Original Articles

By Dr. Antigona Hasani , Prof. Marija Soljakova
Corresponding Author Dr. Antigona Hasani
Pediatric Anesthesiologist, University Clinical Centre of Kosovo, Arberia , Zagrebit no.5 - Albania 10000
Submitting Author Dr. Antigona Hasani
Other Authors Prof. Marija Soljakova
Anesthesiology & Reanimation, University Kiril Metodij, - Republic of Macedonia


Preemtive Analgesia, Caudal Blocks, Midazolam, Postoperative Pain, Children

Hasani A, Soljakova M. Preemptive Analgesia in Children with Caudal Blocks. WebmedCentral PAIN 2011;2(3):WMC001679
doi: 10.9754/journal.wmc.2011.001679
Submitted on: 09 Mar 2011 09:46:34 PM GMT
Published on: 10 Mar 2011 10:35:34 PM GMT


Introduction: The aim of this study was to evaluate the preemptive analgesic effect and duration of postoperative analgesia after caudal blocks in children.
Methods: Forty-five children who underwent distal hypospadias surgery were assigned to group one (n=23) received caudal bupivacaine (0.25%) 0.5 mg kg-1 and midazolam 0.05 mg kg-1 before the surgical incision, and group two (n=22) who received caudal bupivacaine (0.25%) 0.5 mg kg-1 and midazolam 0.05 mg kg-1, after the surgical incision. Anesthesia was induced with propofol and fentanyl and maintained with sevoflurane and nitrous oxide. Postoperative pain was rated on objective pediatric pain scale.
Results: Analgesic requirement was higher in the second group.
Conclusion: Preemptive analgesia with caudal blocks may prevent the intensity and frequency of postoperative wound pain.


Preemptive analgesia involves the introduction of an analgesic before the onset of noxious stimuli. Prevention of the initial neural cascade could lead to eliminating the hypersensitivity produced by noxious stimuli (1-3). One of the techniques for prevention of postoperative pain in children involves the use of caudal block.
Single-shot caudal epidural blockade is one of the most widespread techniques to provide intra and postoperative analgesia in pediatric patients, which is relatively easy to perform (4-6). Caudal block can be performed prior to surgery in combination with general anesthesia, after surgery to be used for postoperative analgesia, or instead of general anesthesia for low abdominal and lower extremity procedures (7).
The aim of this study was to evaluate the preemptive analgesic effect and duration of postoperative analgesia after caudal blocks with bupivacaine and midazolam, given before or after surgical incision, during the surgical treatment for hypospadias in children.


This prospective, randomized, double-blinded study was approved by our institution’s ethics committee and written informed consent was obtained from the parents of each participant. The subjects were 45 boys aged 1 to 9 years. All were ASA physical status I or II. Each patient was assigned randomly to either group, once for each operation. Patients were excluded if they had a known allergy to any of the drugs involved in the study, patients with ASA physical status >II and if caudal block failed.
Each child was premedicated with oral midazolam (0.5 mg·kg-1) 30 minutes before anesthesia induction. The intravenous line was put in both groups of children before the induction of anesthesia. Anesthesia was induced with propofol and fentanyl and laryngeal mask was inserted. Anesthesia was maintained with sevoflurane in 50% nitrous oxide and oxygen. After induction, in a lateral decubitus position a 22 gauge intravenous catheter was inserted in the caudal space. Patients in group one received 0.25% caudal bupivacaine 0.5 mg kg-1 and midazolam 0.05 mg kg-1 before the surgical incision, and patents in group two (n=22) received 0.25% caudal bupivacaine 0.5 mg kg-1 and midazolam 0.05 mg kg-1, after the surgical incision.
Pressure-controlled ventilation was administered throughout the operation. Anesthesia was discontinued after the last suture was tied. The laryngeal mask was removed when the child was breathing spontaneously (on 100% oxygen) and airway reflexes were restored.
In each case, we recorded heart rate, blood pressure, arterial O2 saturation, and end-tidal CO2 concentration (Compact 5XL, Medical ECONET, Germany), at fixed intervals throughout the operation.
In order to keep the study double-blinded,two separate anesthesiologists were involvedin each case. First blinded anesthesiologist collected following data: age, weight, premedication, preoperative anxiety, type of anesthesia, type of surgery, and duration of surgery and anesthesia. The anesthesiologist was blinded to the specifity of the caudal solution. In the post-anesthesia care unit, the second anesthesiologist, blinded as to the specifity of caudal solution, observed and collected following data: recovery time, pain and adverse effects.
Objective Pain Scale (OPS) (minimum score: 0 = no pain; maximum score: 10 = extreme pain) was used to assess pain severity (8). This scale is composed of 5 items and each are scored (Illustration 1). Assessments were made at 15-min intervals for the first hour, 30-min intervals for the second hour and 3, 4, 5, 6, and 24 hr recovery from anesthesia. The observer scored pain on each time (none/insignificant pain (1-3); moderate pain (4-6); severe pain (7-10)). Patients with pain score ≥4 were treated with additional dose of analgesics. Patients with pain score ≥4, received diclofenac suppository (1-2 mg kg-1).
Recovery time (defined as the time until eye opening on command or the time of first response to command after anesthesia), preoperative anxiety, agitation during the emergence period and time to first analgesia administration, were also noted. Preoperative anxiety was assessed (after premedication until the anaesthetic induction) using observational scale, the modified Yale Preoperative Anxiety Scale (YPAS-m) (9). The child was consider anxious if the YPAS-m >30.
Adverse effects during surgery, hypotension and bradycardia and after removal of laryngeal mask (intense coughing, hypersalivation, laryngospasm), nausea and vomiting and muscle weakness were also recorded.
Demographic data (age, sex, weight), duration of surgery, recovery time, preoperative anxiety, intraoperative data and pain are presented as median and percentiles, and differences between the 2 groups were analyzed using paired t tests. Nonparametric data, incidence of adverse events, are expressed as median and range, and differences between the 2 groups were analyzed using the Wilcoxon ranked-sum test, exact Fisher test and chi-squared test. P values less than 0.05 were considered significant.


