Purpose 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 ).

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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 prospective cohort 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.

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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.

Background & objective: Laryngoscopy and endotracheal intubation provoke stress response with consequent hemodynamic instability. Fentanyl is a short acting potent opioid commonly used to control stress response. Magnesium sulphate can attenuate stress response through inhibiting catecholamines release. Systemic administration of lidocaine helps in blocking stress response. This study aimed to compare the effectiveness of high dose fentanyl, magnesium, and lidocaine versus conventional anesthesia on consistent attenuation of stress response to laryngoscopy and endotracheal intubation. Methods: 160 patients were randomly allocated into one of the 4 study groups. Group C: received fentanyl 2µg/kg, Group F: received fentanyl 4 µg/kg, Group M: received magnesium sulphate 30mg/kg combined with fentanyl 2µg/kg and Group L: received lidocaine 1.5 mg/kg combined with fentanyl 2 µg/kg. Outcome measures included heart rate (HR) values and mean arterial blood pressure (MAP) values during endotracheal intubation and over the following 5 min in addition to coughing and lacrimation during intubation. Results: HR in group C and group L increased compared to baseline readings following intubation and at 1,3,5 min and was statistically significant for group C but comparable for group L. In group F and group M, HR decreased significantly compared to baseline following intubation and the rest of the times studied. MAP in group C and L were maintained for the period of 5 min following intubation whereas group F and L showed a statistically significant reduction in their MAP values compared to baseline readings. Conclusion: High dose fentanyl, fentanyl-magnesium combination, and fentanyl- lidocaine combination can attenuate stress response to laryngoscopy and endotracheal intubation when compared to conventional anesthesia. Furthermore, using high dose fentanyl and fentanyl-Magnesium combination results in consistent attenuation of the response. Abbreviations: HR – heart rate; MAP – mean arterial blood pressure; PPV - positive pressure ventilation Key words: Fentanyl; Magnesium sulphate; Lidocaine; Hemodynamics; Intubation Trial registration: This trial was prospectively registered at Clinical Trials.gov on 3 September 2020 with registration number NCT04544163. https://clinicaltrials.gov/ct2/show/NCT04544163 Citation: Elsabeeny WY, Shehab NN. The role of high dose fentanyl, magnesium and lidocaine for effective and consistent attenuation of hemodynamic responses during laryngoscopy and intubation. Anaesth. pain intensive care 2022;26(3):352-359. DOI: 10.35975/apic.v26i2.1910 Received: July 05, 2021; Reviewed: March 03, 2022; Accepted: April 22, 2022

Background:The main contributor to the pain experienced after abdominal surgery is pain from the incision made in the abdominal wall. The Transversus Abdominis Plane (TAP) block is a peripheral nerve block to the nerves supplying the anterior abdominal wall (T6 to L1). The aim of this study was to evaluate the effect of dexmedetomidine as an adjuvant in ultrasound guided TAP block on post-operative analgesia and morphine consumption in patients undergoing major abdominal or pelvic surgeries.Methods: Seventy five patients were randomly enrolled in the study; patients were divided into 3 groups: Bupivacaine group (group TAP, n=25) received TAP block with bupivacaine done after skin closure, bupivacaine with dexmedetomidine group (group TAP + Dex, n=25) received TAP block with dexmedetomidine added to the bupivacaine and intravenous dexmedetomidine group (group TAP + IV-Dex) received TAP block with bupivacaine in addition to intravenous dexmedetomidine. Results:The mean time to the first rescue analgesic requirement was significantly longer in both group TAP + Dex (9.8 ±2.9) hours and group TAP + IV-Dex (10.0±2.3) hours than in group TAP (5.7± 1.6) hours (p<0.001). Total morphine consumption in the first 24 hours post-operatively was significantly higher in group TAP (24.3 ±3.6) mg than in both group TAP + Dex (11 .8±3.7) mg and group TAP + IV-Dex (11.8±3.6) mg (p<0.001). Post-operative VAS pain score was higher in group TAP than in group TAP + IV-Dex at 6 and 12 hours but all three groups were comparable at 2, 4 and 24 hours. Patient satisfaction score was significantly lower for group TAP in comparison to the other two groups (p< 0.001). Conclusion:Dexmedetomidine whether added to bupivacaine in the TAP block or administered intravenously improved postoperative analgesia with lower total morphine consumption in the first 24 hours post-operative as a part of multimodal analgesia in abdominal and pelvic surgeries.