الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Open renal surgeries are considered major surgeries which associated with significant post-operative pain and many complications including hemorrhage. Patients may have pre-existing renal impairment or may develop it post-operatively. 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. The paravertebral block is a technique of injecting local anesthetic 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 anesthesia and pain management have experienced advances recently with ultrasound usage in anesthesia practice and the development of new interfacial plane blocks. One of the newly described techniques is the transmuscular quadratus lumborum block (QLB III) that has the potential to alleviate somatic and visceral pain following abdominal surgeries through spread of local anesthetics into the thoracolumbar fascia which has extensive sensory innervation by both A- and C-fiber nociceptors and mechanoreceptors as well as high-density network of sympathetic fibers to reach to the thoracic paravertebral space however, previous studies revealed some limitations as possible sparing of the upper thoracic dermatomes . Anterior Subcostal quadratus lumborum block has been used effectively for analgesia following hip arthroplasty, lower abdominal surgery and nephrectomy with reported sensory loss between T 8 and L2. In contrast, other anterior transmuscular QL block approaches could only reach a peak sensory level at T11. This study aimed to compare the efficacy of ultrasound-guided TQLB & ASQLB as a safe alternative to ultrasound-guided TPVB for acute postoperative pain management in patients undergoing open renal surgeries. Our study was carried out at Tanta university hospital at urology department after approval of an ethical committee started from December 2019 to November 2021, included 54 adult patients of both sex, ASA I, II randomly assigned (using closed sealed envelopes) into three equal groups, each included 18 patients after obtaining written informed consent from each patient. Exclusion Criteria: Patient refusal, patient with neuropsychiatric disorder, Patients who were taking analgesics for chronic illness or had history of substance abuse, bleeding disorders, uncooperative patient, infection at the block injection site, and history of allergy to LA. group I: Patients in this group received unilateral TQL block at the level of (L4) with 20 ml plain bupivacaine 0.25%. group II: patients in this group received unilateral ASQL block just below the 12th rib at the level of (L1) with 20 ml plain bupivacaine 0.25%. group III: patients in this group received unilateral TPV block at the level of (T10) with 20 ml plain bupivacaine 0.25%. Measurements of our study included: Demographic data, Time of onset of sensory block, total dose of intraoperative fentanyl requirement, Hemodynamic Parameters (MAP & HR) were recorded before block performance, intraoperatively every 30 min and after surgery at T0 (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 (morphine) 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, duration of surgery and type of surgery. The onset of sensory block was significantly different among the three groups with faster onset in group III (TPVB) than in group II (ASQLB)& I (TQLB) (p <0.05). Regarding total intraoperative fentanyl requirement our result revealed a statistically significant difference among the 3 groups due to higher intraoperative fentanyl consumption in group I compared to group II & III, but there was no significant difference between group II & III. Also, our results revealed a significant intraoperative increase of the HR and MAP in group I as compared to group II and group III at skin incision, 30 min, 60 min, 90 min, 120 min and at the end of surgery (P < 0.05) while revealed no significant difference between group II and group III. Postoperatively these parameters showed an early significant increase after surgery before discharging from PACU (T0), 2 hour, 4 hour and 6 hour in group I as compared to group II & group III (P<0.05) while revealed no significant difference between group II & III and revealed no significant difference between the 3 groups at 12 hour,18 hour and 24 hour (p>0.05), this was consistent with the early increased VAS scores and early 1st rescue analgesic demand (morphine) in group I compared to other groups II and III. Regarding VAS comparison between the three groups for the 1st 24h postoperatively; our results showed a significant difference among the 3 groups early postoperatively at T0 before discharging from PACU with higher VAS in group I compared to group II & III, while comparison between group II & III showed no significant difference between them . Also, we found early first rescue analgesic demand in group I with a significant difference when compared to group II & III with no difference between group II & III. Regarding total analgesic consumption of morphine over 24h after surgery, there was a statistically significant difference among the three groups with more morphine consumption in group I. In contrast, the comparison between group II and III showed no statistically significant difference. Incidence of adverse event showed no significant difference among the three studied groups. Finally, regarding patient satisfaction our results showed statistically significant increase in patients’ satisfaction in group II&III compared to group.