Background: Caudal epidural analgesia is one of the most popular reliable, safe and commonly performed regional blocks in pediatric patients undergoing lower abdominal and lower limb surgery. Various adjuvants such as opioids or α2 agonists are being used to improve the quality and duration of caudal analgesia. Addition of Tramadol to local anesthetics has been noted to prolong the duration of analgesia after surgery. Objective: To assess the efficacy of adding caudal tramadol to bupivacine for post operative analgesia in pediatric infraumblical surgery. Method: Hospital based prospective cohort study design was employed. Comparison of two mean with equal sample size formula for two independent cohort was used to get sample size of 56 children's whose age is 1–14 years' old that undergone elective Infraumbilical surgery received caudal block with bupivacaine alone or with tramadol added. A systemic random sampling technique was used to select study participants. Postoperatively severity of pain either by FLACC/NRS, time to analgesic request and analgesic consumption were evaluated at 1st, 2nd,4th,8th,12th and 24th hrs. Pain severity, first analgesia request time and analgesic consumption were assessed using Mann–Whitney U test for 24 h. Chi-square test was used to assess homogenous categorical independent variables between the two groups and a p-value less than 0.05 was considered to be statically significant. Result: Tramadol with bupivacaine has prolonged postoperative analgesia with a median duration of 14 h compared to 5 h in bupivacaine alone. Moreover, total Paracetamol analgesic consumption was lower in tramadol group with a median total dose of 250 mg compared with 437.5 mg in bupivacaine group with statistically significant difference within 24 h (p < 0.018). Also, reduced the pain score in tramadol group, being statically significant at 4th, 8th and12th hours. Conclusion: Caudal tramadol with bupivacaine decrease postoperative pain severity, total analgesic consumption and prolong the duration of analgesia. Based on our finding we recommend the use of caudal tramadol with bupivacaine is effective for postoperative analgesia. Highlights:

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Introduction and importance: Temporomandibular joint (TMJ) ankylosis is increasing dramatically especially in developing countries due to the delay in treatment and difficulty access to specialized healthcare. Patients usually presents with restricted mouth opening, dentofacial deformity, malocclusion, impaired speech, difficulty in mastication, malnutrition, obstructive sleep apnea, and airway obstruction. Case presentation: This case report presented an 18 year old, 32 kg, 1.50 m female patient diagnosed as bilateral temporomandibular ankylosis and her airway was managed with blind nasal intubation without any apparent perioperative complication. Clinical discussion: Administration of anesthesia and airway management to patients with TMJ ankylosis ideally requires the availability of flexible fibreoptic bronchoscope and trained personnel who use the equipment and monitoring facilities. However, many facilities especially in developing countries are lacking the necessary equipments. Retrograde intubation, tracheotomy and blind intubation are also another possible option for airway management of these patients. Conclusion: We believe that blind nasal intubation can be an alternative airway management modality in resource constrained settings where flexible fibreoptic bronchoscope is not available. Highlights

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