ABSTRACT Background: Intrathecal opioids are .frequently used in the management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use; Aim ofthis studywas to compare between six different doses of IT morphine (0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg and 1 mg) as regarding postoperative analgesia and the side effects of IT morphine, and to determine the optimal dose of IT morphine that provides satisfactory analgesia to the patient with minimal side effects. Methods: This study was conducted in Anesthesiology Department, Assiut university hospital, after approval of the local ethics committee. Our study was performed on 95 patients of ASA physical status I and II aged from 20 to 40 scheduled for anorectal surgeries. Spinal anesthesia was performed, with the patient in the sitting position. at L4, 5. Each patient received 5 mg of hyperbaric bupivacaine with different doses of IT morphine in a total volume of 2 ml. patients were kept in the sitting position for five minutes to get sacral block. Intraoperative monitoring; Heart rate, 02 saturation, and non-invasive blood pressure were monitored. Postoperative monitoring: Patients were evaluated for any pain or side effect of IT morphine (Pruritus, PONV, urinary retention, and respiratory depression) during the first 24 hours. Supplemental analgesia in the form of 1. V tenoxicam was available on patient request, and the doses needed for each patient were recorded. Antipruritic and antiemetic therapy was available on patient request. Results: Increasing the dose of IT morphine decreases the incidence of pain during thefirst 24 hours and subsequently decreases the need for supplemental analgesia. The doses of O. 1 mg and 0.2 mg are comparable with each other as regard to pain relief 100% of the patients receiving 0.1 mg and 75% of the patients receiving 0.2 mg of IT morphine experienced pain during the first 24 hours and subsequently required supplemental analgesia and even with 40 mg of 1. V tenoxicam, some patient complained of postoperative pain. The doses of O. 3 mg, 0.4 mg or 0.5 mg are comparable with each other. Theses doses are enough to provide 24-hours analgesia in more than 50% of patients. This percentage increases to 100% with the use of 20-40 mg of tenoxicam intravenously. The dose of 1 mg provides 24-hours analgesia in 87% of patients. Increasing the dose of IT morphine causes significant increase in the incidence and severity of pruritus. Postoperative nausea and vomiting occurred in 30% of the patients in the control group. There is a non-Significant increase in both the incidence and severity of PONV by increasing the dose of IT morphine. Urinary retention occurred in 20% of the patients in the control group. Increasing the dose of IT morphine causes significant increase in the incidence of urinary retention. Respiratory depression was not detected in any patient. In conclusion: Our study clearly demonstrated that the use of IT morphine in a dose of 0.3 mg in adjuvant with intravenous tenoxicam in a dose of 20-40 mg provides excellent pain relieffor 24 hours after anorectal surgeries with minimal side effects of IT morphine.

ABSTRACT Background: Intrathecal opioids are .frequently used in the management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use; Aim ofthis studywas to compare between six different doses of IT morphine (0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg and 1 mg) as regarding postoperative analgesia and the side effects of IT morphine, and to determine the optimal dose of IT morphine that provides satisfactory analgesia to the patient with minimal side effects. Methods: This study was conducted in Anesthesiology Department, Assiut university hospital, after approval of the local ethics committee. Our study was performed on 95 patients of ASA physical status I and II aged from 20 to 40 scheduled for anorectal surgeries. Spinal anesthesia was performed, with the patient in the sitting position. at L4, 5. Each patient received 5 mg of hyperbaric bupivacaine with different doses of IT morphine in a total volume of 2 ml. patients were kept in the sitting position for five minutes to get sacral block. Intraoperative monitoring; Heart rate, 02 saturation, and non-invasive blood pressure were monitored. Postoperative monitoring: Patients were evaluated for any pain or side effect of IT morphine (Pruritus, PONV, urinary retention, and respiratory depression) during the first 24 hours. Supplemental analgesia in the form of 1. V tenoxicam was available on patient request, and the doses needed for each patient were recorded. Antipruritic and antiemetic therapy was available on patient request. Results: Increasing the dose of IT morphine decreases the incidence of pain during thefirst 24 hours and subsequently decreases the need for supplemental analgesia. The doses of O. 1 mg and 0.2 mg are comparable with each other as regard to pain relief 100% of the patients receiving 0.1 mg and 75% of the patients receiving 0.2 mg of IT morphine experienced pain during the first 24 hours and subsequently required supplemental analgesia and even with 40 mg of 1. V tenoxicam, some patient complained of postoperative pain. The doses of O. 3 mg, 0.4 mg or 0.5 mg are comparable with each other. Theses doses are enough to provide 24-hours analgesia in more than 50% of patients. This percentage increases to 100% with the use of 20-40 mg of tenoxicam intravenously. The dose of 1 mg provides 24-hours analgesia in 87% of patients. Increasing the dose of IT morphine causes significant increase in the incidence and severity of pruritus. Postoperative nausea and vomiting occurred in 30% of the patients in the control group. There is a non-Significant increase in both the incidence and severity of PONV by increasing the dose of IT morphine. Urinary retention occurred in 20% of the patients in the control group. Increasing the dose of IT morphine causes significant increase in the incidence of urinary retention. Respiratory depression was not detected in any patient. In conclusion: Our study clearly demonstrated that the use of IT morphine in a dose of 0.3 mg in adjuvant with intravenous tenoxicam in a dose of 20-40 mg provides excellent pain relieffor 24 hours after anorectal surgeries with minimal side effects of IT morphine.

