T Ravi N Dheeraj Kumar Bhrungi - PDF document

T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 115 Original Research Article Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery T. Ravi 1* , N. Dheeraj Kumar 1 , Bhrungi Shireesh Kumar 2 1 Assistant Professor, 2 Post Graduate Department of Anesthesiology, Gandhi Medical College, Secunderabad, India * Corresponding author email: drtravi@yahoo.com International Archives of Inte g rated Medicine, Vol. 3, Issue 9 , September , 201 6 . Copy right © 2016 , IAIM, All Rights Reserved. Available online at http://iaimjournal.com/ ISSN: 2394 - 0026 (P) ISSN: 2394 - 0034 (O) Received on: 18 - 0 8 - 201 6 Accepted on: 30 - 0 8 - 2016 Source of support: Nil Conflict of interest: None declared. How to cite this article: T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 201 6; 3 ( 9 ): 115 - 125. Abstract Background: P a in is a n u n p l ea s a n t s ub je c ti v e s en s a ti o n w h ich c a n on ly b e e x pe r i en c e d an d no t e x p ress ed , e s pe cially in c h i l d re n . T h e p r im a ry re a s o n to t r ea t o r p re v en t pa in is h u m a n it a r i a n . Aim and o bjectives: To a ss e ss U l tras o un d G u id e d Il i o in g u in a l / I l i oh y po g a str i c ne r v e b lock v e rsus Ca uda l b lock f o r po st - o pe rati v e ana l g e sia in c h i l d ren un d e r g o ing un i l a t e ral g roin s u r g e ry in A SA g ra d e I and II c h i l d r e n. Materials and m ethods: S i x ty pa ti e n ts a g e d b e t w ee n 3 - 1 2 y ea rs u n de r g o ing un i l a t e ral g roin s u r g e ry were included. The ob j e cti v e s o f t h i s st ud y w e re to c o mp a re t h e e f f e c ts o f c a u d a l b lock a n d u ltras o u n d g u id e d I l i o i n g u in a l / Ili o h y po g str i c ne r v e b lock in t e r m s o f d urati o n o f a na l g e sia, q ua l i ty o f a na l g e sia and h e m od y nam ic . Results: T h e m ea n a g e o f t w o g ro up s wa s c om p a ra b le w ith M ean ± S D 4 . 6 7 ± 1 .4 f o r B g ro u p an d M e an ± SD 4 . 7 ± 1 . 3 4 f o r C g ro u p , w h ich wa s st a tistic a l l y no t si g n i f i c an t. In t h e p res e n t st u d y, ma jor n u m be r o f c a s e s c am e f o r he rni o t om y be ing 47 % o f t o t a l c a s e s in b o th g ro up s f o l l o w e d b y h i g h l ig a ti o n 27 % in US I I / I H ne r v e b lock , 2 3 % in c a u a d a l g ro up , a n d o rchi d ope x y 27 % in I I / I H ne r v e b l o ck g ro u p a nd 30 % in c a u da l g ro up . M ea n du r a ti o n o f s u r g e ry o f B g ro u p w a s 28 . 17 ± 8 . 5 6 m in u t e s, a n d f o r C g ro u p w a s 29 . 6 7 ± 8 . 6 0 m i n u t e s. T h e d i f f e re n c e b e t w ee n t h e me a n s w a s st a tistic a l l y no t si g n i f ica n t (P � 0 . 0 5 ). T h e ba s e l i ne , i n tra o pe rati v e hea rt r a te c han g e s b e t w ee n t w o g ro up s w e re c om p a ra b le an d w e re st a tistic a l l y no t si g n i f ica n t a n d t h e ra p e u tic i n t e r v en ti on s w e re not T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 116 required. There wa s no significant difference in quality of analgesia in both groups with P - Value �0.05. Duration of Postoperative analgesia is comparable in both the groups with Mean±SD values being 4.95±0.51 for B group and 4.78±0.49 for C group which is statistically not significant with P - Value being� 0.05. Conclusion: U l tras oun d g u i d e d Il i o in g u in a l / Ili o h y po g a str i c ne r v e b locks is a n id e a l p roc e d u re f o r un i l a t e ral g roin s u r g er ies in c h i l d re n , re g a rding qua l i ty o f ana l g e sia w ith less pa in sc o res a n d d u rat i o n o f ana l g e sia is c o mpa r ab le w ith tha t o f c a u d a l b l o c k, w ith l o w e r v o lu m e o f l o c a l a ne st h e tic. Key word s Ili o h y po g a str i c, C a u d a l b l o c k, G roin s u r g er ies . Introduction P a in is a n

u n p l ea s a n t s ub je c ti v e s en s a ti o n w h ich c a n on ly b e e x pe r i en c e d an d no t e x p ress ed , e s pe cially in c h i l d re n . T h e p r im a ry re a s o n to t r ea t o r p re v en t pa in is h u m a n it a r i a n . T h is is e v e n mo re i mp o rta n t in c h i l d ren w h o rely c omp le te ly o n t he ir pa r e n ts o r c a re g i v e rs f o r t he ir w e l lbe in g . T h e c on c e p t o f po st o p e rati v e pa in rel ie f a n d its u til i z a ti o n i n t h e pa e d ia t r i c a g e g ro u p h a s i mp ro v e d d r a m a tic a l l y o v e r t h e rec e n t y ea rs. The v a r i ou s m e t hod s o f p ro v idi n g pa in rel i e f h a v e s om e si d e e f f e c ts w h ich p ro h ibit t h e ir u se in c h i l d ren f o r e . g . Narcotics in c h i l d re n , b e c au se o f t h e ir res p i r a t o ry dep ressio n , t h e o t he r a n a l g e sics w h ich c anno t b e g i v e n f o r s o m e t i m e a f t e r g e n e ral a n a e s t he sia d u e t o t h e f ea r o f v om iting an d a s p i r a t i o n , t h e ob je c ti o n to t h e n e e d les in t h e c a se o f p a re n t e ral l y adm inist e r e d a na l g e sics. The re g io n a l a nae s t h e tic t e c hn i q ue s si g n i f i c an tly de cre a s e p o s t - o pe rati v e pa in an d s y st e m ic a na l g e sic re q u i r emen ts. I n f a n ts an d c h i l d ren un d e r g o a v a r i e ty o f g roin p roc edu res t ha t c a n c au se a si g n i f ica n t de g ree o f d isc o m f o rt p o st o p e rati v e l y . Ca uda l ana l g e sia w ith loc a l ana l g e sics a lo n e is e f fe cti v e bu t is o f te n s ho r t - l i v e d an d a s s o cia t e d w ith unde si r e d mo t o r b l o c k ad e a n d o t he r c o mp l i c a t i ons [1] . Ilioi n g u i n a l/ i l io h y po g a str i c (II/ I H) ne r v e b lock ad e is on e o f t h e mo s t c o m m o n pe r i phe r a l ne r v e b lock t e c hn i q ue s in paed ia