Reduction of bupivacaine dose in spinal anaesthesia for caesarean section may improve maternal satisfaction by reducing incidence of low blood pressure episodes

Spinal anaesthesia for caesarean section exposes to high incidence of arterial hypotension which can result in maternal and neonatal morbidity. We hypothesized that the reduction of this dose from 10 mg to 7.5 mg would minimize hypotension without altering pain relief. In this double-blind prospective study, 80 ASA1 women scheduled for elective caesarean section were randomized into two groups A and B receiving respectively 10 and 7.5 mg of isobaric bupivacaine both with 25 micro g of fentanyl and 100 micro g of morphine in spinal anaesthesia. Intravenous ephedrine was administered for each episode of hypotension. We recorded sensory and motor block, intraoperative pain, nausea and vomiting. In postanaesthesia care unit, sensory and motor recoveries were measured and maternal satisfaction rate was assessed. In group A, a larger dose of ephedrine was needed [32 +/- 23 vs 19 +/- 16 mg; p=0.004]. Incidence of sensory block above T4 [52 vs 10%; p<0.001], nausea [52 vs 22%; p=0.005] and vomiting [25 vs 8%; p=0.03] were all higher than in group B. Arterial hypotension was less frequent in group B [68 vs 88%; p=0.03]. The time required for recovery to T10 sensory level and motor regression were shorter than in group A [p<0.001] and the satisfaction rate was higher than in group A [excellent and good in 90% vs 67%; p=0.03]. There was no difference in pain relief. A dose of 7.5 mg of isobaric bupivacaine reduced incidence of hypotension, nausea and vomiting and improved patient satisfaction

[Patient controlled epidural analgesia: interest in thoracic surgery]

To compare efficacy of pain control, the consumption of local anaesthetics and opioids as well as the side effects between continuous epidural analgesia, patient controlled analgesia and patient controlled epidural analgesia in thoracic surgery. Prospective randomised study included 66 patients who had thoracotomy. Patients were divided into 3 groups, to receive different pain control methods. Group 1 [n=22] received patient control analgesia Group 2 [n=22] received continuous epidural analgesia [Bupivacaine 0,125% + 5 micro g/ml of Fentanyl] between 6 and 10 ml/h in order to obtain a T2 level Group 3 [n=22] received patient controlled epidural analgesia [Bupivacaine 0,08% + 3 micro g/ml of Fentanyl] 6ml/h and bolus of 5ml. There was no difference between the three groups in age, delay of surgical operation and per operative morphine consumption. VAS was less at rest and after cough in patient group with patient controlled epidural analgesia. The difference was less significant in local anaesthetics and opioids consumption in patient with controlled epidural analgesia. The benefit of patient controlled epidural analgesia in thoracic surgery is proven by the following analgesic efficiency which allows good respiratory rehabilitation, decreasing the risk of drug toxicity by decreases consumption, weak hemodynamic effects and absence of motor block

[Clinical benefits related to the combination of ketamine with morphine for patient controlled analgesia after major abdominal surgery]

Combination of ketamine may improve morphine patient controlled analgesia [PCA] but clinical results are still equivocal. The authors designed a powerful study to evaluate this hypothesis after major abdominal surgery. 138 patients undergoing abdominal surgery participated in the randomized double blind study. Patients were allocated to two groups: M-group: morphine 0.5 mg/ml + placebo in PCA and MK-group: morphine 0.5 mg/ml + ketamine 0.5 mg/ml with the same bolus dose and lock out time. The patients were evaluated during 48 hours by visual analog scale [VAS], simplified verbal scale [SVS]. Side effects and amount of morphine used were monitored. The two groups are comparable for demographic data and surgery characteristics. From the 24th hour, morphine consumption was significantly lower in the MK-group. At 48 hours after surgery, the amount of morphine received in the MK-group was significantly lower than in the M-group [48 vs 66 mg, p.<0.001]. The average value of VAS was lower in the MK-group from the 12th hour at rest and 20th hour during mobilization. SVS was significantly lower for the MK-group after the 12th postoperative hour. The incidence of respiratory depression was higher in the M-group: 4 vs none in the MK-group. The incidence of nausea, vomiting and pruritus was halved in the MK-group [p <0.04]. The combination of ketamine with morphine in PCA after major abdominal surgery offers a reduction of the morphine consumption, a reduction of pain scores and a decrease in the incidence of adverse effects

Efficacy of patient controlled epidural analgesia during labor analgesia - a prospective randomized study using 0.1% bupivacaine with fentanyl 2 microg/ml

