Background and Aims:Pain after modified radical mastectomy (MRM) has been successfully managed with thoracic paravertebral block (TPVB). The purpose of this study was to evaluate the effect of adding dexamethasone or ketamine as adjuncts to bupivacaine in TPVB on the quality of postoperative analgesia in participants undergoing MRM.Methods:This prospective randomised controlled study enrolled ninety adult females scheduled for MRM. Patients were randomised into three groups (30 each) to receive ultrasound-guided TPVB before induction of general anaesthesia. Group B received bupivacaine 0.5% + 1 ml normal saline, Group D received bupivacaine 0.5% + 1 ml dexamethasone (4 mg) and Group K received bupivacaine 0.5% + 1 ml ketamine (50 mg). Patients were observed for 24 h postoperatively to record time to first analgesic demand as a primary outcome, pain scores, total rescue morphine consumption and incidence of complications.Results:Group K had significantly longer time to first analgesic demand than group D and control group (18.0 ± 6.0, 10.3 ± 4.5 and 5.3 ± 3.1 hours respectively; P = 0.0001). VAS scores were significantly lower in group D and group K compared to control group at 6h and 12 h postoperative (p 0.0001 and 0.0001 respectively) while group K had lower VAS at 18 hours compared to other two groups (P = 0.0001). Control group showed the highest mean 24 h opioid consumption (8.9 ± 7.9 mg) compared to group D and group K (3.60 ± 6.92 and 2.63 ± 5.24 mg, P = 0.008,0.001 respectively). No serious adverse events were observed.Conclusion:Ketamine 50 mg or dexamethasone 4 mg added to bupivacaine 0.5% in TPVB for MRM prolonged the time to first analgesic request with no serious side effects.

BackgroundManagement of difficult airway due to laryngeal mass is a major challenge to the anesthesiologists, and awake fiberoptic intubation (AFOI) would be the technique of choice.ObjectivesThe current study aimed at comparing the effects of administration of dexmedetomidine-propofol or ketofol for sedation during AFOI in terms of intubation conditions, hemodynamic stability, and patients and anesthesiologist’s satisfaction.MethodsEighty adult patients, 18 - 60 years old, ASA (the American Society of Anesthesiologists) physical status I-III, with difficult airway due to laryngeal mass and planned for AFOI were enrolled. Sedation was randomly given to the patients according to their assigned group by either dexmedetomidine-propofol (group D; n = 40) or ketofol (group K; n = 40). Outcome variables included time to reach Ramsay sedation scale (RSS) ≥ 3, intubation time, number of patients in need of rescue propofol, patient’s discomfort score, tolerance to endoscopy and intubation, hemodynamic parameters, patients and anesthesiologist’s satisfaction, and occurrence of side effects.ResultsTime to reach RSS ≥ 3 and intubation time were significantly shorter, and fewer patients required rescue propofol in the K group as compared to the D group (P = 0.000*, and 0.035*, respectively). Higher discomfort score and better tolerance to endoscopy and intubation were noticed in group K than group D, but with no statistical significance (P = 0.132, 0.137, and 0.211, respectively). Patients in group D had significantly lower mean arterial pressure (MAP) and heart rate (HR) after the loading dose till five minutes after intubation (P = 0.000*). There was no significant difference in patients’ satisfaction between the two groups (P = 0.687), while anesthesiologist’s satisfaction was higher in group K compared with that of group D (P = 0.013*). Cough score as well as incidence of unfavorable respiratory outcomes were not significantly different between the two groups (P = 0.611, 0.348, respectively).ConclusionsKetofol and dexmedetomidine-propofol combination were suitable and satisfactory for AFOI. However, ketofol was more advantageous in offering faster onset of sedation, shorter intubation time, stable hemodynamic profile, as well as higher anesthesiologist’s satisfaction when compared to dexmedetomidine-propofol.

Background and Aims: Hemodynamic changes to pneumoperitoneum and postoperative pain can be detrimental in obese patients; we investigated whether intravenous (IV) or intraperitoneal (IP) magnesium sulphate (MgSo 4 ) administration could attenuate the hemodynamic stress response to pneumoperitoneum and improve postoperative pain control after laparoscopic sleeve gastrectomy (LSG). Material and Methods: In total, 120 patients scheduled for LSG were randomized to either, control group (Group C, IV and IP saline), Group I (IV 30 mg/kg MgSo 4 ), or Group P (IP 30 mg/kg MgSo 4 ). Outcome variables were mean arterial pressure (MAP), heart rate (HR), postoperative pain score, total analgesic consumption, and incidence of adverse events. Results: MAP and HR were significantly lower in Groups I and P than that in control group. Pain score was better in Groups I and P than in control group up to 2 h postoperative ( P = 0.023, 0.010, respectively); it was significantly lower in Group P than other two groups at 4 h postoperative ( P <0.001). Significantly, reduced postoperative analgesic consumption with delayed onset to first analgesic request were observed in magnesium groups compared to control ( P = 0.001, respectively). Moreover, onset to first analgesic request was longer in Group P than Group I ( P = 0.001). No serious side effects were noticed. Conclusion: The IV and IP administration of MgSo 4 significantly attenuated the circulatory response to pneumoperitoneum and reduced postoperative pain as well as opioid consumption as compared to controls in obese patients undergoing LSG with no serious adverse effects.

Objectives We aimed to investigate whether ultrasound guided erector spinae plane block and serratus anterior plane block would provide effective and safe analgesia in patients with fracture ribs, and to detect their effects on diaphragmatic excursion in such cases. Design Prospective double-blind randomized study Settings Tanta University Hospitals Subject Fifty adult patients ASA I, II with fracture ribs. Methods Patients were randomized to receive either ultrasound guided erector spinae block (Group I) or serratus plane block (Group II) with injection of 19 ml bupivacaine 0.25% plus 1 ml dexamethasone (4 mg). Pain scores, 24 hour total analgesic requirements, diaphragmatic excursion and incidence of adverse events were recorded. Results At rest and dynamic pain scores were significantly lower in Group I as compared to Group II from 2 hour up to 24 hour post block [median differences (95% CI): -1(-0.9999;0.0002), -1(-0.9999;0.0002), -1(-0.9998;0.0003), -1(-1.000;-0.000) and -1(-2.0000;-1.0000), -1(-0.9998;-0.0001), -1(-1.0001;-1.0002), -1(-2.000;0.000) respectively], with a significant reduction in 24h opioid consumption in Group I in comparison to Group II (P= 0.004*). Diaphragmatic excursion showed a significant improvement in Group I when compared to Group II at 2, 6, 12, and 24 hour after the block (p = 0.024*, 0.038*, 0.027*, 0.042* correspondingly). No adverse events were noted. Conclusions Both erector spinae block and serratus plane block provided safe and effective pain relief in traumatic rib fractures. Though the erector spinae group displayed significantly reduced pain scores, decreased analgesic needs and improved diaphragmatic excursion as compared to serratus group, nevertheless, this was of no clinical significance.