Infiltration de ropivacaïne en chirurgie carcinologique du sein : effet sur la douleur postopératoire aiguë et chronique

Objectives

Decrease acute pain after breast cancer surgery by an infiltration of ropivacaine. Analyse effect on chronic pain.

Study design

Prospective randomised double blind versus placebo study.

Patients and methods

Eighty-one patients randomised between two groups received wound infiltration with 40 ml of ropivacaine 4.75 mg/ml or placebo. Acute pain was assessed during 24 h with analogical visual scale and antalgic consumption. One year later, telephonic interviews looked for chronic pain and evaluate it with McGill Pain Questionnaire.

Results

Analogical visual scale pain score, antalgic consumption and chronic pain incidence were similar between groups.

Conclusion

Ropivacaine scar infiltration provided no acute or chronic pain relief after breast cancer surgery.     

Le Smur meilleur vecteur pour une analgésie des patients traumatisés à l’arrivée aux urgences

Objectives

To find out prehospital factors linked with low pain on arrival into a traumatic emergency unit.

Methods

A 4-month monocentric prospective study, including patients recruited at their arrival into a traumatic emergency unit. Pain (with a numerical rating scale [NRS]), anxiety, prehospital care including the type of transportation (Physician staffed ambulances Smur, emergency medical technicians or firemen ambulances), immobilization and analgesics used were evaluated. These data were collected on arrival at the hospital by the ED orientation nurse. Uni- and multivariate analysis were performed to identify low pain's predictive factors (e.g. with a NRS ≤ 3).

Results

Three hundred and four patients were recruited, mean age = 51 ± 25, sex ratio = 1.8, mean pain/10 = 5.8 ± 2.9, 64% with a moderate or severe pain on arrival (NRS > 3). For one third of patients, immobilizations hadn’t been performed during the prehospital phase. Medical management by Smur is a low pain predictive factor (OR = 5.8; CI 95% = 1.4–24.16), anxiety is a pejorative factor (OR = 0.53 CI 95% = 0.38–0.75).

Conclusion

Our study highlights the physician staffed ambulances’ effectiveness in prehospital trauma victim's management and raises the question of anxiolysis as an adjuvant for traumatic pain management.     

Analgésie postopératoire à domicile : évaluation de la douleur par les parents,information

Postoperative analgesia at home induces necessarily pain assessment by self-report or observational measure. A special scale has been validated for day-case surgery: the PPMP. Nevertheless, children's and parents’ information and education are essential.     

Le dosage plasmatique de Neutrophil Gelatinase-Associated Lipocalin (NGAL) prédit la défaillance rénale au cours du choc septique dès l’admission en réanimation

Purpose

To validate plasma Neutrophil Gelatinase-Associated Lipocalin (pNGAL) as an early biomarker in intensive care unit (ICU) for acute kidney injury (AKI) in critically ill adult with septic shock.

Patients and method

Fifty consecutive patients with septic shock were included in this observational cohort study. AKI was defined if patients met any RIFLE or AKIN criteria. The main objective was to evaluate diagnosis value of pNGAL measured with a point-of-care device at admission (D0), at 24 hours (D1) and at 48 hours (D2).

Results

Among the 50 patients enrolled, 86% had AKI, 48% had persistent renal AKI and 30% required renal replacement therapy (RRT) during their ICU stay. At D0, pNGAL concentration was significantly higher in patients with AKI compared to patients without AKI (471 ng/mL versus 134 ng/mL, P < 0.001). This level remained significantly higher in the AKI population at D1 and D2 and pNGAL concentration at D0 among AKI patients increased with kidney failure level. At D1, pNGAL was significantly higher for persistent renal AKI rather than transient prerenal (570 ng/mL versus 337 ng/mL, P = 0.027). pNGAL concentration below 348 ng/mL at D1 was never seen in patients with RRT.

Conclusion

Plasma NGAL is a useful, sensitive and early biomarker to predict persistent AKI in septic shock at ICU admission and help to discuss RRT.     

Effet d’une dose unique intramusculaire de déxaméthasone sur la douleur après circoncision. Étude randomisée contrôlée

Objective

To assess the effect of a preoperative single dose of dexamethasone associated with penile block on pain after circumcision.

Study design

Prospective randomized controlled study.

Patients and methods

Forty male children aged 2 to 5 years, scheduled for circumcision under general anaesthesia, combined with penile block, were randomized into two groups. The dexamethasone group received dexamethasone 0.4 mg/kg preoperatively. The control group received the same volume of normal saline. Data compared between two groups were: postoperative pain assessed by the Objective Pain Scale collected in the recovery room, at 8 and 24 hours postoperatively (h0, h8 and h24), time to first analgesic request and the quality of sleep on the first postoperative night.

