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Mohamed Ahmed Hamed, Maged Labib Boules, Mina Mahrous Sobhy, Mahdy Ahmed Abdelhady Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, EgyptCorrespondence: Mohamed Ahmed Hamed, Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, 63511, Egypt, Tel +20 111-856-0065, Email mah07@fayoum.edu.egBackground: We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral transversus thoracic muscle plane block after open-heart surgeries.Methods: Seventy patients aged above 18 years and scheduled for valve replacement or adult congenital via median sternotomy were enrolled in this study. Patients were divided into two groups, randomized by computer-generated random numbers: the block group, which had the ultrasound-guided bilateral transversus thoracic muscle plane block, and the control group, which had a sham block. The primary outcome was total fentanyl consumption in the first 24-hours. The secondary outcomes were pain score, time to the first analgesic request, time to extubation, ICU stays, and hospital stay.Results: The total fentanyl consumption in the first 24 hours was significantly lower in the block group, with a mean difference of − 158.286 (95% CI = (− 179.271 to − 137.300; p =< 0.0001)). The time to the first analgesic request was statistically significantly shorter in the non-block group (median 3 hours) than the block group (median 14 hours). During the postoperative period (0.5– 24 hours), at-rest pain scores were 1.86 units lower in the block group (the estimate was − 1.80, 95% CI = − 2.14 to − 1.45, t = − 10.323 with p < 0.0001). Likewise, pain scores with cough were 3.29 units lower in the block group (the estimate was − 3.29, 95% CI = − 3.80 to − 2.77, t = − 12.703, p < 0.0001).Conclusion: Bilateral transversus thoracic muscle plane block is a promising and effective technique in reducing opioid consumption and controlling post-sternotomy pain after open-heart surgery via median sternotomy.Keywords: transversus thoracic muscle plane block, fentanyl consumption, sternotomy, postoperative pain

Maged Labib Boules, Abeer Shaban Goda, Mahdy Ahmed Abdelhady, Shimaa Adel Abu El-Nour Abd El-Azeem, Mohamed Ahmed Hamed Department of Anesthesiology, Faculty of Medicine, Fayoum University, Cairo, EgyptCorrespondence: Mohamed Ahmed HamedDepartment of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum 63511, EgyptTel +2011 18 560 065Email mah07@fayoum.edu.egBackground: This study compared the analgesic efficacy of a bilateral erector spinae plane (ESP) block with that of a bilateral transversus abdominis plane (TAP) block after elective cesarean delivery.Methods: Sixty mothers scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either ESP block or TAP block. The ESP group received ESP block at the level of the ninth thoracic transverse process with 20 mL of 0.25% bupivacaine at the end of surgery. The TAP group received an ultrasound-guided TAP block with 20 mL of 0.25% bupivacaine on completion of delivery. The primary outcome was the duration of analgesia achieved by each block. Secondary outcome measures were the postoperative pain severity, total tramadol consumption, patient satisfaction.Results: The median (interquartile range) duration of block was longer in the ESP group than in the TAP group (12 hours [10, 14] vs 8 hours [8, 8], p< 0.0001). In the first 24 hours, the mean visual analog pain score at rest was lower by 0.32 units in the ESP group. The median tramadol consumption in the first 24 hours was significantly higher in the TAP group than in the ESP group (125 mg [100, 150] vs 100 mg [75, 100, p=0.003]).Conclusion: Compared with the TAP block, the ESP block provides more effective pain relief, has a longer duration of analgesic action, prolongs time to first analgesic requirement, is associated with less tramadol consumption, and can be used in multimodal analgesia and opioid-sparing regimens after cesarean section.Keywords: erector spinae plane block, transversus abdominis plane block, cesarean, analgesia, tramadol

