Morphine intrathécale et tolérance de l’alimentation précoce post-césarienne

Introduction

Early feeding is well tolerated in patients undergoing caesarean section under general or regional anaesthesia. Intrathecal morphine is effective for postoperative analgesia but can induce nausea and vomiting which may hamper feeding. This study assessed prospectively the effects of intrathecal morphine on early feeding in patients undergoing caesarean section.

Methodology

After ethical committee approval, 66 consenting women scheduled for caesarean section were randomized to receive intrathecal morphine 0.1 mg (group M, n = 32) or not (“control group”, group C, n = 34) at the time of intrathecal anaesthesia performed with a 3 ml mixture containing 8.6 mg bupivacaine, 64 μg clonidine and 4.3 μg sufentanil. Standard antiemetic prophylaxis (5 mg dexamethasone + 2 mg tropisetron) was administered intravenously in all patients after umbilical cord clamping. Standardized multimodal analgesia was initiated postoperatively with 1 g of paracetamol and 30 mg of ketorolac given every 6 hours. Analgesia was evaluated by a numeric rating scale (NRS) at 4 hours intervals and 10 mg of oral morphine was administered if the NRS score exceeded 3. All patients received a protein enriched solution, 8 hours after caesarean section and were allowed to eat solid food on postoperative day 1. Nausea and vomiting episodes, gas and/or stools emission, itching, NRS score and morphine consumption were recorded on the first, second and fourth postoperative hour and then every 4 hours during 48 hours.

Results

Nausea was significantly more frequent and persisted longer in group M. Vomiting occurred equally in both groups and stopped after feeding. Gas and/or stools emission appeared within 48 hours postoperatively in 72 and 77 % of patients in group M and group C respectively. Oral morphine consumption was significantly lower in group M (1.9 ± 4 vs 6.5 ± 7.3 mg, p = 0.006). When compared to group C, NRS were also lower in group M from the second to the 20th postoperative hour. Itching was observed more frequently and persisted longer in group M.

Discussion and conclusion

A small dose of intrathecal morphine provided adequate and prolonged pain relief after caesarean section but increased the incidence of nausea and vomiting despite anti-emetic prophylaxis. Oral food intake was not hampered by intrathecal morphine.     

Régime pauvre en FODMAPS,ce que doivent savoir les nutritionnistes

FODMAPs is an acronym for Fermentable Oligo-, Di-, Mono-saccharides And Polyols, and refers to rapidly fermentable carbohydrates that may be malabsorbed and induce digestive disorders such as abdominal pain, bloating, flatulence and transit disorders. Numerous studies have tested the effect of reducing foods rich in FODMAPs in patients with irritable bowel syndrome, a benign chronic gastrointestinal disease associating abdominal pain and transit disorders (diarrhea, constipation or alternating), and are in favor of a beneficial effect of this diet. The effectiveness of the low FODMAPS diet is unpredictable. This very restrictive diet is difficult to follow, can lead to weight loss, and has been associated with dysbiosis. It is therefore not recommended to follow it in the long-term. It may be offered as a second-line treatment if standard dietary recommendations fail in patients sufficiently embarrassed by their symptoms to accept its constraints. It is preferably carried out with the supervision of a dietician trained on this diet because of its complexity and the risk of long-term dietary restrictions. It is usually tested for a period of 4 weeks, followed in case of symptoms improvement by a period of gradual reintroduction of FODMAPS that allows the patient to determine the FODMAPs that cause symptoms regardless of the amount, and those tolerated but at smaller dose than those usually ingested. The patients can thus resume a varied diet with a clear decrease of their symptoms.     

Prise en charge diététique du sujet obèse à l’hôpital : quels régimes ?

At hospital, nutritional intakes of obese patients are often not covering their nutritional needs. The aim of nutrition support is to maintain the lean body mass, since lean body mass loss may be faster in obese than in non-obese patients. Nutrition support must be adapted to the disease, and particularly to the presence or not of metabolic stress (GI surgery, acute diseases, critical illness…). In all cases, protein intakes are important to consider. As a primary nutrition therapy, food adaptation with frequent and enriched meals, and oral nutritional supplements (ONS), are indicated. In case of morbid obesity, a multidisciplinary systematic approach involving a specialized team in obesity management is pivotal to ensure adequate nutritional care.     

Pensées et ressenti face à l’alimentation de 3 732 personnes de l’agglomération de dijon

Purpose: it was to know the cognitive and emotional thoughts concerning foods and eating in the general and student population of the region of Dijon.Methods: a questionnaire concerning the cognitive and emotional thoughts was beforehand established, validated and handed or sent to 10 000 students and persons of the population of Dijon drawn lots and paired according to district and family. The analysis concerned 3 732 persons, i.e. the 882 students and the 2 850 people of both genders from the general population who restored a more than 95% completed and coherent questionnaire.Results: in this population, negative thoughts and fear in front of the food were noted in a not exceptional way:

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to eat disgusts me: 1.6%;

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to eat frightens me: 3.3%;

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the glance of the other one when I eat frightens me: 13%;

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this food which we propose me make me bad, sink, sad or tightened in 9 at 18% of the cases.

Also, a important percentage of eating disorders or abnormalities was found:

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binge eating: 8%;

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bulimia nervosa: 4.3%;

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anorexia nervosa: 2.2%;

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low weight (IMC<19 kg/(m)²) and frightens in front of glance of the other one: 13%.

These abnormalities were more frequent in young people than in older one’s and in women than in men, but were not so rare in older women (>35 years old) and in men. The questionnaire allowed us to show that a subgroup of people really exists, who are very attentive to the “dietically correct” and anxious about foods. This so-called subgroup “orthorexia” concerned around 1.9% of our total population and 6.1% of thin people (IMC<19 kg/(m)²).Conclusion: the health aspect of the food and the fear of getting fat are important preoccupations of certain number of persons, both in the student population and the general one. This raises the problem of the irrational meaning of the food for a certain number of people, in front of media messages and of the food availability.     

Le processus du vieillissement : longévité et alimentation

Ageing and the nutrition knew two great evolutions recently. First of all, progress of the genetics of ageing which showed the genetic control of longevity. In addition, the important corpus of knowledge accumulated in the field of the food restriction, one of the rare interventions not-genetics known to increase the longevity of the mammals. This type of food mode being associated with a reduction in pathologies related to the age. The conjunction of these two targets of research made it possible to discover at animal models, mainly invertebrate, the subjacent genetic mechanisms binding the level of food and longevity. The comprehension of these genetic mechanisms will make it possible to open therapeutic new prospects connected to the processes of ageing. From yeast to mammals, a certain number of homologous genetic ways were shown. This rise of knowledge brings a beam, always growing, of data showing that the nervous system power station plays a part crucial in the perception of the requirements out of food also in the invertebrates.