t r i c an a e s t he sia a n d h a s been shown to be equally effective compared with caudal blockade for inguinal hernia [2] . A n u ltras o un d ( U S ) - g u id e d t e c hn i q u e f o r I I / I H h a s be e n de scr i be d w ith si g n i f ica n tly b e t te r b l o ck q ua l i ti e s c o m p a red w i t h t h e la n d m a r k - b a s e d t e c h n i q u e [3]. Ac c o r d ing to t h is ne w t e c hn i q ue , t h e ne e d le tip w i l l b e p l a c e d in cl os e p ro x i m ity to t h e t w o n e r v e s in t h e c o r r e ct a na t o m ical p la n e be t w ee n t h e in te r n a l ob l iq u e an d t h e tra n s v e rse abdom inis m u scles. T h e r e f o r e , in t ra m u s c u lar a n d in t ra pe r i t o nea l i n jec t i o n o f L A i s s a f e ly a v o i ded . In c on tras t , t h e pe r f o r m an c e o f la n d ma rk - ba s e d I I / IH ne r v e b locks is a ss o c i a t e d w ith mu ltiple a dm inistra t ion o f L A in ad ja c en t a na t o m ical stru c t u res, pa rt i c u lar l y is m u scle tiss u e [4] . Ilioi n g u in a l n e r v e b lock is c omm o n ly u s e d f o r in g u in a l p roc edu res s u c h a s in g u in a l he r n ior r ha p h y , o rchi d ope x y an d h y d roc e le r epa i r . It is a lso u s e f u l f o r p f a n nen s ti e l incision e . g . h y st e rect om y , u r et e r i c rei mp l a n t a t i on . In t h e p a ed ia t r i c po p u la t io n , c o n tro v e rsy e x ists re g a rding t h e c h o ice o f i l io i n g u i n a l b lock v e rsus c au d a l b lock f o r t h is s u r g e r y . I n itial st ud ies f a i l e d to d em on stra t e s upe r i o r i ty f r o m e it he r t e c hn i q u e [5] A mo r e rec e n t st u d y s ho w e d a re d u cti o n in stress ho r mo n e le v e ls w ith c auda l a na l g e si a [6] . The popu l a r i ty o f c a u da l ly adm inist e red clo n idi n e a n d k e t am i n e ha s a d de d f u rt h e r c on tro v e rsy w ith a rec e n t st u d y u sing c au d a l l y adm inist e r e d bup i v a c a ine an d k e t a m ine s ho w ing mo re p rol o n g e d po st o pe rati v e ana l g e s ia t ha n f a sc i a l cl i ck i l i o in g u in a l b loc k [7]. Ho w e v e r, t h e po t e n ti a l neu r o t o x ic i ty o f k e t a m ine f o r t h is r o u te n e e d s t o b e clar i f ied b e f o re r o u ti n e u s e . Ma n y p ractitio ne r s p lace a c a uda l b lo c k f o r t h e se p roc e d u r e s be c a u se t h e c au d a l b lock is relati v e ly s i mp le a n d h a s a h i g h s u cc e ss rat e . P o t en ti a l ad v an

t a g e s o f t h e i l ioi n g u in a l b lo c k T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 117 incl ud e a low inci d en ce o f p o st o pe rati v e leg w ea k ne ss p ro v id e d l o w v o lu m e s a re u s ed , a n d t h e ab i l i t y t o p lace th e b lock w i t h th e pa t i en t in t h e s u p ine p o sitio n . Furth e r m o re, i l ioi n g u in a l b lock re p res e n ts a n a lt e rn a ti v e t o c au d a l b lock in c h i ld ren in w ho m an a t om ical v a r i an ts re n de r a c a uda l b lock c on trai n d ica t e d o r i mp o ssibl e . W i t h US g u i d an c e , a s l i t t le a s 0 . 07 5 m L /kg o f loc a l ane st h e tic c a n rel i a b ly b lock bo th t h e i l io i n g u in a l a n d i l io h y po g a str i c ne r v e s [8] . Re du cing t h e t o t a l v o lu m e o f loc a l a nae s t h e tic is l i k e l y to re du ce t h e s p re a d o f loc a l an a e st h e tic be l o w t h e in g u in a l l ig a me n t a n d t h e r e f o re t h e inci d e n ce o f un w an t e d f e m ora l ne r v e b lo c k ad e a n d t h e r e f o re leg w ea k ne s s [9] . In a d d ition t o un w an t e d f e mo r a l b lock, i l ioi n g u in a l b lock ha s bee n a s s o cia t e d w ith bo w e l pe r f o rat i o n c o l o n ic p un ct u r e a n d pe l v ic h ae m a t om a . In o n e re po rt t h is w a s c omp lic a t e d b y in te st i na l ob s tructi o n [10] it h a s be e n s u gg e st e d t h a t w ith u ltras oun d g u id e d n eed l e p la c e m en t, t h e r i sk o f i n t e sti n a l pe r f o r a ti o n m a y b e re du c e d . C au d a l b lock is u s ua l l y p lac e d a f t e r t h e in du c ti o n o f g e n e ral anae s t he s i a an d is u s e d a s a n ad j un ct t o in t r a o p e rati v e an a e st he s i a a s w e ll a s po s t ope r a ti v e ana l g e sia in c h i l d ren unde r g o ing s u r g ical p roc edu res b e low t h e le v e l o f t h e umb i l icu s . Ca u d a l a na l g e sia c a n re du c e t h e a mo u n t o f i nha l e d an d IV an a e st h e tic adm i n istratio n , a t t e n u a t e s t h e stress res p on se to s u r g e r y , f a ci l it a t e s a ra p i d , s mo o th re c o v e r y , an d p ro v id e s g oo d i m m ed i a te po s t ope r a ti v e ana l g e si a . In o rd e r to d e cre a s e i n tra ope r a ti v e an d p o st o pe rati v e a na l g e sic re q u i r e me n ts a f te r s i n g le s ho t c a u d a l ep i d u ral b lock a d e , v a r i ou s a d d iti v e s s u ch a s m o r p h in e , f en t an y l, clo n idi n e a n d k e t am i n e w ith l o c a l an a e st h e ti c s ha v e b e e n i n v e sti g a t e d . B up i v a c a ine is a lo n g a cti n g a m ide l o c a l a n e st h e tic w h ich h a s b ee n in u s e for more than 40 years. Its introduction in 1957 is a very important step in the evolution of regional anaesthesia. It is commercially available as a racemic mixture c on t a i n ing e q ua l p ro p o rt i on s o f t h e S ( - ) a n d R ( + ) iso m e rs. It is w id e l y u s e d f o r s uba ra c hno i d b loc k , e p id u ral b lock, c a uda l b lock, ne r v e b locks, i n f i l trati on , p o s t - ope rati v e a na l g e sia a n d l a bo r ana l g e sia. T h e m od i f ic a ti o n o f t h e c on c e n trati o n o f t h e d rug c au s e s d i f fe r e n ti a l s e n s o ry an d mo t o r block. T h e p res e n t st ud y ha s be e n c a r r ied ou t to a s s e ss w he t he r U S - g u id e d I I / I H ne r v e b locks w i t h L A w ou ld p ro v ide c om p a ra b le po s t ope r a ti v e ana l g e sia to b l i n d t e c hn i q u e c a ud a l b lock w ith L A 0 . 