The effect of fentanyl and remifentanil, with or without ketoprofen, on pain after thyroid surgery: a randomized-controlled trial.

BACKGROUND AND OBJECTIVES: This study was designed to quantify the additional postoperative analgesic efficacy of a single dose of ketoprofen in patients undergoing thyroid surgery using two different intraoperative analgesic regimens. METHODS: One hundred and twenty patients were randomly assigned to one of four groups: intraoperative fentanyl or remifentanil with or without ketoprofen (n = 30 for each group). Intravenous ketoprofen (1.5 mg kg-1) or saline was administered 45 min before the end of surgery. Pain scores, opioid demand and length of stay in the postanaesthesia care unit were assessed in a blinded manner. RESULTS: Patients receiving intraoperative fentanyl with saline had significantly lower visual analogue scale pain scores in the postanaesthesia care unit compared with those receiving intraoperative remifentanil with saline (55 +/- 10 mm vs. 80 +/- 18 mm, P < 0.05) and they stayed shorter in the postanaesthesia care unit (86 +/- 24 min vs. 126 +/- 37 min). In conjunction with intraoperative fentanyl, ketoprofen significantly decreased postoperative pain scores (40 +/- 10 mm, P < 0.05 compared with fentanyl alone) and opioid demand (4 of 30 patients vs. 14 of 30 patients compared with fentanyl alone, P < 0.05). Patients receiving intraoperative remifentanil had no additional analgesic benefit with ketoprofen. CONCLUSION: After thyroid surgery, patients receiving intraoperative fentanyl had lower pain scores and needed less rescue analgesia compared with patients receiving intraoperative remifentanil. The adjunction of ketoprofen further improved analgesia in patients who received intraoperative fentanyl only.

Postoperative pain scores and analgesic requirements after thyroid surgery: comparison of three intraoperative opioid regimens.

PURPOSE: This study was designed to compare the effect on postoperative pain, opioid consumption and the length of stay in postoperative care unit (PACU) after three different intraoperative analgesic regimens in thyroid surgery. METHODS: Seventy five patients were enrolled into the study and assigned to one of three groups, fentanyl, sufentanil or remifentanil (n=25 for each group). Before the end of surgery, paracetamol 1 gr and nefopam 20 mg was also administered in all patients. Pain scores, opioid demand and the length of stay in PACU were assessed in a blind manner. RESULTS: Post operative pain scores were significantly lower in the fentanyl and sufentanil groups compared to remifentanil group (55 +/- 15, and 60 +/- 10 versus 78+/- 12, P < 0.05). Patients in the remifentanil group stayed longer in the PACU 108+/- 37 min versus 78+/-31 and 73 +/- 25 min, (P< 0.05). CONCLUSION: After remifentanil based analgesia, anticipation of postoperative pain with opioid analgesic appears mandatory even for surgery rated as being moderately painful, otherwise longer opioid titration due to higher pain scores might delay discharge time.

[Surgery of aneurysms of the abdominal aorta in 1992. Lessons of a decade]. / La chirurgie des anévrysmes de l'aorte abdominale en 1992. Les leçons d'une décennie.

Perioperative mortality of abdominal aortic aneurysm (AAA) remains at a mean of 3% in asymptomatic cases, 6% when symptomatic and 50% when ruptured while many patients with ruptured AAA die prior to surgery. This has changed little over the last decade. The causes of this stagnation are analyzed, strategic choices as a function of clinical situations, size of aneurysm, and associated lesions exposed, and means explored to improve the prognosis. Since the perioperative mortality rate appears incompressible, an improvement in the prognosis of AAA can be obtained only by a combined medical effort. This requires the more rapid recognition of prodromal symptoms of rupture, the detection of a larger number of asymptomatic AAA and improved postoperative life expectancy, already reasonable, by more rigorous vascular and cardiologic surveillance.

Effect of epidural clonidine on analgesia and pharmacokinetics of epidural fentanyl in postoperative patients.

Epidural clonidine produces postoperative analgesia in patients and potentiates opioid analgesia in animals. The aim of the current study was to assess the effect of epidural clonidine on the plasma concentrations and analgesic effect of fentanyl after epidural administration. Twenty ASA physical status 2 or 3 patients recovering from abdominal surgery were allocated randomly to receive either epidural fentanyl (100 micrograms in 10 ml isotonic saline; EF group) or epidural fentanyl (same dose) plus epidural clonidine (150 micrograms; EF + C group) in isotonic saline solution. Analgesia was assessed over a period of 12 h after epidural injection. Venous samples were obtained until 360 min after epidural injection for radioimmunoassay determination of plasma fentanyl concentration. Onset of analgesia was similar in the two groups of patients (13 +/- 6 and 13 +/- 3 min, respectively, after injection), but duration was more than doubled in the patients receiving clonidine (543 +/- 183 vs. 250 +/- 64 min). Peak plasma fentanyl concentrations (Fmax) and the time to reach Cmax (Tmax) were comparable in the two groups (0.29 +/- 0.15 ng.ml-1 at 16.2 +/- 14.8 min in the EF group and 0.27 +/- 0.11 ng.ml-1 at 8.3 +/- 5.5 min in the EF + C group), as were plasma concentrations at each definite time of measurement. Drowsiness and hypotension were noticed in the EF + C group. Thus, epidural clonidine appears to prolong epidural fentanyl analgesia without affecting its plasma concentration.

