الفهرس 
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Abstract
Opioids are widely used for perioperative analgesia. However, the intraoperative use of large bolus doses or continuous infusions of potent opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. When it comes to ambulatory surgery, opioid related side effects, such as PONV, prolonged sedation, ileus and urinary retention may delay recovery and discharge or cause unanticipated hospital readmission. PONV are distressing symptoms that has an incidence around 25% in adults, ranging from 5% to 57%. The incidence, in day care surgeries, is nearly the same varying from 8% to 45 %. PONV commonly occur after surgeries under general anesthesia as laparoscopy, laparotomy, ENT, neurological, breast and gynecological surgeries. Etiopathogenesis of PONV is very complex in nature and is triggered by multiple inputs that arrive from multiple areas. Laparoscopic surgery, bowel obstruction, female gender, younger age group, longer operations, obese patients, non-smokers, a history of PONV, motion sickness, and postoperative opioid therapy are considered as important independent causal factors for PONV. Preoperative anxiety, positive pressure ventilation, inhalational anesthetic agents, and nitrous oxide increase the risk of PONV. The postoperative pain after laparoscopic gynecological surgery is complex in nature and growing evidence suggests that it’s treatment should be multimodal and opioid sparing to accelerate recovery. In spite of multimodal analgesic strategies, which consist of opioids, dexamethasone, non-steroidal anti-inflammatory drugs, and local anesthetics applied into the surgical wound, postoperative pain and PONV are still common complaints reported after laparoscopic gynecological surgery. The aim of this study is to evaluate the effect of opioid sparing technique via infusion of dexmedetomidine, ketamine and lidocaine on postoperative nausea and vomiting in laparoscopic gynecological surgery. The primary outcome is detection of the incidence of PONV. The secondary outcomes are measurement of intraoperative isoflurane and fentanyl consumption and postoperative 24 hr. morphine consumption. Eighty patients were randomly allocated into 2 groups, 40 patients each. Control group (group C): received propofol, atracurium and fentanyl for induction. Study group (group S): received infusion of a mixture of dexmedetomidine, ketamine and lidocaine 10 min before induction of anesthesia. Induction was done with propofol and atracurium. Infusion of the study mixture was continued till head down position at a rate of 0.2 ml/kg/hr then decreased to 0.1 ml/kg/hr till the end of surgery. Anesthesia was maintained with isoflurane in the two groups. The study results showed: • The two groups were comparable regarding the patients’ characteristics (age, BMI and ASA physical status) where there was no significant difference between the two groups (P = 0.292, 0.648 and 0.478 respectively). The duration of surgery was insignificantly different between two groups (P = 0.066). • Mean arterial blood pressure and heart rate were insignificantly different between two groups at the baseline and all times of surgery. • Intraoperative isoflurane consumption was decreased significantly in group S than group C (P <0.001). • Intraoperative fentanyl consumption was significantly decreased in group S than group C (P = 0.006). • There were 7 (17.5%) patients needed fentanyl in group S and 20 (50%) patients needed fentanyl in group C intraoperatively. Number of patients who received fentanyl was significantly decreased in group S than group C (P = 0.001). • First time to request analgesia was significantly decreased in group S than group C (P <0.001). • VAS was significantly increased in group S than group C at 1h (P <0.001) and was insignificantly different between both groups at 0.5, 2, 4, 6, 8, 12, 18 and 24 hours. • 24 hr morphine consumption was significantly decreased in group S than group C (P < 0.001). • PONV score was significantly decreased in group S than group C (P = 0.017). • Hypotension and bradycardia were insignificantly different between both groups. • Patients’ satisfaction was significantly increased in group S than group C (P = 0.019).