Anouar Jarraya

Near-infrared spectrometry in pregnancy: progress and perspectives, a review of literature

Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of in vivo oxygenation in selected tissues. It has been used primarily as a research tool for several years, but it is seeing wider application in the clinical arena all over the world. It was recently used to monitor brain circulation in cardiac surgery, carotid endarteriectomy, neurosurgery and robotic surgery. According to the few studies used NIRS in pregnancy, it may be helpful to assess the impact of severe forms of preeclampsia on brain circulation, to evaluate the efficacy of different treatments. It may also be used during cesarean section to detect earlier sudden complications. The evaluation of placental function via abdominal maternal approach to detect fetal growth restriction is a new field of application of NIRS.

Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery: A randomized controlled trial.

INTRODUCTION Subarachnoid morphine is widely used for pain relief in enhanced recovery program after cesarean section in spite of its side effects. However, the role of TAP block is still controversial. The aim of our study was to compare the impact of these analgesic techniques (subarachnoid morphine and TAP block) on enhanced recovery after cesarean section. MATERIALS AND METHODS In this randomized controlled trial, we included patients scheduled for cesarean delivery under spinal anesthesia. Patients were randomized in two groups. Group I: received spinal anesthesia with 100μg of subarachnoid morphine. Group II: received spinal anesthesia without subarachnoid morphine followed by an ultrasound-guided TAP block. We assessed the time required for mobilization, for re-establishment of gastrointestinal transit and for breast-feeding. RESULTS TAP block allowed earlier postoperative mobilization. Time required for getting up was significantly lower in group II (9.4h versus 6.9h; P=0.024) as well as time required for walking (12.4h versus 7.4h; P=0.001). TAP block allowed earlier re-establishment of gastrointestinal transit (11.2h in group I versus 8.1h in group II; P<0.001). CONCLUSIONS TAP block seems to be suitable with enhanced recovery programs.

Postoperative analgesia in children when using clonidine in addition to fentanyl with bupivacaine given caudally

The aim of the study was to evaluate the efficacy of clonidine in association with fentanyl as an additive to bupivacaine 0.25% given via single shot caudal epidural in pediatric patients for postoperative pain relief. In the present prospective randomized double blind study, 40 children of ASA-I-II aged 1-5 years scheduled for infraumblical surgical procedures were randomly allocated to two groups to receive either bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg and clonidine 1μg/kg (group I) or bupivacaine 0.25% (1 ml/kg) with fentanyl 1 μg/kg (group II). Caudal block was performed after the induction of general anesthesia. Postoperatively patients were observed for analgesia, sedation, hemodynamic parameters, and side effects or complications. Both the groups were similar with respect to patient and various block characteristics. Heart rate and blood pressure were not different in 2 groups. Significantly prolonged duration of post-operative analgesia was observed in group I (P<0.05). Side effects such as respiratory depression, vomiting and bradycardia were similar in both groups. The adjunction of clonidine to fentanyl as additives to bupivacaine in single shot caudal epidural in children may provide better and longer analgesia after infraumblical surgical procedures.

Golden hour for fibrinogen concentrate infusion to improve post partum hemorrhage

Fibrinogen is the first agent to decrease in case of severe postpartum hemorrhage (PPH). It was also reported as an important predictor of PPH and of progression to severe PPH [1]. To date, maintaining fibrinogen levels above 2 g/L is a recommended therapeutic target in bleeding women [2]. However, the current level of scientific evidence of the timing of fibrinogen supplementation is still insufficient and controversial. The purpose of this letter to the editor is to describe our experience in the use of fibrinogen concentrate in PPH in this retrospective study. After obtaining the approval from the medical committee of the Hedi Chaker University Hospital, we analyzed a database of patients who needed fibrinogen concentrate transfusion for the treatment of severe postpartum hemorrhage due to uterine atony after cesarean section delivery from January 2015 to December 2017. PPH was managed according to the clinical protocol of our institution in which fibrinogen concentrate was transfused at the dose of 2 g to treat coagulopathy (when plasmatic fibrinogen concentration<2 g/L), or after massive transfusion, or earlier when practitioners in charge of the patient estimate that the bleeding may lead to coagulopathy (before the result of plasmatic concentration of fibrinogen). Then, we assessed the blood loss estimated by Gross formula and the transfusion requirements. Blood loss (Gross Formula)= total blood volume of a pregnant woman (80ml/kg)×weight (kg)× [(Hb.i−Hb.d2)/((Hb.i+Hb.d2)/ 2]+ 500ml for every erythrocyte unit transfused. Hb.i: Preoperative hemoglobin; Hb.d2: 2nd day post operative hemoglobin concentration. The main outcome of this study was to determine if there is a correlation between the delay of fibrinogen transfusion (time from sulprostone infusion to fibrinogen transfusion) and the blood loss in severe PPH. For statistics analysis, Quantitative variables are presented as mean ± SD. Pearson’s correlation coefficient was adopted to test the correlation between the delay of administration of fibrinogen and the importance of uterine bleeding. We used student T test or Mann Whitney U test for comparison of continuous variables and Chi square test for the comparison of categorical variables. All statistical analyses were performed using SPSS 20.0. P value of< 0.05 was regarded as significant. In this study, 33 patients were included. 12 patients who received fibrinogen concentrates within the first hour after delivery were called group E and the 21 who received it after (> 1 h) were called group L. Demographic parameters (age, weight, patients height, gestity and parity) and pre operative hemostatic status were comparable in both groups (Table 1). Blood loss was correlated to the delay of fibrinogen administration (Fig. 1). The Pearson correlation coefficient was 0.688. The mean blood loss was 2486ml in group E versus 5310ml in group L (p= 0.002) and the delay of fibrinogen transfusion was 27.5min in group E versus 117min in group L (p=0.0001). Fibrinogen concentrates were given after massive transfusion in only 12 patients in group L. Prothrombin ratio and fibrinogen plasmatic concentration (before the fibrinogen transfusion) were respectively 78% and 2.54 g/L in group E versus 58% and 1.34 g/L in group L(p=0.045, p=0.002). Red blood cell transfusion requirement was 4.58 units/patient in group E versus 8.14 in group L (p=0.01). The need of fresh frozen plasma was 7 units/patient in group E versus 12.3 in group L (p= 0.045). Surgical hemostasis like hypogastric arterial ligation was observed in 5 patients in group E versus 13 patients in group L (p=0.529) and hysterectomy was needed in 3 patients in group E versus 13 patients in group L (p=0.338). In our study 3 patients of group L died after multivisceral deficiency in the intensive care unit. However, only one patient died in group E by pulmonary embolism few hours after hysterectomy. In fact, we have no proof that this case of pulmonary em-