Background: Thoracotomy is a very painful surgical procedure that is used to get access into the pleural space, to the lungs, to the heart, to the esophagus or to get access to the thoracic aorta or anterior mediastinum. Objective: To study different modalities of treatment used for post thoracotomy pain control. Recent Findings: Inadequate post-thoracotomy analgesia enhances the postoperative stress response with deleterious effects on respiratory, cardiovascular, gastrointestinal, urinary, immune and coagulation systems. In addition to anxiety and increased risk of Post Thoracotomy Pain Syndrome (PTPS), which can interfere with normal life and may persist for years or even for life? Conclusion: Providing adequate post-thoracotomy analgesia can be challenging, as patients are often elderly or having multiple comorbidities. A multimodal approach is considered in managing post-thoracotomy pain starting with preemptive analgesia and cognitive behavioral modalities in addition to conventional multimodal systemic regimens as opioids, acetaminophen, NSAID, cyclooxygenase (COX)-2-specific inhibitors, gabapentin and pregabalin, steroids, IV lidocaine infusion, ketamine, and many regional analgesic modalities to avoid or decrease adverse effects of systemic regimens. These regional analgesic modalities include thoracic epidural blocks, thoracic paravertebral blocks, intrathecal opioid analgesia, serratus anterior plane blocks, intercostal nerve blocks, interscalene block, erector spinae block and interpleural block.

BACKGROUND: Postdural puncture headache (PDPH) is a complication commonly related to neuraxial anesthesia and dural puncture, with an incidence proportional to the diameter of the needle, ranging from 2% with a 29G to 10% with a 27G and 25% with a 25G. The development of ne gauge spinal needles and needle tip modication, has enabled a signicant reduction in the incidence of postdural puncture headache. PDPH presents as a dull throbbing pain with a frontal-occipital distribution. PDPH is thought to be due to a cerebrospinal uid leak that exceeds the production rate, causing downward traction of the meninges and parasympathetic mediated reex vasodilatation of the meningeal vessels. The sphenopalatine ganglion (SPG) is an extracranial neural structure located in the pterygopalatine fossa that has both sympathetic and parasympathetic components as well as somatic sensory roots. Sphenopalatine ganglion block (SPGB) has been used for the treatment of migraine, cluster headache and trigeminal neuralgia and can be performed through transcutaneous, transoral or transnasal approaches. Obstetric patients are considered at increased risk for this condition because of their sex, young age, and the widespread use of neuraxial blocks. SPGB is minimally invasive, carried out at the bedside without using imaging and has apparently rapid onset than EBP with better safety prole. The most common side effects of SPGB are all temporary, including numbness in the throat, low blood pressure and nausea. OBJECTIVES: We evaluated the efcacy and safety of lidocaine 2%, lidocaine 5% and bupivacaine 0.5% in transnasal sphenopalatine ganglion block for the treatment of post dural puncture headache on 30 patients. PATIENTS AND METHODS: This prospective, randomized and controlled clinical study was conducted at Sohag University Hospital after its approval by the Ethics and Research Committee of Sohag Faculty of Medicine. Written informed consent was obtained from each patient before participation. RESULTS: Our study showed that there were non signicant differences between the three studied groups regarding age, gender, body mass index, type of operation, onset, site of headache, associated symptoms, relieving factors and exaggerated follow up. There was a nonsignicant difference between the three studied groups regarding changes in visual analogue score for severity of headache. There were nonsignicant differences between the three studied groups regarding presence of bleeding and results of treatment of postdural puncture headache. CONCLUSION: SPGB is an effective initial modality for managing severe headache in patients with PDPH.

Background: Chest wall surgeries are accompanied by severe postoperative pain. Inadequate relief of this pain may lead to both pulmonary complications as lung atelectasis and infection and chronic post thoracotomy pain syndrome. Regional analgesic modalities are important portion of the multimodal therapeutic approach suggested for the management of post thoracotomy pain. Objective: To evaluate serratus anterior plane block as a regional analgesia technique for post thoracotomy and thoracoscopy pain. Recent Findings: Serratus anterior plane block (SAPB), a regional analgesic modality developed by Blanco et al. in 2013, has shown good analgesic effect after thoracotomy and thoracoscopy in many case reports and clinical trials. In such block, a local anesthetic is injected in the fascial plane deep or superficial to the serratus anterior muscle leading to block of lateral cutaneous branches of the intercostal nerves. This provides a sensory block of T2-T9 dermatomes. Conclusion: Serratus anterior plane block as a fascial plane block can be a preferred regional analgesia technique for both post-operative pain management with procedures involving anterolateral chest wall as thoracotomy, thoracoscopy and breast surgery and in cases of multiple rib fractures. This is owing to its easy technique, effective pain relief and potentially better side effects profile compared to other regional modalities and systemic opioids.

