Neoplasms

Respiratory Tract (Lung and Bronchial) Diseases

All Conditions

Heart and Blood Diseases

Symptoms and General Pathology

Rare Diseases

Lung Neoplasms

Pleural Diseases

Aortic Dissection

Dissection, Blood Vessel

Aneurysm

Vascular Diseases

Syndrome

Acute Aortic Syndrome

Aortic Diseases

Respiratory Tract Diseases

Acute Graft Versus Host Disease

Central Nervous System Depressants

All Drugs and Chemicals

Anti-Arrhythmia Agents

Channel Blockers

Analgesics

Adjuvants, Anesthesia

Anticonvulsants

Antiemetics

Muscle Relaxants, Central

Psychotropic Drugs

Gastrointestinal Agents

Herbal and Botanical

Anesthetics

Lidocaine

Ropivacaine

Sufentanil

Diazepam

Dsuvia

The Bi-block consisted in performing an ESP block followed by a SAP block on the side ipsilateral to the thoracic surgery. For the ESP block, 40 ml of Ropivacaine 2mg/ml were injected under the erector spinae muscle plane, at the level of the 4th thoracic vertebra. For the SAP block, 40 ml of Ropivacaine 2 mg/ml were injected under the serratus anterior muscle plane. The cumulative dose of Ropivacaine did not exceed 3 mg/kg.

Regional anesthesia was performed before surgery.

The thoracic epidural was performed according to a standardized protocol, with a Tuohy needle via the median puncture technique, at the level of T4-T5 intervertebral space. After a test dose of 2 to 3 ml of Lidocaine, 5 to 10 ml of a mixture of Ropivacaine 2 mg/ml and Sufentanil 0.5 µg / mL were injected. Epidural continuous administration was performed with the same mixture of anesthetic connected to a CADD Solis ™ pump set according to a PCEA protocol adapted to the patient's weight (continuous flow rate from 3 to 6 ml/h, self-administered bolus dose from 3 to 5 ml, refractory period 30 min).

Regional anesthesia was performed before surgery.

In the TEA group, a thoracic epidural was performed before VATS. In the Bi-block group, a SAP block associated with an ESP block were performed before surgical incision under general anesthesia.

Thoracic Regional Analgesia

Pierre Sentenac, MD

Pascal H Colson, MD, PhD

Video-Assisted thoracic surgery (VATS) is the standard treatment for localized lung cancer. However, there is no consensus on analgesic management in patients undergoing VATS.

The aim of the study is to compare the analgesic efficacy of thoracic epidural with that a "Bi-block" combining an Erector Spinae muscle plane Block (ESP) and a Serratus Anterior Block (SAP) in patients undergoing VATS for lung or pleural surgery.

Our main hypothesis is that the analgesic efficacy of the Bi-block, assessed by morphine consumption, is not inferior to that provided by a thoracic epidural during the first 48 hours after VATS. We conducted a age, gender and type of surgery-matched retrospective cohort study in the Department of Thoracic Anesthesia of the Montpellier University Hospital (France).

Analgesic Non Inferiority of the Thoracic Bi-block in Comparison With Thoracic Epidural for VATS.

Analgesic Non Inferiority of the Thoracic Bi-block Combining an Erector Spinae Muscle Plane Block and a Serratus Anterior Muscle Plane Block in Comparison With Thoracic Epidural for Video-Assisted Thoracic Surgery.

cumulative morphine consumption on postoperative day 2, including the morphine administered in Post anesthesia care unit (PACU), on postoperative day 0, 1 and 2.

Paracetamol, Tramadol, Ketoprofen, Nefopam cumulative consumption on POD 2.

mean VAS, maximal VAS, number of events with a VAS \> 3

University Hospital, Montpellier

Digestive System Diseases

Colonic Neoplasms

Colorectal Neoplasms

Intestinal Neoplasms

Gastrointestinal Neoplasms

Digestive System Neoplasms

Gastrointestinal Diseases

Colonic Diseases

Intestinal Diseases

Fentanyl

Bupivacaine

Propofol

Cola

Group (EP) received epidural (fentanyl and bupivacaine) - propofol based anesthetic technique and postoperative analgesia through patient controlled analgesia device (PCA)

Group (EH) received epidural (fentanyl and bupivacaine)- inhalational based anesthetic technique and postoperative analgesia through patient controlled analgesia device (PCA)

undergo insertion of an epidural catheter, between T9 and T11 in patients undergoing left-sided resections and between T8 and T10 in patients undergoing right-sided resections

thoracic epidural

samy ab amr, professor

Surgery is the primary treatment for colon cancer. However, the rate of recurrence or metastasis in colon cancer can be as high as 30%, even in stages 1 and 2 . Most colon cancer-related deaths are caused by metastatic disease . Many patients with colon cancer harbour micrometastases and disseminated tumour cells at the time of surgery . Whether the micrometastases develop into clinically significant metastases depends on the immune system's ability to eradicate them.The aim of the study is to declare the effect of epidural-intravenous based anesthetic technique on anti-tumor immunity and in comparison to epidural inhalational based anesthetic technique in patients undergoing open surgical resection of colon cancer.