Group I (n = 23) represented 51% of the total children in the study and group II (n = 22) represented 49%. There were no significant differences between the 2 study groups with respect to age, sex distribution, weight, proportions of patients with physical status ASA I and physical status ASA II, or type of operation, and frequency of preoperative anxiety or emergence agitation (P > 0.05) (Illustration 2).
Illustration 3 lists the frequencies of different adverse effects that were noted in the 2 groups. Four patients (17.4%) in group I and 3 (13.6%) in group II developed hypotension intraoperativelly. These differences were significant. None of the 45 children required treatment with vasoactive agents. Motor block was present only in one child in group I and one in second groups.
Table 4 shows the results for first requirement of analgesics. The mean time for group II was significantly shorter than the corresponding mean for group I (4.6 ± 1.3 vs 5.2 ± 2.4 hours respectively; P< 0.01).
Group II had a significantly higher proportion of patients who exhibited postoperative pain than group I (40.9% vs.8.7%, respectively; P < 0.05). The OPS score in group I was 3 (range, 0–10), whereas the corresponding in group II was 8 (range, 1–10). The difference between these results was statistically significant (P < 0.01) (Illustration 4).


Knowledge that preemptive analgesic interventions are more effective than conventional treatment in managing acute postoperative pain remains controversial. Several reviews have very different conclusions. For example, some reviews have concluded that preemptive analgesia is effective as such (10,11), but some have concluded it to be effective only for certain analgesic drugs (1,12). The evidence on preemptive analgesia in animal studies is very credible (13); results from human clinical studies remain controversial.
Our study with comparation of pre-incisional and post-incisional caudal block with bupivacaine and midazolam revealed an effectiveness of preemptive analgesia. The significantly higher frequency of postoperative pain was during realizing a block after surgical incision (40.9% vs. 8.7%, respectively).
Several studies have compared the effect of preoperative and postoperative anesthesia infiltration for inguinal herniorrhaphy. No firm evidence was observed regarding the timing of analgesic treatment that has important effects on postoperative pain control (14, 15).
Katz and colleagues studied patients scheduled for elective thoracic surgery, which received epidural fentanyl before incision and the same dose of epidural fentanyl after incision. They found that pain scores were significantly less in patients who applied epidural block before surgical incision (16).
The other study which supports our findings was from Amr et al. they applied pre-incisional epidural bupivacaine and fentanyl in patients undergoing thoracic surgery and demonstrate the significant lower score of postoperative pain (17).
Arici et al. demonstrates that preemptively administered iv paracetamol 1 g in patients undergoing a total abdominal hysterectomy operation, ensures an effective analgesia during the postoperative period and reducing postoperative morphine consumption and side effects (18).
As mentioned, research has established that multiple factors are associated with postoperative pain. Some of the possible causes include anxiety just prior to surgery, or emergence delirium. A number of groups have looked at the correlation between preoperative anxiety, postoperative agitation and postoperative pain. Kain and colleagues evaluated the relationship between preoperative anxiety and both postoperative delirium and new maladaptive behaviours using data from several previous studies (19). They found that higher levels of preoperative anxiety put patients at increased risk for postoperative pain. In our study, our data demonstratea similar incidence of preoperative anxiety (8.7% versus 4.5% respectively) and emergence agitation (1.3 ± 0.6 versus 1.4 ± 0.7 respectively) in first and second group (Tab.2).
The incidence rates of adverse effects were low in both our treatment groups (Tab.3).
Findings in our study demostrate the significant difference in time until first anesthesia request in group I and II (4.6 ± 1.3 vs 5.2 ± 2.4 hours respectively; P< 0.01).


