Thesis (Ph.D)-Cairo University, 2024.

Bibliography: pages 141-159.

Breast cancer is the most common malignancy among females in Egypt with incidence of about 22700 women in 2020 and is expected to approach 46000 new cases in 2050. The incidence of death from breast cancer presents 11% of all cancer related death in women.(1) Modified Radical Mastectomy (MRM) is one of the main surgical treatment of breast cancer.(2) It is commonly operated under general anesthesia with or without regional block.(3)
Perioperative pain management usually involves opioids which may be associated with side effects including prolonged sedation, respiratory depression, nausea, vomiting and ileus. In an attempt to reduce these side effects thoracic epidural analgesia and paravertebral block became the gold standard regional techniques for breast surgery.(4-5) However, both techniques may be associated with serious complications such as pneumothorax, spinal cord injury, incompatibility with pre-existing anticoagulation or antiplatelet therapy, hemodynamic instability, dural puncture with the needle or the catheter and post puncture headache.(6)

Dexmedetomidine (DEX) is a potent α2 agonist and is now emerging as an adjuvant to regional anesthesia and analgesia. (12) It produces dose-dependent sedation, anxiolysis and analgesia without respiratory depression.(13) Dexmedetomidine enhances anesthesia produced by other anesthetic drugs, it has some side effects as perioperative systemic vasodilatation and decreases blood pressure by stimulating central α2 receptors.(14)
Dexamethasone is considered to work by reducing the release of inflammatory mediators and by inhibiting potassium channel-mediated discharge of C-fibers. Results of human studies proved that the dexamethasone-treated group demonstrated a longer duration of sensory and motor blockade than the control. (15) The use of ultrasound guidance for regional anaesthesia has gained enormous popularity in the last 10 years and makes regional anesthesia more easier.(16)
A Previous study showed the effectiveness of bilevel erector spinae plane block (ESPB) in minimising postoperative opioid consumption and improving recovery after breast surgeries. (17). Another one used DEX with superior pain relief and long-term postoperative recovery following video-assisted thoracic surgery (VATS).(18)
Aim of Work
In the present study we compared compare the effect of adding DEX versus dexamethasone as adjuvants to bupivacaine in ultrasound guided Bilevel Erector Spinae Plane Block in Modified Radical Mastectomy on acute post operative pain.



Summary of results
• Time to first rescue morphine was significantly lower in DEX group

• Total 24 hr postoperative morphine consumption was significantly lower in group C.

• Intraoperative fentanyl consumption was significantly lower in DEX group

• Postoperative VAS score was significantly lower in DEX group




Conclusion: Dexmedetomidine as adjuvant to Bupivacaine in ultrasound-guided bilevel erector spinae plane block in modified radical mastectomy provided better postoperative pain control than using dexamethasone.

الخلفية العلمية و الهدف من الرساله:
سرطان الثدي هو أكثر أنواع السرطان شيوعًا بين الإناث في مصر حيث بلغ معدل الإصابة به حوالي 22700 امرأة في عام 2020 ومن المتوقع أن يقترب من 46000 حالة جديدة في عام 2050. يمثل معدل الوفاة بسبب سرطان الثدي 11٪ من جميع الوفيات المرتبطة بالسرطان لدى النساء. (1) استئصال الثدي الجذري المعدل (MRM) هو أحد العلاجات الجراحية الرئيسية لسرطان الثدي. (2) يتم إجراؤه عادةً تحت التخدير العام مع أو بدون التخدير الإقليمي. (3)

عادةً ما تتضمن إدارة الألم أثناء الجراحة المواد الأفيونية التي قد تكون مرتبطة بآثار جانبية بما في ذلك التخدير لفترات طويلة، واكتئاب الجهاز التنفسي، والغثيان، والقيء، والانسداد المعوي. في محاولة للحد من هذه الآثار الجانبية، أصبح التخدير فوق الجافية الصدري والحصار حول الفقرات هما المعيار الذهبي للتقنيات الإقليمية لجراحة الثدي.(4-5) ومع ذلك، قد ترتبط كلتا التقنيتين بمضاعفات خطيرة مثل استرواح الصدر، وإصابة الحبل الشوكي، وعدم التوافق مع مضادات التخثر أو العلاج المضاد للصفيحات الموجود مسبقًا، وعدم استقرار الدورة الدموية، وثقب الجافية بالإبرة أو القسطرة والصداع بعد الوخز

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