Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial.

OBJECTIVES: To compare the efficacy, safety and satisfaction from two modes of oral analgesia administration for the treatment of post-caesarean pain in the first 48 h following surgery: on-demand versus fixed time interval administration. DESIGN: Open label parallel-group, randomised-controlled trial from February to December 2013. SETTING: University-affiliated hospital in Israel. POPULATION: Two-hundred women who underwent caesarean delivery with regional anaesthesia. METHODS: Patients were randomly assigned to receive predetermined combinations of tramadol, paracetamol and diclofenac either following patient demand or at predetermined 6-h intervals for the first 48 h. If the patient requested additional analgesia, Percocet (oxycodone and paracetamol) was given as a rescue treatment. MAIN OUTCOME MEASURES: Pain intensity and satisfaction were self-evaluated with visual analogue scale of 0 (no pain/least satisfaction) to 10 (worst pain/highest satisfaction). Breastfeeding, need for supplemental formula, and maternal and neonatal adverse effects were also evaluated. RESULTS: The 'fixed time interval' group, compared with the 'on-demand' group, had lower mean pain score (2.8 ± 0.84 versus 4.1 ± 0.48, respectively; P < 0.0001), higher satisfaction rate (9.1 ± 1.2 versus 8.3 ± 1.5, respectively; P < 0.0001), more breastfeeds (23.7 ± 6.5 versus 19.2 ± 6.2, respectively; P < 0.0001) and less use of supplemental formulas (8.2 ± 5.2 versus 11.9 ± 6.5, respectively; P < 0.0001). The number of times that drugs were given was slightly higher in the 'fixed time interval' group without an increase in maternal adverse effects, which were mild. No adverse effects were reported for the neonates. CONCLUSION: Administration of oral analgesia in fixed time intervals is superior to drug administration following patient demand without increasing maternal or neonatal adverse outcomes. TWEETABLE ABSTRACT: Oral analgesia in fixed time intervals is superior to analgesia following demand.

Risk factors for persistent disability in children with obstetric brachial plexus palsy.

OBJECTIVE: Obstetric brachial plexus palsy (OBPP) at birth, is a serious neurologic injury that may lead to a long lasting disability. We aimed to examine the occurrence and risk factors associated with disability lasting >1 year. STUDY DESIGN: A retrospective cohort study conducted between 1993 and 2012 included individuals with diagnosis of OBPP at birth. Affected individual's motor function was evaluated by a direct physical exam based on a muscle grading system of the limb, shoulder, elbow and hand. When not feasible a telephone questionnaire was used. Participants reported on activities of daily living, disability duration and any type of intervention. Stepwise logistic regression model was used to identify demographic and obstetric risk factors for disability lasting >1 year. RESULTS: Of all 83 806 deliveries during this period, 144 OBPP cases were identified (1.7/1000). Of the 91 (63.2%) individuals located 42 (46.2%) were evaluated by a physical exam and 49 (53.8%) answered a telephone questionnaire. In 12 (13.2%) disability lasted >1 year. Significant predictors for disability lasting >1 year included birthweight >4 kg (P=0.02; odds ratio (OR) 6.17; 95% confidence interval (CI) 1.33-28.65) and younger maternal age (P=0.02; OR 0.84; 95% CI: 0.73-0.97). OBPP decreased 16% per 1 year increase in maternal age. CONCLUSIONS: OBPP is a transient injury in most cases. Birthweight over 4 kg and younger maternal age maybe associated with disability lasting >1 year.

[Tolerability of once-daily-dosing of intravenous gentamicin in preterm neonates born at 32-37 weeks of gestation].

OBJECTIVE: Gentamicin is an important factor in the empiric therapy of premature babies with suspected invasive bacterial infection. The aims of the study were to assess the tolerability of short course of gentamicin in preterm neonates. PATIENTS AND METHODS: Preterm neonates aged 24 hours or less who were born at 32-37 weeks of gestation and weighed over 1500 grams were included in the study. Those infants suspected of having invasive non-CNS bacterial infection were assigned to treatment with ampicillin 50 mg/kg twice daily and either ODD (once daily dosing) or twice daily dosing (TDD) of gentamicin 5 mg/kg/day (17 and 18 patients, respectively). Neonates with shock, impaired renal function and known kidney, ear, and heart malformations, and metabolic disease were excluded from the study. At 72 to 96 hours of therapy, serum and urine creatinine, and sodium concentrations, peak (PGt) and though (TGt) serum levels of gentamicin, and urinary lysosyme secretion were measured. Fractional excretion of sodium (FeNa), and glomerullar filtration rate (GFR) were calculated for each infant. Audiometric evaluation was performed at 1 to 2 months of age. RESULTS: For the ODD and TDD groups respectively, the values of serum creatinine, FENa, GFR, and urinary lyzozim were similar. The mean SD PGt levels were 9.9 +/- 4.6 vs 5.9 +/- 1.9 g/ml (p < 0.04), and that of the TGt levels was 1.55 +/- 0.55 vs 2.4 +/- 0.9 micrograms/ml (p = 0.028), Ten (55.6%) vs 3(23.1%) of the TDD and ODD groups respectively had TGt levels above 2 micrograms/ml (p = 0.035). Audiometric evaluation was normal in all infants. CONCLUSIONS: Short course of ODD of gentamicin could be safe and potentially more effective in preterm babies.

Doppler diastolic transmitral flow patterns in severe heart failure: response to controlled changes in filling pressure using intravenous isosorbide dinitrate.

Serial Doppler diastolic transmitral flow patterns were compared with simultaneous hemodynamic measurements in a homogeneous group of patients with severe (New York Heart Association class 4) heart failure who were receiving high dose (508 +/- 271 micrograms/min) intravenous isosorbide dinitrate. The Doppler tracing uniformly showed a severe restrictive pattern, with tall peak early diastolic filling (E) wave (84 +/- 12 cm/s), small late filling (A) wave (28 +/- 8 cm/s) and very high E/A ratio (3.2 +/- 0.8). Isosorbide dinitrate decreased wedge pressure and systemic vascular resistance by a third and increased cardiac index by more than 40%. Transmitral Doppler E/A ratio changed directly in relation to the changes in pulmonary capillary wedge (r = 0.85, p = 0.03) and right atrial pressure (r = 0.84, p = 0.03), indicating preload dependence of transmitral flow velocity, even in severe heart failure.