Avoiding propofol injection pain in children: a prospective, randomized, double-blinded, placebo-controlled study.

BACKGROUND: Pain on injection limits the use of propofol in children. The combination of lidocaine and propofol is widely used to reduce pain. A new solvent [medium-chain triglyceride (mct)/long-chain triglyceride (lct)] has been advocated to be less painful than standard (lct) propofol in adults, but no information is available of its usefulness in pre-school children. We designed a prospective, randomized, double-blinded, placebo-controlled study to assess injection pain with two different propofol emulsions, each given with or without lidocaine in children <7 yr. METHODS: A total of 160 ASA I-III children were randomly assigned to receive lct-propofol or mct/lct-propofol, 5 mg kg(-1), with lidocaine 10 mg ml(-1) or saline. The site and size of venous cannulation and restlessness before injection were recorded in each patient. A pain score graded 0-6 was established based on spontaneous verbal and motor reaction during injection, each graded 0-3. Kruskall-Wallis and Mann-Whitney tests were used for statistical analysis. RESULTS: Median pain scores decreased in all groups compared with lct-propofol-saline (P<0.001) and were least in the lct/mct-propofol-lidocaine group (P<0.001). Painless injection (score, 0-2) occurred in 92.5% of patients in the mct/lct-propofol-lidocaine group compared with 41-77% in the others (P<0.001). CONCLUSIONS: Mct/lct-propofol caused significantly less pain than lct-propofol in preschool children. Mixing of lidocaine with mct/lct-propofol resulted in a further significant decrease, virtually eliminating the pain on injection.

Brachial plexus block with bupivacaine: effects of added alpha-adrenergic agonists: comparison between clonidine and epinephrine.

The effects of clonidine and epinephrine, administered into the brachial plexus sheath, were evaluated in 60 patients who underwent surgery of the upper limb. All patients received 40 to 50 ml of 0.25% bupivacaine, injected into the brachial plexus sheath, using the supraclavicular technique. The patients were randomly allocated to two groups so that 30 patients received 150 micrograms clonidine hydrochloride (Group I), and 30 received 200 micrograms epinephrine (Group II). The quality and the duration of analgesia were assessed as well as the possible side-effects. The block produced with the addition of clonidine was longer (994.2 +/- 34.2 vs 728.3 +/- 35.8 min) and superior to that with epinephrine (P less than 0.001). No major side-effects were recorded. We conclude that the injection of clonidine into the brachial plexus sheath is an attractive alternative to epinephrine to prolong the duration of analgesia following upper limb surgery under conduction anaesthesia.

[Comparison of propofol and propanidid administered at a constant rate]. / Comparaison du propofol au propanidide administrés à débit constant.

So as to compare the anaesthesia obtained using propofol with that obtained using propanidid, 40 ASA I patients, aged between 18 and 50 years, who were to undergo elective orthopaedic or plastic surgery lasting more than 60 min, were randomly divided into two equal groups, one receiving propofol (PF) and the other propanidid (PD). All the patients received 0.5 mg atropine, 100 mg pethidine and 7.5 mg droperidol (10 mg if weight greater than 60 kg) intramuscularly 45 min before induction. Patients in group PF were then given 2 mg.kg-1 propofol over 1 min and 0.9 microgram.kg-1 fentanyl over 3 min, followed by a constant rate infusion of 5 mg.kg-1.h-1 propofol and 3 micrograms.kg-1.h-1 fentanyl. For PD patients, the doses of fentanyl were identical; they were given 10.6 mg.kg-1 propanidid over 3 min for induction, and 37 mg.kg-1.h-1 for maintenance. All the patients were intubated and ventilated mechanically. The usual anaesthetic parameters were monitored at induction, during surgery, and during recovery. Consciousness was lost more quickly with propofol (p less than 0.05), but the corneal reflex returned more rapidly in group PD (p less than 0.02). The time required for a full return to normal consciousness was identical in both groups. The fall, during induction, and the increase, during recovery, of Pasys were greater in group PD (p less than 0.05 and less than 0.001 respectively). Padia and heart rate were lower in group PF after the 30th min (p less than 0.05 and less than 0.01 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cervical peridural selective sensitive anesthesia in surgery and rehabilitation of the hand]. / Anesthésie sélective sensitive par péridurale cervicale dans la chirurgie et la rééducation de la main.

Active patient participation in the operative and postoperative programme is very important for tenolysis, tendon grafts and joint releases. Different anesthesic means can be used to perform selective sensitive analgesia. Cervical epidural anesthesia was used for fifteen cases of hand surgery. The technique is described, the results are analyzed. Indications and use of cervical epidural anesthesia for hand surgery are discussed.

[Midazolam used for premedication reinforces sleep induced by flunitrazepam]. / Le midazolam utilisé en prémédication renforce le sommeil induit par le flunitrazépam.

This single blind study aimed to discover possible effects of intramuscular premedication with midazolam on the sleep induced by intravenous flunitrazepam. 24 male patients, aged 17 to 71 years, who were to undergo surgery to the distal parts of an upper limb under regional anaesthesia, were randomly assigned to two equal groups: in the midazolam group, an intramuscular premedication of 0.12 mg.kg-1 midazolam with 0.5 mg atropine was given, whereas in the control group atropine only was used. In all patients, 1 mg flunitrazepam was given intravenously 45 min after the premedication, before carrying out regional anaesthesia. No other drug was given. In the midazolam group, the time of loss of spontaneous conversation was reduced (p less than 0.05), as well as the time of eye closure (p less than 0.001), and the time for recovery of the capacity to count backwards was increased (p less than 0.001). So, premedication with 0.12 mg.kg-1 midazolam intravenously 45 min before giving 1 mg flunitrazepam reinforced the sleep induced by the latter.

