الفهرس 
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Abstract
Cirrhotic patients undergoing liver surgery are prone to coagulation and metabolic changes, providing optimal postoperative pain relief can be a challenge. This study prospectively compared the postoperative analgesic efficacy of intravenous fentanyl patient-controlled analgesia (PCA) with and without combined transversus abdominis plane (TAP) and rectus sheath block (PCA+RSB+TAP). Fifty five patients with Child’s A cirrhosis undergoing liver resection were divided into PCA (Control group) + placebo saline injected and PCA+RSB+TAP (Study group) (1mg/kg/8 hr of 0.2ml/kg of 0.25% bupivacaine). In both groups two epidural catheters were inserted surgically in the related anatomical planes during closure of the inverted L-shaped right subcostal with midline extension . Venous samples were collected after bupivacaine injection at 10min, 30min, 1hr, 2hr and 4hr and ½ h before next injection. Bupivacaine blood levels measured with ELISA. Five patients were excluded in the control group. one due to early postoperative reintubation and ventilation, and two cases due to suspicion of intra-vascular migration of the catheter, one patient for slipped catheter and one because of a technical failure involving their PCA syringe pump. Age, weight, and sex were comparable between both groups (P>0.05). Rescue Pethidine (Meperdine) and paracetamol were frequently required in the Control group more than the Study group. Visual Analogue Scale (VAS) on exertion was significantly lower postoperatively in the study group (30min, 1hr, 2hr, 4hr after injection) (P<0.05), but an increase in VAS (4.24±0.510) in Study group was observed in comparison to Control group (3.6±0.577) half an hour immediately before next scheduled 8 hourly Bupivacaine dose injection, in association with a significant reduction in Bupivacaine blood levels when compared to levels 10 min post injection (47.58±22.733 vs 93.57±60.973 ng/ml). First 24 hrs Fentanyl consumption was reduced in Study group vs the Control (325.4±169.08 vs 1034±231.7, micrograms, P<0.05). Ramsay sedation score in both groups were comparable with hemodynamically stable during 1st 48h (p>0.05). No nausea and vomiting in 89.7% of Study group compared to 40.0% of the Control group during first postoperative day (p<0.05). Significant changes in INR indicating the temporary hypocoagulability associating the liver resection procedure was reported in both groups (P<0.01). Bupivacaine levels did not exceed referred toxic plasma levels, at any sampling time (10min, 30min, 1hr, 2hr and 4hr). Mean Bupivacaine peak plasma levels (ng/ml) after 10 min (93.57±60.973) with an extended plateau level up to 4 hrs post injection, this was followed by a significant decrease in levels 1/2h before injecting next dose (47.58±22.733) (P<0.05). In conclusion a multi-modal approach combining TAP and RSB with intravenous fentanyl PCA improved postoperative pain management and reduced opioid demand. The timing of TAP and RSB repeated catheters injections need to be studied further to reduce out breaks of pain in between top up doses. Repeated Bupivacaine injections in cirrhotic patients were not associated with any toxic plasma levels or any clinical signs of toxicity, despite of this a close monitoring of this category of cirrhotic liver patients for early signs of local anaesthetic toxicity is always recommended. Future multicenter studies on a larger scale are needed particularly introducing other peripheral blocks with special focus on their pre-emptive use.