Sahar Abd-Elbaky Mohamed

Background: The most common surgical procedure for breast cancer is the modified radical mastectomy (MRM), but it is associated with significant postoperative pain. Regional anesthesia can reduce the stress response associated with surgical trauma. Objectives: Our aim is to explore the efficacy of 1 mu g/kg dexmedetomedine added to an ultrasound (US)-modified pectoral (Pecs) block on postoperative pain and stress response in patients undergoing MRM. Study Design: A randomized, double-blind, prospective study. Setting: An academic medical center. Methods: Sixty patients with American Society of Anesthesiologists (ASA) physical status I-II (18-60 years old and weighing 50-90 kg) scheduled for MRM were enrolled and randomly assigned into 2 groups (30 in each) to receive a preoperative US Pecs block with 30 mL of 0.25% bupivacaine only (group 1, bupivacaine group [GB]) or 30 mL of 0.25% bupivacaine plus 1 mu g/kg dexmedetomidine (group II, dexmedetomidine group [GD]). The patients were followed-up 48 hours postoperatively for vital signs (heart rate [HR], noninvasive blood pressure [NIBP], respiratory rate [RR], and oxygen saturation [Sao2]), visual analog scale (VAS) scores, time to first request of rescue analgesia, total morphine consumption, and side effects. Serum levels of cortisol and prolactin were assessed at baseline and at 1 and 24 hours postoperatively. Results: A significant reduction in the intraoperative HR, systolic blood pressure (SBP), and diastolic blood pressure (DBP) starting at 30 minutes until 120 minutes in the GD group compared to the GB group (P < 0.05) was observed. The VAS scores showed a statistically significant reduction in the GD group compared to the GB group, which started immediately up until 12 hours postoperatively (P < 0.05). There was a delayed time to first request of analgesia in the GD group (25.4 +/- 16.4 hrs) compared to the GB group (17 +/- 12 hrs) (P = 0.029), and there was a significant decrease of the total amount of morphine consumption in the GD group (9 + 3.6 mg) compared to the GB group (12 + 3.6 mg) (P = 0.001). There was a significant reduction in the mean serum cortisol and prolactin levels at 1 and 24 hours postoperative in the GD patients compared to the GB patients (P < 0.05). Limitations: This study was limited by its sample size. Conclusion: The addition of 1 mu g/kg dexmedetomidine to an US-modified Pecs block has superior analgesia and more attenuation to stress hormone levels without serious side effects, compared to a regular Pecs block in patients who underwent MRM.

Background and Objectives: Postoperative pain and stress elicit hormonal changes. We aimed at comparing the effects of wound infiltration with ketamine versus dexmedetomidine on postoperative pain and stress response.Methods: This double‐blinded study included ninety patients scheduled for total abdominal hysterectomy and were randomly assigned into three groups to receive local wound infiltration with 40 mL of 0.25% bupivacaine (group C), plus 2 mg/kg ketamine (group K) or 2 μg/kg dexmedetomidine (group D). Primary outcome was postoperative morphine consumption; secondary outcomes included first request of analgesia, VAS scores at rest and movement (VAS–R/M) and side effects. Serum cortisol, prolactin and glucose levels at baseline, pre‐infiltration, 6 and 24 h postoperatively were measured.Results: Rescue analgesia was less in K (6.80 ± 3.19 mg) and D (8.39 ± 3.86 mg) compared to C (13.33 ± 4.01 mg) (p < 0.05). First request of analgesia was delayed in K (7.60 ± 4.16 h) and D (6.00 ± 3.73 h) compared to C (4.20 ± 1.13 h) (p < 0.05). Both VAS and R/M were significantly lower in K (all over 24 h) and D (for 8 and 4 h, respectively) compared to C. Stress markers were significantly lower in K and D compared to C at 6 and 24 h, and in K compared to D at 24 h (p < 0.05).Conclusions: Local wound infiltration with ketamine or dexmedetomidine added to bupivacaine had an opioid‐sparing effect, delayed first request of rescue analgesia, and attenuated postoperative stress response, especially with ketamine in patients underwent total abdominal hysterectomy.