ABSTRACT Background: Intrathecal opioids are .frequently used in the management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use; Aim ofthis studywas to compare between six different doses of IT morphine (0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg and 1 mg) as regarding postoperative analgesia and the side effects of IT morphine, and to determine the optimal dose of IT morphine that provides satisfactory analgesia to the patient with minimal side effects. Methods: This study was conducted in Anesthesiology Department, Assiut university hospital, after approval of the local ethics committee. Our study was performed on 95 patients of ASA physical status I and II aged from 20 to 40 scheduled for anorectal surgeries. Spinal anesthesia was performed, with the patient in the sitting position. at L4, 5. Each patient received 5 mg of hyperbaric bupivacaine with different doses of IT morphine in a total volume of 2 ml. patients were kept in the sitting position for five minutes to get sacral block. Intraoperative monitoring; Heart rate, 02 saturation, and non-invasive blood pressure were monitored. Postoperative monitoring: Patients were evaluated for any pain or side effect of IT morphine (Pruritus, PONV, urinary retention, and respiratory depression) during the first 24 hours. Supplemental analgesia in the form of 1. V tenoxicam was available on patient request, and the doses needed for each patient were recorded. Antipruritic and antiemetic therapy was available on patient request. Results: Increasing the dose of IT morphine decreases the incidence of pain during thefirst 24 hours and subsequently decreases the need for supplemental analgesia. The doses of O. 1 mg and 0.2 mg are comparable with each other as regard to pain relief 100% of the patients receiving 0.1 mg and 75% of the patients receiving 0.2 mg of IT morphine experienced pain during the first 24 hours and subsequently required supplemental analgesia and even with 40 mg of 1. V tenoxicam, some patient complained of postoperative pain. The doses of O. 3 mg, 0.4 mg or 0.5 mg are comparable with each other. Theses doses are enough to provide 24-hours analgesia in more than 50% of patients. This percentage increases to 100% with the use of 20-40 mg of tenoxicam intravenously. The dose of 1 mg provides 24-hours analgesia in 87% of patients. Increasing the dose of IT morphine causes significant increase in the incidence and severity of pruritus. Postoperative nausea and vomiting occurred in 30% of the patients in the control group. There is a non-Significant increase in both the incidence and severity of PONV by increasing the dose of IT morphine. Urinary retention occurred in 20% of the patients in the control group. Increasing the dose of IT morphine causes significant increase in the incidence of urinary retention. Respiratory depression was not detected in any patient. In conclusion: Our study clearly demonstrated that the use of IT morphine in a dose of 0.3 mg in adjuvant with intravenous tenoxicam in a dose of 20-40 mg provides excellent pain relieffor 24 hours after anorectal surgeries with minimal side effects of IT morphine.

