Perforated Crohn's disease presenting during pregnancy.

Severe exacerbations of Crohn's disease (CD) requiring acute surgery are rare, and rarer still are those that occur during pregnancy. We present a case of perforated CD in an obstetric patient. A 24-year-old woman at 27 weeks gestation, with abdominal pain, leucocytosis and concern for preterm labour, presented to our institution. MRI was obtained and demonstrated a phlegmon in the small bowel mesentery near the distal ileum, with concern for perforation. The patient was taken for an emergent exploratory laparotomy. Intraoperatively, an ileal perforation with small bowel fistula was observed and an ileocolectomy with primary anastomosis was performed. Pathology of the resection revealed CD, a new diagnosis for the patient. She was ultimately discharged on postoperative day 13 and later went on to deliver a healthy term infant, and, 5 years later, has had no significant recurrence.

Randomized, controlled trial comparing the effects of anesthesia with propofol, isoflurane, desflurane and sevoflurane on pain after laparoscopic cholecystectomy.

BACKGROUND: Pain is the primary complaint and the main reason for prolonged recovery after laparoscopic cholecystectomy. The authors hypothesized that patients undergoing laparoscopic cholecystectomy will have less pain four hours after surgery when receiving maintenance of anesthesia with propofol when compared to isoflurane, desflurane, or sevoflurane. METHODS: In this prospective, randomized trial, 80 patients scheduled for laparoscopic cholecystectomy were assigned to propofol, isoflurane, desflurane, or sevoflurane for the maintenance of anesthesia. Our primary outcome was pain measured on the numeric analog scale four hours after surgery. We also recorded intraoperative use of opioids as well as analgesic consumption during the first 24h after surgery. RESULTS: There was no statistically significant difference in pain scores four hours after surgery (p=0.72). There were also no statistically significant differences in pain scores between treatment groups during the 24h after surgery (p=0.45). Intraoperative use of fentanyl and morphine did not vary significantly among the groups (p=0.21 and 0.24, respectively). There were no differences in total morphine and hydrocodone/APAP use during the first 24h (p=0.61 and 0.53, respectively). CONCLUSION: Patients receiving maintenance of general anesthesia with propofol do not have less pain after laparoscopic cholecystectomy when compared to isoflurane, desflurane, or sevoflurane.

Randomized, controlled trial comparing the effects of anesthesia with propofol, isoflurane, desflurane and sevoflurane on pain after laparoscopic cholecystectomy / Estudo randômico controlado que compara os efeitos da anestesia com propofol, isoflurano, desflurano e sevoflurano sobre a dor pós-colecistectomia videolaparoscópica / Estudio aleatorizado controlado comparando los efectos de la anestesia con propofol, isoflurano, desflurano y sevoflurano sobre el dolor poscolecistectomía videolaparoscópica

Background: Pain is the primary complaint and the main reason for prolonged recovery after laparoscopic cholecystectomy. The authors hypothesized that patients undergoing laparoscopic cholecystectomy will have less pain four hours after surgery when receiving maintenance of anesthesia with propofol when compared to isoflurane, desflurane, or sevoflurane. Methods: In this prospective, randomized trial, 80 patients scheduled for laparoscopic cholecystectomy were assigned to propofol, isoflurane, desflurane, or sevoflurane for the maintenance of anesthesia. Our primary outcome was pain measured on the numeric analog scale four hours after surgery. We also recorded intraoperative use of opioids as well as analgesic consumption during the first 24 h after surgery. Results: There was no statistically significant difference in pain scores four hours after surgery (p = 0.72). There were also no statistically significant differences in pain scores between treatment groups during the 24 h after surgery (p = 0.45). Intraoperative use of fentanyl and morphine did not vary significantly among the groups (p = 0.21 and 0.24, respectively). There were no differences in total morphine and hydrocodone/APAP use during the first 24 h (p = 0.61 and 0.53, respectively). Conclusion: Patients receiving maintenance of general anesthesia with propofol do not have less pain after laparoscopic cholecystectomy when compared to isoflurane, desflurane, or sevoflurane. .