Group (EP) received epidural - propofol based anesthetic technique and postoperative analgesia through patient controlled epidural analgesia and Group (EH) received epidural- inhalational based anesthetic technique and postoperative analgesia through patient controlled epidural analgesia

Epidural-inhalational Versus Epidural-intravenous Anaesthesia on Anti-tumor Immunity in Patients With Cancer Colon

Effect of Epidural-inhalational Versus Epidural-intravenous Anaesthesia on Anti-tumor Immunity in Patients Undergoing Open Surgery for Cancer Colon

Venous blood samples are withdrawn. Samples for measurement of percentage of expression of CD8,CD16 and CD56 will be collected in sodium heparin anticoagulant tubes and will be processed according to manufacturer's instructions,and samples for VEGF-C will be centrifuged at 4000 g. Thereafter, the serum will be stored at -22 C for future measurement

pain intensity measured by Visual analogue scale from 0 to 10 where 0 no pain and 10 is sever pain

South Egypt Cancer Institute

Assistant lecturer

Nervous System Diseases

Chronic Pain

Pain

Acute Pain

Neurologic Manifestations

Chronic Graft Versus Host Disease

Vasoconstrictor Agents

Respiratory System Agents

Epinephrine

Anesthetics, Local

Racepinephrine

Epinephryl borate

Sodium Channel Blockers

Diuretics, Potassium Sparing

Adrenergic Agents

Adrenergic alpha-Agonists

Adrenergic Agonists

Neurotransmitter Agents

Adrenergic beta-Agonists

Bronchodilator Agents

Anti-Asthmatic Agents

Mydriatics

Sympathomimetics

in lateral position a linear transducer (10-12MHz, M-Turbo) will be used, The 5th rib is identified in the mid-axillary line. The following muscles are overlying the rib latissimusdorsi ,teres major, and serratus muscle.The needle (22G, 50-mm Tuohy needle) is introduced in-plane targeting the plane superficial to serratus muscle. local anesthetic is injected then a catheter is threaded and . Ultrasound-guided SAPB was done using a serratus anterior catheter Group DL (n=20) received a bolus of 30 mL of 0.25% bupivacaine followed by a continuous infusion of 0.125% bupivacaine at a rate of 7-12 ml/hr according to patient response upon ICU arrival after the stabilization of the clinical status. The infusion was continued until the end of the 1st 24 hours postoperatively .

Continuous Serratus anterior plane block

A thoracic epidural catheter was done to the patient while sitting. Tuohy needles are used. Epidural space can be identified by loss of resistance. Injection begins with a negative aspiration and a test dose (3 ccs of 1.5% lidocaine with 1:200,000 epinephrine) .A Continuous epidural technique through the placement of a catheter 3-5 cm beyond the needle is applied. Injection in 5ml increments of 0.25% bupivacaine is used until the block of the required segments achieved ( 10 to 15ml). sensory testing is via pinprick and cold test to detect sympathetic block . Throughout the technique hourly injection of 5 ml 0.25% bupivacaine for maintenance.

Thoracic Epidural

3 ccs of 1.5% lidocaine with 1:200,000 epinephrine

lidocaine with epinephrine

Ashgan R Ali, Professor

Heba I Ahmed, Ass. Professor

Reham M Gamal, Lecturer

Sylvia Samy Bassily Morgan, Master

Thoracic surgeries is known to be one of the most painful surgeries . Multiple analgesic techniques have been used for post operative analgesia including Thoracic epidural , Patient Controlled Analgesia and systemic opioids. Opioids are associated with multiple sied effects including : PONV , Respiratory depression and ileus while thoracic epidural has its own complications such as hemodynamic instability , injury of spinal cord, pneumothorax and epidural hematoma.

Peripheral nerve blocks provide good alternative for perioperative analgesia. The purpose of our study is to compare the effectiveness of perioperative continuous serratus anterior plane block versus continuous thoracic epidural in pain management during thoracic surgeries for malignancy resection.

