الفهرس 
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Abstract
This study was conducted at the period from October 2012 to October 2015 on patients in surgical oncology department and postoperative intensive care unit in South Egypt Cancer Institute (SECI), Assuit University, Egypt. After obtaining hospital ethics committee and informed written consent from the patient. Sixty adult Patients complaining of coronary artery disease (CAD), ASA physical status II or III scheduled for elective major abdominal cancer surgery were consecutively enrolled in the study. The purpose of the present study was to assess the Effect of Thoracic Epidural analgesia (TEA) on the incidence and the course of major advanced cardiac events MACE in ischemic cardiac patients who scheduled for elective major upper abdominal cancer surgery and value of RCSI, serum levels of both Troponins I and BNP in prediction, diagnosis and prognosis of MACE. group 1 :( control group no. =30). Patients received standard general anesthesia, intraoperative analgesia was provided by intravenous continuous fentanyl infusion 1-2 μg g/kg/hr intra operatively to maintain heart rate (HR) and blood pressure within 20% of the basal value. Postoperative analgesia was provided through (PCIA) for 72 hours postoperatively. (Background infusion of 3 ml/ hr of Fentanyl 10 μg / ml solutions, top up dose of 2 ml, lockout interval of 15 minutes). group 2 (TEA group No.=30). Patients received standard general anesthesia, intraoperative analgesia was provided by epidural bolos dose of 0.1 ml ∕ kg of 0.125% bupivacaine ∕ fentanyl 10 μg ∕ ml, followed by continuous infusion of 0.1 ml ∕ kg of 0.125% bupivacaine ∕ fentanyl 5 μg ∕ ml until the end of surgery. Postoperative analgesia was provided through Patient controlled epidural analgesia (PCEA) for 72 hours postoperatively (Background infusion of 0.1 ml ∕ kg of 0.125% bupivacaine ∕ fentanyl 3 μg ∕ ml, bolus dose of 3 ml, lockout interval of 20 minutes). After recovery all patients were transmitted to surgical ICU for at least 72 hours and patients ‘ follow up were continued in surgical oncology department till discharge. Patient’s hemodynamic, daily 12-leads ECG, Echocardiography to evaluate cardiac function, sedation score, and VAS scores were recorded. And side effects (Nausea, vomiting, respiratory depression, urinary retention, drowsiness and itching) were also recorded. Venous blood samples were taken for assessment of the base line BNP and Troponine I and daily post operatively for 3 days. The study end point was occurrence MACE. There were no cases of serious epidural catheter-related complications, such as respiratory depression, epidural hematoma or abscess, local inflammation, or permanent neurologic damage in our study. The study showed that perioperative thoracic epidural analgesia in patients suffering from coronary artery disease subjected to major abdominal cancer surgery reduced significantly postoperative cardiac injury in comparison to perioperative intravenous analgesia. Also, it significantly reduced postoperative arrhythmia and decreased hospital stay. Also, there were trends towards decreased other complication as Congestive heart failure But did not reach statistical significance. The quality of postoperative analgesia was better in TEA group. In conclusion, ischemic cardiac patients undergoing major abdominal cancer surgery have an increased risk for perioperative cardiac morbidity and mortality. Perioperative thoracic epidural Fentanyl–bupivacaine infusion was effective in reduction of major advanced cardiac events and myocardial injury in ischemic cardiac patients with better pain relief and less sedating effect. This was confirmed by the postoperative serum levels of (BNP and Troponin I) which were decreased in TEA group. And RCSI and serum levels of (BNP and Troponin I) are objective, rapid, and convenient factors for predicting MACE, mortality and stay of patients in hospital and ICU. Further studies are required to confirm our results with larger sample size to provide more powerful results with smaller statistical error, and longer follow up periods of the patients are recommended by serum levels of (BNP and Troponin I) to get more solid conclusion which may have been more interesting with greater value in near future for more widespread clinical uses.