الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Pain, which is often inadequately treated, accompanies the more than 23 million surgical procedures performed each year and may persist long after tissue heals. The goal should be to make the patient ”pain-free at rest”. Multi-modal analgesia is recommended so as to achieve optimal pain relief with minimal side effects.
The relief of pain has been one of the primary reasons for development of health care. It is well documented that inadequately relieved pain is deleterious and can lead to a number of complications in the postoperative period. Therefore the pain of surgery must be relieved totally.
Ketamine is traditionally recognized as an intraoperative anesthetic agent however, increasing interest in use of low dose ketamine for postoperative analgesia has developed in part because of its N-methyl-D-aspartate (NMDA) antagonistic properties, which may be important in attenuating central sensitization and opioid tolerance.
perioperative administration of a small dose of ketamine maybe valuable to a multimodal analgesic regimen and an adjuvant to opioids and local anesthetics by enhancing analgesia and reducing opioid-related side effects.
Local anesthetics (LA) are drugs that produce reversible block in nerve conduction when applied locally to the nerve tissue in appropriate concentration. They prevent the initiation and transmission of sensory impulses.
Local anesthetics may be infiltrated at the wound site or at a distance from the surgical site as in regional techniques. Good local anaesthesia will inhibit the peripheral nociceptive response to pain, which has shown to be very beneficial.
The widespread use of local anesthetic solutions, either alone or in conjunction with other analgesics, can result in excellent pain relief.
Neuraxial blocks (spinal, epidural, and caudal) result in sympathetic block, sensory analgesia and motor block (depending on dose, concentration or volume of the local anesthetic). Epidural block is popular for postoperative analgesia because of the familiarity with the technique and the ease of the insertion of the catheter. Continuous epidural anaesthesia through a catheter offers several options for perioperative analgesia. . Local anesthetic boluses or infusions can provide profound analgesia. For optimal results with the least amount of local anesthetic, the epidural catheter tip should be near the segments innervating the incision.
The aim of the study was to compare the analgesic effect of either bupivacaine thoracic epidural or intravenous ketamine infusion plus wound infiltration with lidocaine & bupivacaine mixture. Comparison included the effect on pain relief and requirements of tramadol postoperatively in patients undergoing open cholecystectomy under general anesthesia.
A prospective randomized study was performed in which 40 patients scheduled for elective open cholecystectomy under general anesthesia admitted to the Medical Research Institute were included and further subdivided into 2 groups.
Group (A): received thoracic epidural at level of T7-T8 and activation was done 20 minutes before induction of anesthesia with plain bupivacaine at a concentration of 0.25% at a volume of 1 ml/segment aiming to block sensory supply from T4-L2.Then continuous infusion intra- and postoperatively with plain bupivacaine at a concentration of 0.125% at a rate of 5 ml/hour for 24 hours was started. Blood pressure was controlled by IV fluids and ephedrine if needed.
Group (B): received 0.3mg/kg bolus of ketamine at the time of induction then 0.1mg/kg/hour ketamine IV infusion during surgery followed by wound infiltration with a mixture of 10 ml of plain bupivacaine 0.5% plus 5 ml lidocaine 1% at the time of skin closure.
All patients received fentanyl (1-1.5µg/kg) 2 minutes before induction of anesthesia.
Induction of anesthesia was carried out with an anesthetic dose of propofol (1.5-2mg/kg) intravenously followed by rocuronium (0.6mg/kg) intravenously to facilitate endotracheal intubation with cuffed tube, then patients were connected to anesthetic machine (Fabius GS-Drager-Germany). Anesthesia was maintained with isoflurane 0.8-1.5% in 100% oxygen and respiration was controlled (tidal volume 6-10ml/kg, respiratory rate 10-12 cycles/minute)to maintain Etco2 between 30-40mmhg. At the end of the operation, intravenous neostigmine (0.05 mg/kg) and atropine (0.015 mg/kg) were administrated for reversal of residual muscle relaxation.
In this study we measured the difference between the two groups as regard hemodynamic changes (heart rate and mean arterial blood pressure) intra and post-operatively,the Visual analogue scale postoperatively,1st time for need for analgesia, side effects and sedation score.
The present study showed that bupivacaine thoracic epidural had better control on heart rate and mean blood pressure than ketamine infusion plus wound infiltration with local anesthetics in patients undergoing open cholecystectomy.
The present study showed a significant decrease in visual analogue scale in both groups but it was significantly lower in group A. also there was significant decrease in sedation score in group A.
Comparing the two groups, there was no significant difference as regard side effects,1st need of analgesia or total dose of rescue analgesia.
We conclude that
Thoracic epidural analgesia had better control on hemodynamic changes(heart rate and blood pressure) intra and postoperatively than ketamine infusion in open cholecystectomy.also thoracic epidural provided better analgesia(significantly lower VAS) and better sedation score than ketamine infusion.