Effective postoperative pain control reduces postoperative morbidity. In this study, we investigated the effects of intrathecal morphine, ketamine, and their combination with bupivacaine for postoperative analgesia in major abdominal cancer surgery. Prospective, randomized, double-blind. Academic medical center. Ninety ASA I–III patients age 30 to 50 years were divided randomly into three groups: the morphine group (group M) received 10 mg of hyperbaric bupivacaine 0.5% in 2 mL volume and 0.3 mg morphine in 1 mL volume intrathecally. The ketamine group (group K) received 0.1 mg/kg ketamine in 1 mL volume instead of morphine. The morphine + ketamine group (group K + M) received both 0.3 mg morphine and 0.1 mg/kg ketamine in 1 mL volume intrathecally. Postoperative total morphine consumption, first request of analgesia, visual analog score (VAS), and side effects were recorded. Total PCA morphine was significantly decreased in group M + K compared with groups M and K. Time to first request of analgesia was prolonged in groups M and M + K compared with group K (P < 0.001). VAS in group M + K was reduced from two to 24 hours, and in group M from 12 and 18 hours postoperation compared with group K, with an overall good analgesia in the three groups. Sedation was significantly higher in group M + K compared with group M until six hours postoperation. No other side effects were observed. Adding intrathecal ketamine 0.1 mg/kg to morphine 0.3 mg in patients who underwent major abdominal cancer surgery reduced the total postoperative morphine consumption in comparison with either drug alone, with an overall good postoperative analgesia in all groups, with no side effects apart from sedation.

Objectives: Analgesics had been suspected of impairing various immune functions either directly or indirectly. Our primary objective was to compare the effects of intravenous (IV) morphine, tramadol, and ketorolac on stress and immune responses in patients who underwent modified radical mastectomy. Patients: Sixty patients randomly assigned to receive IV morphine 5 mg (group M, n=20), tramadol 100 mg (group T, n=20), or ketorolac 60 mg (group K, n=20) at the end of surgery. Methods: Serum cortisol, prolactin were measured immediately, 40 minutes, and 24 hours postoperatively. Expressions of peripheral T lymphocytes (CD3⁺, CD3⁺CD4⁺, CD3⁺CD8⁺) and natural killer cells (CD3⁺, CD56⁺) were measured as percentages of total lymphocytes by flow cytometry immediately, 90 minutes, and 24 hours postoperatively. Results: After 40 minutes, cortisol level increased but prolactin decreased significantly (P=0.001), then both decreased after 24 hours (P=0.001) compared with baseline within the 3 groups. CD3, CD4, CD8, and CD56 significantly decreased at 90 minutes and 24 hours (P≤0.033) compared with baseline in the 3 groups. CD4, CD8, and CD56 significantly decreased in group M, compared with group T and K (P≤0.016) and CD3, CD8, and CD56 in group T compared with group K at 90 minutes (P≤0.024) postoperatively. After 24 hours, CD4, and CD8 decreased in group M compared with group T (P≤0.048) and CD4 and CD56 in groups M and T compared with group K (P≤0.049). Conclusions: IV morphine, tramadol, and ketorolac suppressed stress and immune responses. Ketorolac was the least immunosuppressive among the 3 drugs.

Intrathecal ketamine has been studied extensively in animals, but rarely in humans. Intrathecal dexmedetomidine prolongs the duration of spinal anesthesia. To investigate the efficacy and safety of intrathecal dexmedetomidine, ketamine, or both when added to bupivacaine for postoperative analgesia in major abdominal cancer surgery. Double-blinded, randomized, controlled trial. Academic medical center. Ninety patients were randomly allocated to receive either intrathecal 10 mg of hyperbaric bupivacaine 0.5% and 5 µg of dexmedetomidine (group I, n = 30), 10 mg of hyperbaric bupivacaine 0.5% and 0.1 mg/kg ketamine (group II, n = 30), or 10 mg of hyperbaric bupivacaine 0.5% and 5 µg of dexmedetomidine plus 0.1 mg/kg of ketamine (group III, n = 30). Hemodynamics, pain score, time to first request of analgesia, total PCA morphine consumption, sedation score, and adverse effects in the first 24 hours postoperatively were recorded. Time to first request of analgesia was longer in group II (7.42 ± 1.43 h) and group III (13.00 ± 7.31h) compared to group I (3.50 ± 1.57 h). PCA morphine consumption was less in group III (6.67 ± 2.8 mg) compared to group I (9.16 ± 3.63 mg) and group II (8.66 ± 3.49 mg). Group III showed lower postoperative pain scores, and a higher incidence of postoperative sedation (P < 0.03). This study is limited by its relatively small sample size. In conclusion, the combination of intrathecal dexmedetomidine and ketamine provided superior postoperative analgesia, prolonged the time to first request of rescue analgesia, and reduced the total consumption of PCA morphine, without serious side effects compared to either drug alone.