Immunstimulatory properties of Tramadol mainly affects natural killer cells [NK] , and T- lymphocytes production . No proved evidence that Tramadol affects HLA-DR expression from activated monocytes .This study evaluate a combined approach using I.M tramadol 1.5 mg/kg and I.V paracetamol 15 mg/kg used for treatment of postcraniotomy pain in patients with supratentorial space occupying lesions. The analgesic efficacy and immunological status were our subject of interest. 40 patients ASA I or II scheduled for elective supratentorial craniotomy divided into two groups: Group Paracetamol received paracetamol 15 mg/kg i.v. before end of surgery for postcraniotomy pain relief repeated 6 hours postoperative. Group paracetamol+ received same dose of paracetamol + tramadol 1.5 mg/kg i.m. started 1 hour before end of surgery and repeated 6 hours postoperative. Analgesic efficacy was assessed by visual analogue scale "VAS" at 3, 6, 12 and 24 hours postoperative. Immunological parameters measured were HLA-Dr expression and γ-interferon. Venous blood samples were withdrawn at 4-time points: Preoperative, intraoperative, first and third day postoperative. HLA-Dr expression mean values showed no significant difference inside and in between the two groups. In group paracetamol they were 87.27 ± 1.65 , 86.73 ± 1.79, 85.28 ± 2.33 and 88.12 ± 1.66 at do, doo , d1 and d3, respectively while in group paracetamol+, they were 86.17 ± 1.77, 87.96 ± 1.91, 89.19 ± 1.37 and 89.92 ± 1.81 at d0, d00, d1 and d3, respectively. While γ-interferon mean values significantly decreased after induction of anesthesia in both groups. They were 3.6 ± 0.33 versus 3.55 ± 0.33, 3.25 ± 0.36 versus 3.14 ± 0.44, 3.55 ± 0.29 versus 3.93 ± 0.35 and 3.7 ± 0.41 versus 4.21 ± 0.36 at d0, d00, d1 and d3 in group paracetamol versus group paracetamol+, respectively. γ-interferon release recovered earlier in group paracetamol+ (by first day postoperative) rather in group paracetamol (by third day postoperative). The "VAS" mean values were significantly lower in group paracetamol+ patients than in group paracetamol ; 2.4 ± 0.11 versus 3.2 ± 0.17, 2.55 ± 0.11 versus 3.65 ± 0.18, 2.05 ± 0.05 versus 2.45 ± 0.11 and 1.05 ± 0.08 versus 1.8 ± 0.16 at the 3rd, 6th, 12 and 24 hours postoperative, respectively. In Group paracetamol+, eight patients experienced nausea and two vomited once. Tramadol when combined to paracetamol have yielded a better analgesia for post craniotomy pain and an improved immunological profile as regards to increased levels of γ-interferon. Although it had a negative effect on HLA-Dr expression, no infectious complications were reported in this study.

Immunstimulatory properties of Tramadol mainly affects natural killer cells [NK] , and T- lymphocytes production . No proved evidence that Tramadol affects HLA-DR expression from activated monocytes .This study evaluate a combined approach using I.M tramadol 1.5 mg/kg and I.V paracetamol 15 mg/kg used for treatment of postcraniotomy pain in patients with supratentorial space occupying lesions. The analgesic efficacy and immunological status were our subject of interest. 40 patients ASA I or II scheduled for elective supratentorial craniotomy divided into two groups: Group Paracetamol received paracetamol 15 mg/kg i.v. before end of surgery for postcraniotomy pain relief repeated 6 hours postoperative. Group paracetamol+ received same dose of paracetamol + tramadol 1.5 mg/kg i.m. started 1 hour before end of surgery and repeated 6 hours postoperative. Analgesic efficacy was assessed by visual analogue scale "VAS" at 3, 6, 12 and 24 hours postoperative. Immunological parameters measured were HLA-Dr expression and γ-interferon. Venous blood samples were withdrawn at 4-time points: Preoperative, intraoperative, first and third day postoperative. HLA-Dr expression mean values showed no significant difference inside and in between the two groups. In group paracetamol they were 87.27 ± 1.65 , 86.73 ± 1.79, 85.28 ± 2.33 and 88.12 ± 1.66 at do, doo , d1 and d3, respectively while in group paracetamol+, they were 86.17 ± 1.77, 87.96 ± 1.91, 89.19 ± 1.37 and 89.92 ± 1.81 at d0, d00, d1 and d3, respectively. While γ-interferon mean values significantly decreased after induction of anesthesia in both groups. They were 3.6 ± 0.33 versus 3.55 ± 0.33, 3.25 ± 0.36 versus 3.14 ± 0.44, 3.55 ± 0.29 versus 3.93 ± 0.35 and 3.7 ± 0.41 versus 4.21 ± 0.36 at d0, d00, d1 and d3 in group paracetamol versus group paracetamol+, respectively. γ-interferon release recovered earlier in group paracetamol+ (by first day postoperative) rather in group paracetamol (by third day postoperative). The "VAS" mean values were significantly lower in group paracetamol+ patients than in group paracetamol ; 2.4 ± 0.11 versus 3.2 ± 0.17, 2.55 ± 0.11 versus 3.65 ± 0.18, 2.05 ± 0.05 versus 2.45 ± 0.11 and 1.05 ± 0.08 versus 1.8 ± 0.16 at the 3rd, 6th, 12 and 24 hours postoperative, respectively. In Group paracetamol+, eight patients experienced nausea and two vomited once. Tramadol when combined to paracetamol have yielded a better analgesia for post craniotomy pain and an improved immunological profile as regards to increased levels of γ-interferon. Although it had a negative effect on HLA-Dr expression, no infectious complications were reported in this study.