Thoracic surgeries is known to be one of the most painful surgeries and it is considered the major factor to the morbidity and mortality postoperatively. A variety of analgesic techniques for example; systemic opioid, intercostal nerve blockade, intra-pleural analgesia, an epidural opioid with or without local anesthetic, and patient-controlled analgesia (PCA) via systemic or epidural route has been used very commonly for thoracotomy pain management.The use of systemic opioids alone was associated with a 23.4% incidence of post-thoracotomy pain syndrome. Also, high doses of opioids represent a safety concern due to respiratory depression. The high incidence of postoperative nausea and vomiting (PONV) exacerbates patients' discomfort. Long-acting opioids hinder faster recovery, thereby delaying discharge. , Serratus anterior plane block (SAPB) has been recently introduced as a promising method that can be used between T2 and T9 levels for analgesia in thoracic surgery. SAPB seems to provide its effect through blockade of the lateral cutaneous branches of the intercostal nerves. Previous reports showed that after superficial SAPB the duration of sensory block was between 7 and 12 hrs. Continuous SAPB could represent an important analgesic alternative in patients who have contraindications to thoracic epidural for example patients with coagulopathies. Hence it is important to thoroughly study this block as an analgesic modality in thoracotomies. Moreover, episodes of hypotension during thoracotomies as during vascular clamping are challenging in the presence of thoracic epidural.

The purpose of our study is to compare the effectiveness of perioperative continuous serratus anterior plane block versus continuous thoracic epidural in pain management during thoracic surgeries for malignancy resection. To the best of our knowledge controlled randomized, prospective studies about the use of this technique in thoracotomies for resection of malignancies are lacking and none has been published to discuss this issue. Also, studies reporting patients' satisfaction are lacking.

Aim of the work

This study aims at evaluating the efficacy of applying continuous serratus anterior plane block (SAPB)as a perioperative analgesic modality for thoracic cancer surgeries (mesothelioma and bronchogenic carcinoma) as compared to continuous thoracic epidural as reflected on decreasing perioperative opioids consumption and postoperative VAS.

Hypothesis

We hypothesize that continuous Serratus anterior plane block via an indwelling catheter is effective in the management of pain in thoracic cancer surgeries when compared to thoracic epidural. Continuous SAPB could reduce both intraoperative and postoperative opioid requirements and improve postoperative VAS scores better than or equivalent to thoracic epidural. It may also delay the time to first required analgesic dose. In addition to providing more stable intraoperative hemodynamics. We planned for this study to evaluate this block continuous (SAPB) which can have a positive effect on pain control, ICU stay.

Ethical Considerations This study will be conducted after the approval of the research committee of the department of anesthesia, surgical ICU, and pain management in KasrAlainy Hospital, Cairo University, and the ethical committee of the Faculty of Medicine, Cairo University. Informed consent will be taken from all patients included in the study.

Methodology

* Study design A controlled randomized double blinded comparative study.
* Study setting and location National Cancer Institute - Cairo University

Randomization The participants in this study will be randomized into two groups based on computer-generated numbers using an online randomization program (research randomizer).

Study Protocol The study will include74 patients. 37patients in each group .Preoperative assessment is conducted on the patients that will be enrolled in this study including history taking, physical examination, and routine laboratory investigations; in the form of CBC, coagulation profile, creatinine, urea, ALT, AST, and radiological investigations; according to the medical condition of the patients. All patients should fulfill the inclusion criteria. A written informed consent form will be obtained from the patients that will be enrolled in the study.

Preoperative On the day of surgery, the patient ID will be confirmed in the preparation room, then 22G cannula will be inserted to the patient, premeditations will be given including lactated ringer solution 500ml, midazolam 2mg, ranitidine 50mg \& metoclopramide 10mg. VAS scale will be explained to all patients. The patient marks on the line the point that they feel represents their perception of their current state.

Intraoperative: Before induction of anesthesia The patient is allocated in one of 2 groups , This is known to the anesthesiologist inserting the catheter .

Group 1: Serratus anterior plane block:

Patients are placed in the lateral position with the diseased side up. A linear ultrasound transducer (10-12MHz, M-Turbo Ultrasound, USA) is placed over the midclavicular region of the thoracic cage in a sagittal plane.

The fifth rib is identified in the mid-axillary line. The following muscles are identified easily overlying the fifth rib: the latissimusdorsi (superficial and posterior),teres major (superior), and serratus muscle (deep and inferior).