2 5 % B up i v a c a ine f o l lo w i n g ped ia t r i c unilateral groin surgery. Materials and methods Source of d ata T h e s t ud y w a s c ondu c t e d in G a ndh i Hos p it a l, S e c u nde r ab a d a f te r o b t a ini n g app ro v a l f r o m ins t i t u t i ona l e t h ical c o mm i t t e e an d w r i t te n i n f o r m e d c on s e n t w a s ob t a i ne d f r o m ea ch p a ti en t . Si x ty pa ti e n ts a g e d b e t w ee n 3 - 1 2 y ea rs u n de r g o ing un i l a t e ral g roin s u r g e ry w e re i n clu de d i n t h e s t ud y . T h e p a ti e n ts w e re r an d om ly d i v id e d i n to t w o g ro up s o f 3 0 p a ti e n ts ea c h : Gro u p C – T o re c e i v e c au d a l b lock w ith 0 . 7 m l/kg 0 . 25 % B up

i v a c a i n e . Gro u p B – T o rec e i v e u ltras o u n d g u id e d Ilioi n g u in a l/ Ilio h y po g a st r ic ne r v e b lock w ith 0 . 1m l/kg 0 . 25 % o f B up i v a c a in e . Inclusion criteria P a ti e n ts o f e it h e r se x , a g e d b e t w ee n 3 - 1 2 y ea rs. P a ti e n t s w ith A me r i c a n s o ci e ty o f A nae s t h e siol o g ists g ra d e I a n d II ph y sical st a t u s. Elec t i v e un i l a t e ral g ro in s u r g e r i e s o f in g u in a l he rnia s , H y d roc e les a n d Un de sc e nd e d t e st e s. Exclusion c riteria Patients less than 3 years and more than 12 years, patient refusal, P at ie n ts w ith c oa g u lo p a t h y, P a ti e n ts w ith Pe r i p h e ral Ne u ro p a t h y, H i st o ry o f a l l e r g y t o d ru g s, Si g n i f ica n t p r e - e x isting s y st em ic d ise a s e s, I n f e ct i o n a t t h e si t e o f t h e b l o ck, Sk e le ta l d e f o r m itie s , H i st o ry o f d e v e lo p m en t a l de lay and Fai l e d b locks. Procedure For u ltra s ound guid e d IL / IH n e r v e blo c k A f t e r a s ep tic p r e pa rat i o n o f bo t h p un c t u re s ite a n d t h e u ltras o u n d p ro be , pa ti e n t in s up i n e p o sitio n , t h e b lock w a s pe r f o r m e d u si n g “ i n T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 118 p l an e t e c hn i q ue ” a n d ins u la t e d 22 G 4 0 - m m ne e d le w ith a f a c e t t e t ip a n d a n inj e cti o n l in e . U n de r d i r e ct v isu a l i z a ti o n o f t h e t i p o f t h e ne e d le w h ich w a s p lac e d l a t e r a l to t h e ne r v e struct u res b e t w ee n t h e in te rn a l o b l iq u e an d tra n s v e rse abd o m inis mu sc l e s, 0 .1 m l/kg o f 0 . 2 5 % bup i v a c a ine inj e c t ed . T h e d istr i bu ti o n o f L A w a s mon i t o red u n d e r re a l ti m e u ltra s ono g ra p h y . For caudal block Un de r a s e p tic p rec a u ti on s, a s h o rt be v e l l e d 2 2 G n e ed le w a s in t ro du c e d in c au d a l ep i d u ral s p a c e , a f t e r c o n f o r m ing t h e s pa ce 0 . 7 m l/kg o f l o c a l a n ae st h e tic a g en t 0 . 25 % B u p i v a c a ine w a s a d m inist e r e d s l o w l y . A f t e r d epo sit i o n o f t h e d rug pa t i en ts w e re p lac e d i n s up i n e po s i ti o n a n d an a e st he s i a w a s ma in t a in e d b y 0 . 5 % S e v o f l u ra ne , 6 0 % o f N i tro u s o x ide in o xy g e n and top up doses of vecuronium bromide (1/5 th of the loading dose or 0.1 mg/Kg). H ea rt rate a n d M ea n a rter i a l p ress u re o f pa ti en ts a re rec o r d e d j u st b e f o re an d a f t e r sur g ical i n cis i o n a n d t h e n e v e ry 1 0 m in u t e s i n t e r v a l till th e en d o f s u r g e r y . Us i n g t h e paed ia t r i c ob s e r v a ti on s FLACC pa in sc a le w ith its 0 - 1 0 sc o re ra n g e , ea ch p a ti e n ts p a in in ten sity w a s a ss e ss e d a t t h e en d o f s u r g er y an d t he n e v er y 1 hou r in t e r v a l u n til 6 h ou rs. If t h e F L ACC pa in sc a le w a s 4 o r mo re, rec t a l P a rac e t a m o l 2 0 m g /kg w a s adm i n ist e re d . M o t o r b l o ck w a s n o t a ss e ss e d in p res e n t s t ud y . Fai l u re o f b lock w a s de f in e d a s a n y incre a se in HR o r M AP � 20 % t h a n p re incision v a lu e s. Statistical analysis Da t a w a s ana l y s e d u s ing SPSS v e rs i o n 1 5 .0 c o m pu t e r s o f t w a re. Nu m e r i c a l v a r i ab les w e re p res en t e d a s m e a n a n d st a nda r d d e v ia t ion ( M ean + SD ) . Co m p a r i s o n b e t w ee n t h e g ro up s w as b y th e Krusk a l l - W a l l is o n e An o v a . Results T h e p re s en t st u d y c on d u ct e d in G a n dh i M ed ical Colle g e & Hos p it a l, S e c u n de r a ba d , incl u d e s 6 0 p a t ie n t s , a g e d 3 y ea rs to 1 2 y ea rs w h o a re po s t e d f o r un i l a t e ral g roin s u r g e r i e s s u ch a s he rn i o t om y , o rchid ope xy , an d h i g h l ig a ti o n a re ra nd o m ly c ho s e n a n d d i v id e d in t o t w o g ro up s o f 3 0 ea c h . Gro u p C rec e i v e d 0 . 2 5 % B up i v a c a ine 0 . 7m l/kg an d Gro u p B rec e i v e d 0 . 2 5 % B up i v a c a i n e 0 . 1 m l/k g . T h e ana l g e sic e f fe ct a n d du rati o n o f a n a l g e sia o f

