The bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not prevent postoperative pain after total thyroidectomy.

BACKGROUND AND OBJECTIVES: Patients undergoing thyroid surgery need postoperative pain management. Bilateral superficial cervical plexus block by administration of 0.25% bupivacaine with 1:200000 epinephrine at the end of surgery has been shown to improve postoperative analgesia. The objective of this study was to assess the analgesic efficacy in the first 36 postoperative hours after total thyroidectomy of bilateral superficial cervical plexus block with 0.75% ropivacaine administered before the incision or on completion of the surgical procedure. METHODS: We performed a prospective double-blinded, randomized controlled trial that compared 3 parallel groups: the CONT group did not receive any block, the PRE group received bilateral superficial cervical plexus block before surgery while under general anesthesia, and the POST group received bilateral superficial cervical plexus block after surgery while under general anesthesia. The study included 111 patients (37 in each group). Postoperative pain was assessed every 4 hours by use of a 0 to 10 numeric rating scale. All patients received paracetamol every 6 hours. Morphine was administered following a standardized protocol if the numeric rating scale was 4 or higher. The main outcome variables were the proportion of patients given morphine during the 36 hours period, pain intensity scores, and morphine consumption. RESULTS: No intergroup differences were observed in terms of percentage of patients who required morphine, morphine delivery, pain scores, and intraoperative opioid consumption. CONCLUSIONS: Bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not improve postoperative analgesia after total thyroidectomy.

Massive hemoptysis: what place for medical and surgical treatment.

OBJECTIVE: The objective of the study was to define timing of surgical treatment in management of massive hemoptysis. METHODS: We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment. RESULTS: Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death. CONCLUSION: Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed.