prevention of emergence agitation in children by adding Ketamine or midazolam to bupivacaine caudally

Emergence agitation (EA), which is also referred to as emergence delirium in children is a major postoperative issue that increases the risk of patient self harm ,places a burden on nursing staff, and reduces parentsatisfaction with treatmentThe definition of EA is “a disturbance in a child’s awareness of and attention to his or her environment with disorientation and perceptual alterations, including hypersensitivity to stimuli and hyperactive motor behavior in the immediate post-anesthesia period.” Risk factors for EA include age, preoperative anxiety, patient personality, pain, anesthesia method, and surgical procedure. In cases of EA, patients often remove drains or catheters, causingself-harm. Thus, sedation or restraint by health care providers may be required. Furthermore, this EA is often a particularly unpleasant experience for parents or caregivers. Therefore, various approaches allowing uneventful emergence from anesthesia have been studied. Ketamine and Midazolam both are being used to prevent EA in children mainly through intravenous route.The primary outcome of this study is prevention of EA this outcome will be measured by the pediatric anesthesia emergence delirium scale (PAED). The secondary outcomes are post operative analgesia which will be determined by the face legs activity cry consolability scale (FLACC), time of first analgesic request, 24 hours postoperative analgesic requirement and intraoperative hemodynamics.