Patients participants will be randomized into 3 groups:
Group M (mid-point transverse process to pleura block MTP) N=3o Patients will receive
Ultrasound guided mid-point transverse process to pleura block preoperative with
injection of 20 ml bupivacaine 0.25%.
Group M: The block will be performed preoperatively with full aseptic precautions. The
ultrasound probe will be placed on the back in a vertical orientation on the lateral side
of the posterior median line to identify the transverse processes of the 4th and 5th
thoracic vertebrae and pleura.
A skin wheal using 3ml of 1% lidocaine will be made 2 to 3 cm superior to the superior
aspect of the transducer. Using the in plane needling technique in the space between the
transverse processes of the 4th and 5th thoracic vertebrae, the puncture needle needle
tip will be placed at the mid-point between the transverse process and pleura, with no
blood, gas, or cerebrospinal fluid observed on aspiration, 20 mL of 0.25% bupivacaine
will be administered. The local anesthetic spread will be noted in the area midway
between the transverse process and pleura is an indication of a successful puncture.
Group E (Erector Spinae Plane Block ESB) N=3o Patients will receive Ultrasound guided
erector spinae plane block with injection of 20 ml bupivacaine 0.25%.
Group E: The block will be performed preoperatively with full aseptic precautions. The
ultrasound probe will be placed on the back in a vertical orientation on the lateral side
of the posterior median line to identify the transverse process of the 5th thoracic
vertebra and erector spine muscle.
A skin wheal using 3ml of 1% lidocaine will be made 2 to 3 cm superior to the superior
aspect of the transducer. The puncture will be performed using the intra-plane needling
technique after local anaesthesia infiltration. A 20-gauge Tuohy needle connected to a
syringe containing the anesthetic mixture or saline will be advanced. When the puncture
needle touch the transverse process, with no blood, gas, or cerebrospinal fluid observed
on aspiration, 20 mL of 0.25% bupivacaine will be administered between the erector spine
muscle and transverse process.
Local anesthetic diffusion between the transverse process and erector spinae muscle is an
indication of a successful puncture.
Group C (control group) N=30 Patients will not receive any block. Induction will be
performed by using a regimen of IV by fentanyl 1 μg/kg, Additional bolus doses of
fentanyl 0.5 μg/kg will be given if the mean arterial blood pressure or heart rate rises
above 20% of baseline levels.
Randomization will be done by statistician and each group of the patient will revealed
only when the included patient is transferred to preanesthetic room.