hours or those requiring analgesics by 24 hours^[14].

In our study the average time for first request of postoperative analgesia was longer in Group I 10.74±5.04 hours as compared to 8.63±3.05 hours in the Group C, which was statistically significant with ( p<0.05). The study conducted by A.bualhassanet^[13] al supported our study. They also found that the duration of analgesia was longer with USG-guided II/IH block than blind caudal analgesia. The average time for request for first rescue analgesia was also longer in the USG-guided II/IH block with 253±102.6 min as compared to 219.6 ± 48.4 min in the caudal group, although this difference was not statistically significant. Our study was also supported by the study done by Abdellatif comparing Ultrasonography guided ilioinguinal block and caudal block where it was found that there was a difference in the doses of post-operative pain rescue medication administered to the studied groups. Mean number of rescue analgesia required in ilioinguinal block was 0.65 which was lower as compared in caudal block group where it was 0.74. In contrast to Year 2014 Daryoush Sheikhzadeh1et al^[12] conducted a study in which in Group C, 7 / 34 and in Group I 12/33 patients required post-operative analgesia (P = 0.174). Five patients (15.5%) in group I and one patient (2.94%) in group C had severe pain after operation. In this study duration of analgesia was much shorter in both the groups and the request of first dose of rescue analgesia was also much early in both the groups.

 In our study, Group I required lower dose of postoperative analgesia (Rectal Acetaminophen 20 mg/kg) was 336.57±110.84 mg than those in Group C 454.29±129.42 mg, which was significant (p<0.05).In contrast to our study another study showed a significant difference in the duration of post-operative analgesia and the requirement for subsequent analgesia between two techniques. Subjects in group I required greater doses of post-operative analgesia then group C (P < 0.05) ^[20].

In comparison to caudal block, the USG-guided II/IH block was thus more effective in terms to quality and duration of postoperative analgesia, postoperative first request of analgesia, total dose of postoperative analgesic drug requirement..

1. Miller RD, Erikson LI, Flewasher LA, Jeanine P, Kronwash W, Young WL. Miller's Anaesthesia. 7 th ed. Churchill Livingstone; 2010. p. 1691-92, 2519-57 and 2757-81.
2. Wasiams RK, Adams DC, Aladjem EV, Kreutz JM, Sartorelli KH, VaneDW,etal. The safety and efficacy of spinal anaesthesia for surgeryinfants: The Vermont Infant Spinal Regwastry. AnesthAnalg 2006; 102:67-71.
3. Seyedhejazi M, Zarrintan S. Evaluation of caudal anaesthesia performed iconscious infants for lower abdominal surgeries. Neurosciences (Riyadh) 2008; 13:46-8.
4. Lönnqvwast PA, Morton NS. Postoperative analgesia in infants and children. Br J Anaesth 2005; 1:59-68.
5. Johr M. Regional techniques for paediatric day surgery.[Pediatri.c
6. Blocks 2000;4:38-44. ].
7. BERNARD DALENS. Regional anaesthesia in infants, children
8. and adolescents: 1995; first edition pg 113.
9. Mirjalili SA (2015) Chapter 45 - Anatomy of the Lumbar Plexus.
10. In: Nerves and Nerve Injuries, edited by Tubbs RS, Rizk E, Shoja M, Loukas M, Barbaro N, et al. (Eds.), Academic Press, San Diego, 609-617.
11. Eichenberger U, Greher M, Kirchmair L, Curatolo M, Moriggl B (2006) Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dwassection. Br J Anaesth 97: 238-243. [Crossref]
12. Caetano AM, Falbo GH, Lima LC. Comparwason among three
13. techniques of postoperative regional analgesia with ropivacaine in children. Rev Bras Anestesiol2006;56:561-70.
14. Cook B, Grubb DJ, Aldridge LA, Doyle E. Comparison of the effects of adrenaline, clonidine and ketamine on the duration of caudal analgesia produced by bupivacaine in children. Br J Anaesth. 1995;75:698–701.
15. iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dwassection. Br J Anaesth 97: 238-
16. 24[Crossref]
17. Seyedhejazi M, Sheikhzadeh D, Adrang Z, Rashed FK. Comparing the analgesic effect of caudal and ilioinguinal iliohypogastric nerve blockade using bupivacaine-clonidine in inguinal surgeries in children 2-7 years old. African Journal of Paediatric Surgery. 2014 Apr 1;11(2):166.
18. Abulhassan Abdellatif                   Ultrasound guided ilioinguinal/iliohypogastric nerve blocks versus caudal block for postoperative analgesia in children undergoing unilateral groin surgery. Saudi J Anaesth2012;6:367‑72
19. Fwasher QA, McComwaskey CM, Hill JL, Spurrier EA, Voigt RE, Savarese AM, et al. Postoperative voiding interval and duration of analgesia following peripheral or caudal nerve blocks in children. AnesthAnalg1993;75:173-7.
20. Moores MA, Wandless JG, Fell D. Paediatric postoperative analgesia A comparwason of rectal diclofenac with bupivacaine after inguinal herniotomy.Anaesthesia.1990 FEB;45(2):156-8.
21. Busoni P, Andreucetti T. The spread of caudal analgesia in children: A mathematical model. Anaesthesia Intensive care.1986; 14:140-144.
22. Takasaki M, Dohi S, Kawabata Y, Takayashi T. Dosage of lignocaine for caudal anaesthesia in infants and children. Anesthesiology 1977; 47: 527 – 529.
23. Armitage En. Regional anaesthesia in paediatrics. Clinical
24. Anesthesiology. 1985: 3;553-568.
25. Ravi T, Kumar ND, Kumar BS. Ultrasound guided nerve block versus caudal block for post‑operative analgesia in children undergoing unilateral groin surgery. Int Arch Integr Med 2016;3:115‑25.
26. 20          Saadawy I, Boker A, Elshahawy MA, Almazrooa A, Melibary S, Abdellatif AA, et al. Effect of dexmedetomidine on the
27. characteristics of bupivacaine in a caudal block in paediatrics. Acta AnaesthesiolScand2009;53:251‑6.