Background: Perioperative analgesia is very important during an abdominal hysterectomy. Determining the impact of the erector spinae plane block (ESPB) on patients undergoing an open abdominal hysterectomy while under general anesthesia was our aim., Methods: In order to create equal groups, 100 patients who underwent elective open abdominal hysterectomies under general anesthesia were enlisted. The preoperative bilateral ESPB with 20 ml of bupivacaine 0.25% was administered to the ESPB group (n = 50). The same procedure was performed on the control group (n = 50), but they received a 20-ml saline injection instead. The primary outcome is the total amount of fentanyl consumed during surgery., Results: We found that the mean (SD) intraoperative fentanyl consumption was significantly lower in the ESPB group than in the control group (82.9 (27.4) g vs. 148.5 (44.8) g, with a 95% CI = -80.3 to -50.8; p 0.001). Likewise, mean (SD) postoperative fentanyl consumption was significantly lower in the ESPB group than in the control group (442.4 (17.8) g vs. 477.9 (10.4) g, with a 95% CI = -41.3 to -29.7; p 0.001). On the other hand, there is no statistically significant difference between the two study groups regarding sevoflurane consumption (89.2 (19.5) ml vs. 92.4 (15.3) ml, with a 95% CI = -10.1 to 3.8; p 0.4). We documented that during the post-operative period (0-24 h), VAS scores at rest were, on average, 1.03 units lower in the ESPB group (estimate = -1.03, 95% CI = -1.16-(-0.86), t = -14.9, p-value 0.001), and VAS scores during cough were, on average, 1.07 units lower in the ESPB group (estimate = -1.07, 95% CI = -1.21-(-0.93), t = -14.8, p-value 0.001)., Conclusion: Bilateral ESPB can be utilized as an adjuvant method to reduce intraoperative fentanyl consumption and enhance postoperative pain control in patients undergoing open total abdominal hysterectomy under general anesthesia. It is effective, secure, and little obtrusive., Trial Registration: No protocol revisions or study amendments have been made since the trial's inception, according to the information on ClinicalTrials.gov (NCT05072184; principal investigator: Mohamed Ahmed Hamed; date of registration: October 28, 2021)., (© 2023. The Author(s).)

Background: Etomidate was associated with an inhibition of adrenal steroid synthesis. This study aimed to evaluate the effects of adding low-dose ketamine to etomidate to minimize the decrease in serum cortisol level in critically ill cardiac patients., Methods: Sixty adult cardiac patients, ≥ 18 years, who underwent upper endoscopy and Colonoscopy to manage acute anemia in the cardiac intensive care units were enrolled. Patients were randomly divided into two groups: (group (E): n = 30) received etomidate 0.2 mg/kg IV followed by etomidate 0.05 mg/kg IV, and (group (KE): n = 30) received ketamine 0.5 mg/kg IV, then etomidate 0.1 mg/kg IV, followed by etomidate 0.05 mg/kg IV. The primary outcome was Serum cortisol level at 6 h after the procedure., Results: The mean postoperative cortisol level was significantly lower in group E (295.60 ± 49.218 nmol/L) versus group KE (461.00 ± 67.946 nmol/L), with 95% CI = 351.94 to 404.66; p = 0.000. In addition, the estimated serum cortisol reduction level was also significant between groups; In group E, the estimated cortisol level decreased nearly 53% from 632.40 ± 35.066 nmol/L to 295.60 ± 49.218 nmol/L 6 hours postoperative. While in group KE, the estimated cortisol level decreased only 27% from 639.13 ± 43.035 nmol/L to 461.00 ± 67.946 nmol/L., Conclusions: Single-dose ketamine (0.5 mg/kg) was helpful to decrease the total dose of etomidate and hence decreased the percentage of serum cortisol level in such critically ill patients with preservation of patient satisfaction., Trial Registration: This study is registered on ClinicalTrials.gov ( NCT04857450 ; principal investigator: Mostafa Mohammed Elsaid Elhamamsy; registration date: 23/04/ 2021)., (© 2022. The Author(s).)