Justificativa e objetivo: a dor é a principal queixa e também o motivo principal de recuperação prolongada pós-colecistectomia laparoscópica. A nossa hipótese foi que os pacientes submetidos à colecistectomia laparoscópica apresentariam menos dor quatro horas após a cirurgia se recebessem manutenção anestésica com propofol em comparação com isoflurano, desflurano ou sevoflurano. Métodos: neste estudo prospectivo e randômico, 80 pacientes agendados para colecistectomia laparoscópica foram designados para receber propofol, isoflurano, desflurano ou sevoflurano para manutenção da anestesia. Nosso desfecho primário foi dor mensurada em escala analógica numérica quatro horas após a cirurgia. Também registramos o uso intraoperatório de opiáceos, bem como o consumo de analgésicos durante as primeiras 24 horas pós-cirúrgicas. Resultados: não houve diferença estatisticamente significante nos escores de dor quatro horas após a cirurgia (p = 0,72). Também não houve diferença estatisticamente significativa nos escores de dor entre os grupos de tratamento durante as 24 horas pós-cirúrgicas (p = 0,45). O uso intraoperatório de fentanil e morfina não variou significativamente entre os grupos (p = 0,21 e 0,24, respectivamente). Não houve diferença no consumo total de morfina e hidrocodona/APAP durante as primeiras 24 horas (p = 0,61 e 0,53, respectivamente). Conclusão: os pacientes que receberam propofol para manutenção da anestesia geral não apresentaram menos dor pós-colecistectomia videolaparoscópica em comparação com os que receberam isoflurano, desflurano ou sevoflurano. .

Justificación y objetivo: el dolor es el principal motivo de queja y también la principal razón de una prolongada recuperación tras una colecistectomía laparoscópica. Nuestra hipótesis fue que los pacientes sometidos a colecistectomía laparoscópica tenían menos dolor 4 h después de la cirugía cuando recibían propofol para la anestesia en comparación con isoflurano, desflurano o sevoflurano. Métodos: en este estudio prospectivo y aleatorizado, 80 pacientes programados para colecistectomía laparoscópica fueron designados para recibir propofol, isoflurano, desflurano o sevoflurano para el mantenimiento de la anestesia. Nuestro primer resultado fue el dolor medido en escala analógica numérica 4 h después de la cirugía. También registramos el uso intraoperatorio de opiáceos y el consumo de analgésicos durante las primeras 24 h del postoperatorio. Resultados: no hubo diferencias estadísticamente significativas en las puntuaciones del dolor 4 h después de la cirugía (p = 0,72). Tampoco hubo diferencias estadísticamente significativas en las puntuaciones del dolor entre los grupos de tratamiento durante las 24 h del postoperatorio (p = 0,45). El uso intraoperatorio de fentanilo y morfina no varió significativamente entre los grupos (p = 0,21 y 0,24 respectivamente). No hubo una diferencia en el consumo total de morfina e hidrocodona/APAP durante las primeras 24 h (p = 0,61 y 0,53 respectivamente). Conclusiones: los pacientes que recibieron propofol para el mantenimiento de la anestesia general no tenían menos dolor poscolecistectomía videolaparoscópica en comparación con los que recibieron isoflurano, desflurano o sevoflurano. .

Intrapartum epidural analgesia and maternal temperature regulation.

OBJECTIVE: To examine maternal temperature changes after epidural analgesia. METHODS: A prospective cohort of nulliparas at term was monitored with hourly maternal tympanic temperatures after epidural analgesia (n=99). Temperature response after epidural analgesia was examined in the group as a whole. Subsequently, mean maternal temperature curves were compared between women who remained afebrile throughout labor (n=77) and women who developed intrapartum fever with body temperature greater than 100.4 degrees F (n=22). Baseline maternal characteristics were assessed. RESULTS: Women who later developed intrapartum fever had a higher mean temperature within 1 hour after epidural analgesia. In contrast, women who remained afebrile had no increase in core temperature. During the first 4 hours after epidural analgesia initiation, women who later develop intrapartum fever have an increase in mean tympanic temperature of 0.33 degrees F per hour. CONCLUSION: Epidural analgesia is not associated with increased temperature in the majority of women. Hyperthermia is an abnormal response confined to a minority subset, which occurs immediately after exposure. Our findings do not support a universal perturbation of maternal thermoregulation after epidural analgesia. LEVEL OF EVIDENCE: II.