As an extra-reference point, the thoracodorsal artery is used to aid the identification of the plane superficial to the serratus muscle. The needle (22G, 50-mm Tuohy needle) is introduced in-plane concerning the ultrasound Probe targeting the plane superficial to the serratus muscle.

Under continuous ultrasound guidance, a local anesthetic solution is injected then a catheter is threaded and Level of spread of analgesia in the SAPB group by cold and pinprick testing of the chest wall between T2 and T8/9 (assessed by an on-duty ICU resident who was unaware of the present study on the 1st postoperative day). Ultrasound-guided SAPB was done using a serratus anterior catheter Group DL (n=20) received a bolus of 30 mL of 0.25% bupivacaine followed by a continuous infusion of 0.125% bupivacaine at a rate of 7-12 ml/hr according to patient response upon ICU arrival after the stabilization of the clinical status. The infusion was continued until the end of the 1st 24 hours postoperatively .

GROUP 2: Thoracic epidural :

A thoracic epidural catheter was done to the patient while sitting. Tuohy needles are used. Epidural space can be identified by loss of resistance. Injection begins with a negative aspiration and a test dose (3 ccs of 1.5% lidocaine with 1:200,000 epinephrine) .A Continuous epidural technique through the placement of a catheter 3-5 cm beyond the needle is applied. Injection in 5ml increments of 0.25% bupivacaine is used until the block of the required segments achieved ( 10 to 15ml). sensory testing is via pinprick and cold test to detect sympathetic block . Throughout the technique hourly injection of 5 ml 0.25% bupivacaine for maintenance.

Both groups will have catheters covered by a sterile dressing and the area covered by the dressing will be extended to be the same for both groups. The anesthesiologist who will collect the data, and all the staff, other than the anesthesiologist inserting the catheter, are all blinded to the site of the catheter insertion . Catheter and infusion will be continued for 24 hours postoperatively.

Anaesthesia Management:

Inside OR ( operation room) The patient who is fasting for at least six hours before surgery and will be monitored continuously using electrocardiography, noninvasive blood pressure, peripheral oxygen saturation, and end-tidal carbon dioxide - using the Datex-Ohmeda S5 anesthesia monitor, model no: USE1913A - throughout the surgical procedure. Venous access and monitoring are installed before the regional technique.

Induction of general anesthesia will be performed for both groups using a regimen of IV fentanyl 2 μcg/kg, propofol 2 mg /kg, and rocuronium 0.5 mg/kg. Anesthesia will be maintained with inhaled sevoflurane with MAC 2-2.5% in oxygen;-enriched air (FiO2=50%) and top-up doses of rocuronium (0.1 mg/kg) IV will be administered by time every 45 minutes.

All patients will receive 1 g of IV paracetamol. Titrating doses of fentanyl (0.05-0.1 mic/kg) will be given if the mean arterial blood pressure or heart rate rises above 20% of baseline levels.

Ringer acetate will be infused to replace their fluid deficit, maintenance, and losses, and the patients will be mechanically ventilated at an appropriate setting that keeps end-tidal CO2 at 30-35mmHg.

One reading of mean arterial pressure and heart rate will be taken before induction of general anesthesia to be defined as a baseline reading and then will be recorded immediately before surgical incision and at 30 min intervals intraoperatively.

Hypotension (a decline of systolic blood pressure \>20 % of the baseline) will be treated with 0.9% normal saline and/or 5mg ephedrine in incremental doses to maintain mean blood pressure above 70 mmHg.

The residual neuromuscular blockade will be reversed using Sugammadex (2 mg/kg), and extubation will be performed after complete recovery of the airway reflexes.

Extubated patients will be transferred to post-anesthesia care unit(PACU) where pain scores and MAP and heart rate will be recorded immediately on arrival and at 2, 4, 6, 12, and 24 h postoperatively in ICU and rescue analgesia will be provided in the form of morphine 3-5 mg I.V doses (according to the patient demand) In PACU (PACU discharge criteria: The modified Aldrete scoring system for determining when patients are ready for discharge from the postanesthesia care unit Discharge Criteria from Postanesthesia Care Unit Score Activity: able to move voluntarily or on command Four extremities 2 ,Two extremities 1, Zero extremities 0 and Respiration: Able to breathe deeply and cough freely 2, Dyspnea, shallow or limited breathing 1, Apneic 0 and Circulation: Blood pressure 20 mm of preanesthesia level 2, Blood pressure 20-50 mm preanesthesia level 1 ,Blood pressure 50 mm of preanesthesia level 0 and Consciousness :Fully awake 2 ,Arousable on calling 1, Not responding 0 and O2 saturation: Able to maintain O2 saturation \>92% on room air 2, Needs O2 inhalation to maintain O2 saturation \>90% 1 , O2 saturation \<90% even with O2 supplementation 0) A score≥9 was required for discharge. ) . The total amount of morphine given in 24 h will be recorded in the two groups. Side effects such as nausea, vomiting, hypotension, bradycardia, over sedation will be recorded.

