[Ambulatory Essure implant placement sterilization procedure for women: prospective study comparing general anesthesia versus hypnosis combined with sedation]. / Étude prospective comparant l'hypnosédation et l'anesthésie générale pour la pose de dispositif de stérilisation intratubaire en ambulatoire.

OBJECTIVE: implant placement Essure, sterilization procedure for women, were performed under hypnosedation (HYP) and compared to the operative anxiety and analgesia of 12 patients operated-on under general anesthesia (GA). STUDY DESIGN: prospective and comparative group study. PATIENTS AND METHODS: two groups of twelve patients were matched and compared based on the choice of anesthetic technique: hypnotics (HYP) with possible additional sedation by propofol and remifentanil or GA involving propofol, sevoflurane and remifentanil. The assessment of anxiety and pain based on a visual analogy scale (0-10) and use of analgesics were studied in the recovery room and at discharge of hospital. The statistical analysis relies on nonparametric tests for paired data (Wilcoxon test). RESULTS: all patients were operated. The two groups are statistically comparable. The preoperative anxiety before premedication is lower in the HYP group (p<0.05). No conversion to general anaesthesia is necessary in the HYP group, but five patients were using sedatives drugs but doses are very low compared to general anaesthesia. The analgesic consumption was equivalent in both groups. CONCLUSION: we conclude that hypnosedation is a valuable alternative to traditional anesthetic techniques for ambulatory Essure implant. The use of hypnotic tool is an interesting alternative for the management of patients during invasive medical procedures or surgical, providing psychological benefits to the patient.

Single-shot spinal anesthesia with small doses of bupivacaine.

BACKGROUND AND OBJECTIVES: The potential risks of spinal lidocaine have generated interest in an alternative local anesthetic solution. Features of anesthetic block were therefore assessed in a double-blind randomized prospective study following administration of spinal bupivacaine in small doses. METHODS: Ninety patients scheduled for lower limb saphenous vein stripping were randomized to receive a 4-mL hyperbaric solution containing 4, 6, or 8 mg bupivacaine in the subarachnoid space. Sensory and motor block and hemodynamic changes were assessed at regular intervals. Patients were also questioned regarding transient radicular irritation symptoms. RESULTS: The mean duration of sensory block increased with increasing dose (duration at L2: 56 +/- 27, 71 +/- 29, 79 +/- 25 minutes in groups 4, 6, and 8 mg, respectively, P < .05). Motor block was also dose dependent. The incidence of grade 3 motor block increased from 0%, to 21%, and to 53%. No patient had symptoms of transient radicular irritation. Arterial pressure and heart rate were stable throughout the study. CONCLUSION: Hyperbaric bupivacaine 6-8 mg provides a suitable alternative to spinal lidocaine for surgical procedures of short duration.

Intra-articular morphine and clonidine produce comparable analgesia but the combination is not more effective.

Both intra-articular morphine and clonidine produce analgesia. This study was designed to compare the analgesic effects of the two drugs, used separately and in combination. We studied 90 patients undergoing arthroscopy of the knee under general anaesthesia. Patients were allocated randomly to receive 20 ml of intra-articular isotonic saline solution containing morphine 2 mg, clonidine 150 micrograms or both. Pain was assessed on an visual analogue scale after operation and time for rescue medication was measured. There was no difference in VAS scores between the three groups and the time for rescue analgesic was comparable. We conclude that intra-articular morphine and clonidine have comparable analgesic effects in the doses used. The combination of both drugs did not seem to increase analgesia.

[Oral contraception and surgery]. / Contraception orale et chirurgie.

PIP: Oral contraceptives (OCs) and surgery are both recognized risk factors for thromboembolism. Observation of a postoperative deep venous thrombosis and pulmonary embolism in a 21-year-old OC user prompted the authors to define the risk of OC use in surgical patients through a review of the literature. The patient had no other relevant risk factors except a moderate smoking habit. Surgery increases risk of thromboembolism because of the postoperative hypercoagulation state with declines in AT III, elevation of fibrinogen and products of degradation of fibrin, decline of plasminogen, and elevation of antiplasmin. The risks are greater in the immobile postsurgical phase and are increased as well by direct vascular lesions during surgery. Estimates of rates of deep venous thrombosis are very variable according to different authors because of the difficulties of diagnosis, heterogeneity of risk factors encountered, and variety of prophylactic methods employed. The most thrombogenic surgery is believed to be that on the legs; 1 literature review produced a range of estimates from 45-70% without prophylaxis and with 2% involving fatal pulmonary emboli. Another study estimated the risk of deep venous thrombosis at 2% for young subjects in good health undergoing minor surgery lasting less than 30 minutes and at 10-40% for subjects over 40 undergoing moderately serious general surgical procedures. No ideal method of prevention has been found that is well accepted by patients, nurses, and physicians. OC use entails multiple physiopathologic modifications including among others alterations of the vascular walls with endothelial proliferation and/or thickening of the media, increased blood viscosity, hyperaggregability of platelets, and increases in certain coagulation factors. Synthetic estrogens play the major role in modifications but progestins diminish venous tone and increase stasis. Large epidemiologic studies in the US and Great Britain found a significantly increased thromboembolic risk in OC users beginning in the 1st month of use and persisting until 3-4 weeks after termination of treatment. Most authors believe that OC use increases the postsurgical risk of thromboembolism by a factor of about 3. More selective choice of OC users, reduced estrogen doses, and better surveillance of users appear to have diminished the risk of thromboembolic disease with OC use. But unfortunately there are no sure predictors of thromboembolic disease. All authors recognize the reversibility of modifications caused by OCs on hemostasis by 4 weeks after termination. If therefore is recommended that OC use be interrupted 1 cycle before surgery.^ieng