Maternal corticosteroids to prevent intrauterine exposure to hyperthermia and inflammation: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Intrauterine exposure to hyperthermia at term is associated with adverse neonatal neurologic outcomes. The objective of this study was to determine whether prophylactic maternal corticosteroid treatment prevents fetal exposure to hyperthermia and inflammatory cytokines after epidural analgesia. STUDY DESIGN: A 2-phase, randomized, institutional review board-approved, double-blind, placebo-controlled trial was performed. Term nulliparous women were enrolled at epidural placement. Patients with a temperature of >99.4 degrees F or with diabetes mellitus were excluded. In phase 1, 25 mg methylprednisolone (low dose) or placebo was administered every 8 hours. In phase 2, the treatment dose was increased to 100 mg every 4 hours (high dose). Our primary outcome was a rate of intrapartum fever of >100.4 degrees F. Secondary outcomes were fetal interleukin-6 levels and the rate of neonatal bacteremia. RESULTS: One hundred one patients were assigned randomly to placebo; 50 patients were assigned to the low-dose group, and 49 patients were assigned to the high-dose group. Treatment with the high dose resulted in a 90% reduction in maternal fever, compared with placebo and low dose therapy (2.0% vs 21.8% vs. 34.0%, respectively; P < .001). Neonatal sepsis evaluations were reduced significantly in the high-dose group (4.1% vs 17.8% vs 24%, respectively; P = .01), but the rates of asymptomatic bacteremia were increased (9.3% vs 0% vs 2.1%, respectively; P = .005). Median cord blood interleukin-6 levels were reduced with the high-dose steroid treatment, but this result was statistically significant only between the high-dose and placebo groups (24.0 +/- 38.5 vs 32.0 +/- 95.0 pg/mL, respectively; P = .02). CONCLUSION: Prophylaxis with high-dose corticosteroids significantly reduces fetal exposure to hyperthermia and inflammation. However, maternal high-dose corticosteroids increase the rate of neonatal asymptomatic bacteremia. Stress-dose corticosteroid use in labor should trigger consideration of a screening neonatal blood culture.

Prophylactic acetaminophen does not prevent epidural fever in nulliparous women: a double-blind placebo-controlled trial.

OBJECTIVE: Epidural analgesia is associated with a four- to five- fold increase in noninfectious maternal fever in nulliparous women. Fever prophylaxis may safely reduce both unnecessary neonatal sepsis evaluations and the potential effect of fever on the fetus. STUDY DESIGN: We performed a randomized double-blind placebo-controlled study. Immediately after epidural placement, full-term nulliparas with a temperature of <99.5 degrees F received acetaminophen 650 mg or placebo, per rectum, every 4 hours. Tympanic membrane temperatures were measured hourly. Our power to detect an effect of acetaminophen treatment on maternal temperature over time was 90%. RESULTS: In all, 21 subjects were randomized to each arm. Treatment with acetaminophen did not impact maternal temperature curves. Fever >100.4 degrees F was identical in the acetaminophen and placebo groups (23.8%, p=1.0). Neonatal surveillance blood cultures did not reveal occult infection. CONCLUSIONS: Acetaminophen prophylaxis prevented neither maternal hyperthermia nor fever secondary to epidural analgesia, suggesting that the mechanism underlying fever does not include centrally mediated perturbations of maternal thermoregulation.

Elevated maternal and fetal serum interleukin-6 levels are associated with epidural fever.

OBJECTIVE: The study was performed to explore the evidence for a noninfectious inflammatory cause for epidural fever. STUDY DESIGN: A secondary analysis of a prospective randomized trial was performed. At epidural placement, afebrile term nulliparous women were randomized to receive acetaminophen 650 mg or placebo every 4 hours. Maternal serum was collected every 4 hours until delivery. Cord blood samples were collected at delivery. Interleukin-6 (IL-6) and interleukin-8 levels were measured using enzyme-linked immunosorbent assay techniques. Student t tests, chi(2), repeated measure analysis of variance, Pearson correlation coefficients, and linear regression modeling were used as appropriate. RESULTS: Twenty-one subjects received placebo, and 21 received acetaminophen. The rate of fever more than 100.4 degrees F was identical in the placebo and acetaminophen groups (23.8%). Maternal serum IL-6 levels before delivery were significantly higher in mothers who had a fever (596.0 vs 169.1 pg/mL, P <.001), as was the cord blood IL-6 levels of their infants (370.5 vs 99.0 pg/mL, P <.01). Linear regression modeling demonstrated that initial maternal serum IL-6, fever, and duration of epidural but not length of rupture of membranes or number of vaginal examinations were significantly associated with final maternal serum IL-6 levels. All neonatal blood cultures were negative. CONCLUSION: Epidural fever is associated with maternal and fetal inflammation in the absence of neonatal infection. Higher levels of cytokines in maternal serum suggest that the maternal compartment is the primary inflammatory source.