Background: After laparoscopic abdominal surgery, we aim to evaluate the analgesic efficiency of US-directed bilateral transversus abdominis plane block (TAPB) and quadratus lumborum block (QLB)., Methods: 50 patients aged 18-60 years listed for elective laparoscopic abdomen operation were registered in this study. Cases were randomly allocated into two similar groups: TAPB and QLB groups. The first outcome was the growing morphine consumption on the 1 st day postoperatively. The second outcome involved VAS score, first analgesic necessities, and any postoperative complications. Statistical analysis was done with the 2-sample t -test, and Mann-Whitney U testing was utilized to compare medians for skewed end points. Qualitative data were introduced as numbers and percentages, and chi-squared testing was utilized to determine the significance., Results: The median cumulative morphine consumptions on the 1st day were high significantly in the TAPB group than in the QLB group (6 mg [6, 9] vs. 3 mg [3, 6], p value ≤0.0001]). The QLB group showed an increase in the median of the time to the first analgesic request in comparison with the TAPB group (17 hours [12, 24] vs. 8 hours [6, 24], p ≤ 0.001). In addition, on the 1st day, the mean VAS scoring at rest was lower in the QLB group., Conclusion: In comparison to the TAPB, the QL block delivers more successful pain relief, has an extended period of analgesic actions, extends interval to the 1 st analgesic necessity, is accompanied with lesser morphine consumptions, and may be utilized in multimodal analgesia and opioid-sparing regimens after that laparoscopic operation. This trial is registered with NCT04553991., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Omar Sayed Fargaly et al.)

Objectives: We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral pectointercostal fascial plane block after open heart surgeries., Methods: Seventy patients aged above 18 years and scheduled for on-pump coronary artery bypass grafting or valve replacement or both through median sternotomy were enrolled in this study. Patients were randomly allocated into 2 groups of 35 (block group or control group). The block group had the block performed through 20 ml of a solution of 0.25% bupivacaine plus epinephrine (5 mcg/mL), and the control group received dry needling. The primary outcome was the 24-hour cumulative morphine consumption. The secondary outcomes were time to the first analgesic request, pain score, quality of oxygenation, intensive care unit stays, and hospital stay., Results: The cumulative morphine consumption in the first 24 hours was significantly lower in the block group, with a mean difference of -3.54 (95% confidence interval=-6.55 to -0.53; P=0.015). In addition, the median estimate time to the first analgesic request was significantly longer in the block group than in the control group. Finally, during the postoperative period (4 to 24 h), mean sternal wound objective pain scores were, on average, 0.58 units higher in the block group., Conclusion: pectointercostal fascial block is an effective technique in reducing morphine consumption and controlling poststernotomy pain after cardiac surgeries. Also, it may have a role in better postoperative respiratory outcomes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Ketofol's effect on hemodynamics and the airway response during inducing general anesthesia has been studied previously. However, ketofol's effect on the smoothness of extubation has not been studied yet., Objectives: We aimed to assess ketofol's effect on the smoothness of extubation and compare it with propofol for inducing general anesthesia., Methods: This double-blind, randomized, and controlled study was conducted on 106 class I and II female patients with the "American Society of Anesthesiologists Physical Status (ASAPS)," aged 18 - 40 years, scheduled for laparoscopic drilling for polycystic ovary disease under general anesthesia. The patients were assigned to two groups of 53 patients each: Group KP = ketofol and Group P = propofol., Results: There was an excellent sedation score during suction and extubation in the ketofol group. The airway response and smoothness of extubation were better in the ketofol group than in the propofol group., Conclusions: Ketofol as an induction anesthetic agent more effectively attenuated the airway response during extubation than only propofol., Competing Interests: Conflict of Interests: The author(s) declare(s) that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2021, Author(s).)

Chronic neck pain (CNP) is a major concern for pain therapists. Many drugs including antidepressants such as amitriptyline have been used in the management of CNP. This study compared the efficacy and safety of 2 different doses of amitriptyline (5 mg and 10 mg at bedtime) in patients with CNP. A total of 80 patients of both sexes with idiopathic CNP, ranging in age from 18 to 75 years, were divided into 2 groups that received 5 or 10 mg oral amitriptyline at bedtime for 120 days. The primary outcome measure was neck pain disability index (NPDI). Neck pain intensity, Athens Insomnia Scale score, Hospital Anxiety and Depression Scale (HADS), side effects of the drug, and patient satisfaction were secondary outcome measures. NPDI decreased by 71.9% ± 13.4% in the 10 mg group compared to 47.3% ± 17.3% in the 5 mg group, representing a statistically significant difference (95% confidence interval: 27.3-12.6). Additionally, the 10 mg group showed greater mean reductions in pain score and HADS scores (both the anxiety and depression subscales), as well as improvement in sleep disturbance compared to the 5 mg group. A higher dose (10 mg) of amitriptyline at bedtime significantly reduced neck pain intensity, sleep disturbance, and anxiety and depression compared to a lower dose (5 mg) in patients with idiopathic and nontraumatic CNP after 120 days of treatment, with no significant difference between groups in the rate of side effects., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2021 Atef Mohamed Sayed Mahmoud et al.)

