L’adjonction de sulfate de magnésium à la morphine en intrathécal améliore-t-elle l’analgésie après césarienne ?

Background

Intrathecal morphine (IT) is commonly used for postoperative analgesia after caesarean section. The addition of intrathecal (IT) magnesium to spinal bupivacaine-fentanyl anaesthesia increases the duration of spinal analgesia for labour without additional side effects. In this prospective, randomized, double blind, controlled study, we evaluated whether adding intrathecal magnesium could prolong spinal morphine analgesia after caesarean section.

Parturient and methods

After ethics committee approval and obtaining written consent, one hundred and five (ASA I or II) adult patients undergoing caesarean section were recruited. They were randomly allocated to one of three groups: (1) group Morphine (M): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (2) group Magnesium (Mg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (3) group Morphine + Magnesium (MMg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml).We recorded the following: time to the first analgesic request, pain scores with the visual analogic scale at rest and in movement at h0, h1, h2, h4 and then every 4 h for the first 36 postoperative hours, the occurrence of adverse events and patients’ satisfaction.

Results

Time of the first analgesic request was 28 ± 8 h in group MMg versus 19 ± 6 h in group M and 7 ± 6 h in group Mg (p < 0.01). Pain scores were statistically lower in group MMg (9 ± 7 and 17 ± 9 mm respectively) compared to group M (16 ± 9 and 28 ± 11 mm respectively) and Mg (21 ± 9 and 37 ± 13 mm respectively) (p < 0.01). There was no difference in adverse events among the three groups. Patients satisfaction was better in group MMg (p < 0.01).

Conclusion

In patients undergoing caesarean section under spinal anaesthesia, the addition of IT magnesium sulphate (100 mg) to morphine 100 μg improved the quality and the duration of postoperative analgesia without increasing the incidence of adverse effects.     

Pratique de l’anesthésie réanimation en milieu pénitentiaire. Un détenu peut-il bénéficier d’une anesthésie ambulatoire ?

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France.     

L’anesthésie,l’analgésie et la modulation sympathique augmentent-elles l’incidence des récidives néoplasiques après chirurgie ? Une revue de la littérature centrée sur la modulation de l’activité des lymphocytes natural killer

Objective

The Natural Killer cells (NK) are an important part of non-specific cellular-mediated and antitumoral immunity. The goal of this review is to recapitulate data published over NK activity during the perioperative period and the influence of anaesthesia, analgesia and modulation of sympathetic system.

Data sources

Pubmed/Medline database.

Study selection and data extraction

Keywords-based selection, without limit of date: fundamental studies, randomized controlled trials and non-randomized comparative studies.

Data synthesis

In human as in animal studies, an important correlation exists between NK activity and prognosis linked to the development of metastasis. The great depression of this cytotoxicity during the perioperative period could be able to compromise host defenses. The influence of anaesthetics and analgesics is important. The effects of the opioids, the agonists and the antagonists of the sympathetic nervous system, the prostaglandins, the NSAIDs, the ketamine, the hypnotics and the locoregional anaesthesia are systematically reviewed. The limits of experimental model presented are covered.

Conclusion

The effects of anaesthetic/analgesic drugs and techniques, the consequences of sympathomodulation on NK activity are numerous and sometimes opposite. It is important for the anaesthesiologist to keep in mind that the long term consequences of his techniques on the patients’ outcome must be clarified.     

Quoi de neuf dans le monitorage anesthésique au quartier opératoire ?

This paper critically reviews the new devices that can be used on the operating room to monitor the oxygenation and the haemodynamics of the child undergoing general anaesthesia.     

Il y a-t-il une place pour le sérum salé hypertonique dans les états septiques graves ?

Fluid loading is the first step, necessary to care for severe sepsis. Two main classes of solutions are currently available: crystalloids and colloids. The concept of small volume resuscitation with hypertonic saline has emerged these last years in the care of traumatic haemorrhagic shock. The main benefits are the restoration of intravascular volume, improvement of cardiac output and improvement of regional circulations. Many experiments highlight modulation of immune and inflammatory cascades. We report the mechanisms of action of hypertonic saline based on experimental human and animal studies, which advocate its use in septic shock.     