Postoperative nausea and vomiting (PONV) will be rated on a four-point verbal scale (none =no nausea, mild =nausea but no vomiting, moderate =vomiting one attack, severe =vomiting \>one attack). 0.1 mg/kg of IV ondansetron will be given to patients with moderate or severe postoperative nausea and vomiting.

Sedation will be assessed in the recovery room with Ramsay scores (1 = anxious or restless or both; 2 = cooperative, orientated, and tranquil; 3 = responding to commands; 4 = brisk response to a stimulus; 5 = sluggish response to a stimulus, and 6 = no response to stimulus) excessively high sedation levels with Ramsay 5 or 6; adequate sedation levels needing observation with Ramsay 2 to 4; inadequate or insufficient sedation levels with Ramsay 1.

All Patients in our study will be transferred to ICU where the same recording protocol continues .

Statistical Analysis

The collected data will be, tabulated, and statistically analyzed using SPSS program (Statistical Package for Social Sciences) software version 20.0 Descriptive statistics were done for numerical parametric data as mean±SD (standard deviation) and minimum \& maximum of the range and for numerical non parametric data as median and 1st\& 3rd inter-quartile range, while they were done for categorical data as number and percentage.

Inferential analyses were done for quantitative variables using independent t-test in cases of two independent groups with parametric data and Mann Whitney U in cases of two independent groups with non parametric data.

Inferential analyses were done for qualitative data using Chi square test for independent groups. The level of significance was taken at P value \<0.050 is significant, otherwise is non significant. The p-value is a statistical measure for the probability that the results observed in a study could have occurred by chance.

Sample size Using power and sample size calculator for intervention study ; with 0.05 alpha error and power of the study 0.80 and -0.5 non inferiority margin to calculate minimal sample size needed to Efficacy of perioperative US guided Serratus anterior plane block versus Thoracic epidural in adult patient undergoing Thoracotomy

* According to literature total 24 hrs' morphine consumption by group SAPB was 10.3±3 mg/24h. While it was 9.6± 4.3 mg/24 for group TEA The sample size calculated is 74 persons (37 in each arm of the study)

Sampling technique:

A convenient sample of patients with the inclusion and exclusion criteria will be assigned to the study. Each patient will be randomly allocated to each arm of the study using concealed random allocation technique till reaching total sample size calculated

US-Guided Serratus Anterior Plane Block Versus Thoracic Epidural in Patients Undergoing Thoracotomy

Efficacy of Perioperative US-Guided Serratus Anterior Plane Block Versus Thoracic Epidural in Adult Patient Undergoing Thoracotomy: A Randomized Comparative Double-Blinded Trial

Postoperative total morphine requirement.

time from postoperative period until the patinets asks for analgesia

patients will be classified either satisfied or not

National Cancer Institute, Egypt

Infections

Blood and Lymph Conditions

Pleural Effusion

Pleural Effusion, Malignant

Lung Diseases

Empyema

Pulmonary Atelectasis

Lymphadenopathy

Empyema, Pleural

Pleural Neoplasms

Mesothelioma

Mesothelioma, Malignant

Pneumothorax

Pericardial Effusion

Hemothorax

Adenoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Neoplasms, Mesothelial

Respiratory Tract Neoplasms

Thoracic Neoplasms

Lymphatic Diseases

Suppuration

Communicable Diseases

Inflammation

Heart Diseases

Hemorrhage

Respiratory Tract Infections

Malignant Mesothelioma

Anti-Inflammatory Agents

Antineoplastic Agents

Dexamethasone

Neostigmine

Atropine

Midazolam

Isoflurane

Dexamethasone acetate

Metoclopramide

Cisatracurium

Ranitidine

Ranitidine bismuth citrate

General Anesthesia with One Lung Ventilation

Group A pre-medicated once using Midazolam 3-4mg intravenous (IV) and Fentanyl 50mcg, placed in the setting position. Using a winged 18G (Gadge), 9cm length Tuohy Epidural needle, a 20G springwound closed tip epidural catheter be inserted between T3-T4. A test dose (5ml) 2% Lidocaine given, followed by 5-8 ml Bupivacaine 0.5% and 50mcg Fentanyl as a loading dose. Further top-up dose of 5 ml Bupivicaine 0.5% after 45 minutes.