Epidural analgesia is the most effective for the control of pain during labor but irregularity of analgesia, toxicity of local anesthetics [LA] and driving block are the major limits of the modalities of maintenance. The purpose of this work was to assess efficiency and adverse effects of adaptations offered with Patient Controlled Epidural Analgesia [PCEA]. 40 monofoetal parturients were randomized in two groups: 0.1% bupivacaine continuous drip associated to fentanyl 2 Ig/mL [CP-group] or same products administrated in PCEA. Evaluation of analgesia, driving and sensory block allows adapting the outputs of drip. Consumption schedule in LA was of 7.5 +/- 2 mL/h in the CP-group and 3.5 +/- 1.5 mL/h in PCEA-group [p < 0.05]. Consumption accumulated by LA is reduced by 35% from the very beginning and 43% a 4-th hour [p < 0.05]. Incidence of the driving block was of 11 cases in CP-group against 4 in PCEA-group per first hour and of 13 cases against 3 per second hour [p < 0.001]. 50% of clinical obstetric interventions were brought together in the CP-group against 5% in the PCEA-group [p = 0.013]. Incidence of side effects is comparable. Besides the perfect analgesia, PCEA offers a psychic independence which explains comfort and maternal satisfaction. Accumulation of LA entails a driving block involved in the change of dynamics of the labor. Incidence of clinical obstetric interventions is the major observation of our study

[Postoperative analgesia after laparoscopic cholecystectomy comparison of the preoperative administration of celecoxib with paracetamol?]

The goal of this study was to evaluate the preventive analgesic effectiveness of paracetamol and celecoxib in laparoscopic cholecystectomy. Randomized prospective study was undertaken, 75 patients of class ASA I and II were included, divided into three groups: P [Paracetamol 1000 mg]. C [Celecoxib 200 mg] given orally one hour before induction and group T [without preoperative analgesia]. The VAS at rest and effort was noted on arrival in the recovery room then with regular intervals [T 30mn to T h24]. A morphine titration was carried out during the first 12 postoperative hours. Hemodynamic parameters. Ramsay score and the adverse effects were noted. The three groups were comparable for the demographic data, the duration of anesthesia and peroperative morphine consumption. The evolution of VAS scores shows a significant difference between the groups P and T with the effort of cough at t24h [p = 0.04], and between the groups C and T at postoperative T 4h [p = 0.016]. In our study the group C consumed to a significant degree less morphine 5.44 +/- 3.00 Mg against 7.83 +/- 4.00 Mg for the group P [p <0.03] and 8.04 +/- 3.00 Mg for the group T [p <0,008]. The administration of 200 Mg of celccoxib in the preoperative period of a laparoscopic cholecystectomy allows a significant decrease in morphine consumption in the postoperative period and a reduction in the scores of the VAS at rest and at the effort of cough compared to the groups which received only one placebo or paracetamol

[Sedative practice in intensive care units: results of a Maghrebian survey]

sedation is central to the management of intensive care patients. The aim of this study was to establish the current sedation practice in Maghrebian intensive care units [ICUs]. The use of sedation policies with or without a written protocol. The use of scoring systems, the influence of costs on drug choice, the most common drugs for sedation and the use of neuromuscular blocking agents. A self-administered questionnaire composed of 20 items was sent to 138 intensivists in the Maghreb working in 25 teaching hospitals and 16 private clinics 50 of 138 questionnaires were returned [response rate = 36.2%]. Midazolam and Fentanyl were the sedative agents used [respectively 98% and 87%] less than 14% of the ICUs used the Propofol mainly in the first 48 hours. A sedation policy was adopted in 63.6% with a written protocol in 20% of cases. Sedation scoring systems were noted in 14.3% of cases [RAMSAY scale in 100%]. Economic aspect was important for 64.6% of ICUs. sedation may seem secondary in the initial management of intensive care patients,only 63% of our respondents had a sedation policy and 20% a written protocol though its use is thought to improve outcome and reduce costs. Economic aspect was important for the choice of the drug to use [64%], this may explain the preferential use of Midazolam 98% in association with an analgesic [Fentanyl: 85%] while Propofol is used only in 14% though pharmacoeconomic studies may be in fact in favor of the latter. Neuromuscular blocking agents are less frequently used [16%] mainly because of the risk of complications

Tracheotomie ou intubation tracheale prolongee en ventilation mecanique prolongee

130 critically ill patients undergoing long term mechanical ventilation were divided into two groups, Tracheotomy versus translaryngeal intubation, There were no difference in demographic characteristics between the two groups. The incidence of chronic obstructive pulmonary disease [COPD] was also higher in T. The tracheotomy was achieved at mean within 14 days after the beginning of mechanical ventilation. The incidence of pneumonia is the same in the two groups [41% for T versus 39% for I]. The length of mechanical ventilation is longer in T [25 +/- 12 d versus 12 +/- 4 d]. The COPD represent a risk factor for prolonged mechanical ventilation in T [18 da/s in COPD patients with tracheotomy versus 9 days in non COPD patients]. The length of slay in intensive care unit is higher in T [29 +/- 13 d versus 15 +/- 4 d]. The 28th day mortality is similar between the two groups. The tracheotomy didn't allow a shorter duration of mechanical ventilation. That's can be explain by the fact that we performed the tracheotomy in a high risk population for pulmonary complications [COPD] and often after o first failure of weaning form mechanical ventilation