Low Dose Caudal VS Dorsal Penile Nerve Block for Postoperative Analgesia After Circumcision
Condition: Pain, Postoperative
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      in order to eliminate fear and anxiety. Regional techniques are more effective than systemic
      opioids, non steroidal anti-inflammatory drugs, and acetaminophen for postoperative analgesia
      in circumcision, The most preferred techniques are dorsal penile nerve block and caudal
      block.

      Objective: To investigate the effectiveness of post operative analgesia and complications
      among dorsal penile nerve block, caudal block and the combination of both.

      Patients and Methods: Our study was carried out to compare the effectiveness, duration of
      post-operative analgesia, and the complications among dorsal penile nerve block (DPNB),
      caudal nerve block (CNB) and the combination of both. This study will carrey out on 81 male
      patients, aged from 3-12 years old & undergoing circumcision. The patients were divided into
      3 groups, each is composed of 27 patients; group 1 including DPNB patients, group 2 including
      CNB patients and group 3 for combined block. This study compared between the three groups
      regarding the intra-operative vital data (HR,BP), post-operative VAS scores and the
      complications (nausea, vomiting, urinary retention, itching, constipation & CNS depression).
    

Detailed description: 
      Cases were subdivided into three groups: Group 1: included dorsal penile block patients.
      Group 2: included caudal block patients. Group 3: included combined block patients.

      Circumcision was performed under general anesthesia and dorsal slit technique was used.

      Study procedure:

      General anesthesia was induced and maintained by inhalation of sevoflurane in oxygen mixed
      with air gas flow. A 22-G intravenous (i.v.) cannula was placed after induction. Spontaneous
      respiration was maintained via a selected laryngeal mask airway, and the inhaled sevoflurane
      was modified and maintained as 0.8 to 1.0MAC.

      Block techniques:

      Technique of the caudal block The patient was placed in lateral decubitus position for blind
      caudal epidural block. A line was drawn to connect the bilateral posterior superior iliac
      crests and used as one side of an equilateral triangle; then the location of the sacral
      hiatus was approximated by palpating the sacral cornua as 2 bony prominences, the sacral
      hiatus was identified as a dimple in between. A needle was inserted at 45 degrees to the
      sacrum and redirected if the posterior surface of sacral bone was contacted.

      A subjective feeling of loss of resistance suggests piercing the SCL but was associated with
      a miss rate up to 26% even in experienced hands. The "whoosh test," performed by auscultation
      at the thoracolumbar region with a stethoscope while injecting 2 mL of air, had a sensitivity
      of 80% and a specificity of 60% in adults. Palpating for subcutaneous bulging on rapid
      injection of 5 mL air or saline had a positive predictive value of 83% and a negative
      predictive value of 44%. The inaccuracy of using blind technique for caudal epidural
      injection in adults, even confirmed by various tests, is clearly evident.

      Drugs and doses used: 0.5 ml/kg of 0.25% Bupivacaine (diluted by saline solution 0.9).

      Technique of Dorsal penile nerve block:

      Under aseptic technique and under ultrasound guidance. A 'hockey-stick' probe was used,
      covered by transparent sterile dressing. The probe was placed vertically over the pubic
      symphysis and the base of the penile shaft. With adjustment of the probe, a sagittal view of
      the penile shaft was produced. Scarpa's fascia was seen as a hyperechoic line superficial to
      the penile shaft. Under real-time guidance, the needle was inserted and advanced until its
      tip laid deep to Scarpa's fascia (i.e., within the subpubic space), where local anesthetic
      was deposited. The local anesthetic solution injected was 0.5% bupivacaine in a recommended
      volume. (2 ml up to 3 years and an additional 1 ml for each3 years up to maximum 6 ml).
      Combined block:

      The caudal block was performed then the patient was placed in supine position and the DPNB
      was done .
    

Intervention name(s): Caudal nerve block /neuroaxial; Dorsal penile nerve block; Combined caudal and dorsal penile nerve block
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): Technique of the caudal block The patient was placed in lateral decubitus position for blind caudal epidural block. A line was drawn to connect the bilateral posterior superior iliac crests and used as one side of an equilateral triangle; then the location of the sacral hiatus was approximated by palpating the sacral cornua as 2 bony prominences, the sacral hiatus was identified as a dimple in between. A needle was inserted at 45 degrees to the sacrum and redirected if the posterior surface of sacral bone was contacted.
A subjective feeling of loss of resistance suggests piercing the sacral ligament.The "whoosh test," performed by auscultation at the thoracolumbar region with a stethoscope while injecting 2 mL of air, Palpating for subcutaneous bulging on rapid injection of 5 mL air or saline had a positive predictive value of 83% and a negative predictive value of 44%.; Technique of Dorsal penile nerve block:
Under aseptic technique and under ultrasound guidance. A 'hockey-stick' probe was used, covered by transparent sterile dressing. The probe was placed vertically over the pubic symphysis and the base of the penile shaft. With adjustment of the probe, a sagittal view of the penile shaft was produced. Scarpa's fascia was seen as a hyperechoic line superficial to the penile shaft. Under real-time guidance, the needle was inserted and advanced until its tip laid deep to Scarpa's fascia (i.e., within the subpubic space), where local anesthetic was deposited. The local anesthetic solution injected was 0.5% bupivacaine in a recommended volume. (2 ml up to 3 years and an additional 1 ml for each3 years up to maximum 6 ml).; Combined techniques of caudal and dorsal penile nerve block
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Prevention