b o th g ro up s w a s c o m pa red a n d c on tras t ed . T h e re w e re n o cl i n ical o r s t a tistic a l l y s i g n i f ica n t d iff e re n c e s in t h e d em o g ra ph ic p r o f i l e o f p a ti en ts in e i t he r g ro u p . T h e m ea n a g e o f t w o g ro up s is c om p a ra b le w ith M ean ± S D 4 . 6 7 ± 1 .4 f o r B g ro u p an d M e an ± SD 4 . 7 ± 1 . 3 4 f o r C g ro u p , w h ich wa s st a tistic a l l y no t si g n i f i c an t as per Table - 1 . In t h e p res e n t st u d y, ma jor n u m be r o f c a s e s c am e f o r he rni o t om y be ing 47 % o f t o t a l c a s e s in b o th g ro up s f o l l o w e d b y h i g h l ig a ti o n 27 % in US I I / I H ne r v e b lock , 2 3 % in c a u a d a l g ro up , a n d o rchi d ope x y 27 % in I I / I H ne r v e b l o ck g ro u p a nd 30 % in c a u da l g ro up . The baseline, intra operative heart rate changes between two groups were comparable and were statistically not significant and therapeutic interventions were not required. The baseline mean arteria l pressures in both the groups were comparable with mean and standard deviations being 74±4.8 for B g roup and 73.5±6.03 for C group. At 5, 10 , 20, 30 m in after skin incision the MAP values are slightly higher in caudal group when compared to ilioinguinal group which i s statistically not significant (P - Value �0.05). There wa s no significant changes in h emodynamic parameters in two groups postope ratively with P Value� 0.05. According to the above observations there is no significant difference in quality of analgesia in both groups with P - Value �0.05.There is slight less scores observed in ultrasound guided ilioinguinal nerve block which is stat istically not significant. M ea n du r a ti o n o f s u r g e ry o f B g ro u p w a s 28 . 17 ± 8 . 5 6 m in u t e s, a n d f o r C g ro u p w a s 29 . 6 7 ± 8 . 6 0 m i n u t e s. T h e d i f f e re n c e b e t w ee n t h e T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 119 me a n s w a s st a tistic a l l y no t si g n i f ica n t (P � 0 . 0 5 ). T h e ba s e l i ne , i n tra o pe rati v e hea rt r a te c han g e s b e t w ee n t w o g ro up s w e re c om p a ra b le an d w e re st a tistic a l l y no t si g n i f ica n t a n d t h e ra p e u tic i n t e r v en ti on s w e re not required ( Table – 2, 3, 4 and Figure – 1 ) . Table - 1 : Demographic distribution of age in two groups. Age in y ears Gr o u p B Gr o u p C T o tal N o . % N o . % N o . % 3 7 2 3 % 6 2 0 % 13 2 2 % 4 8 2 7 % 7 2 3 % 15 2 5 % 5 8 2 7 % 12 4 0 % 20 3 3 % 6 3 1 0 % 2 7% 5 8% 7 3 1 0 % 1 3% 4 7% 8 1 3% 2 7% 3 5% T o tal 30 1 0 0 % 30 1 0 0 % 60 1 0 0 % M ean ± S D 4 .67 ± 1 . 4 4 .7 ± 1 . 3 4 5 .37 ± 2 . 3 1 S ign if i ca n ce P �0 . 0 5 Type of Surgery Her n i o t omy 14 47% 14 47% 28 47% High l i g a t i o n 8 27% 7 23% 15 25% Orc h ido p e x y 8 27% 9 30% 17 28% Table - 2 : Comparison of intra op heart rate (beats/minute) changes between two groups. Heart rate/min Group B Group C P - Value Duration Mean ± SD Mean ± SD Baseline/ Before incision 102.5 ± 8.2 106.3 ± 8.19 0.08 After incision 5 min 94.1 ± 7.3 97.7 ± 7.69 0.74 10 min 90.9 ± 6.6 94.1 ± 6.33 0.74 20 min 88.9 ± 6.1 92.1 ± 5.72 0.06 30 min 87.6 ± 5.9 90.5 ± 5.35 0.06 Post operatively HR beats/min 0 hour 89.8 ± 5.7 92.3 ± 5.4 0.08 1 hour 87.4 ± 4.9 89.7 ± 5.5 0.09 2 hours 86 ± 4.8 89.2 ± 5.1 0.08 3 hours 85.6 ± 4.8 88.5 ± 5.1 0.06 4 hours 85.6 ± 5.1 87.9 ± 4.8 0.07 5 hours 87 ± 5.3 89 ± 3.9 0.09 6 hours 85.6 ± 5.4 89.7 ± 4.8 0.06 Discussion C on trol o f p o s t ope rati v e pa i n is i m p o rta n t in p aed i a tr i c pa ti en ts b e c a u s e poo r pa in c on trol m a y res u lt in i n c re a s e d m o rbidity an d mo r t a l i t y [11] . The v a r i ou s m e t hod s o f p ro v idi n g pa in rel ie f h a v e s o m e side e f fe cts w h ich p r o h ibit t h e ir u se in c h i l d ren f o r e . g . Narc o tics in c h i l d re n , b e c a u se o f t he ir re s p i r a t o ry dep ressi o n , t h e o t he r a na l g e sics w h i c h c an n o t T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016;

3(9 ): 115 - 125. Page 120 b e g i v e n f o r s om e t i m e a f t e r g en e ral anae s t he sia du e to t h e f ea r o f v om iting an d a s p i r a ti o n , t h e ob jec t i o n to t h e n ee d les in t h e c a se o f p a re n t e ral l y adm ini s t e red ana l g e sic s . C au d a l an a e s t he tics u s ua l l y p ro v ide ana l g e sia f o r app ro x i ma t e ly 4 - 6 h ou rs. Ho w e v e r, its c omp l i c a ti on s d o e x ist s u ch a s a ccid e n t a l d u ral o r bon e ma r r o w pun c t u r e , i n t e st i na l d a ma g e , i n tra v a sc u lar in j e cti o n a n d s y st em ic t o x ic i t y , in f e ct i o n an d ep id u r a l ab sc e s s f o r m a ti o n an d ep i du ral h a e m a t om a [12] . Ce n tral ne r v ou s d isord e rs, s p in a l d e f o r m ities, i n f l a m ma ti o n o f t h e b lock site a n d c oa g u la t i on d isord e rs a re c on tr a - i n d ica t io n s f o r c a u da l an ae st h e sia, s o it is ne c e ss a ry to f i n d a s ub stit u te t o c o n trol pa i n [13]. Ilioi n g u in a l/ i l io h y po g a str i c (II/ I H) n e r v e b lock ad e is o n e o f t h e m o st c o m m o n pe r i p h e ral n e r v e b lock t e c hn i q ue s in pa e d i a tr i c a n e st he s i a an d ha s b ee n s ho w n to b e e q ua l l y e f fe cti v e c om p a red w ith c auda l b loc k a d e f o r in g u in a l he rnia re pa i r . An u ltras o u n d ( U S ) - g u id e d t e c hn i q u e f o r I I / I H ne r v e b l o ck ha s b e e n de scr i be d w ith si g n i f i c an tly be t t e r b lock q ua l i ti e s c o m p a red w ith t h e l a n d m a rk - based technique. Des p i t e its popu lar i t y , w he n c on v en ti o na l m e t h o d s a re u s ed , t h e I I / I H ne r v e b lock on ly ha s a s u cc e ss rate o f 7 0 - 80 % in s om e p u b l i s he d s e r i e s . S e v e ral c omp l i c a ti on s s u ch a s c o lo n i c o r s ma ll bo w e l pun c t u re, p e l v ic he m a t o ma , f e mo ral ne r v e pa lsy an d q u a d r i c ep s mu scle pa resi s [14] ha v e b e e n de scr i b e d . Acc o r d ing to U l tr a s oun d g u id e d t e c hn i q u e , t h e n e ed le tip w i ll b e p lac e d i n close p ro x i m ity to t h e t w o ne r v e s in t h e c o r r e ct ana t om ical p l a n e be t w ee n t h e in te rn a l o b l iq u e an d t h e tra n s v e rse a b d o m inis mu scles. T h e r e f o r e , in