Ahmed Salah

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. 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).

Management of postoperative pain relieves suffering and leads to earlier mobilization, shortened hospital stay, reduced hospital costs, and increased patient satisfaction

The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia. This goal is best accomplished with multimodal and preventive analgesia.

Perioperative thoracic epidural analgesia (TEA), especially with a local anesthetic-based analgesic solution, can decrease the incidence of postoperative morbidity and mortality. In the case of the cardiovascular system, TEA may decrease the incidence of postoperative myocardial infarction by providing a favorable redistribution of coronary blood flow, attenuating the stress response, hypercoagulability and postoperative pain. As for the respiratory system, TEA provides superior analgesia, allowing patients to do deep breathing exercises and early ambulation.

Local anesthetic molecules consist of a lipophilic (aromatic) ring and a hydrophilic (tertiary amine) structure connected by a short alkyl intermediate chain containing either an amide or an ester bond.

Bupivacaine, the widely used local anesthetic in regional anesthesia is available in a commercial preparation as a racemic mixture (50:50) of its two enantiomers, levobupivacaine, S (−) isomer and dextrobupivacaine, R (+) isomer. Severe central nervous system (CNS) and cardiovascular adverse reactions reported in the literature after inadvertent intravascular injection or intravenous regional anesthesia have been linked to the R (+) isomer of bupivacaine. The levorotatory isomers were shown to have a safer pharmacological profile

with less cardiac and neurotoxic adverse effects

The decreased toxicity of levobupivacaine is attributed to its faster protein binding rate

The pure S (−) enantiomers of bupivacaine, i.e., ropivacaine and levobupivacaine were thus introduced into the clinical anesthesia practice.

In the current study, forty patients were enrolled in this study in National Cancer Institute – Cairo University. The patients age range from 18-65 years and they were randomly allocated by a computer-generated table into one of the 2 study groups. They were all scheduled to undergo abdominal surgery and equally divided into two groups. Each constitute of 20 patients (n= 40) Members of each group received general anesthesia, before induction of anesthesia Thoracic epidural was performed by loss of resistance technique as intraoperative and postoperative analgesia using :

• Group A

  : levobupivacaine &fentanyl.

• Group B

  : bupivacaine &fentanyl.

We compared between two groups as regards Intraoperative assessment of hemodynamics (HR, MAP, SO2) & Analgesic consumption and Postoperative assessment of hemodynamics, VAS score, PONV &

Rescue analgesia 0,1,2,3h postoperatively.

  Our study demonstrates that epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamic parameters, and postoperative analgesia for major abdominal surgery.