Unlike adults, children are more anxious and uncooperative during invasive and painful clinical procedures. Sedation and analgesia are required to keep the child immobile to facilitate painful procedures.

Various Sedo-analgesic drugs such as ketamine, dexmedetomidine, midazolam, and propofol either alone or in combination are commonly used for several painful invasive procedures with variable degrees of success.

Caudal epidural analgesia is one of the most popular and commonly performed regional blocks in pediatric anesthesia.

Caudal blocks combined with periprocedural sedation are an efficient way to offer perioperative analgesia for painful infraumbilical interventions. 

They enable not only early ambulation but also perioperative hemodynamic stability and spontaneous breathing in children with cardiopulmonary co-morbidities.

Bupivacaine has been in clinical use for more than 30 yr and is widely used for caudal epidural analgesia in children because of its long duration of action and beneficial ratio of sensory to motor block.

The combination of Dexmedetomidine-Ketamine (DexKet) and Midazolam-Ketamine (MiKe) seems to have favorable characteristics in the pediatric population.

Ketamine is an anesthetic and analgesic agent with a wide range of applications in paediatric anesthesia. Ketamine (KET) is a phencyclidine derivative whose action is due to the central dissociation of the cortex from the limbic system providing both sedative and analgesic properties while preserving upper airway muscular tone and respiratory drive. It has a rapid onset with a short duration of action that induces good analgesia, sedation, and amnesia with a rapid recovery. ketamine‑induced agitation can be overcome by co‑administration of other drugs. Numerous studies have been tried to compare different drugs such as midazolam, dexmedetomidine (Dex), propofol, clonidine, and haloperidol to reduce these adverse responses.

Dexmedetomidine (DEX) is a specific central alpha 2-adrenergic agonist that is associated with sedative and analgesic sparing effects, reduced delirium and agitation, perioperative sympatholytic, cardiovascular stabilizing effect and preservation of respiratory function.

When used together, DEX may prevent tachycardia, hypertension, salivation and emergence phenomena from KET, whereas KET may prevent bradycardia and hypotension which has been reported with DEX. An additional benefit of rapid onset of sedation^.

Midazolam is a benzodiazepine used for procedural sedation, and to treat severe agitation. Midazolam induces sleepiness, decreases anxiety, and causes amnesia.It has a fast onset time for sedative effects and a fast recovery period.

The combination of midazolam and ketamine provides effective procedural sedation and analgesia and appears to be safe in pediatric patients.

Therefore, we planned to compare the efficacy of the Dexmedetomidine-Ketamine and Midazolam- Ketamine combination for sedo-analgesia in pediatric patients undergoing infraumbilical surgeries under caudal epidural block.