t r a mu sc u l a r an d in t r a pe rit o n ea l inj e cti o n o f L A is a v o i d ed . In c o n trast, t h e p e rfor m a n ce o f la n d ma rk - ba s e d I I / IH ne r v e b locks is a ss o c i a t e d w ith mu ltiple a dm inistra t ion o f L A in ad ja c en t a n a t o m i c a l struct u res, pa rt i c u lar l y mu scle tiss ue . The p res e n t s t ud y ha s b e e n c a r r ied ou t t o a ss e ss w he t h e r U S - g u id e d I I / I H ne r v e b locks w ith L A w ou ld p ro v ide c ompa r ab le p o st o pe ra t i v e an a l g e sia to c au d a l b lock w ith L A f o l l o w ing ped i a tr i c un i l a t e ral g r o in s u r g e r y . The p res e n t s t ud y c ondu c t e d in G a ndh i Me d ical Colle g e , S e c u nde r a b a d a f t e r ob t a ini n g app ro v a l f r o m ins t it u ti o na l e t h ical c o m m itt e e an d w r itt e n in fo r m e d c on s e n t w a s ob t a i ne d f r o m ea ch pa r e n t . S i x t y pa ti en ts a g e d b e t w ee n 3 - 8 y ea rs. un d e r g o ing un i l a t e ral g roin s u r g e ry w e re i n clu de d i n t h e s t ud y . Si x ty paed ia t r i c pa ti e n ts b e t w ee n a g e g ro u p 3 to 8 yea rs. ha v e bee n s e lec t e d an d r a nd o m i z a ti o n d on e an d d i v id e d in t o t w o g ro up s w h o were po s t e d f o r un i l a t e ral g roin s u r g e r i e s . In o n e g ro u p c a uda l b lock is g i v e n w i th 0 . 7m l/kg o f 0 . 25 % b u p i v a c a in e . I n t h e s e c o n d g ro u p u ltra s ou n d g u id e d i l ioi n g u in a l / iliohypogastric block given with 0.1 ml/kg of 0.25% bupivacaine. Postoperative ana l g e sia i n t e r m s o f bo th q ua l i ty an d d u rat i o n is c o mpa r e d in b o t h g ro up s u sing “ F L ACC s ca l e”. M o n it o r i n g is do n e u n til t h e du rati o n o f a n a l g e sia. Failed Blocks: Intraoperative haemodynamics namely heart rate, mean arterial pressure, SpO2, Quality of analgesia in terms of FLACC scale, Duration of analgesia using FLACC scale. Duration of analgesia In Pres e n t s t ud y t h e me a n d u rati o n o f a n a l g e sia f o r US G u i d e d

I l i o in g u in a l/ Ilio h y po g a str i c ne r v e b lock is 4 . 9 5 hou r s. an d Ca u d a l Block is 4 .8 H r s. w ith P v a lue 0. 2 ( � 0 . 05) . It s ho w s t ha t t he re is n o si g n i f ica n t d i f fe re n c e in du rati o n o f po st o pe rati v e a na l g e sia b e t w ee n t w o g ro up s. Ro be rt A P au l , e t a l. c o ndu c t e d a st u d y en titl e d “p a ed ia t r i c re g io na l an a e st he s i a : c o m pa r in g c auda l an a e st h e sia an d i l ioi n g u i n a l b lock f o r p a ed ia t r i c in g u in a l he rnio t om y ”. T h e y c on clu de d t ha t in bo th t h e g ro up s’ du rati o n o f ana l g e sia w a s c o m pa r ab le an d n o si g n i f ic a n t d i f f e re n c e in bo t h g ro u p s [15] . J a g ann a da n N , S o h n L , e t a l. ha v e c on d u ct e d a st u d y “u n i l a t e ral g ro in s u r g e r i e s in c h i l d re n : w i l l t h e a dd ition o f u ltras o u n d g u id e d i l ioi n g u in a l ne r v e b lock en h an c e s t h e du r a ti o n o f ana l g e sia o f si n g le s ho t c auda l b loc k ” an d f ou n d add iti v e b lock t o b e e f f e cti v e in i n g u in a l h e rnia re pa ir pa ti e n t s [16]. M ah in S e y edhe ja z i, Dar y ou sh S he ikh z a de h , e t a l . h a v e c on d u c t e d a st u d y en titl e d “ Co mpa r i n g t h e a na l g e sic e f f e ct o f c au d a l a n d i l ioi n g u in a l i l io h y po g a str i c ne r v e T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 121 b l o ck a d e u sing bup i v a c a in e - cl on idi n e in in g u i n a l s u r g e r i e s in c h i l d ren 2 - 7 y rs o ld” an d f ou n d du r a ti o n o f ana l g e sia c o mpa r ab le w ith p - v a lue be ing �0 .0 5 w it hou t m u ch si g n i f ica n t d i f f e r e n ce in b o th g ro up s [17]. A bua l ha ss a n A . A b d e l l a t i f , e t a l. h a v e c on du ct e d a st ud y “ultras o un d g u i d e d i l ioi n g u i na l / i l io h y po g a str i c ne r v e b locks v e rsus c a u da l b lock f o r po st ope r a ti v e ana l g e sia in c h i l d ren un d e r g o ing un i l a t e ral g roin s u r g er y ” t h e f o l l o w ing res u lts ha v e bee n ob s e r v e d T h e a v e ra g e pa in sc o res du r i n g ho s p i t a l st a y w e re 1 . 82 ± 1 . 7 1 a n d 1 . 5 2 ± 1 . 4 1 f o r c a u da l g ro u p a n d I I / IH g ro u p res pe cti v e ly ( P � 0 . 05 ). T h e a v e ra g e ti m e to f i r st resc u e a na l g e sia w a s lo n g e r in I I / I H g ro u p 253 ± 10 2 .6 m in a s c o mpa r e d t o 2 1 9 . 6 ± 48 . 4 m in in c au d a l g ro up . In rec o v e ry ro om , f ou r p a ti en ts in c au d a l g ro u p re q u i r e d pa in resc u e m e d ic a ti o n c o m pa r e d to f i v e p a ti e n ts in I I /I H g ro u p ( P � 0 . 05 ). Si m i l a r l y e i g h t pa ti e n ts i n t h e c au d a l g ro u p C an d six pa t i en ts in I I / I H g ro u p r e q u i r e d pa in resc u e m ed ica t i o n a t da y - st a y un it o r a t ho m e ( P �0 . 05 ). Ca u da l g ro u p rec e i v e d 0 . 7 4 pa in res c u e med i c a ti o n d o s e s ( r an g e 0 - 8 ), w h i l e I I / I H g ro u p rec e i v e d 0 . 6 5 pa in resc u e med i c a ti o n d o s e s ( r a ng e 0 - 6 ) a t ho s p it a l an d a t ho m e ( P � 0 . 05 ) an d c on clu d e d t ha t t he re is n o si g n i f ic a n t d i f fe re n c e in d u rati o n o f ana l g e sia i n bo t h t h e g ro up s. W e i n tr a u d , e t a l. w e re ab le to s ho w t h a t t h e u se o f t h e classic l a n d ma r k - ba s e d app r o a ch res u l t e d in on ly 14 % o f t h e inj e c ti on s be ing m ad e a t t h e c o r r e ct ana t om i c a l loc a t i o n [4] . In a p r o s pe cti v e ra n d o m i z e d st u d y b y W i l ls c h ke a n d C o w o rkers t h e u se o f a n U S - g u id e d I I / I H n e r v e b lock w a s c omp a r e d w ith t h e la n d ma r k - ba s e d a pp ro a c h c on c e rning e f f icacy o f t h e t w o t e c hn i q ue s. It w a s cle a r l y de m on st r a t e d t h a t t h e u se o f t h e U S - g u id e d t e c hn i q u e w a s a s s o cia te d w ith a si g n i f ica n tly h i g he r s u cc e ss ra t e , a s e v id en c e d b y a r e du c e d h e m o d y nam ic r e a c ti o n

