Epidural vs. intravenous fentanyl during colorectal surgery using a double-blind, double-dummy design.

BACKGROUND: The overall therapeutic effectiveness of epidural fentanyl vs. the intravenous route is controversial. The present work describes a randomized, controlled, double-blind, double-dummy study of the intraoperative requirements of fentanyl administered by the intravenous or epidural routes during open colon surgery. METHODS: Thirty patients were randomized to receive intraoperative analgesia with boluses of fentanyl administered by either the epidural or intravenous route (2 µg/kg). The first fentanyl bolus was administered 10 min before incision, and repeated boluses were given when mean arterial pressure or heart rate increased more than 20% over basal values. General anaesthesia was maintained with a propofol infusion. Intraoperative fentanyl and propofol requirements, time to awakening, time to analgesia request, and incidence of adverse effects were recorded. RESULTS: Median [interquartile range (range)] fentanyl requirements in the epidural and intravenous groups were 0.81 [0.65 (0.47-2.61)] and 2.5 [1.08 (1.07-4.85)] µg/kg/h, respectively (P < 0.001). The epidural group had a shorter time to awakening, with a median of 8 min [4.5 (3-18)] compared with 20 min [12.5 (7-34)] for the intravenous group (P < 0.001). There were no significant differences in propofol requirements. The time to analgesia request was also delayed in the epidural group, with a median of 5 h [5.5 (1-16)] vs. 2 h [1 (1-5)] when fentanyl was administered intravenously (P < 0.001). The incidence of adverse effects was similar in both groups. CONCLUSION: During major abdominal surgery, epidural administration requires lower doses of intraoperative fentanyl when compared with the intravenous route. Epidural fentanyl also facilitates early awakening and residual analgesia without increasing adverse events.

[Usefulness of activated recombinant factor VII for controlling massive bleeding: 4 years' experience in a university hospital]. / Utilidad del factor VII recombinante para el control de la hemorragia masiva. Experiencia de cuatro años en un centro hospitalario universitario.

OBJECTIVE: Massive bleeding that cannot be controlled by the usual means, such as transfusion, is a serious medical problem with high associated mortality. Our aim was to assess the efficacy and safety of treatment with activated recombinant factor VII (rFVIIa) to control massive bleeding after the failure of other methods. PATIENTS AND METHODS: This was a retrospective study of all cases of rFVIIa-treated massive bleeding in patients without a history of coagulation disorder from January 2003 through June 2007. RESULTS: The prevalence of rFVIIa treatment for this indication was 1 in 5200 hospitalized patients. Thirty patients were treated. Bleeding was reduced or stopped in 80% and consumption of blood products was reduced after administration of rFVIIa. Mortality was 43% and death was due to continued bleeding in 5 cases. No deaths were due to thromboembolism. CONCLUSIONS: rFVIIa is efficacious for controlling bleeding and reducing transfusion requirements in cases of massive hemorrhage, but mortality unrelated to bleeding is high in patients experiencing this complication. Further study is needed to better assess the utility, dosing, and ideal timing in the use of this drug.

Utilidad del factor VII recombinante para el controlde la hemorragia masiva. Experiencia de cuatro añosen un centro hospitalario universitario / No disponible

OBJETIVO: La hemorragia masiva no controlada pese alas medidas terapéuticas habituales como el soporte transfusional,supone un grave problema médico y tiene unaelevada mortalidad. El objetivo del trabajo ha sido evaluarla eficacia y seguridad del tratamiento con factor VII activadorecombinante (rFVIIa) en el control de la hemorragiamasiva, cuando las demás medidas han fracasado.PACIENTES Y MÉTODOS: Estudio retrospectivo de todoslos casos de hemorragia masiva en pacientes sin transtornoprevio de la coagulación, que fueron tratados conrFVIIa en nuestro centro desde enero de 2003 a junio de2007.RESULTADOS: La prevalencia de uso de rFVIIa con estaindicación ha sido de 1/5.200 pacientes hospitalizados. Sehan tratado 30 pacientes de los cuales el sangrado se redujoo paró en el 80% de los casos, con una disminución deluso de hemoderivados tras la administración de rFVIIa.La mortalidad fue del 43%, 5 casos por persistencia delsangrado, pero ninguna muerte fue por proceso tromboembólico.CONCLUSIONES: El rFVIIa resulta eficaz en el control delsangrado y en reducir los requerimientos transfusionalesen la hemorragia masiva, pero la mortalidad en estospacientes por causa no hemorrágica es alta. Son necesariosmás estudios para evaluar mejor la utilidad, dosificación ymomento idóneo de administración de este fármaco (AU)

OBJECTIVE: Massive bleeding that cannot be controlledby the usual means, such as transfusion, is a seriousmedical problem with high associated mortality. Our aimwas to assess the efficacy and safety of treatment withactivated recombinant factor VII (rFVIIa) to controlmassive bleeding after the failure of other methods.PATIENTS AND METHODS: This was a retrospective studyof all cases of rFVIIa-treated massive bleeding in patientswithout a history of coagulation disorder from January2003 through June 2007.RESULTS: The prevalence of rFVIIa treatment for thisindication was 1 in 5200 hospitalized patients. Thirtypatients were treated. Bleeding was reduced or stopped in80% and consumption of blood products was reducedafter administration of rFVIIa. Mortality was 43% anddeath was due to continued bleeding in 5 cases. No deathswere due to thromboembolism.CONCLUSIONS: rFVIIa is efficacious for controllingbleeding and reducing transfusion requirements in cases ofmassive hemorrhage, but mortality unrelated to bleedingis high in patients experiencing this complication. Furtherstudy is needed to better assess the utility, dosing, and idealtiming in the use of this drug (AU)