[Comparison between conventional and continuous spinal anesthesia using bupivacaine]. / Comparaison entre rachianesthésie conventionnelle et rachianesthésie continue utilisant la bupivacaïne.

A study was carried out to find out whether dividing the dose of local anaesthetic would give a better control of the spread and duration of sensory blockade due to spinal anaesthesia. It was carried out in 34 patients (mean age 62 years) scheduled for elective limb vascular surgery. All were classed ASA 2 or 3. Sensory blockade was assessed using a fine needle, and the degree of motor blockade with Bromage's scale. This was carried out every 5 min for the first 30 min, and thereafter, every 15 min until recovery from anaesthesia was complete. In the first group of patients (n = 16), spinal anaesthesia was obtained with a 26 gauge needle, the patient lying on his side; 4 ml of 0.5% bupivacaine were injected (1 ml every 10 seconds) before putting the patient supine. In the second group (n = 18), the catheter for continuous spinal anaesthesia was set up with the patient in the same position as for the first group. Once a length of 1 cm had been introduced in the subarachnoid space, the patient was placed supine and 2 ml of 0.5% bupivacaine were injected. If 15 min later sensory blockade did not reach T10, further 0.5 ml aliquots were given every 10 min so as to obtain a level of sensory blockade between T9 and T11. Maximum extension of sensory blockade was 15.1 +/- 2.3 metamers in group 1, with an extension to T3 in 2 patients. In group 2, 12.9 +/- 3.1 mg bupivacaine anaesthetized 14.2 +/- 1.9 metamers.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuroleptanesthesia versus thoracic epidural anesthesia for abdominal aortic surgery.

The hemodynamic consequences of abdominal aortic surgery with infrarenal cross-clamping were studied in 21 patients randomized in two groups. In Group I (11 patients), neuroleptanesthesia was utilized, while Group II (10 patients) received thoracic epidural anesthesia at the T8-9 level. Hemodynamic measurements were performed using Swan-Ganz catheters during the surgical procedures in all patients, with special attention to the periods of clamping and unclamping of the abdominal aorta. The thoracic epidural anesthesia group was characterized by greater hemodynamic stability during surgery, while patients in the neuroleptanesthesia group had significant lability of blood pressure, heart rate, and cardiac index. Nevertheless, in the two groups of patients, it is suggested that cardiac function was unfitted to the tissue oxygen demand after unclamping of the aortic prosthesis because the saturation in oxygen of the mixed venous blood and an increase in arteriovenous difference in oxygen were documented. These results point out that, whatever the anesthesia technique, the critical period in abdominal surgery could be aortic unclamping.

Risk factors of postoperative pulmonary complications after vascular surgery.

Smoking and chronic obstructive disease are common in patients who undergo vascular surgery. These patients seem especially at risk for postoperative respiratory complications (PRCs). The value of preoperative spirometric tests to determine the risk of PRC has been recently challenged. The current prospective study was undertaken to identify the risk factors of PRC in these patients. One hundred fifty-one patients, including 67 patients who underwent abdominal aortic surgery, were included in this study. Preoperative and peroperative parameters were collected and analyzed in a multivariate analysis. PRCs were classified as minor and major. A significantly prolonged postoperative hospital stay was associated with major complications (21.3 +/- 9.0 vs 14.3 +/- 6.0 days). The overall incidence of PRC was 37.1%, and the incidence of major PRC was 15.2%. Patients who underwent abdominal aortic surgery had a higher incidence of PRC (53%; major PRC, 24%). In addition to abdominal aortic surgery, other risk factors were chest deformation, recent bronchitis, duration of surgery, and FEV1/VC. In patients who underwent abdominal aortic surgery, the risk factors for major PRC were decreases in preoperative FEV1/VC and PaO2. This study confirms the importance of an evaluation of a patient's respiratory condition, especially by preoperative spirometry and blood gas analysis, to determine the risk of PRC in a given population. General risk factors, such as the American Society of Anesthesiologists' classification, fail to achieve this task. The identification of patients with unacceptable risks remains a challenge.

[Management of anesthesia for surgery of the abdominal aorta]. / Conduite de l'anesthésie pour la chirurgie de l'aorte abdominale.

Anesthesia and post operative care of patients requiring abdominal aorta surgery are frequently complicated because of associated ischemic cardiopathy or respiratory insufficiency. Pre operative evaluation indicates the optimal peri-operative strategy and the need to appropriate peri-operative monitoring. This applies to patients with a previous history of myocardial infarction or with a poorly or not controlled cardiac insufficiency. The use of Swan-Ganz catheters allows monitoring of the hemo-dynamic parameters during operation, especially at the moment of clamping or unclamping of the aorta. Vasodilators and optimal volume loading allow myocardial adaptation and reduce the incidence of myocardial infarction, the main cause of peri-operative death. To perform these operations in the best conditions requires a close medicosurgical cooperation in specialized teams.