Immunstimulatory properties of Tramadol mainly affects natural killer cells [NK] , and T- lymphocytes production . No proved evidence that Tramadol affects HLA-DR expression from activated monocytes .This study evaluate a combined approach using I.M tramadol 1.5 mg/kg and I.V paracetamol 15 mg/kg used for treatment of postcraniotomy pain in patients with supratentorial space occupying lesions. The analgesic efficacy and immunological status were our subject of interest. 40 patients ASA I or II scheduled for elective supratentorial craniotomy divided into two groups: Group Paracetamol received paracetamol 15 mg/kg i.v. before end of surgery for postcraniotomy pain relief repeated 6 hours postoperative. Group paracetamol+ received same dose of paracetamol + tramadol 1.5 mg/kg i.m. started 1 hour before end of surgery and repeated 6 hours postoperative. Analgesic efficacy was assessed by visual analogue scale "VAS" at 3, 6, 12 and 24 hours postoperative. Immunological parameters measured were HLA-Dr expression and γ-interferon. Venous blood samples were withdrawn at 4-time points: Preoperative, intraoperative, first and third day postoperative. HLA-Dr expression mean values showed no significant difference inside and in between the two groups. In group paracetamol they were 87.27 ± 1.65 , 86.73 ± 1.79, 85.28 ± 2.33 and 88.12 ± 1.66 at do, doo , d1 and d3, respectively while in group paracetamol+, they were 86.17 ± 1.77, 87.96 ± 1.91, 89.19 ± 1.37 and 89.92 ± 1.81 at d0, d00, d1 and d3, respectively. While γ-interferon mean values significantly decreased after induction of anesthesia in both groups. They were 3.6 ± 0.33 versus 3.55 ± 0.33, 3.25 ± 0.36 versus 3.14 ± 0.44, 3.55 ± 0.29 versus 3.93 ± 0.35 and 3.7 ± 0.41 versus 4.21 ± 0.36 at d0, d00, d1 and d3 in group paracetamol versus group paracetamol+, respectively. γ-interferon release recovered earlier in group paracetamol+ (by first day postoperative) rather in group paracetamol (by third day postoperative). The "VAS" mean values were significantly lower in group paracetamol+ patients than in group paracetamol ; 2.4 ± 0.11 versus 3.2 ± 0.17, 2.55 ± 0.11 versus 3.65 ± 0.18, 2.05 ± 0.05 versus 2.45 ± 0.11 and 1.05 ± 0.08 versus 1.8 ± 0.16 at the 3rd, 6th, 12 and 24 hours postoperative, respectively. In Group paracetamol+, eight patients experienced nausea and two vomited once. Tramadol when combined to paracetamol have yielded a better analgesia for post craniotomy pain and an improved immunological profile as regards to increased levels of γ-interferon. Although it had a negative effect on HLA-Dr expression, no infectious complications were reported in this study.

Abstract: Background and Aims: Extracorporeal shock wave lithotripsy (ESWL) represents first line therapy for the majority of urinary tract calculi and requires anesthesia. The purpose of this study is to prospectively evaluate the analgesic effects and safety of lidocaine 1% by local infiltration as a monotherapy during renal ESWL and ensure stone clearance after the procedure. Methods: One hundred patients with renal stones, aged 18 to 65 years, were randomly allocated into two groups; 49 patients in group 1 received intramuscular injection of 20 mg Ketorolac tromethamine, 20 minutes before start of the procedure and 51 patients in group 2 received Lidocaine 1% by local infiltration (5mg/kg) into the 30 cm2 area after localizing the stones site, 10 minutes before the session. A visual analog scale, (0 to 100 mm) was used to evaluate pain every 10 minutes. Results: The visual analog scores for group 2 were significantly lower than (group 1) at 10, 20, 30 and 40 minutes till end of the procedure, (p 0.001). The mean requirements of supplemental fentanyl analgesia (μg) were significantly decreased in group 2 than group 1, (3.34 ± 7.32 versus 15.72 ± 6.41, p0.001). All patients in group 2 were discharged earlier, 1 hour after the end of the procedure while 13 patients (26.5%) in group 1 had delayed discharge. No significant difference was detected between the two groups with regards to complete stone clearance after 1 month, no. of shocks, voltage power or duration of procedure. No patient in group 2 reported neurological side effects of local anesthesia. Conclusions: Lidocaine 1% by local infiltration cannot be used alone for pain relief but effectively reduced the analgesic needs and minimized hospital stay after renal ESWL, without affecting stone clearance.

