Dr. Azza Mahrous shaffik :: Publications:

Summary Surgical pain is due to inflammation from tissue trauma (i.e., surgical incision, dissection, burns) or direct nerve injury (i.e., nerve transaction, stretching, or compression). The patient senses pain through the afferent pain pathway which can be altered by various pharmacologic agents. Postoperative management of pain in pediatric population is of major concern as it reduces the incidence of complications and leads to earlier hospital discharge.Regional anesthesia is accepted as the cornerstone of post-operative pain relief in the pediatrics , it has the advantage of providing good post-operative analgesia as well as decreasing parenteral opioids requirements. Data on postoperative pain after surgery consistently shows moderate-to-severe pain in the first 24 hours after surgery with traditional systemic analgesic techniques, such as intravenous or intramuscular opioids, patient-controlled opioid analgesia, and multimodal analgesia with opioids combined with acetaminophen, NSAIDs, neuropathic agents, and ketamine. Aim of the study: the study was done to evaluate efficacy of ultra-sound guided transverses abdominus plane block versus local anaesthetic wound infiltration versus ultra-sound guided ilioinguinal /iliohypogastric nerve block with or without using of dexmedetomidine as an additive to bupivacaine, in the management of the postoperative pain in pediatric patients undergoing unilateral inguinal hernia repair. Patients and methods: This prospective randomized blinded, controlled, clinical study,in which 140 Patients were randomized into four groups , Group I :- received unilateral ultrasound guided transverses abdominis plane block as follow :-Group 1B(20 patients received ultrasound guided transverses abdominis plane block with 0.3 ml/kg of bupivacaine 0.25% alone).Group 1D(20 patients received ultrasound guided transverses abdominis plane block with 0.3 ml/kg of bupivacaine 0.25% mixed with1μg/kg dexmedetomidine)and Group II:- received local anaesthetic wound infiltration as follow :-Group II B(20 patients received local anaesthetic wound infiltration with 0.2 ml/kg of bupivacaine 0.25% alone. Group II D(20 patients received local anaesthetic wound infiltration with 0.2 ml/kg of bupivacaine 0.25% mixed with1μg/kg dexmedetomidine)and Group III :- received ultrasound guided Ilioinguinal / Iliohypogastric Nerve block as follow:- Group III B(20 patients received ultrasound guided Ilioinguinal / Iliohypogastric Nerve block with 0.3 ml/kg of bupivacaine 0.25% alone).Group III D (20 patients received ultrasound guided Ilioinguinal / Iliohypogastric Nerve block with 0.3 ml/kg of bupivacaine 0.25% mixed with1μg/kg dexmedetomidine) and Group IV(control) (20 patients received regular analgesics). Patients with Local skin infection at the site of injection , known allergy to one of the used drugs and coagulopathy were excluded from the study. One day before surgery all patients were interviewed to explain FLACC score, also routine investigations were fulfilled. Before the induction of general anaesthesia, Intravenous access (IV) was established and monitoring of the patients.Induction of general anaesthesia in patients undergoing inguinal herniorrhaphy were premedicated with atropine at a dose of 0.01-0.02mg/kg. After pre-oxygenation with 100% oxygen for 3-5 minutes, general anesthesia was induced with inhalation of sevoflurane (6-8%) in oxygen followed by atracurium 0.5 mg/kg to facilitate endotracheal intubation . fentanyl 1 mcg/kg was given for intraoperative analgesia. End tidal CO2 was monitored with capnography. Anesthesia was maintained with sevoflurane 2% and atracurium 0.1 mg/kg as a maintenance dose till the end of the procedure.Heart rate was continuously monitored and blood pressure/ 5 minutes was maintained within ± 20% of the preoperative baseline. Activation of regional block at the end of the surgical procedure with recording of parameters in the post-operative period. The ultrasound used for the block, we had used ( GE " LOGIQ P5" ultrasound machine ) with 5 -12 MHz probes and colour Doppler imaging capability. The main outcome measures:- The primary targets of this current study were FLACC score for pain at (at PACU, one hour, two hours, 6 hours , 12 hours and 24 hours postoperative) and measuring the mean paracetamol consumption in 24 hours. The secondary measurements include:- Age, body weight , ASA status, vital signs (arterial blood pressure , heart rate and respiratory rate) at PACU, every 15 minutes for one hour , then at two hours , 6 hours, 12 hours and 24 hours postoperative , time and complications that occurred in all groups (nausea,vomiting) Results: Regarding comparison between the four groups involved in our study , the postoperative analgesia is more effective with TAP group ( the gold standard ) than groupII,groupIII and groupIV, the latter is being the least effective in postoperative pain control . Also the postoperative consumption of paracetamol in TAP group is lower than other groups.Using dexmedetomidine as an additive to bupivacaine provides prolonged duration of postoperative analgesia, and lowered FLACC pain scores. As regard demographic data were not significantly different between the groups . Vital parameters (heart rate, systolic and diastolic blood pressure, respiratory rate per minute) were also not significantly different between the groups. There were no significant differences between the groups in terms of type of operation or duration ofsurgery. Asregard complications during the study in all groups , complications as nausea and vomiting were recorded but show no significant changes. Conclusion:- ultra-sound guided transverses abdominus plane block is more effective in postoperative analgesia when compared to local anaesthetic wound infiltration and ultra-sound guided ilioinguinal /iliohypogastric nerve block. Using dexmedetomidine as an additive to bupivacaine provides prolonged duration of postoperative analgesia, and lowered FLACC pain scores.