t o s kin incision (4 v s. 24 %) a n d a c on s i de ra b l e re d u cti o n i n t h e nu mbe r o f p a ti e n ts ne e d ing s upp l e m en t a l ana l g e sia in t h e rec o v e ry ro o m (6 v s. 40 % ) [3] . F i s he r , e t a l. ra n d o m ly a ssi g ne d c h i l d r e n w h o u n de r w en t o rchi o p e xy to on e o f t h ree g ro up s a t t h e e n d o f s u r g e ry a s f o l lo w s: Ca uda l b lock w ith bup i v a c a i n e an d 1 : 20 0 , 0 0 0 ep i n e ph r i n e ( g ro u p I); b u p i v a c a ine a lo n e ( g ro u p I I ) an d i l ioi n g u in a l/ i l io h y po g a str i c ne r v e b lock w ith bup i v a c a ine a dm i n ist e r e d t h r o u g h t h e w oun d b y t h e s u r g eo n ( g ro u p I I I). Th e y re po rted n o d i f fe r e n c e s in t h e nu m be r o f p a ti en ts w it hou t p a in f o r mo r e t ha n 4 h ou rs o r t ho s e re q u i r ing ana l g e sics b y 2 4 h o u rs. Also, t h e ti m e s t o m ict u r i ti o n d id n o t d i f f e r si g n i f ica n tly am o n g g ro ups [5] . Q u a li t y o f a n a l g es i a Q ua l i ty o f a na l g e sia i n b o th t h e g ro u p s is e v a lu a t e d b y FLACC sc a le a n d f ou n d sl ig h t l o w e r sc o res in u ltras ou n d g u id e d i l i o in g u in a l/ i l io h y po g a str i c ne r v e b lock w he n c o m pa r e d to c au d a l b lock w h ich w a s no t v e ry s i g n i f ica n t in t e r m s o f p v a lu e ( � 0 . 05 ). The f o l lo w i n g s tud ies h a v e be e n d o ne : M ah in S e y e d he ja z i, Dar y ou sh S h e ikh z ade h , e t a l. [17] h a v e c on d u c t e d a st u d y en titl e d “ C ompa r i n g t h e ana l g e sic e f f e ct o f c a uda l a n d i l ioi n g u in a l / i l io h y po g a str i c ne r v e b l o ck a d e u sing bup i v a c a in e - clo n idi n e in in g u i n a l s u r g e r i e s in c h i l d ren 2 - 7 y ea rs o ld” a n d f ou n d t h e q ua l i t y o f a n a l g e sia sl ig h tly m o re w ith i l ioi n g u in a l g ro u p w h e n c o m pa red t o c a u da l b lock g ro u p bu t t h e d i f fe re n ce w a s no t s t a tistic a l l y si g n i f ica n t . A bua l ha ss a n A . A b de l l a t i f , e t a l . [18] ha v e c o n du ct e d a s t ud y “ultras o un d g u id e d i l ioi n g una l/ i l io h y po g a str i c ne r v e b locks v e r su s c au d a l b lock f o r p o st o p e rati v e ana l g e sia in c h i l d ren un d e r g o ing un i l a t e ral g roin s u r g er y ” an d f o un d sl ig h tly i mp ro v e d q ua l i ty in i l i o in g u in a l g ro u p w ith lo w e r FLACC sc a le v a lu e s w h e n c om p a red to c a u d a l b lock g ro u p b u t t h e d iff e re n c e in q ua l i ty be t w e e n t w o g ro up s is no t si g n i f ic a n t in t e r m s o f p - v a lue ( � 0 . 05 ). H e m o d y n a m ic p a r a m e ter s M ea n a r t e r i a l p ress u re an d h e a rt rat e s w e re rec o rd e d i n b o th g ro up s a t b a s e l i n e a n d in t ra o p e rati v e ly a t 5 , 1 0 , 2 0 , 3 0 m in. an d e v e ry hou r l y the re a f t e r. The f o l l o w ing ob s e r v a ti on s ha v e b ee n ma d e : T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 122 Table - 3 : Comparison of intra op MAP (mm of hg) changes between two groups. M.A.P. in mm of Hg Group B Group C P Value Duration Mean ± SD Mean ± SD Baseline/ Before incision 74 ± 4.8 73.5 ± 6.03 0.9 After incision 5 min 94.1 ± 4.3 97.7 ± 4.50 0.73 10 min 90.9 ± 4.9 94.1 ± 4.82 0.61 20 min 88.9 ± 5.2 92.1 ± 5.20 0.59 30 min 87.6 ± 5.6 90.5 ± 5.08 0.61 Post - operative 0 hour 68.4 ± 13.3 69 ± 5.7 0.3 1 hour 66.8 ± 4.8 67.3 ± 4.5 0.6 2 hours 66.4 ± 4.4 66.6 ± 4.5 0.9 3 hours 66.1 ± 5 66.1 ± 4.6 0.9 4 hours 66.9 ± 4.1 66.7 ± 4.5 0.8 5 hours 67.4 ± 4.7 67.1 ± 5.2 0.7 6 hours 67.9 ± 4.2 67.8 ± 4.9 0.9 Figure - 1 : Comparison of FLACC scores in two groups . M e a n A r ter i a l P r essu r e T h e m e a n a rter i a l p r e ss u res in t w o g ro up s ha v e n o si g n i f ica n t d i f f e re n c e an d t h e p - v a lue be ing ( � 0 . 05 ). M ea n a rter i a l p ress u res w e re in t h e a v e ra g e ra n g e o f 68 .5 in w ho le i n tra ope rati v e pe r i od . T h is f in d ing is s uppo rt e d b y t h e f o l l o w ing st ud ies: A bua l ha ss a n A . A b de l l a t i f , e t

a l . [18] ha v e c o n du ct e d a s t ud y “ultras o un d g u id e d i l ioi n g una l/ i l io h y po g a str i c ne r v e b locks v e r su s c au d a l b lock f o r p o st o p e rati v e ana l g e sia in c h i l d ren unde r g o i n g un i l a t e r a l g roin s ur g er y ” a n d f ou n d n o si g n i f ica n t d i f f e r en ce in m e a n a rter i a l p res s u re in b o th g ro up s . J a g ann a da n N , S o h n L , e t a l. h a v e c o n du ct e d a st u d y “u n i l a t e ral g r o in s u r g e ry in c h i l d ren : w i l l t h e add iti o n o f u ltra s ou n d g u id e d i l ioi n g u in a l ne r v e b lock en h an ce t h e du rat i o n o f a n a l g e sia o f sin g le s ho t T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 123 c au d a l b lock” an d ha v e ob s e r v e d in t r a - ope r a tive he mod y n a m ics an d f o un d t h a t t he re is n o si g n i f ic a n t d iff e re n c e in m e a n a rt e r i a l p ress u re in bo t h th e g ro up s . In a p ros p e cti v e ra nd o m i z e d st u d y b y W i l l s c h ke a n d c o - w o rkers t h e u se o f a n U S - g u id e d I I / IH w a s c om p a red w ith t h e la nd ma r k - ba s e d app r o a ch c on c e rning