Abstract: Background and Aims: Extracorporeal shock wave lithotripsy (ESWL) represents first line therapy for the majority of urinary tract calculi and requires anesthesia. The purpose of this study is to prospectively evaluate the analgesic effects and safety of lidocaine 1% by local infiltration as a monotherapy during renal ESWL and ensure stone clearance after the procedure. Methods: One hundred patients with renal stones, aged 18 to 65 years, were randomly allocated into two groups; 49 patients in group 1 received intramuscular injection of 20 mg Ketorolac tromethamine, 20 minutes before start of the procedure and 51 patients in group 2 received Lidocaine 1% by local infiltration (5mg/kg) into the 30 cm2 area after localizing the stones site, 10 minutes before the session. A visual analog scale, (0 to 100 mm) was used to evaluate pain every 10 minutes. Results: The visual analog scores for group 2 were significantly lower than (group 1) at 10, 20, 30 and 40 minutes till end of the procedure, (p 0.001). The mean requirements of supplemental fentanyl analgesia (μg) were significantly decreased in group 2 than group 1, (3.34 ± 7.32 versus 15.72 ± 6.41, p0.001). All patients in group 2 were discharged earlier, 1 hour after the end of the procedure while 13 patients (26.5%) in group 1 had delayed discharge. No significant difference was detected between the two groups with regards to complete stone clearance after 1 month, no. of shocks, voltage power or duration of procedure. No patient in group 2 reported neurological side effects of local anesthesia. Conclusions: Lidocaine 1% by local infiltration cannot be used alone for pain relief but effectively reduced the analgesic needs and minimized hospital stay after renal ESWL, without affecting stone clearance.

Abstract: Background and Aims: Extracorporeal shock wave lithotripsy (ESWL) represents first line therapy for the majority of urinary tract calculi and requires anesthesia. The purpose of this study is to prospectively evaluate the analgesic effects and safety of lidocaine 1% by local infiltration as a monotherapy during renal ESWL and ensure stone clearance after the procedure. Methods: One hundred patients with renal stones, aged 18 to 65 years, were randomly allocated into two groups; 49 patients in group 1 received intramuscular injection of 20 mg Ketorolac tromethamine, 20 minutes before start of the procedure and 51 patients in group 2 received Lidocaine 1% by local infiltration (5mg/kg) into the 30 cm2 area after localizing the stones site, 10 minutes before the session. A visual analog scale, (0 to 100 mm) was used to evaluate pain every 10 minutes. Results: The visual analog scores for group 2 were significantly lower than (group 1) at 10, 20, 30 and 40 minutes till end of the procedure, (p 0.001). The mean requirements of supplemental fentanyl analgesia (μg) were significantly decreased in group 2 than group 1, (3.34 ± 7.32 versus 15.72 ± 6.41, p0.001). All patients in group 2 were discharged earlier, 1 hour after the end of the procedure while 13 patients (26.5%) in group 1 had delayed discharge. No significant difference was detected between the two groups with regards to complete stone clearance after 1 month, no. of shocks, voltage power or duration of procedure. No patient in group 2 reported neurological side effects of local anesthesia. Conclusions: Lidocaine 1% by local infiltration cannot be used alone for pain relief but effectively reduced the analgesic needs and minimized hospital stay after renal ESWL, without affecting stone clearance.

Islet damage attributed to impaired exocrine cells during pancreas preservation and isolation procedure remains elusive, although released exocrine enzymes could directly damage islets. The aim of this study is to investigate the cellular mechanisms associated with exocrine cells and their possible impact on the islet cell survival and function after isolation. Mouse pancreata were stored in cold University of Wisconsin preservation solution for 0, 24 and 48 h and incubated with or without collagenase at 37°C for 15 min. During preservation, the percentage of exocrine cells with necrosis, which means impaired cellular membrane that allows intracellular enzymes to be released, remains low (10%) regardless of preservation time; whereas the percentage of exocrine cells with apoptosis, which means impaired nucleus and possible intact cellular membrane, increases over time of preservation. After collagenase-free incubation, however, the percentage of exocrine cells with necrosis became higher in longer preservation time, and more than 60% of the necrotic exocrine cells contained apoptosis as well. Islet cells located in pancreata with intact structure are almost kept away either from necrotic or apoptotic changes even after 48 h preservation followed by collagenase-free incubation. However, when islets are isolated after collagenase-containing incubation, the percentage of islet cells with necrosis increases over time of preservation up to approximately 40%. This study suggests that exocrine cells with necrosis could cause damage of isolated islets when the pancreas is dissociated and that the necrosis in exocrine cells might be induced mainly as the conversion from apoptosis that has already existed during preservation.