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Ehab H Shaker,1 Mahmoud S Soliman,2 Ayman Hanafy,3 Walaa Y Elsabeeny1 1Department of Anesthesia, Intensive Care and Pain Management, National Cancer Institute, Cairo University, Cairo, Egypt; 2Department of Anesthesia, Surgical ICU and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt; 3Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, EgyptCorrespondence: Walaa Y Elsabeeny, Department of Anesthesia and Pain management, National Cancer Institute, Kasr Al Eini Street, Fom El Khalig, Cairo, Egypt, Tel +20 1007798466, Email walaa.elsabeeny@nci.cu.edu.egObjective: Several modalities for analgesia after laparoscopic procedures have been used. This study aimed to investigate the efficacy of early versus late bupivacaine/tramadol combination and bupivacaine/dexmedetomidine combination in analgesia for laparoscopic cancer surgeries.Methods: A total of 100 patients of both genders scheduled for elective laparoscopic cancer surgeries were included. Patients were randomly assigned to one of four groups each comprises 25 patients. Group 1: early bupivacaine/tramadol, Group 2: late bupivacaine/tramadol, Group 3: early bupivacaine/dexmedetomidine, and Group 4: late bupivacaine/dexmedetomidine. Early groups received the intraperitoneal instillation before start of surgery and late groups received the instillation after completion of surgery. Perioperative heart rate (HR) and mean arterial blood pressure (MAP) were recorded. The degree of postoperative pain was measured at rest and with cough using Visual analogue scale (VAS) score at 2, 4, 6, 12, 18 and 24 h after surgery. In addition, the total intraoperative fentanyl and postoperative morphine doses were calculated.Results: Both late bupivacaine/tramadol, bupivacaine/dexmedetomidine groups had longer time to receive first analgesic requirement (13.4± 3.9, 11.3± 3.9 h) respectively as compared to early bupivacaine/tramadol, bupivacaine/dexmedetomidine groups (9.8± 3.6, 8.4± 2.8 h), respectively. Between each early and late group, intraoperative fentanyl consumption was higher for the late groups (75± 22.8, 73± 21.55μg) versus (32.7± 10.9, 37.5± 13.3 μg), respectively. As regards to rescue analgesic requirements, both early bupivacaine/tramadol and bupivacaine/dexmedetomidine groups consumed more analgesics (5.2± 2.0 and 6.1± 1.8 mg) as compared to the late groups (3.2± 0.8 and 4.3± 1.5 mg), respectively. The four groups were comparable for their perioperative HR and MAP values.Conclusion: Intraperitoneal instillation of bupivacaine/tramadol and bupivacaine/dexmedetomidine could be considered an effective route for analgesic administration during laparoscopic cancer surgeries. Early instillation reduced the intraoperative opioid consumption and late instillation resulted in reduced postoperative opioid consumption.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04813016.Keywords: intraperitoneal analgesia, tramadol, dexmedetomidine, bupivacaine, laparoscopic surgeries

Walaa Y Elsabeeny, Nahla N Shehab, Mohamed A Wadod, Mostafa A Elkady Department of Anesthesia and Pain Management, National Cancer Institute, Cairo University, Cairo, EgyptCorrespondence: Walaa Y ElsabeenyDepartment of Anesthesia and Pain Management, National Cancer Institute, Kasr Al Eini Street, Fom El Khalig, Cairo 11796, EgyptTel +20 1007798466Email walaa.Elsabeeny@nci.cu.edu.egPurpose: Various analgesic modalities are adopted for perioperative analgesia in breast cancer surgeries. This study aimed to compare the efficacy of intravenous morphine versus serratus anterior plane block (SAPB) and erector spinae plane block (ESPB) in breast cancer surgeries.Patients and Methods: Seventy-five breast cancer patients undergoing modified radical mastectomy from January 2020 to June 2020 were randomly allocated into 3 groups; the morphine group received morphine 0.1 mg/kg, the SAPB group received ultrasound-guided SAPB with 25 mL bupivacaine 0.25% and the ESPB group received ultrasound-guided ESPB with 25 mL bupivacaine 0.25%. A visual analogue scale (VAS) 0– 10 was used to evaluate pain postoperatively, where 0 denotes no pain and 10 worst pain. If any patient in the 3 studied groups reported breakthrough pain with VAS ≥ 4 then a bolus of 3 mg morphine was given.Results: There was no difference in VAS scores between the 3 groups postoperatively. Morphine consumption was higher in the morphine group (9.19 ± 2.32 mg) than the SAPB group (4.00 ± 1.55 mg) and the ESPB group (4.20 ± 1.64 mg), respectively. First time to receive postoperative morphine was significantly longer for the ESPB and SAPB groups than the morphine group (20.40 ± 4.98 hours), (19.00 ± 5.9 hours), (5.00 ± 4.62 hours), respectively. Intraoperative hemodynamics and fentanyl consumption showed no difference between groups, whereas postoperative mean arterial blood pressure values at 2 and 4 hours were higher in the morphine group. Ramsay sedation score and postoperative nausea and vomiting values in the post anesthesia care unit were higher for the morphine group compared to the SAPB and ESPB groups. No complications related to the blocks were reported.Conclusion: SAPB and ESPB can be used as an effective and safe alternative to opioids with fewer side effects in breast cancer patients undergoing modified radical mastectomy.Trial Registration: This trial was prospectively registered at Clinical Trials.gov on 22 January 2020 with registration number NCT04248608 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JS5&selectaction=Edit&uid=U0004LIG&ts=7&cx=− 81xkwa).Keywords: modified radical mastectomy, morphine, serratus plane block, erector spinae block