The optimum dose of dexmedetomidine for shivering control with the least hemodynamic derangements is still under research. To compare the efficacy, hemodynamic and side effects of dexmedetomidine in 3 different doses with those of meperidine for the treatment of shivering in patients undergoing spinal anesthesia for minor elective lower abdominal surgery. Prospective double-blind randomized clinically controlled study. University hospital. One hundred twenty patients who developed shivering under spinal anesthesia.On shivering, patients were randomly allocated to receive an intravenous 2 mL bolus dose of meperidine 0.4 mg/kg (meperidine group, n = 30), dexmedetomidine 0.5 µg/kg (DEX I group, n = 30), 0.3 µg/kg (DEX II group, n = 30), or 0.2µg/kg (DEX III group, n = 30). Control of shivering, time taken for cessation of shivering, response rate, recurrence, hemodynamic changes, sedation score, tympanic temperature, and side effects were noted and compared between groups. The groups were comparable regarding demographic profile, tympanic temperature decline, and shivering onset time (P > 0.05). Lower shivering cessation time (P < 0.001) and higher response rate (P < 0.01) were observed in DEX I and II groups compared with DEX III and meperidine groups, with a nonsignificant difference between DEX I and II groups. Recurrence of shivering activity was higher in DEX III group (36.7%, P < 0.01) compared with DEX I (10%), DEX II (6.7%) and meperidine (16.7%) groups. Lower heart rates, systolic and diastolic blood pressure mean values were recorded in DEX I group (P < 0.05). Nine patients (30%) in DEX I group were in levels 3 - 5 of sedation (P < 0.02) compared with 5 (16.66%), 2 (6.66%), and 4 (13.3) patients in DEX II, DEX III, and meperidine groups, respectively. This study is limited by its small sample size. Among the 3 doses investigated, dexmedetomidine 0.3µg/kg effectively treated shivering associated with spinal anesthesia with modest hemodynamic and sedation effects. ClinicalTrials.gov Identifier: NCT02382432. Dexmedetomidine, hypothermia, shivering, spinal anesthesia.

Objective. To compare the analgesic effect of combined intrathecal morphine and dexmedetomidine with either drug alone for postoperative analgesia in patients undergoing major abdominal cancer surgery. Methods. Ninety patients were allocated to receive intrathecal 10 mg bupivacaine 0.5% (bupivacaine group, n = 30), 10 mg bupivacaine 0.5% and 0.5 mg morphine (Morphine Group, n = 30), or 10 mg bupivacaine 0.5%, 0.5 mg morphine and 5 µg dexmedetomidine (morphine-Dex group, n = 30). The groups were compared with time to first postoperative analgesia, iv patient-controlled analgesia (PCA) morphine consumption, pain scores, hemodynamics, sedation, and adverse events in the first 48h postoperative. Results. The time to first use of morphine PCA was longer in morphine (22.13 ± 5.21h, P = 0.000) and morphine-Dex (23.46 ± 4.69h, P = 0.000) groups compared with bupivacaine group (0.50 ± 0.09h). Dexmedetomidine addition increased the duration of intrathecal morphine (ITM) analgesia by 1.33 h ( P = 0.485). Morphine consumption was less in morphine (10.83 ± 2.96 mg, P = 0.000) and morphine-Dex (11.00 ± 3.32 mg, P = 0.000) groups than in bupivacaine group (27.5 ± 4.30 mg), with a nonsignificant difference between morphine and morphine-Dex groups ( P = 0.375). Morphine and morphine-Dex groups showed lower pain scores ( P < 0.001). Intraoperative blood pressure and heart rate were lower in morphine and morphine-Dex groups ( P < 0.05) with no significant difference between groups in postoperative hemodynamics. Patients in bupivacaine group showed a higher incidence of postoperative nausea ( P < 0.03) and vomiting ( P < 0.01), while patients in morphine and morphine-Dex groups had a higher incidence of pruritus ( P < 0.02). Conclusions. Our results do not support improved analgesia with the combination of intrathecal morphine and dexmedetomidine, despite the absence of significant adverse effects.