Postoperative Analgesia in Breast Cancer Surgery: Efficiency and Safety of Ultrasound Guided Erector Spinae Plane Block, a randomized controlled double blinded trial.

INTRODUCTION: Breast cancer surgeries are the mainstay and usually the first step of treatment. AIM: To assess the efficiency and safety of ultrasound guided Erector Spinae Plane Block (ESPB) for the management of postoperative pain in patients undergoing elective breast cancer surgery. METHODS: Between December 2018 and June 2019, a prospective, controlled, randomized, double-blinded study was conducted at the maternity and neonatology center of Tunis. We included fifty ASA I-II female patients who were scheduled for elective breast cancer surgery. They were randomly divided into two groups: Group R (n=25) with Ropivacaine, while Group P (n=25) received a placebo. The study recorded PCA morphine consumption and patient demand for PCA. The primary outcome was to compare the visual analogue scale (VAS) pain scores at various points throughout the 24 hours postoperatively (1st, 2nd, 4th, 8th, 12th, 16th, 20th, 24th) between the two groups. RESULTS: Except for the first hour and 16th hour post-surgery, the mean VAS pain scores were significantly lower in Group R compared to Group P. The 24-hour morphine consumption was significantly lower in Group R (5.5±0.9 mg) compared to Group P (16.6±2.8 mg); p<0.001. Per-operative fentanyl consumption was also significantly lower in Group R (9.1±4.2 mcg; Group P: 50±9.1 mcg; p< 0.001). Moreover, the mean total morphine demand was significantly lower in Group R. CONCLUSION: ESPB with Ropivacaine is effective and safe for pain management after breast cancer surgery with a consequent morphine sparing and less use of systemic analgesia.

Pelvic Packing for Intractable Obstetric Hemorrhage After Emergency Peripartum Hysterectomy: A Review.

IMPORTANCE: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. Even after emergency peripartum hysterectomy (EPH), bleeding may occur in the setting of acquired coagulopathy. This type of bleeding resistant to clipping, ligating, or suturing could be successfully controlled with a pelvic packing. OBJECTIVE: This review provides an overview of the different pelvic packing techniques used after the failure of an EPH to control severe PPH. It aims to highlight the outcome of patients after packing, the morbidity and complications of packing, the timing and indications of packing, and finally the optimal duration of packing. EVIDENCE ACQUISITION: Literature relating to pelvic packing after EPH in a PPH setting was reviewed. RESULTS: Packing techniques can be divided into 2 types: pads or roller gauze and balloon pack. The overall success rate was as high as 78.8% with a mortality rate of 12.5%. No major morbidity related to the pelvic packing was documented. The optimal duration of packing is in the range of 36 to 72 hours. CONCLUSIONS: Pelvic packing should be part of the armamentarium available to the obstetrician whenever intractable pelvic hemorrhage is encountered. It is quite simple and quick to perform and requires no special medical materials, the rate of complications is very low, and the success rate is high. RELEVANCE: The pelvic packing should be particularly useful in developing countries where more advanced technologies such as selective arterial embolization are not always available. In developed countries, the pelvic packing may be a valuable temporary measure pending transport to a tertiary care facility.

Are the Wells Score and the Revised Geneva Score valuable for the diagnosis of pulmonary embolism in pregnancy?

OBJECTIVES: To evaluate and to compare the predictive accuracy of the Wells score and the revised Geneva scores for the diagnosis of pulmonary embolism in the pregnant and postpartum population. STUDY DESIGN: All pregnant or post-partum patients with a suspected PE and for whom a diagnostic imaging testing was performed (VQ scintigraphy or computed tomography pulmonary angiography) over a 3-year period were included in the study. The Wells and Revised Geneva Scores were calculated on the same cohort of patients and dichotomized into low and intermediate/high probability groups. The sensitivities and specificities were calculated. Overall accuracy was determined using receiver operator characteristic curve analysis. RESULTS: A total of 103 patients were included. The overall prevalence of PE was 26.2% (27/103). Using the Wells Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 20.5%, 43.5% and 50% respectively. Using the Revised Geneva Score, the prevalence of patients with PE in the low, intermediate and high probability categories was 17%, 36.2 and 33.3% respectively. In low risk groups of the Wells score and the simplified revised Geneva score the prevalence of PE was not statistically significantly different: respectively: 20.5% and 17.5% (p = 0,232). The agreement on clinical assessment using the Wells score and using the revised Geneva score was weak (κ coefficient = 0.154). In total, 26 (25.2%) patients were classified differently using the 2 scores. There was no significant difference in the overall accuracies of the Wells (0.67, 95% CI 0.54-0.79) and Revised Geneva Scores (0.64, 95% CI 0.52-0.76) as determined by the area under the ROC curves (P = 0.628). The sensitivity, specificity, PPV and NPV of the Wells score and the revised Geneva score were respectively: 40.7%, 81.5%, 44%, 79.4% and 62.9%, 59.2%, 35.4%, 81.8%. CONCLUSION(S): The Wells score and the revised Geneva seems not to be valuable in the pregnant and post partum population. A specific risk score of PE for pregnant and postpartum population is needed to reduce the rate of unnecessary imaging studies, especially in this specific population were the use of radiation and contrast agent is problematic.

Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting.

OBJECTIVES: To study the safety and effectiveness of pelvic packing in the control of post emergency peripartum hysterectomy (EPH) bleeding in a postpartum hemorrhage (PPH) setting. STUDY DESIGN: From 39 patients with a severe PPH leading to an EPH (January 2010-December 2013), we identified a group of 17 patients requiring a pelvic packing (packing group) and a second group of 22 patients not requiring a pelvic packing (non-packing group). For each group, transfusion requirements were recorded from time of PPH diagnosis to end of the surgical procedure (P1: Period 1) and from that point to the end management in the SICU (P2: Period 2). Laboratory values, transfusion requirements and complications were compared between the 2 groups. Statistical comparisons were performed using Mann-Whitney test, Fisher's exact test and chi-square test. A p-value <0.05 was considered statistically significant. RESULTS: Pelvic packing was successful in the control of bleeding in all the cases. During the second laparotomy for pack removal, none of the patients developed complications such as bowel injuries or necrosis. The 2 groups were similar in term of laboratory values at the end of the surgical procedure and 24h after the end of the surgical procedure. The number of PRBC units required in P1 was higher in the packing group compared to the non-packing group (16.6±5.3 vs 14±5; p=0.04), however the decrease in the amount of PRBCs transfused between P1 and P2 was higher in the packing group (13.3) compared to the non-packing group (9.1) (p<0.01). The incidence of febrile morbidity was higher in the packing group compared to the non-packing group (53% vs 9%; p=0.04); but no significant difference was shown in term of generalized sepsis, as well as renal failure, ARDS, deep vein thrombosis, pulmonary embolism and MOF. CONCLUSION: The pelvic packing is a valuable method with a high success rate in the control of hemorrhage after an EPH in PPH setting with a low rate of complications. It is quite simple and quick to perform, and therefore should be kept in mind by all obstetricians as a lifesaving technique.