Automated titration of propofol and remifentanil decreases the anesthesiologist's workload during vascular or thoracic surgery: a randomized prospective study.

Closed loop target-control infusion systems using a Bispectral (BIS) signal as an input (TCI Loop) can automatically maintain intravenous anesthesia in a BIS range of 40-60 %. Our purpose was to assess to what extent such a system could decrease anesthesia workload in comparison to the use of a stand alone TCI system manually adjusted to fit the same BIS range of 40-60 % (TCI Manual). Patients scheduled for elective vascular or thoracic surgery were randomized to the TCI Loop or TCI Manual method for administering propofol and remifentanil during both induction and maintenance of general anesthesia. Assessment of workload was performed by an independent observer who quoted each time the physician looked at the BIS monitor. The number of propofol and remifentanil target modifications, the percentage of time of adequate anesthesia i.e. BIS in the range 40-60 and hemodynamic data were recorded. Eighteen patients per group were enrolled. Characteristics, duration of surgery and propofol-remifentanil consumption were similar between groups. However, the percentage of time in the BIS range 40-60 % was higher in the TCI Loop versus TCI Manual groups (94 % ± 12 vs. 74 % ± 19, p < 0.001). Mean arterial pressure was lower with TCI Manual (78 ± 6 vs. 88 ± 13 mmHg, p < 0.001). The number of times the anesthesiologist watched the controller or BIS monitor (p < 0.05) and the number of manual adjustments (p < 0.001) performed in each group was lower with TCI Loop group during induction and maintenance of anesthesia. An automated controller strikingly frees the anesthesiologist from manual intervention to adjust drug delivery.

First report of lamotrigine-induced drug rash with eosinophilia and systemic symptoms syndrome with pancreatitis.

OBJECTIVE: To report a case of lamotrigine-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome with pancreatitis as the initial visceral involvement. CASE SUMMARY: A 75-year-old man was admitted to the local hospital for generalized tonic-clonic seizures. Results of the clinical examination and neurologic investigations were unremarkable. Lamotrigine treatment was initiated and the patient was discharged a few days later. Forty days after lamotrigine initiation, he developed an exanthematous maculopapular rash with fever, peripheral lymphadenopathies, and hypereosinophilia. Lamotrigine hypersensitivity was suspected and the drug was suspended on day 45. On day 47, the patient presented with acute abdominal pain with an elevated lipase level. Acute pancreatitis was confirmed on computed tomography scan. The patient's condition worsened and he was transferred to the intensive care unit with multiorgan failure. The diagnosis of lamotrigine-induced DRESS syndrome was confirmed by a compatible skin histology and concomitant human herpesvirus-6 infection. DISCUSSION: This observation has 2 points of interest. First, pancreatic toxicity of lamotrigine has been rarely reported in the literature. Secondly, pancreatitis is uncommon at the early stage of DRESS syndrome. Only 1 other case of DRESS syndrome, secondary to allopurinol, reports pancreatitis along with an Epstein-Barr virus infection. The Naranjo probability scale indicated a probable causality between lamotrigine and DRESS syndrome in this patient. CONCLUSIONS: This is the first reported case of lamotrigine-induced DRESS syndrome with pancreatitis as the initial visceral involvement. Clinicians should be aware of this mode of presentation of DRESS syndrome.