Thoracic Epidural Anesthesia

Group B premedicated once by 3-4mg Midazolam IV, Ranitidine 50mg, Metoclopramide 10mg and Dexamethasone 4mg. Preoxygenation with 100% O2. Induction of anesthesia with Propofol (2mg/kg) and Fentanyl (1mcg/kg). Tracheal intubation by 37-39 Fr Double Lumen Endotracheal Tube insertion facilitated with Cisatracurium 0.1mg/kg. and confirmation of its position by Fiberoptic Bronchoscopy. Selective Lung Ventilation strategy can be performed through the endobroncheal tube of the non operated lung once needed. Anesthesia maintained with Isoflurane (1-2%) and Cisatracurium (0.05mg/kg per dose). Later, anesthesia discontinued and extubation after full neuromuscular recovery after reversal of muscle relaxant by Neostigmine (0.05mg/kg) and Atropine (0.02mg/kg).

Samia A M Abdel Latif, Professor

Waleed El Taher, Professor

Hany H El Sayed, Professor

Ahmed F Koraitim, MD

Mohamed A A alhadidy, MD

Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and single lung ventilation. However, performing thoracic surgery under awake regional anesthesia has several potential advantages including avoidance of airway trauma and ventilator dependence associated with endotracheal intubation, besides promoting enhanced recovery after surgery and shorter mean hospital stay.

The aim of this study is to investigate the feasibility and the effect of Thoracic Epidural Anaesthesia for awake thoracic surgery to speed up recovery in patients as well as avoiding the complications accompanying General Anesthesia with one lung ventilation.

Type of Study: Prospective randomized clinical study. Study Setting: This study will be conducted in Ain Shams University Hospitals..

Study Period: Expected for two years starting from 2019.

Sampling Method: Randomized sampling by a computer generated random numbers table.

Sample Size: 40 patients. Sample size was calculated using PASS 11 program for sample size calculation and according to the (Pompeo et al., 2004) study, the mean PaO2 perioperatively in the awake group = -3±1.5 mmHg and in the second group = -6.5±1.83 mmHg. Sample size of 40 cases per group (total 40) can detect this difference with power 100% and α-error 0.05.

the study will include 40 participants, randomized into 2 equal groups, Group A: Awake participants will receive sole Thoracic Epidural Anesthesia. Group B: Participants receiving General Anesthesia with One Lung Ventilation.

A Comparative Study Between Regional Anesthesia in Thoracoscopes and the Conventional General Anesthesia

A Comparative Study Between Thoracic Epidural Anesthesia in Non-Intubated Video-Assisted Thoracoscopes and the Conventional General Anesthesia With One Lung Ventilation

all IPD that underlie results in a publication

Ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2), arterial carbon dioxide tension (PaCO2). Hypoxemia is defined as peripheral oxygen saturation (SpO2) \&lt; 92% on room air with a need for oxygen supplementation.

The Visual Analogue Scale (VAS) consists of a 10 cm straight line with the endpoints defining extreme limits of "no pain at all" (0 cm) and "pain as bad as it could be" (10 cm). The patient is asked to mark his pain level on the line between the two endpoints. The distance between 0 and the mark then defines the subject pain score.

heart rate (HR) in beats per minute (bpm)

Rate of occurence of falling after ambulance will be recorded in each group.

Mohamed Reda Ashour

Assistant lecturer, Dept of Anesthesia, Intensive Care and Pain Management

Pharmaceutical Solutions

Anti-Infective Agents

Blood Substitutes

Micronutrients

Povidone-Iodine

Povidone

Iodine

Cadexomer iodine

Under full aseptic conditions and wearing sterile gloves while the patient is in setting position, skin infiltration will be done with 2 ml of 1% lidocaine, then an 18-G Epidural needle with a 20-G catheter (Perifix, B.Braun, Germany) will be inserted through the T6-T7 interspace, and the epidural space located using the loss of resistance technique. The catheter then advanced approximately 3 cm cephalic. A test dose of 3 ml of 1% lidocaine containing epinephrine in a ratio of 1:200,000 administered to detect unintentional intrathecal or IV injection. After negative response, 15 ml of 0.25% epidural bupivacaine will be injected and the patient will be turned to the supine position.