[Course of the neuromuscular block under atracurium. Comparison with alcuronium]. / Evolution du bloc neuromusculaire sous atracurium. Comparaison avec l'alcuronium.

Using a standardized anaesthetic protocol, the continuous monitoring of the twitch height after a 0.1 Hz stimulus was used to follow the evolution of curarization following injection of either atracurium (0.6 mg . kg-1) or alcuronium (0.2 mg . kg-1). The maximum twitch height inhibition was always greater than 99% of the control value and occurred after 107 +/- 50 s with atracurium (n = 30) and 172 +/- 120 s for alcuronium (n = 30) (p less than 0.02). Although surgical stage of muscular relaxation (twitch height less than 25% of reference value) was the same for both drugs (55 +/- 15 min for alcuronium versus 52 +/- 10 min for atracurium; n = 30 for both groups), the clinical duration (spontaneous restoration of twitch height to 90% of the reference value) was significantly longer (p less than 0.005) for alcuronium: 89 +/- 20 min (n = 10) versus 62 +/- 9 min for atracurium (n = 10). The spontaneous return to normal of the train of four was also significantly longer (p less than 0.001) for alcuronium: 118 +/- 23 min (n = 10) versus 69 +/- 7 min for atracurium (n = 10). The recovery index (the time required for twitch height to rise from 25% to 75%) was three times quicker (p less than 0.01) for atracurium (10 +/- 3 min; n = 10) than for alcuronium (30 +/- 13 min; n = 10).(ABSTRACT TRUNCATED AT 250 WORDS)

[Midazolam as an intramuscular premedication agent: definition of posology as a function of age]. / Le midazolam comme agent de prémédication intramusculaire: définition des posologies en fonction de l'âge.

In order to determine the optimal posology of midazolam as an intramuscular premodication according to age, three groups of 25 patients were constituted. The mean age of group 1 receiving 0.12 mg . kg-1, was 31.6 +/- 7.3 years, the mean age of group 2, receiving 0.16 mg . kg-1, was 31.8 +/- 7.6 years and the mean age of group 3, receiving 0.10 mg . kg-1, was 73.8 +/- 8.2 years. The results were the following: sedation of anxiety was good or very good in respectively 80 p. 100 and 95 p. 100 of patients in groups 2 and 3, versus 48 p. 100 in group 1; a reversible sleep was obtained in 18 p. 100 of cases in group 2 and 44 p. 100 in group 3; no patient was asleep in group 1; overall clinical results were found satisfactory in 80 p. 100 of patients in group 2, and 95 p. 100 in group 3 versus 48 p. 100 in group 1. Neither incident nor adverse reactions were to be reported. There was no modification in respiratory rate; the slight hemodynamic modifications which appeared can be attributed to atropine sulfate administered together with midazolam. In conclusion, the appropriate posology of midazolam administered intra-muscularly decreases with age, from 0.16 mg . kg-1 for the thirty years old patients to 0.10 mg . kg-1 for the seventy years old patients. Midazolam exhibits a remarkable cardiorespiratory neutrality event in the elderly.

[Prognostic value of cutaneous delayed hypersensitivity tests in patients with acute decompensation of chronic respiratory failure. Relation to the nutritional state]. / Valeur pronostique des tests d'hypersensibilité cutanée retardée chez l'insuffisant respiratoire chronique en décompensation aiguë. Leur relation avec l'état nutritionnel.

This study involved 15 chronic respiratory failure patients admitted to intensive care because of acute decompensation. Study of delayed hypersensitivity skin tests made it possible retrospectively to divide these patients into two groups according to whether tests were positive or negative. Group A: patient positive on admission and remaining so: or negative becoming positive on the 10th day = 8 patients. Group B: patient negative and remaining negative; or positive on admission and becoming negative on the 10th day = 7 patients. In group A, 7 patients survived, whilst one died of an intercurrent condition. In group B, all the patients died. Study of nutritional balance showed a deficiency in protein metabolism--with hypoproteinaemia, hypoalbuminaemia, decrease in creatine index, negative nitrogen balance--combined with a deficiency in trace elements. Such disturbances were particularly marked in group B. Under the influence of nutritional therapy, these deficiencies tended to return to normal in reacting subjects but worsened in non-reacting subjects. In patients of this type, nutritional therapy must be administered well before acute decompensation. It should be able to prevent the latter in a substantial number of cases.

[Study of delayed skin hypersensitivity using the multitest in an intensive care unit]. / Etude de l'hypersensibilité cutanée retardée par le multitest chez une population de réanimation polyvalente.

A multiple puncture procedure was employed to determine delayed skin hypersensitivity in 76 patients admitted to an Intensive Care Unit. This new method enables the responses to 7 antigens to be measured after a single application. Patient reactivity was assessed on admission (D0) and during hospitalisation (D7 and D14). Results were analysed as a function of modifications in antigenic response during hospitalisation, and its incidence on subsequent infection and mortality. Mortality in anergic patients was 85.71 p. cent, infection being the cause in 90 p. cent of these cases. A very association was found between anergy and mortality (p less than 0.001). These results suggest that cell immunity skin tests in patients admitted for intensive care treatment can be of some value for assessing prognosis. Tests must be repeated during hospitalisation, however, as immunity defences progress, in fact--in one direction or another--up to the 14th day or even beyond, an a single test on the day of admission is insufficient for prognostic purposes.