Background: A straightforward and efficient anesthetic approach for hand and forearm surgery is intravenous regional anesthesia (IVRA), often known as the Bier Block. Dr. August Bier developed this method in 1908, and it offers total anesthesia as well as a bloodless operating room. Historically, the local anesthetic has been contained and a bloodless surgical field has been created by using an upper arm tourniquet. Major issues following IVRA with an upper arm tourniquet are uncommon, although they typically arise from systemic toxicity of local anesthetics upon tourniquet relaxation. Convulsions, coma, respiratory depression and arrest, and cardiovascular depression are signs of significant systemic local anesthetic responses, which might be lethal. Because of this, some medical professionals favor general anesthesia or other loco-regional procedures for hand and forearm surgery. Objective: The aim of this review was to compare the effects of early vs late distal tourniquet deflation during hand and forearm surgery under intravenous regional anesthetic with or without ketorolac. Methods: A comprehensive search was conducted in PubMed, Google Scholar, and Science Direct, from August 2000 to July 2021, using the keywords "Deflation, Distal tourniquet, Intravenous Regional Anesthesia, Ketorolac, Hand and Forearm Surgery". The reviewers evaluated relevant literature references as well. Only the most recent or complete study was taken into account. Examples of articles that weren't regarded as significant scientific research include unpublished manuscripts, oral presentations, conference abstracts, and dissertations. The lack of resources for translation has led to the ignoring of documents written in languages other than English. Results: The reviewed literature showed that alternative adjustments in extremities surgery can improve IVRA. In shortterm hand procedures, the forearm tourniquet may be chosen since it is simple to administer, has a minimal risk of toxicity, and offers an early block to healing. Conclusion: Depending on the patient's preferences, a Bier block with a forearm tourniquet can be utilized with or without further sedation or analgesics.

Background: Multiple modalities are existing for pain management in knee osteoarthritis cases. This study was conducted to compare between the efficacy of genicular nerves radiofrequency ablation versus intraarticular steroid injection in pain management in knee osteoarthritis. Patients and methods: A total of 58 cases with knee osteoarthritis were included and they were divided into 2 equal groups; the RF group who underwent radiofrequency for the genicular nerves, and the IA group who underwent intraarticular steroid injection. Follow up visits were scheduled after 1week, 2 weeks, 1,2, 3, and 6 months. Both visual analog score and The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were assessed in each visit. Furthermore, patient satisfaction was also recorded. Results: Patient characteristics did not differ significantly between the two groups (p > 0.05). Both VAS and total WOMAC scores were improved in both groups. However, the RF showed better scores at 2-, 3-, and 6-month visits. Satisfaction grades did not differ between the two groups. Conclusion: Both genicular nerve RF and intraarticular steroid injection are safe and efficacious in pain management in knee osteoarthritis cases. Nevertheless, the effect is more prolonged after RF.

Background: Shivering is an involuntary, repetitive contractions of skeletal muscles, which commonly occurred after spinal block and it is an uncomfortable problem to the patients and the anesthetists. Shivering is considered as a complication of anesthesia. Shivering has deleterious effects on the cardiac function especially in patients who have limited cardiopulmonary reserve and coronary disease, which could be explained by increased oxygen consumption, production of carbon dioxide and lactic acidosis caused by shivering. Objective: Our study was aiming at evaluating the effect of intrathecal nalbuphine versus intrathecal midazolam in the prevention of shivering during subarachnoid block. Patients and Methods: Ninety patients (ASA physical status I or II) scheduled for lower limb surgeries under spinal anesthesia were randomly allocated into three groups using sealed envelopes technique; Control group receiving mixture of bupivacaine and saline, Nalbuphine (N) group receiving nalbuphine and bupivacaine, and Midazolam group receiving midazolam and bupivacaine. Upon arrival to the operation room basic monitoring was applied and lactated ringer solution at room temperature was infused through peripheral venous catheter. Results: Shivering occurred in 20 patients (66.7%) in control group, 7 patients in nalbuphine group (23.3%), and 10 in midazolam group (33.3%). The incidence of shivering and core temperature differed significantly between group N and the other two groups (P values in saline and midazolam groups > 0.05, while that of nalbuphine < 0.05). Conclusion: Intrathecal nalbuphine is more effective than intrathecal midazolam in prevention of post-spinal shivering for patients undergoing lower limb surgery.

Background: For those with Obstructive Sleep Apnea (OSA), the most effective therapy is continuous positive airway pressure (CPAP). CPAP uses positive airway pressure to keep the patients' respiratory passages open while they sleep (or are awake and breathing normally). End-expiratory alveolar pressure that exceeds ambient pressure is known as a "positive end-expiratory pressure" (PEEP). PEEP is created by CPAP, which maintains a predetermined pressure during the whole breathing cycle, including inhalation and exhalation. It has been shown to lower daytime exhaustion, cardiac risk factors, as well as blood pressure. Objective: The primary therapy for OSA is CPAP. CPAP was evaluated in this study to see if it reduced blood pressure in OSA patients. Research on CPAP and blood pressure in various subgroups of people was analyzed specifically for this study. Methods: Research was carried out through PubMed, Google scholar and Science direct using the terms [Continuous positive airway pressure And Positive end-expiratory pressure OR Obstructive Sleep Apnea]. References from relevant literature, including all identified research and reviews, were also evaluated by the authors, although only studies published between December 2007 and June 2021 were included. Conclusion: Although the overall impact of CPAP on blood pressure is minimal, even modest reductions in blood pressure may benefit in the prevention of cardiovascular events. This impact on those with uncontrolled hypertension merits further investigation. Variability in blood pressure response to CPAP therapy gives an opportunity for more study on this topic. Constant CPAP use has long been associated with an increased risk of hypertension.

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