Under full aseptic conditions, the patient is placed in lateral position with the diseased side up, sterile field is established with a povidone iodine solution, and the linear transducer 8-12 MH (sonosite M-turbo ; Inc., Bothell, WA, USA) is covered by a disposable sterile cover and will be placed over the mid-clavicular region of the thoracic cage in a sagittal plane. The ribs will be counted until the fifth rib is identified in the mid-axillary line. The muscles will be identified easily overlying the fifth rib, the latissimus dorsi , teres major and serratus muscles . A skin wheal of 1% lidocaine will be made 1 cm away from the lateral edge of the transducer thorough which the needle (22-G, 50-mm Touhy needle) will be introduced in-plane with respect to the ultrasound probe targeting the plane superficial to the serratus muscle beneath the latissimus dorsi. Under continuous ultrasound guidance 30 ml of 0.25% bupivacaine will be injected

Under full aseptic conditions, the patient is placed in lateral position with the diseased side up, sterile field is established with a povidone iodine solution, and the linear transducer 8-12 MH (sonosite M-turbo ; Inc., Bothell, WA, USA) is covered by a disposable sterile cover and will be placed over the mid-clavicular region of the thoracic cage in a sagittal plane. The ribs will be counted until the fifth rib is identified in the mid-axillary line. A skin wheal of 1% lidocaine will be made 1 cm away from the lateral edge of the transducer thorough which the needle (22-G, 50-mm Touhy needle) will be introduced in-plane with respect to the ultrasound probe targeting the plane between the posterior border of the serratus anterior muscle and the corresponding surface of the rib. Under continuous ultrasound guidance 30 ml of 0.25% bupivacaine will be injected deep to the serratus muscle separating the serratus anterior muscle from the external intercostal muscle.

neuroaxial thoracic epidural analgesia and regional analgesia supeficial and deep serratus plane blocks

Thoracic epidural analgesia , superficial serratus plane block and deep serratus plane block

Ekramy Mansour, MD

Pain after thoracotomy is known to be sever acute pain that is resulted from retraction, resection or fracture of ribs .This pain increases post operative morbidity and if not properly managed peri-operatively, chronic post thoracotomy pain syndrome may develop. Different methods are described to manage post thoracotomy pain.Thoracic epidural analgesia is believed to be the corner stone in the peri-operative care for thoracotomy providing the most effective analgesia. Serratus anterior plane (SAP) block has recently been described as a regional anesthetic technique to provide analgesia for thoracic wall surgeries. During SAP block, local anesthesia are deposited in the fascial plane either superficial to the serratus muscle or deep to the serratus anterior muscle in the mid-axillary line . Serratus anterior block provides analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. This study aims To compare the effect of superficial, deep serratus plane blocks and thoracic epidural analgesia in maintaining hemodynamic and controlling post thoracotomy pain.

The aim of thoracotomy surgery is to explore the thoracic cavity and manage different pathologies including pulmonary, diaphragmatic, mediastinal, esophageal and vascular pathologies. It can be performed posterolaterally, anterolaterally or even anteriorly.

Pain after thoracotomy is known to be sever acute pain that is resulted from retraction, resection or fracture of ribs and dislocation of costovertebral joints; injury of intercostal nerves or even irritation of the pleura by chest tubes inserted at the end of surgery. This pain increases post-operative morbidity and if not properly managed peri-operatively, chronic post thoracotomy pain syndrome may develop.

Different methods are described to manage post thoracotomy pain. Intravenous (IV) drugs such as opioids and non-steroidal anti-inflammatory drugs (NSAIDS), infiltration of local anesthetics to the wound and regional anesthetic techniques such as thoracic epidural analgesia (TEA), paravertebral block, intercostal block and intra/extra pleural block are methods frequently used to relieve post thoracotomy pain.

Thoracic epidural analgesia is believed to be the corner stone in the peri-operative care for thoracotomy providing the most effective analgesia. However, thoracic epidural analgesia is associated with serious complications such as hypotension, dural puncture with the needle or the catheter, post-dural puncture headache, respiratory depression with adding opioids, spinal cord injury and anterior spinal artery syndrome.

The serratus muscle is a superﬁcial and easily identified muscle that is considered a true landmark to implement thoracic wall blocks because the intercostal nerves pierce it.Serratus anterior plane (SAP) block has recently been described as a regional anesthetic technique to provide analgesia for breast and thoracic wall surgeries. During SAP block, local anesthesia are deposited in the fascial plane either superficial to the serratus muscle or deep to the serratus anterior muscle in the mid-axillary line .Serratus anterior block provides analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves.SAP block is also expected to avoid autonomic blockade associated with TEA and other complications involving the pleura and central neuraxial structures.