Background: Vascular access is a top priority in the critically ill patients. Cannulation - venous and/or arterial - is the first step in any emergency situation. Ultrasound (US)-guided vascular cannulation was found to have a higher success rate and a decreased incidence of mechanical complications as compared with the landmark one., Aim: This study aims to compare subclavian vein (SCV) access through supraclavicular (SC) approach by endocavitary (EC) probe technique versus linear array high-frequency probe technique., Settings and Design: A prospective, randomized controlled study conducted on 60 patients., Patients and Methods: Study was carried out on 60 adult patients presenting for the surgical intensive care unit in Fayoum University Hospital. Patients were classified into two groups: Group (A) ( n = 30): Catheter was inserted using the EC probe and Group (B) ( n = 30): Catheter was inserted using the linear array high-frequency probe., Statistical Analysis Used: Student's t -test was applied for calculation of normally distributed variables and Mann-Whitney U-test for nonnormally distributed variables. Categorical data between the groups were compared using Chi-squared test. P < 0.05 indicated a statistically significant difference., Results: The frequency of successful cannulation of the SCV at first attempt was significantly higher in Group A compared to Group B ( P = 0.044). The number of attempts and the time needed for venous access were significantly lower in Group A compared to Group B ( P = 0.038, <0.001 respectively). No significant difference was found regarding the incidence of posterior wall puncture, arterial puncture, or hematoma, ( P = 0.671, 0.055, 1 respectively)., Conclusion: The use of EC probe technique for Subclavian venous access through the SC approach significantly increased the success rate compared to the linear array high-frequency probe., Competing Interests: There are no conflicts of interest.

The PEEP in ALI/ARDS had been used since its' description (1967). Up-to-date no optimal approach to PEEP setting had been introduced, however common approaches that had been introduced included Pressure volume curves, increasing PEEP trial, decreasing PEEP trial & PEEP/FiO2 tables adopted by ARDS network. The present work assessed the safety and efficacy of three introduced approaches for PEEP setting namely increasing PEEP trial, decreasing PEEP trial and PEEP/FiO2 table. Sixty patients fulfilling the American-European Consensus Conference (AECC) criteria for ALI/ARDS were enrolled in this study, patients were randomly allocated into three equal groups (n = 20) 1, 2 & 3 using closed envelope technique. In GA: patients received an increasing PEEP trial, GB: patients received a decreasing PEEP trial and GC: PEEP was set according to PEEP/FiO2 tables of the ARDS network trial. Hemodynamic parameters (mean arterial blood pressure (MAP) and heart rate (Hr) were recorded. Respiratory & oxygenation parameters (peak airway pressure (Paw), plateau pressure (Pplat), mean airway pressure (Pmean), PEEP, PaO2, PaO2/FiO2 and arterial oxygen saturation (Sao2) were also recorded at eight specific times, prior to randomization (baseline), following PEEP setting and twice daily for 72 hours. Both increasing and decreasing PEEP trials were considered superior to PEEP/FiO2 tables in identifying desired PEEP level. Although increasing and decreasing PEEP trials had demonstrated increased PaO2, and decreased FiO2 and better PaO2/FiO2 ratios compared to baseline values, however increasing PEEP trial was associated with lower Paw and Pplat due to lower PEEP values compared to decreasing PEEP trial. Decremental trial was associated with best PaO2, FiO2, and PaOz/FiO2 compared to increasing PEEP trial and PEEP/FiO2 tables.