Background Caudal epidural analgesia with bupivacaine is very popular in paediatric anaesthesia for providing intra- and postoperative analgesia. Several adjuvants have been used to prolong the action of bupivacaine. Objectives To compare the efficacy of ketamine, fentanyl and clonidine in terms of quality and duration of analgesia they produce when added with caudal bupivacaine by single shot technique in children. Methods Eighty children, age one to ten years, undergoing sub-umbilical surgery, were prospectively randomized to one of four groups: caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine in normal saline (Group B) or caudal analgesia with 0.75 ml/kg of 0.25% bupivacaine with 1 μg/kg of clonidine in normal saline (Group BC) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with ketamine 0.5mg/kg (Group BK) or caudal analgesia with 0.75ml/kg of 0.25% bupivacaine with fentanyl 1mcg/kg (Group BF). Post-operative pain was assessed for 24 hours using the FLACC scale. Results The mean duration of analgesia was significantly longer in Group BC (629.06 ± 286.32 min) than other three groups P < 0.05. The pain score assessed using FLACC scale was compared between the four groups, and children in Group BC had lower pain scores, which was statistically significant. The requirement of rescue medicine was lesser in Group BC. Clonidine in a dose of 1 μg/kg added to 0.25% bupivacaine for caudal analgesia, during sub-umbilical surgeries, prolongs the duration of analgesia of bupivacaine, without any side effects in compare to fentanyl or ketamine. Conclusion We conclude that clonidine in a dose of 1 μg/kg, added to 0.25% bupivacaine for caudal analgesia and administered as a 0.75 ml/kg mixture in children, for sub-umbilical surgery, significantly prolongs the duration of post-operative analgesia when compared to 0.75 ml/kg of 0.25% bupivacaine in normal saline than 0.75 ml/kg of 0.25% bupivacaine with ketamine 0.5 mg/kg or 0.75 ml/kg of 0.25% bupivacaine with fentanyl 1 mcg/kg or 0.75 ml/kg of 0.25% bupivacaine alone, without any side effects. Kathmandu University Medical Journal | VOL.10 | NO. 3 | ISSUE 39 | JUL- SEP 2012 | Page 25-29 DOI: http://dx.doi.org/10.3126/kumj.v10i3.8013

Background Fentanyl, a synthetic opioid, is a popular choice amongst anaesthesiologists in the operating room. Pre induction intravenous fentanyl bolus is associated with coughing in 28 – 65% of patients. Fentanyl induced cough is not always benign and can be remarkably troublesome at the most critical moment of anaesthesia when airway reflex is lost. Objectives To study the effect of pre emptive use of minimal dose fentanyl through the peripheral venous cannulae on the incidence of cough by a larger bolus of intravenous fentanyl. Methods One hundred and fifty patients aged 18 -75 years undergoing elective surgical procedures were randomized into three groups of 50 each. The first group received 0.5 ml saline 0.9 % intravenously one minute prior to the administration of fentanyl 150μg (3 ml); the second group received pre emptive fentanyl 25μg(0.5ml) prior to the administration of fentanyl 125μg(2.5ml); and the third group received preemptive fentanyl 25 μg(0.5ml), followed by the administration of fentanyl 150μg(3ml).. Based on the number of coughs observed, cough severity was graded as mild(1-2), moderate (3-5),or severe (>5). Results The incidence of fentanyl induced cough was significantly lower in both pre emptive group 4(8%) for 125μg fentanyl and 7(14%) for 150μg than in the saline group 15(30%). Conclusion Pre- emptive use of minimal dose fentanyl 25μg administered one minute before a larger bolus dose of fentanyl (125 or 150μg ) can effectively suppress cough. DOI: http://dx.doi.org/10.3126/kumj.v10i4.10988 Kathmandu Univ Med J 2012;10(4):16-19

Background Spinal anesthesia is widely used for caesarean section due to its rapid onset, low failure rate, complete analgesia. Addition of intrathecal ketamine and opioids to local anaesthetics seems to improve the quality of block and prolong the duration of analgesia.Objectives The purpose of this study was to compare the effect of intrathecal ketamine mixed with hyperbaric bupivacaine to intrathecal fentanyl mixed with hyperbaric bupivacaine.Methods One hundred parturients ASA Grade I scheduled for elective or semiurgent caesarean section under spinal anaesthesia were randomly divided into two groups. Group A received 2ml (10 mg) hyperbaric bupivacaine 0.5% plus 25 mg preservative free ketamine. Group B received 2ml (10mg) hyperbaric bupivacaine 0.5% plus 25?g fentanyl. The patients were observed intraoperatively for the onset of sensory block, degree of motor block and total duration of analgesia.Results The time to achieve Bromage scale 3 motor blockade was shorter in Group A than in Group B.(p= 0.445) whereas time to achieve highest dermatomal level of sensory block was shorter in Group A than in Group B (p= 0.143). The duration of spinal analgesia was longer in Group B than in Group A (p= 0.730). The frequency of side effect such as sedation score was higher in Group A compared to Group B (p= 0.048). The incidence of pruritus was significantly higher in Group B compared to Group A (p = 0.000).Conclusion Addition of preservative free ketamine lead to faster onset of sensory and motor blockade, although it did not prolong the duration of spinal analgesia compared to addition of fentanyl in parturients undergoing caesarean section with spinal anaesthesia.Kathmandu Univ Med J 2013; 11(4): 287-291