Results

Pain scores at h0 were similar between the two groups. The dexamethasone group showed significantly lower pain scores at h8 [0 (0–1) vs. 2 (0–3); P = 0.04] and h24 [0 (0–0) vs. 0 (0–1); P = 0.02]. The time to first analgesic administration was also significantly delayed in the dexamethasone group compared to the control group (240 vs 180 min; P = 0.035). The quality of sleep was also better in children in the dexamethasone group (P = 0.018).

Conclusion

This study showed that the combination of a preoperative single dose of dexamethasone 0.4 mg/kg with penile block significantly improves the quality of analgesia after circumcision.     

Enquête sur les attentes de la famille et/ou des proches d’un patient hospitalisé en réanimation après prise en charge extrahospitalière par une équipe du samu

Introduction

Emergency admission of a patient into an intensive care unit (ICU) is a source of stress for family and/or relatives. Expectations of family and/or relatives are important endpoints for the medical and paramedical team in charge of the patient, to better answer to their questions.

Objective

The aim of this study was to determine family's and/or relatives expectations concerning a patient emergently hospitalized into an ICU after out-of-hospital medical care of by a samu team.

Materials and method

We performed a survey using a questionnaire sent by email to 500 randomly chosen individuals from the French population.

Results

We received 220 responses (44 %). Family and/or relatives expectations are different about short, medium and long terms. Elements perceived as the most important in the short term are severity, diagnosis and prognosis, whereas in the medium and long terms they are hospital-stay and potential sequels. Medical language used is considered as too much complex for more than half of respondents. In case of foreseeable unfavourable outcome, 90 % of respondents would like to receive immediate information using a simple and brief language. At last, nearly two thirds of respondents had been really exposed to such a situation before, and assessed the quality of information received as moderate, with a score of 5/10.

Conclusion

Information of families and/or relatives of a patient hospitalized in ICU is essential. Their expectations concern short, medium and long terms. At last, most of them prefers that information would be delivered by a physician, and using a simple and brief language.     

Enquête nationale sur l’utilisation du rémifentanil comme alternative à l’analgésie péridurale obstétricale dans les maternités de niveau II et III

Objectives

The last French survey on alternatives to neuraxial anaesthesia for labour pain was published in 1997. However, intravenous remifentanil has become increasingly used as an option for labour analgesia. We evaluated the use of remifentanil as an alternative to epidural analgesia in level 2 and 3 French maternities in 2009.

Study design

This was an internet-based French survey performed in 2009 including all level 2 and 3 maternities. Data recorded were maternity unit characteristic, alternatives to neuraxial analgesia used, and remifentanil administration protocols.

Results

Two hundred and forty maternity units received the survey and 103 responses were completed. A written institutional alternative analgesia protocol for labour pain was present in 78%. Alternative labour analgesia included intermittent nitrous oxide inhalation (58%), intravenous nalbuphine (52%), patient-controlled intravenous administration of remifentanil (52%) and sufentanil (46%). Pethidine administration was reported by one maternity unit (1%). The bolus dose of remifentanil scheduled, and background infusion varied widely between maternity units. The analgesic efficacy of remifentanil used for labour pain was evaluated as moderate (55%) or good (43%). Two serious adverse events were reported.

Conclusion

Intravenous administration of remifentanil was largely reported as an alternative to neuraxial anaesthesia for labour pain. Although remifentanil administration was most often based on a local written protocol, bolus dose and background infusion varied widely between maternity units.     

Traitement précoce du diabète de type 2 chez l’obèse après gastric bypass et diversion bilio-pancréatique : rôle de l’axe entéro-insulinique

Improvement in Type 2 diabetes is seen in 80-98% of obese diabetic patients who undergo gastric bypass or bilio-pancreatic diversion. This improvement is evident early after the operation before significant weight loss has occurred. Although numerous teams have extensively studied the physiology of this early post-bypass amelioration of type 2 diabetes, the exact mechanism of diabetes remission remains unclear. Studies have focused on changes in the entero-insular axis, which is mediated in part by the interaction of insulinotropic hormones GIP and GIP 1 on the beta islet cells of the pancreas. Other mechanisms which have been postulated focus on the adipo-insular axis; the actions of adiponectin and leptin seem to have an important role in insulin resistance but their action is weight-loss dependent. Post-operative caloric restriction may also contribute to the early resolution of type 2 diabetes observed after gastric bypass and bilio- pancreatic diversion.