الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Nephrectomy surgery is one of the most common urological procedures done for different surgical indications. It can be done for the removal of healthy kidney for donor transplantation or diseased kidney as in traumatic kidney injury, tumour, and cystic lesions. It can be done either open or by laparoscopy. Minimally invasive surgical procedures have gained popularity due to less trauma, less postoperative pain, shorter hospital stays, but still conventional open procedures preferred for faster kidney removal. Acute postoperative pain is a major risk factor for the development of chronic postoperative pain if not properly managed. Blocking afferent nociceptive input reduces liability to have chronic pain. Optimizing perioperative analgesia improves clinical outcomes and increases patient satisfaction while uncontrolled postoperative pain can result in significant morbidity and mortality. Thoracic epidural analgesia was the gold standard analgesic technique for the majority of the upper abdominal surgeries as nephrectomy, but limited performance nowadays due to hazardous adverse events that occur and the presence of many contraindications. The paravertebral block is an alternative technique of injecting local anaesthetic solution alongside the vertebral column, close to the exit of the spinal nerves, resulting in unilateral somatic, visceral, and sympathetic nerve blockade. But pneumothorax is a serious complication that may occur while performing thoracic PVB limited its performance. Regional anaesthesia and pain management have experienced advances recently with ultrasound usage in anaesthesia practice and the development of new interfacial plane blocks. One of the newly described techniques is the erector spinae block (ESB). In the past 5 years, several publications referring to ESB and its analgesic efficacy in different painful conditions and its value compared to traditional central neuraxial blocks. ESB displayed value for perioperative analgesia for different thoracic and lumbar surgeries. This study aimed to compare the efficacy of ultrasound-guided ESB as a safe alternative to ultrasound-guided TPVB and TEB for pain management in patients undergoing nephrectomy. Our study was carried out at Tanta university hospital at urology department after approval of an ethical committee started from September 2018 to September 2020, included 105 adult patients of both sexes, ASA I, II randomly assigned (using closed sealed envelopes) into three equal groups, each included 35 patients after obtaining written informed conscent from each patient. Exclusion Criteria: Patient refusal, patient with neurological deficit, bleeding disorders, uncooperative patient, infection at the block injection site, and history of allergy to LA. group I: Patients of this group received (20 ml) (plain bupivacaine 0.25% injected beneath the erector spinae muscle sheath) at the level of the eighth thoracic segment (T8). group II: Patients of this group received (20 ml) (plain bupivacaine 0.25% injected in the paravertebral space) at (T8). group III: Patients of this group received (20 ml) (plain bupivacaine 0.25% injected in the Epidural space) at T8. Measurements of our study included: Demographic data, Time of onset of sensory block, Hemodynamic Parameters (MAP & HR) were recorded before block performance T 0, intraoperatively every 30 min and after surgery at T00 (before discharge from PACU), at 2, 4, 6, 12, 18, 24 h postoperatively. Adverse events, VAS assessed after surgery over 24 hours, Time to first rescue analgesia, Total analgesic consumption (meperidine) over 24 h after surgery, and degree of patient satisfaction were recorded. After data collection and statistical analysis performed: The demographic data comparison between the 3 groups showed no significant difference between them regarding age, sex, weight, BMI, and duration of surgery. The onset of sensory block was significantly different among the three groups with faster onset in group III (TEB) than in group II (PVB)& I (ESB) (p <0.05). Also, our results revealed a significant decrease in HR, MAP compared to baseline value in group III compared to group I, II at 30 min then no detected difference among the three groups at 60, 90, 120 min intraoperatively. Postoperatively hemodynamic measures (HR, MAP) showed an early increase in group III than in group I and II with a significant difference at 4, 6, 12 hours. Regarding VAS comparison between the three groups for the 1st 24h postoperatively; there was an early significant increase of VAS score in group III at 4 hours postoperatively with significant difference compared to the other groups and no detected difference between group I & II. Also, we found early first rescue analgesic demand in group III with a significant difference when compared to group I & II with no difference between group I & II. Regarding total analgesic consumption of meperidine over 24h after surgery, there was a statistically significant difference among the three groups with more meperidine consumption in group III. In contrast, the comparison between group I and II showed no statistically significant difference. Incidence of hypotension, bradycardia occurred more in group III with a significant difference compared to group I and II with no significant difference in other side effects (block failure, LAST, and pneumothorax). Finally, regarding patient satisfaction rates among the studied groups, there was no statistically significant difference.