Quelle technique d’anesthésie en ventilation spontanée pour l’intubation difficile?

Difficult intubation in children is rare and often predicable during anesthesia consultation. This allows to establish a strategy to provide fiberoptic guided tracheal intubation with spontaneous ventilation in function of age and children pathology. A good knowledge of physiologic and anatomic children particularities, of fiberoptic technique and the respect for some principles lead to ensure the security of this procedure. First principle is to use only one anesthetic inhaled or intravenous agent in order to limit an important decrease of ventilation. The anesthetic technique recommended for pediatric fiberoptic guided intubation is inhaled anesthesia with sevoflurane. But it is possible to use an intravenous agent, like propofol, with a continuous infusion (bolus of 0.1 to 0.3 mg/kg then 0.1–0.3 mg/kg per hour for maintenance) or with target controlled infusion (Schnider model, initial concentration 2.5 μg/mL, then increase by 0.5 μg/mL steps) particularly in children older than 5 years with an anesthetic depth control. Whatever the agent, the dose must to be titrated to maintain spontaneous ventilation. Second principle is to combine an airway local anesthesia with general anesthesia to limit airway reactivity. First, a nose topical anesthesia is administered with lidocaïne plus naphazoline in children older than 2 years. Then, a laryngeal topical anesthesia is realized with lidocaïne 1% (1–2 mL, 2 mg/kg) through operating channel of fiberoptic bronchoscope. Finally, third principle is to ensure patient oxygenation with several techniques like use of endoscopic facial mask or nasopharyngeal tube. The use of laryngeal mask is a rescue technique in case of spontaneous ventilation lost. In conclusion, each institution has to establish an algorithm with his own knowledge, constantly feasible and regularly teached.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Comment gérer une expertise en responsabilité en anesthésie réanimation ?

Search for responsibility in medicine became everyday. Anaesthetists are particularly exposed and will be, several times, confronted to it during their career. They have to have knowledge of some necessary elements to get to grips with expertise. Expertise can be asked by a penal jurisdiction. In that case, the anaesthetist can be directly and personally implicationed. When expertise is asked by a civil jurisdiction, it concerns anaesthetists, whichever the (liberal or employee of private). Expertise during administrative procedures concern hospital's anaesthetists. It is important to organize a preparatory meeting in any expertise. Praticians must collect together the complete medical file to establish the most exactly possible, chronology of facts. The anaesthetist can be accompanied by medical consultant appointed by the insurance companies and a lawyer. But he does not have to content with be represented by them. Presence in expertise is essential; praticians can so give evidence of their good faith and answer the expert's questions. Vagueness or doubt are never favorable to pratician. It is also, a responsible and respectful behavior toward the patient.     

Dermohypodermite bactérienne nécrosante avec fasciite nécrosante : complication d’une installation opératoire ?

Necrotizing fasciitis is a hypodermis, muscular fascia then dermis necrotizing infection. It disseminates along fascias with a mortality sometimes within 18 hours. The average mortality, reported in the literature, is about 30%. A 65-year-old man, with a history of Vaquez disease (under hydroxurea) and a smoke addiction, had an epidermoid carcinoma of the left vocal cord (T2 N0 M0). The cancer treatment consisted of a functional lymph node excision, followed by tracheotomy then by partial laryngectomy. At the end of the intervention, after removal of operative fields, it was noticed that the Montandon cannula had slid and was between the medial side of the left upper limb and the lateral side of the chest. There was a cutaneous imprint with ecchymosis on the route of the cannula. At the second postoperative day, a necrotizing fasciitis quickly developed on the left side of the chest, the medial side of the left upper limb, and the left hip without infection of the operating site. An Escherichia coli was identified in tracheal secretions and operative samples. The presumed hypothesis of this necrotizing infection is the cutaneous contamination of the thoracic wall by tracheal secretions colonized by E. coli, whose penetration was induced by the cutaneous traumatism due to the cannula. We remind, by analyzing this unusual case, the caring principles one of which diagnosis and the surgical excision must be as premature as possible. We insist on the elementary measures of protection of the support points and the good binding of cannulas.