e f f icacy o f t h e t w o t e c h n i q ue s. It w a s cle a r l y de m on st r a t e d t ha t t h e u se o f t h e U S - g u id e d t e c h n i q u e w a s a ss o cia te d w ith a si g n i f ica n tly h i g he r s u cc e ss rat e , a s e v id en c e d b y a re d u c e d h e m o d y nam ic r e a cti o n to sk i n incision (4 v s. 24 %) an d a c on sid e r ab le r e du cti o n in t h e nu mbe r o f pa ti e n ts n eed ing s upp l e m e n t a l ana l g e sia in t h e rec o v e ry ro o m (6 v s. 40 % ) [3] . Table - 4 : c omparison of mean duration of analgesia in hours in two groups. M ea n d u rat i o n o f a na l g e sia in hou r s Gro u p B Gro u p C T o t a l No. % No. % No. % 4 4 13% 4 13% 8 13% 4.5 5 17% 11 37% 16 27% 5 11 37% 9 30% 20 33% 5.5 10 33% 6 20% 16 27% Total 30 100% 30 100% 60 100% Mean ± SD 4.95 ± 0.51 4.78 ± 0.49 4.87 ± 0.5 Significance P Value 0.20 H e a rt r a te Skin incision is pe r m it t e d 1 5 m in a f t e r b lock in bo th g ro up s a n d in c re a se in hea rt rate incr e a se o f mo re t ha n 2 0 % o f b a s e l i n e is in te rpre t e d a s f a i l e d b lock. I n t h e o t he r c a se h e a rt rat e s ha v e be e n m e a s u red a t ba s e l i n e a n d e v er y 5m in u p to 3 0 m i n a n d e v e ry hou r t he re a f te r. N o t mu c h si g n i f ica n t d i f f e r e n ce i n hea rt r a t e s in in t ra o p e rati v e pe r i o d w a s ob s e r v e d in b o th t h e g ro u p s. As t h e an a l g e sia is w a r i n g o ff in po st o pe rati v e p e r i o d incre a se in h ea rt rat e s w e re ob s e r v ed . T h e a b o v e ob s e r v a ti o n is s up p o r t e d b y f o l l o w ing s tud ie s : A bua l ha ss a n A . A b d e l la t i f , e t a l . [18] h a v e c on du ct e d a st ud y “ultras o un d g u i d e d i l ioi n g una l/ i l io h y po g a str i c ne r v e b locks v e r su s c au d a l b lock f o r p o st o p e rati v e ana l g e sia in c h i l d ren unde r g o ing un i l a t e r a l g roin s ur g er y ” a n d f ou n d n o si g n i f ica n t d i f f e r en ce in hea rt r a t e s i n b o th g r o u p s. J a g ann a da n N , S o h n L , e t a l. ha v e c on d u ct e d a st u d y “u n i l a t e ral g ro in s u r g e r i e s in c h i l d ren: w i l l t h e add iti o n o f u ltra s ou n d g u id e d i l ioi n g u in a l ne r v e b lock en h an ce t h e du rat i o n o f a n a l g e sia o f sin g le s ho t c au d a l b lock” an d ha v e ob s e r v e d in t r a - ope r a ti v e he mod y n a m ics an d f o un d t h a t t he re is n o si g n i f ic a n t d iff e re n c e in m e a n a rt e r i a l p ress u re in bo t h th e g ro up s . M a rkh a m , e t a l. u s e d c a rdio v a sc u lar res p o n se a s a s u r r o g a te ma rker f o r in t ra o p e rati v e pa in a n d f o un d n o d i f f e r e n ce be t w ee n c au d a l b lo c k an d U S g u id e d I l i o in g u in a l / Ili o h y po g a str i c ne r v e b loc k [2] . G a itini an d c o - w o rkers s ho w e d t ha t c a u da l b lock w a s mo re e f fe c

ti v e t ha n I I / IH ne r v e b lock in s up res s ing t h e stress res pon s e a s r e f lec t e d b y ep i n eph r i n e an d no re p i n e p h r i n e b l o o d le v e ls in g roin s u r g e r i e s, bu t in p re s en t s t ud y , bo th b l o c k s w e re e q ua l l y e f f e cti v e in re du cing stress res p on se a s s h o w e d b y mea n a r t e r i a l p ress u re an d h e a rt ra t e c h a n g e s. I n p res e n t s t ud y it is a l s o o b s e r v e d t ha t t h e re q u i re me n t o f L o c a l an a e st h e tic do s e is less in US g u id e d Ili o in g u in a l / i l io h y po g a str i c ne r v e b lock (0. 1 m l/kg bod y w e i g h t) w he n c om p a red w ith c au d a l b lock (0. 7 m l/kg bod y w e i g h t ) . W i l l sc h k e an d co - workers [3] s ho w e d t ha t a s ub st a n ti a l re du cti o n in t h e v o lu m e o f L A (t r ad itio na l l y rec o mm en d e d v o lume 0 . 3 - 0 . 5 m l/ k g ). Re s c u e a n a lg e si a Resc u e a na l g e sia is g i v e n if t h e FLACC p a in sc a le w a s 4 o r m o re, rect a l P a rac e t a m o l 2 0 T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 124 m g / k g w a s adm inist e red in bo th t h e g ro up s. In p res en t st u d y FLACC Sc o re 4 o r m o re c on sid e r e d a s p a in, an d st a rt f o r resc u e a na l g e sia. Th e re w a s n o si g n i f ica n t d i f fe re n ce i n t h e re q u i r eme n t o f resc u e a n a l g e sia in b o th t h e g ro up s w h ich is s u p p o rted b y t h e s t ud y c on du ct e d b y A bua l ha ss a n A . A b d e l l a t i f , et al. [18] w he re f en t an y l 1 m ic/ k g is g i v e n a s resc u e ana l g e sia. No si g n i f i c an t d i f fe re n ce in re q u i r emen t o f res c u e ana l g e sia is f o u n d in bo t h t h e g ro up s w ith p - v a lue be ing 0 . 6 5 9 w ith mea n v a l u e in g ro u p o f c a u da l b lock be ing 16 . 6 % a n d me a n v a lue in i l ioi n g u in a l g ro u p be i n g 21 . 74 %. Co m pli c a tion In p r e s e n t s t ud y w e h a v e no t en c o un t e r e d c o mp l i c a ti o n s in b o th st u d y g ro up s. T h e side e f fe cts w e re n o t d i f fe re n t in b o th g r oup s i n th is s t ud y . G o f e ld M , Chr i st a kis M , e t a l . s t ud i e d o n s o n o g ra ph ically g u id e d i l ioi n g u in a l n e r v e b lock an d c on clu d e d t ha t h is t e c hn i q u e is rel i ab le an d r e p ro du c i b le. The b lock i s a c h ie v ab le b y a l o w - v o lu m e loc a l ane s t h e tic inj e cti on . Vis u a l i z a ti o n o f t h e in te sti n e s a n d b lo o d v e ss e ls in t h e ab do m i n a l w a ll m a y he lp p re v e n t a n i n ad v e r t en t inj u r y [25] . P o la n e r , e t a l . re v ie w e d 7 3 7 i l ioi n g u in a l/ i l i o h y po g a str i c ne r v e b locks, a n d f o u n d on e a d v e rse e v en t i. e . po siti v e a s p i r a ti o n . T h is l o w mo rbidity rate was a t t r i bu t e d to t h e w id e s p re a d u s e o f u ltras o u n d g u id a n c e . P o la n e r e t a l. re v ie w e d 6 0 1 1 s i n g le s h o t c a uda l b lock s , a n d id e n t i f i e d 1 7 2 (2 . 