Ultrasound imaging made the practice of regional anesthesia easier in visualization and identification of usual and unusual position of nerves , blood vessels , needle during its passage through the tissues, as well as deposition and spread of local anesthetics in the desired plane and around the desired nerve.

The Effect of Ultrasound Guided Superficial, Deep Serratus Plane Blocks and Thoracic Epidural in Thoracotomy

Evaluation the Effect of Ultrasound Guided Superficial, Deep Serratus Plane Blocks and Thoracic Epidural in Cancer Patients Undergoing Thoracotomy: A Prospective Randomized Controlled Study

Mean arterial blood pressure to be measured after completion of intervention in patients with thoracotomies then every five minutes till the end of surgery.

the rescue analgesia will be administered intra-operative by fentanyl IV and the total fentanyl used will be recorded and compared between the groups

Pain scores using Visual analogue score (VAS) (0 mm = no pain to 10mm = worst pain imaginable) at predetermined time intervals (1, 2, 6, 12 and 24h) postoperative.

In case of postoperative pain recorded, rescue analgesia will be provided as IV morphine (3 mg) then continuous infusion of morphine through Patient Controlled Analgesia ( PCA ) to keep the VAS scores\<3. The total 24-hour morphine consumption will be recorded for every patient.

The total 24-hour morphine consumption will be recorded for every patient post operative.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Analgesic Non Inferiority of the Thoracic Bi-block in Comparison With Thoracic Epidural for VATS.	NCT04538235	Erector Spinae ... Serratus Anteri... Video-Assisted ... Lung Cancer Pleural Disease... Thoracic Epidur... Analgesia Enhanced Recove...	Thoracic Region...	18 Years -	University Hospital, Montpellier
Epidural-inhalational Versus Epidural-intravenous Anaesthesia on Anti-tumor Immunity in Patients With Cancer Colon	NCT04518579	Immunity Factor...	thoracic epidur...	20 Years - 70 Years	South Egypt Cancer Institute
US-Guided Serratus Anterior Plane Block Versus Thoracic Epidural in Patients Undergoing Thoracotomy	NCT05672394	Lung Cancer Acute Pain Chronic Pain	Continuous Serr... Thoracic Epidur... Bupivacaine lidocaine with ...	18 Years - 65 Years	National Cancer Institute, Egypt
A Comparative Study Between Regional Anesthesia in Thoracoscopes and the Conventional General Anesthesia	NCT05077111	Pleural Effusio... Pleural Mesothe... Pleural Empyema Pulmonary Disea... Pleural Neoplas... Pulmonary Atele... Pleural Disease... Pericardial Eff... Mediastinal Lym... Pneumothorax an... Hemothorax Pyopneumothorax	Thoracic Epidur... General Anesthe...	21 Years - 65 Years	Ain Shams University
The Effect of Ultrasound Guided Superficial, Deep Serratus Plane Blocks and Thoracic Epidural in Thoracotomy	NCT04189120	Post-thoracotom...	Thoracic epidur...	18 Years - 60 Years	National Cancer Institute, Egypt
Optimal Postoperative Pain Management After Lung Surgery (OPtriAL)	NCT05491239	Lung Cancer Pain, Postopera... VATS Locoregional An... Thoracic Epidur...	Thoracic epidur... Continuous regi... Single shot int...	18 Years -	Maxima Medical Center
Paravertebral Block Versus Thoracic Epidural Analgesia	NCT04025606	Lung Cancer Postoperative P...	Thoracic epidur... Paravertebral b...	18 Years - 85 Years	St. Olavs Hospital
Analgesic Non Inferiority of the Thoracic Bi-block in Comparison With Thoracic Epidural for VATS.	NCT04538235	Erector Spinae ... Serratus Anteri... Video-Assisted ... Lung Cancer Pleural Disease... Thoracic Epidur... Analgesia Enhanced Recove...	Thoracic Region...	18 Years -	University Hospital, Montpellier
Optimal Postoperative Pain Management After Lung Surgery (OPtriAL)	NCT05491239	Lung Cancer Pain, Postopera... VATS Locoregional An... Thoracic Epidur...	Thoracic epidur... Continuous regi... Single shot int...	18 Years -	Maxima Medical Center

Spots Global Cancer Trial Database for thoracic epidural