Preanaesthetic checkup:  

A detailed preoperative evaluation will be done including details and duration of disease, traumatic or degenerative cause , treatment taken, duration of treatment, and dose of preoperative analgesics for pain relief.

Routine investigations, Coagulation profile , ECG and Chest x ray will be performed.

Patients will be briefed about the PCA (Patient Controlled Analgesia) device to be used postoperatively and patient dexterity with the device will be ensured.

Visual analog scale will also be explained.

 Patients will receive standard premedication with T.Alprazolam 0.5mg at night prior to day of surgery and two hours before surgery.

Anaesthesia technique: 

After mid night fasting, patient, in operating room peripheral venous access will be placed. Standard intraoperative monitoring with ECG,  SpO2,  NIBP,  EtCO2 will be instituted.

After preoxygenation, anaesthesia will be induced with Inj. Propofol  2-3mg/kg i.v , Inj. Fentanyl  2µg/kg i.v. , and Inj. Atracurium followed by endotracheal intubation. Anaesthesia will be maintained with Oxygen : N2O (50 : 50) and Isoflurane ( MAC 0.8  -1).

I.V. fluids will be administered as per the requirement. Intra operative monitoring will include ECG, EtCO2, anesthetic gases, SpO₂ , NIBP, and blood loss.

Following prone positioning, the patients will be randomly divided into two groups using computer generated randomisation.

One group will receive ultrasound guided caudal epidural block with  morphine 50 µg/kg diluted with 20 ml of 0.25% bupivacaine. Second group will receive ultrasound guided caudal epidural block with 0.25% bupivacaine alone. The block will be administered using 18 gauge tuohy needle.

Tranexamic acid (bolus 10 mg/kg followed by 1mg/kg/hour infusion) will be given to reduce perioperative blood loss.

 Rescue boluses of fentanyl 0.5-1 µg/kg, will be given if there is an increase in the heart rate or blood pressure more than 20% of the baseline after ensuring adequate depth of anaesthesia and normovolemia.

Thirty minutes prior to extubation, injection Ondansetron (4mg) will be given to prevent postoperative nausea and vomiting . After the completion of surgery neuromuscular block will be reversed with Inj. neostigmine 40-70mcg/kg and Inj.glycopyrrolate 7-10mcg/kg. Trachea will be extubated when patient fulfills the clinical criteria(regular breathing, respiratory rate>10 and <30 and tidal volume> 5-6 ml/kg).

Postoperative Management and assessment

Postoperatively patients will be shifted from Operation room to Recovery room (PACU).  PCA device will be attached and patient instructed to take boluses on demand as soon as cognitive function recovers. Each bolus will deliver 1mg morphine, with a lockout period of 10 minutes. No basal infusion will be provided. Paracetamol 1g intravenous infusion (20mg/kg for smaller patients) 8 hourly will be continued for 24 hours.