Background: Caudal block has evolved to become the most popular regional anesthetic technique for use in children. It provides excellent analgesia during surgery as well as during postoperative period in subumblical surgeries in children, however one of the major limitations of the single injection is relative short duration of post operative analgesia even with long acting local anesthetics such as Bupivacaine. This problem can be circumvented by the use of different adjunct drugs to the local anesthetic solutions. The aim of the present study was to compare the analgesic efficacy and safety of Neostigmine - bupivacaine mixture to that of bupivacaine- clonidine mixture following caudal administration in children undergoing infra-umbilical  surgeries.

Methods: In a prospective, randomized, double blind study, 100 patients of ASA physical status I  of either sex in the age range of 1 to 5 years scheduled for elective infra- umbilical surgical procedures were randomly allocated to one of the groups of 50 patients each to receive  caudal injection of either 1µg/Kg of clonidine in addition to 1ml/kg  of 0.25% bupivacaine hydrochloride in Group BC or  2µg/Kg of neostigmine added to 1ml/kg of  0.25% bupivacaine hydrochloride  in Group BN. The perioperative hemodynamic effects, post operative pain scores (OPS), supplementary analgesic requirement and side effects were assessed by a blind observer during 24 hour observation period.

Results: Both the groups were homogenous with reference to age, sex, weight and duration of anesthesia and duration of surgery. No significant differences with respect to mean heart rate, blood pressure (systolic and diastolic) and oxygen saturation were noted during perioperative period between the two groups. The mean duration of analgesia in group BC was 10.87±3.5 hours while in group BN mean duration of analgesia was 4.26±1.6 hours. The duration of analgesia in group BC was longer and the difference was statistically significant (p< 0.05). In the postoperative period rescue analgesia in the form of diclofenac suppository (1mg/kg) was required in 16 patients (32%) in the  group BC and 31 (62%) patients in the group BN. Statistically a significant difference (p<0.001) was observed between the two groups.  In our study 2 patients in BC (group) had nausea and vomiting (4%), while in  group BN  3 patients had nausea and   vomiting (6%). The total number of patients who had side effects was less in study group compared to control group. However, the difference was statistically insignificant (p>0.05) between the two groups. None of our patient developed any other complication. In our study there was very low incidence of nausea and vomiting which was probably due to i/v ondansetron given intra operatively.

Conclusion: Caudal clonidine provides effective and prolonged intra and postoperative analgesia in patients undergoing infra-umbilical surgeries. Neostigmine and clonidine when added to caudal bupivacaine are safe and without any significant side effects.

Keywords: caudal anesthesia, neostigmine, clonidine , post operative pain ,children, bupivacaine.

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