Comparaison prospective et randomisée de la morphine nébulisée versus la péridurale thoracique dans la prise en charge de la douleur des traumatisés thoraciques

Introduction

Successful management of pain reduces morbidity and improves patient satisfaction of patient after a chest trauma. The purpose of the study was to evaluate the efficacy of the respiratory administration of nebulized morphine in such patients.

Patients and methods

Patients were included in this prospective and randomized study patients to receive either nebulized morphine in group M or a mixture of bupivacaine-fentanyl by epidural route. In group M, patients received nebulized morphine every 30 minutes until the second hour then every 4 hours during 48 hours. In the thoracic epidural analgesia group (group P) they received a mixture of 0.125% bupivacaine and 0.115% of fentanyl continuously infused at the rate of 7 ml/h during 48 hours. The main criterion of judgment was the analgesic effects of analgesic regimen with EVA < 4. Sedation, haemodynamic and respiratory parameters were continuously recorded, as adverse side effects were they occurred. Statistical comparisons were performed with Chi², Fisher or Student t-test when appropriate (p < 0.05).

Results

Forty patients were randomized in two groups. Groups were not different regarding the demographic parameters. Analgesia was effective in both groups (NS). Sedation, hemodynamic and respiratory parameters were not different between groups. No side effect was noted in groups.

Conclusion

Nebulized morphine was an analgesic technique as effective as epidural bupivacaine-fentanyl in our series. This non-invasive route of administration of morphine appears to be useful to treat pain after a chest trauma.     

La pupillométrie en anesthésie-réanimation

Pupil size reflects the balance between sympathetic and parasympathetic systems. Due to technological advances, accurate and repeated pupil size measurements are possible using infrared, video-recorded pupillometers. Two pupil size reflexes are assessed: the pupillary reflex dilation during noxious stimulation, and the pupil light reflex when the pupil is exposed to the light. The pupillary reflex dilation estimates the level of analgesia in response to a painful procedure or to a calibrated noxious stimulus, i.e., tetanic stimulus, in nonverbal patients. This might be of particular interest in optimizing the management of opioids in anaesthetized patients and in assessing pain levels in the intensive care unit. The pupil light reflex measurement is part of the routine monitoring for severely head-injured patients. The impact of pupillometry in this condition remains to be determined.     

Anesthésie infiltrative tumescente et mastectomie : à propos de six cas

Objective

To assess safety and efficacy of tumescent infiltration of the supraclavicular nerve and the anterior and lateral branches of the intercostal nerves in major breast surgery.

Methods

A retrospective analysis of six selected patients undergoing mastectomy was performed. A mixture composed of 150 mg ropivacaine, 400 mg of lidocaine and 0.5 mg epinephrine diluted in 500 ml Ringer's were administered subcutaneously as follows: 80 ml along the parasternal line from the second to the sixth intercostal space, 80 ml along the mid axillary line from the second to the sixth intercostal space, 80 ml along the infraclavicular line, 80 ml in the space between the pectoralis muscle and the mammary gland and 80 ml in the axilla in case of axillary dissection.

Results

This technique achieved effective analgesia in six patients associated with sedation or light anaesthesia; conversion to general anaesthesia or supplementation with local anaesthesia was not required. No complication was observed. No emesis was noted.

Conclusion

This technique provides adequate peroperative analgesia and is a technically low-risk procedure. Further evaluation of this technique is recommended.     

Rôle de la génétique dans la variabilité interindividuelle en anesthésie

Objective

This review discusses variability among patients in anesthesia, due to genetic polymorphisms.

Data sources

Articles in French and English languages were retrieved from PubMed database. The initial request was “anesth* and (genotyp* or polymorphism* or genetic*)”.

Study selection

Original articles, general reviews and one case report. Letters were excluded.

Data extraction

Rare genetic diseases were excluded from the scope of this review. We stressed on frequent genetic polymorphisms that may have a daily impact in anesthesiology.

Data synthesis

Most results were related to pain studies. We selected various examples to describe how genetic polymorphisms impacts the pharmacology of a given drug, and what are the clinical consequences.

Conclusion

There is a growing field of pharmacogenetic related evidences in anesthesiology. The results from various animal and human studies underline the genetic origin of variability among individuals. How anaesthesists have to integrate these parameters for their daily practice is still unclear, but pharmacogenetic will obviously be a leading field of anesthesia research in the future.     

Organisation des soins en analgésie,anesthésie et réanimation en maternité en France métropolitaine : résultats comparés des enquêtes nationales périnatales 2003 et 2010

Objective

The equipment and practices in obstetric analgesia, anaesthesia and intensive care, as well as their evolution between 2003 and 2010 in metropolitan France, were described.

Population and methods

Data were derived from two representative samples of births in 2003 and 2010, based on all births in France during one week. The sample included 534 maternity units and 14,903 births in 2010 and 618 maternity units and 14,737 births in 2003.