9 %) ad v e rse e v en ts, incl u d ing 1 8 po siti v e t e st d o s e s, f i v e du ral pun c t u res, 3 8 v a sc u lar inj u r i e s, 7 1 a b an d o n e d b locks a n d 2 6 f a i l e d b l o cks. Conclusion U l tras oun d g u i d e d Il i o in g u in a l / Ili o h y po g a str i c ne r v e b locks is a n id e a l p roc e d u re f o r un i l a t e ral g roin s u r g er ies in c h i l d re n , re g a rding qua l i ty o f ana l g e sia w ith less pa in sc o res a n d d u rat i o n o f ana l g e sia is c o mpa r ab le w ith tha t o f c a u d a l b l o c k, w ith l o w e r v o lu m e o f Lo c a l A ne st h e tic. References 1. Narasi mh a n J, L isa S, A m o d S , A n d rew A , J e nn i f e r H , A n t h o n y C, e t a l. Unila te ral g roin s u r g er y in c h i l d re n : W i l l t h e a dd ition o f a n u ltras o u n d - g u id e d i l ioi n g u in a l ne r v e b lock enhan c e t h e d u rati o n o f ana l g e sia o f a sin g l e - s ho t c au d a l b lock? P e d ia t r i c Ane s t h ., 2 0 0 9 ; 1 9 : 8 9 2 - 8. 2. M a rkh a m SJ, T o m l i n s o n J, H a in W R . Ilioi n g u in a l n e r v e b lock in c

h i ld re n : A c om p a r i s o n w ith c a u da l b lock f o r in t ra an d po s t ope r a ti v e ana l g e sia. A ne s t he sia, 1 9 86 ; 41 : 10 9 8 - 1 0 3 . 3. W i l l sc h k e H, M a rshier P, B o s e n be rg A, J oh n st o n S, W a n z e l O, Cox SG, e t a l. U l tras o n o g ra ph y f o r i l ioi n g u in a l/ i l io h y po g a str i c ne r v e b locks i n c h i l d re n . B r J Ane s t h., 2 0 0 5 ; 9 5 : 2 26 - 30. 4. W e i n tr a u d M, M arh o f e r P , B o s e n b e rg A , K ap r a l S, W i l l sc h ke H, a n d Felf e rnig M , e t a l. Ilioi n g u in a l / il i oh y po g a str i c b locks in c h i l d re n : W h e re d o w e adm i n ist e r t h e loc a l an e st he tic w it hou t d i r e ct v isu a l i z a ti on? A n e st h A na l g ., 200 8 ; 1 0 6 : 8. 5. F i s he r Q A , M cC o m is k e y C M , H i ll J L , e t a l. P o st o p e rati v e v o idi n g i n t e r v a l an d du rati o n o f a n a l g e sia f o l l o w ing pe r i phe ral o r c au d a l ne r v e b locks in c h i l d re n . Anesth. Analg., 1993; 76: 173 - 7. 6. S om ri M , G a it i n i L A, V a ida SJ, e t a l. E f fe ct o f i l ioi n g u in a l ne r v e b l o ck o n t h e c a t e c h o l a m ine p l a s m a le v e ls in o rchid o p e x y : c ompa r i s o n w i t h c au da l ep id u ral b lock. P a e d ia t r A nae s th., 20 0 2 ; 1 2 : 7 9 1 - 7. 7. F r i g o n C, M a i R, V a loi s - G o m e z T , e t a l . B o w e l he m a t o m a f o l l o w ing a n i l io h y po g a str i c - i l ioi n g u i na l n e r v e b lock. P a ed i a tr A n ae s t h., 2 006 ; 16 : 9 9 3 - 6. 8. J oh r M , S o s s a i R. Co l on ic p u n ct u re du r i n g i l ioi n g u in a l ne r v e b lock i n a T. Ravi, N. Dheeraj Kumar, Bhrungi Shireesh Kumar. Ultrasound guided nerve block versus caudal block for post - operative analgesia in children undergoing unilateral groin surgery . IAIM, 2016; 3(9 ): 115 - 125. Page 125 c h i ld . A ne s t h A na lg., 19 9 9 ; 8 8 : 10 5 1 - 2. 9. V a is m a n J. P e l v ic hema t o m a a f t e r a n i l ioi ng u in a l ne r v e b lock f o r o rchial g ia. A ne s t h A na lg., 20 0 1 ; 9 2 : 10 4 8 - 9. 10. A m o ry C, M a r i sc a l A , G u y o t E, e t a l. Is i l ioi n g u in a l/ i l io h y po g a str i c ne r v e b lock a l w a y s to t a l l y s a fe in c h i l d r e n ? P a e d ia t r A nae s th., 20 0 3 ; 1 3 : 1 6 4 - 6. 11. M i l ler R D, Er i ks o n L A, J e a n ine P, Kr o n ish W , Y oun g W L . M i l le r ’s A nae s t he s i a . 7 th edition, Ch u rchil l i L i v in g st one ; 20 1 0 , p . 1 6 9 1 - 9 2 , 25 1 9 - 5 7 a n d 27 5 7 - 81. 12. Ra u x O, Da du r e C, Carr J, Roc he t t e A , Ca pd e v i l la X . P aed i at r i c c auda l an a e st he s i a . U p da t e i n a n ae s t he sia, 2 0 10 ; 2 6 : 3 2 - 6. 13. Hansen TG, Henneberg SW, Waltherlarsen S, lund J, Hansen M. Caudalbupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double blind study. Br J anesth ., 2004 ; 92: 223 ‑ 7. 14. Lim S, Ng Sb, Tan GM. Ilioinguinal and iliohypogastric nerve block revisited: Single shot versus double shot technique for hernia repair in children. Paedritric anaesth., 2002; 12: 255 - 60. 15. Ro b e rt A P au l. P aed i a tr i c re g io na l an a e st he s i a c o m pa r i n g c auda l an a e st he sia a n d i l ioi n g u in a l ne r v e b lo c k f o r p a ed ia t r i c in g u i n a l he rni o t o m y. A M SJ, 2013; 4(1). 16. J a g anna t h a n N, S o h n L , S a w a rd e k a r A, A mb rosy, e t a l. Unila t e ral g roin s u r g e ry i n c h i l d re n ; w i l l th e a dd iti o n o f a n u ltr a s ou n d - g u id e d il i o in g u i n a l ne r v e b lock e n h an ce t h e d u rati o n o f a na l g e sia o f a sin g l e - s ho t c a u d a l b loc k ? P aed i a tr A n ae s t h ., 20 0 9 ; 19 (9) : 89 2 - 8. 17. M ah in S e y edhe ja z i, A bdo l n a s e r M o g had a m , B eh z a d Al i a k ba ri S h a ra b ia n i , S a m a d E. J . G o l z a r i , Nasr i n Ta g h i z ad ieh, e t a l. Success rates and complications of awake caudal versus spinal block in preterm infants undergoing inguinal hernia repair: A prospective study. S a ud i J ou rn a l o f A n ae st h e si a , 2015; 9(4): 348 - 352. 18. A bde l la t i f AA. U l tra s ou n d - g u id e d i l ioi n g u in a l/ i l io h y p o g a sr i c ne rve b locks v e rsus c auda l b lock f o r po st o pe rati v e an a l g e sia in c h i l d ren u n de r g o ing un i l a t e ral g roin s u r g e ry. Sa u d i jo u r n a l o f a n a e st he sia, 2 0 12 ; 6 : 36 7 - 3