Background: Uncontrolled elevation of intraoperative blood pressure can result in deleterious effects with increased risk of morbidity and mortality., Objectives: We aimed to compare nitroglycerine infusion with dexmedetomidine infusion in controlling accidental intraoperative uncontrolled hypertension., Methods: This comparative study was conducted on 73 hypertensive patients undergoing cancer surgeries who experienced uncontrolled intraoperative hypertension. The data of 38 patients were retrieved from the medical records for the nitroglycerine group and 35 patients were prospectively enrolled for the dexmedetomidine group. Group N received nitroglycerine infusion (0.3 - 1 µg/kg/min), while group D received dexmedetomidine infusion (0.2 - 0.7 µg/kg/h)., Results: Both groups were comparable regarding their demographic data and clinical characteristics. Systolic, diastolic, and mean arterial pressure (MAP) values were significantly lower in group N compared to group D during the period between 60 and 120 minutes intraoperatively (P < 0.001). Heart rate values were significantly lower in group D than in group N (P < 0.001). Postoperative sedation scores were better for group D with lower analgesic requirements (P < 0.001)., Conclusions: Dexmedetomidine infusion can be used to manage the uncontrolled intraoperative elevation of blood pressure in selected patient population., Competing Interests: Conflict of Interests: The authors have no personal financial interests., (Copyright © 2023, Author(s).)

Background: In thoracic surgeries requiring thoracotomy incisions, correct positioning of the double-lumen endotracheal tube (DLT) is mandatory. After the pandemic of novel COVID-19, using simple, noninvasive technology such as lung ultrasound (LUS) can be important in avoiding the possibility of spreading infectious diseases or contagious infections that can follow using fiberoptic bronchoscopy (FOB)., Objectives: We aimed to assess the accuracy of auscultation and LUS in relation to FOB in the assessment of DLT placement and to identify the possibility of using LUS as an alternative to FOB during DLT insertion., Methods: This diagnostic accuracy study was conducted according to STARD guidelines; enrolled 120 cases requiring DLT intubation. After DLT insertion, all patients were examined by stethoscope, then by LUS for determination of DLT position, and then confirmed by FOB in the same patient., Results: Three patients dropped out due to failed intubation, and only 117 cases were analyzed. Time was significantly longer for LUS than for auscultation and FOB and was insignificantly different between auscultation and FOB. Auscultation had 76.14% sensitivity, 34.48% specificity, and 65.81% accuracy in the determination of correct DLT placement. LUS had 92.05% sensitivity, 79.31% specificity, and 88.89% accuracy in detecting correct DLT placement. There was substantial agreement between LUS and FOB (κ = 0.705) and poor agreement between auscultation and FOB (κ = 0.104)., Conclusions: LUS can be used as a simple, noninvasive tool for detecting DLT placement with a substantial agreement with FOB., Competing Interests: Conflict of Interests: There is no external fund received for this work. There is no personal financial interest., (Copyright © 2022, Author(s).)

Objectives: This study was designed to evaluate the safety and efficacy of erector spinae plane block and serratus anterior plane block versus thoracic epidural in perioperative pain control for patients with cancer undergoing lung surgeries., Design: Single blinded, randomized, controlled trial., Setting: The study was carried out at the National Cancer Institute in Cairo, Egypt., Participants: Fifty-one patients with cancer., Interventions: Patients were allocated randomly into three groups: thoracic epidural analgesia (TEA) group, serratus anterior plane block (SAPB) group, and erector spinae plane block (ESPB) group., Measurements and Main Results: Outcome measures were 24 hours postoperative visual analog scale (VAS), intraoperative rescue fentanyl consumption, perioperative heart rate, mean blood pressure (mean arterial pressure [MAP]), and total postoperative morphine consumption. VAS scores at rest were significantly lower in the TEA group at the postanesthesia care unit and 24 hours. VAS scores with cough were significantly higher in the SAPB group at eight and 24 hours. The first time to receive morphine was significantly longer in the TEA group. No patients in the TEA group required postoperative morphine, whereas 88.2% and 47.1% required morphine in the SAPB and ESPB groups, respectively, p < 0.001. In the TEA group, intraoperative MAP values were lower than the other two groups, p < 0.05., Conclusions: Erector spinae plane block can be used as an effective and safe alternative to thoracic epidural analgesia and shows superior analgesic profile to serratus anterior plane block for patients with lung cancer undergoing posterolateral thoracotomy., (Copyright © 2021 Elsevier Inc. All rights reserved.)