الفهرس 
introduction
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Abstract
The effective relief of pain is a paramount importance to everyone treating patients undergoing surgery. This should be achieved for humanitarian reasons, but there is now evidence that pain relief has significant physiological effects. Not only does effective pain relief means a smoother postoperative course with earlier discharge from hospital, but it may also reduce the onset of chronic pain syndromes.(178)
Clinically used doses of potent inhalational agents have shown minimal effect in preventing central hyper sensitization regarding pain control. Several studies have demonstrated that decreased postoperative pain can be achieved when cutaneous wound infiltration with local anesthetic is used in addition to inhalational anesthesia. Most general anesthetic regimen nowadays include an opiate given pre-, intra- and postoperatively.(179)
With the increasing popularity of epidural opioids , their analgesic benefit has always been weighed against their side effects especially as regards to respiratory depression . That is why the appearance of a new safe drug which can provide excellent analgesia with minimal side effects attracted much attention.(180)
The aim of the study was to evaluate and compare the analgesic effects of epidural tramadol versus intravenous tramadol for postoperative analgesia in major abdominal surgeries.
The study was carried out in Alexandria Main University Hospital on fifty patients, ASA class II or III, of both sexes, scheduled for elective major abdominal surgery.
Patients were categorized into two groups:
• Group I: Twenty five patients received an initial intravenous loading dose of 100 mg tramadol given 30-45 min after induction of general anesthesia, then 1-1.5 hr after that an infusion of 4-7mg/kg/day tramadol was started for 24 h using a syringe pump.(120)
• Group II: Twenty five patients received an initial dose of 100 mg tramadol epidurally given 30-45 min after induction of general anesthesia, then 1-1.5 hr after that a continous epidural infusion of 4-7mg/kg/day was started for 24h using a syringe pump.(121)
The daily dose should not exceed 400mg/day.
All patients were premedicated with 3-5 mg of IV midazolam on the morning of surgery in the operating room. A balanced anesthetic technique using general anesthesia with100 μg fentanyl, 2-3 mg/kg propofol and tracheal intubation was facilitated with non depolarizing muscle relaxant )cisatracurium 0.2mg ⁄ kg(. General anesthesia was maintained by isoflurane 1-2% in oxygen, incremental doses of muscle relaxant guided by nerve stimulator and controlled ventilation was maintained all over the time of surgery.
By the end of the operation, residual neuromuscular block was reversed by 0.04mg/kg neostigmine and 0.02mg/kg atropine sulfate i.v and the endotracheal tube was extubated after full recovery and patients was discharged to the postoperative care unit ﴾PACU﴿.
During the first 24 hours postoperatively (for patients in the two groups) if visual analogue scale exceeds 4, additional analgesia will be given to the patient in the form of 1 gram paracetamol every 8 hours. If additional analgesia is needed, it will be given in the form of opioids (25-30 mg pethidine).
The following parameters were measured in the first 24 hours of the postoperative period after full recovery as:
• Vital signs ( Mean arterial blood pressure , Heart rate , ECG , Respiratory rate ).
• Blood gases (Arterial PO2, PCO2 and pH every 8 hours during the first 24 hours postoperatively).
• Assessment of pain and analgesia was done using (Visual Analogue Scale (VAS) and the time lapsed until the first analgesic dose is asked by the patient postoperatively).
• The Degree of sedation using Ramsay Sedation Scale (RSS).
• Any observed side effects (nausea and vomiting, pruritis and headache) were noticed and recorded during the first 24 hours postoperatively.
The following results were obtained:
• Heart rate, mean arterial blood pressure and respiratory rate showed no significant difference between the two groups. Patients in group ІІ showed lower MABP and HR than patients in group І during the postoperative period.
• Arterial blood gases showed no changes during the postoperative period except for PaO2 , where there was a significant decrease in group І patients when compared to group ІІ patients at 16 and 24 hour postoperatively.
• Low pain scores were observed in the two groups , with better analgesia in group ІІ than in group І.
• Time lapsed till the need for first analgesic dose, showed no difference between the two groups. where total doses of perfalgan showed no difference. Regarding the total amount of pethidine, group І patients needed higher doses than patients of group ІІ.
• As for the degree of sedation, there was no difference between patients of the two groups postoperatively.
• The observed side effects were:
a- Pruritis:
Group І (6 patients) _ Group ІІ (5 patients).
b- Nausea and Vomiting:
Group І (12 patients) _ Group ІІ (9 patient).
c-Headache:
Group І (3 patients_ Group ІІ ( 2 patient ).