Results

The caesarean operating room was adjacent or inside the labour ward in 66% of maternity units in 2010 vs 56% in 2003. An anaesthetist was appointed permanently to the labour ward in 38.9% of maternity units in 2010 vs 21.5% in 2003. Locoregional analgesia or anaesthesia rate increased significantly: 81.5% in 2010 compared to 74.9% in 2003. Almost all operative vaginal deliveries were performed under epidural anesthesia in 2010. Patient controlled epidural analgesia (PCEA) was available in 58% of the units in 2010 but only 34.2% of women had PCEA. Newborn's resuscitations were performed mainly by paediatricians in 2010, but 11.4% of children were resuscitated by an anaesthetist in level 1 maternity units.

Conclusion

The conditions required to ensure anaesthetic care safety in maternity units has improved since 2003. Improvements in quality of care are still possible.     

Hypothermie profonde après rachianesthésie et morphine intrathécale après césarienne : un nouveau cas clinique

After an uneventful caesarean delivery under spinal anaesthesia (hyperbaric bupivacaine 10 mg, sufentanil 5 μg and morphine 50 μg), hypothermia (nadir 34 °C) was recorded in a ASA 1 patient. Partial recovery was rapidly obtained with 400 μg of naloxone but full recovery was obtained after seven hours of active rewarming with a forced-air warming blanket. Suggested pathophysiology and incidence of this hypothermia are described.     

Tatouages lombaires et anesthésie périmédullaire : enquête de pratique dans les maternités du Languedoc-Roussillon

To determine neuraxial anesthesia practices in obstetric departments in Languedoc-Roussillon in parturient with large lumbar tattoo covering the puncture area. “A prospective anonymous survey was sent to anaesthesiologists” including a clinical case scenario with a tattooed woman. Questionnaire included items on neuraxial anaesthesia in various circumstances, reasons for the decision process, and “consensus management” or not “within the unit”. Fifty-four anaesthesiologists answered (response rate: 57%). Fifty-seven percent would perform an epidural anaesthesia (EA) through the tattoo. Thirty-nine percent would not; among which two third only would propose an alternative for EA. Elective or emergency caesarean section would prompt most of the anaesthesiologists to perform a spinal anaesthesia, especially in parturients with Mallampati Class III (93%) versus Class I (70%) airway. Seventy percent of responders reported no consensual management in their unit. Our study illustrates this lack of consensus in obstetrical units and among anaesthesiologists along with a variable attitude linked with the obstetrical and anaesthesiological situation.     

Analgésie péridurale continue versus bloc continu du compartiment psoas pour l’analgésie postopératoire après chirurgie majeure du bassin ou du fémur chez l’enfant : étude prospective comparative randomisée

Background

Intravenous opioids and/or continuous epidural block (CEB) are used for postoperative analgesia after hip and/or femoral shaft surgery but adverse effects limit their use in children. A continuous psoas compartment block (CPCB), effective technique in adults can be an alternative. In this randomized comparative study, we wanted to evaluate CEB and CPCB in children after major hip surgery in terms of adverse events, pain relief and ropivacaine plasma concentrations.

Methods

After ethical committee and parents’ approval, 40 children scheduled for hip surgery were included and randomly allocated to receive CPCB or CEB. After general anaesthesia induction, 0.5 mL/kg of 0.375% ropivacaine were injected via the epidural or lumbar plexus catheter. After surgery, 0.1 ml/kg per hour (group CPCB) or 0.2 ml/kg per hour (group CEB) of 0.2% ropivacaine was infused for 48 h. Post-operative pain was evaluated using VAS or CHIPPS scores values at h1, h6, h12, h18, h24, h36 and h48, as well as doses of first line (paracetamol 15 mg/kg/6 h) or second line rescue analgesia (0.2 mg/kg intravenous nalbuphine), if pain score remained high after 30 mm. niflumic acid was systematically used. Adverse events were noted as well as parents’ satisfaction at 48 h. Ropivacaine plasma concentrations were measured four times up to 48 h (h1, h6, h24 and h48) by high performance gas chromatography.

Results

Forty children 1 to 12 years old (CPCB = 20, CEB = 20) were included. The demographic data were equivalent in both groups. Postoperative analgesia was excellent for both continuous block techniques during the whole studied period. Doses of rescue analgesics were comparable in both groups at the end of the 48 h. Number of children who had at least one side effect is significantly higher in CEB group. Furthermore, the number of local anaesthetic premature stops was significantly more frequent in this group. Median values of ropivacaine plasma level in CEB group were significantly higher than CPCB group at h6 and h24. Ten parents in the CEB group and 15 in CPCB group were satisfied.

Conclusion

Continuous psoas compartment block is an effective technique of postoperative analgesia after major hip or femoral surgery in children. It equally manages postoperative pain with significantly less adverse event and decreased ropivacaine doses and plasma concentration than CEB.