In summary, postoperative pain in children remains a significant problem. Our results indicate that, caudal block with bupivacaine and midazolam before surgical incision is associated with a lower incidence of postoperative pain intensity and reduced postoperative analgesics requirements when compared with the caudal block applied after surgical incision. Preemptive analgesia may prevent the intensity and frequency of postoperative wound pain.


1. Igor Kissin. Preemptive analgesia at the crossroad. Anesth Analg 2005; 100: 754-6.
2. Bachiocco V, Scesi M, Morselli AM, Carli G. Individual pain history and familial pain tolerance models: relationships to post-surgical pain. Clin J Pain 1993; 9:266-71.
3. Kissin I. Preemptive analgesia. Anesthesiology 2000; 93: 1138–43.
4. Miller RD, Fleisher LA, Johns RA, Savarese JJ, Weiener-Kronish JP, Young WL. Miller’s Anesthesia, USA, Elsevier, 2005; 1732-4.
5. Litman RS. Pediatric Anesthesia the Requisites in Anesthesiology, USA, Mosby, 2004; 160-5.
6. Tobias JD. Therapeutic application of regional anesthesia. Paediatr Anaesth 2002; 12:272-7.
7. Zaglaniczny K, Aker J. Clinical Guide to Pediatric Anesthesia. USA. Saunders Company, 1999; 359-412.
8. Norden J, Hanallah R et al. Reliability of an objective pain scale in children. J Pain and Symptom Management. 1991; 6: 196.
9. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain BC, et al. Preoperative anxiety and emergency delirium and postoperative maladaptive behaviors. Anesth Analg 2004; 99:1648-54.
10. Wilder-Smith OH. Pre-emptive analgesia and surgical pain. Prog Brain Res 2000; 129:505–24.
11.  Kelly DJ, Ahmad M, Brull SJ. Preemptive analgesia. II. Recent advances and current trends. Can J Anaesth 2001; 48:1091–101.
12. Moiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief. Anesthesiology 2002;96:725–41.
13. Simone DA, Sorkin LS, Oh O et al. Neurogenic hyperalgesia: central neural correlates in responses of spinothalamic tract neurons. J Neurophys 1991; 66: 228-246.
14. Rice LJ, Pudimat MA, Hanallah RS. Timing of caudal block placement in relation to surgery does not affect duration of postoperative analgesia in pediatric ambulatory patients. Can J Anaesth 1990; 37: 429-431.
15. Goodarzi M. The effect of perioperative and postoperative caudal block on pain control in children. Paediatr Anaesth 1996; 6: 475-477.
16. Katz J, Kavanagh BP et al. Pre-emptive analgesia. Clinical evidence of neuroplasticity contributing to postoperative pain. Anesthesiology 1992; 77: 439-446.
17. Amr YM, Yousef AA, Alzeftawy AE et al. Effect of preincisional epidural fentanyl and bupivacaine on postthoracotomy pain and pulmonary function. Ann Thorac Surg 2010 Feb; 89:381-5.
18. Arici S, Gurbet A, Türker G et al. Preeptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. Agri. 2009 Apr; 21(2):54-61.
19. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain BC, et al. Preoperative anxiety and emergency delirium and postoperative maladaptive behaviors. Anesth Analg 2004; 99:1648-54.

Source(s) of Funding


Competing Interests



This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

2 reviews posted so far

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)