Dominique Chassard

Cytokine and hormonal changes after cholecystectomy. Effect of ibuprofen pretreatment.

OBJECTIVE Surgical stress induces hormonal and cytokine responses proportional to the extent of the injury. Therefore, the authors assessed the effect of ibuprofen pretreatment on metabolic and hormonal changes after surgery. SUMMARY BACKGROUND DATA Postoperative administration of cyclo-oxygenase inhibitor reduces cytokine production and nitrogen losses. METHODS The authors studied the plasma hormones and metabolic and cytokines changes after perioperative ibuprofen administration in 22 patients undergoing cholecystectomy under inhalational anesthesia. Suppositories containing ibuprofen (500 mg) or placebo were administered 12 and 2 hours before surgery, and every 8 hours until the third postoperative day. Blood samples were collected 24 and 2 hours before surgery and 2, 4, 6, 24, 48, and 72 hours after surgery for glucose, C-reactive protein, leukocytes, adrenocorticotropic hormone (ACTH), cortisol, tumor necrosis factor, and interleukin-1 and interleukin-6 determinations. RESULTS In both groups, plasma cortisol levels remained elevated for 3 days, whereas plasma ACTH levels returned to the basal level at day 1. The ACTH (p < 0.01), cortisol (p < 0.01), and glucose changes (p < 0.001) were smaller in the ibuprofen group and their duration was shorter. The interleukin-6 levels increased gradually after skin incision until the sixth hour and were significantly lower (p < 0.05) in the ibuprofen group. CONCLUSION Ibuprofen pretreatment in perioperative course is able to reduce the endocrine response and cytokine release. Therefore, ibuprofen may be useful in decreasing the stress response in severely surgical patients.

Laryngeal injuries and intubating conditions with or without muscular relaxation: an equivalence study.

Purpose: The need for muscular relaxation to improve intubat-ing conditions and to reduce the incidence of laryngeal morbidity is still controversial. The aim of this study was to determine the incidence of symptomatic laryngeal injuries (SLI) and of acceptable intubating conditions (including both good and excellent conditions), both with and without cisatracurium during induction of anesthesia, along with moderate doses of remifen-tanil and propofol.Methods: In this prospective, randomized double-blind equivalence trial, the intubating conditions were compared in 130 ASA I or II female patients. All subjects received remifentanil 2 µg·kg−1iv and propofol 2.5 mg·kg−1iv, with either cisatracu-rium 0.15 mg·kg−1iv (group Cisatracturium), or saline (group Placebo). Tracheal intubating conditions were assessed with the Copenhagen Score. A systematic screening for postoperative hoarseness and sore throat was performed 24 and 48 hr after anesthesia, followed by a nasofibroscopic examination when laryngeal symptoms persisted at 48 hr.Results: Twenty-four hr after anesthesia, the incidence of postoperative hoarseness and sore throat in the Cisatracurium and Placebo groups was 26.5% and 21.5%, respectively, and 48 hr after anesthesia, the incidence was 7.8% and 6.1%, respectively (P=0.32 andP=0.50 between groups, respectively). In the clinically evaluable population, the incidence of SLI, assessed at 48 hr by nasofibroscopy, was equivalent in both groups, 1.6%vs 1.5% in group Placebo and group Cisatracurium, respectively (P<0.001 for equivalence test), as was the occurrence of acceptable intubating conditions (95.4%vs 100%,P<0.05 for equivalence test). However, the occurrence of excellent intu-bating conditions was more frequent in group Cisatracurium than in group Placebo (P=0.0003).Conclusion: Following induction of anesthesia with propofol and moderate-dose remifentanil, cisatracurium did not confer a higher rate of good-to-excellent conditions for tracheal intubation, nor did muscle relaxation with cisatracurium decrease the rate of SLI after tracheal intubation.RésuméObjectif: Le besoin de relaxation musculaire dans le but d’améliorer les conditions d’intubation et de réduire l’incidence de morbidité laryngée demeure controversé. L’objectif de cette étude était de déterminer l’incidence de lésions laryngées symptomatiques et des conditions d’intubation acceptables (incluant les conditions bonnes et excellentes), avec ou sans cisatracurium pendant l’induction de l’anesthésie, et combiné à des doses modérées de rémifentanil et de propofol.Méthode: Dans cette étude d’équivalence prospective, randomisée et à double insu, les conditions d’intubation ont été comparées chez 130 patientes ASA I ou II. Toutes les patientes ont reçu 2 µg·kg−1 de rémifentanil iv et 2.5 mg·kg−1 de propofol iv, avec soit 0,15 mg·kg−1 de cisatracurium iv (groupe Cisatracurium), soit une solution saline (groupe Placebo). Les conditions d’intubation trachéale ont été évaluées à l’aide de l’échelle de Copenhague. Un dépistage systématique de l’enrouement et des maux de gorge postopératoires a été réalisé 24 et 48 h après l’anesthésie, suivi d’un examen nasofibros-copique lorsque les symptômes laryngés persistaient à 48 h.Résultats: L’incidence d’enrouement et de maux de gorge postopératoires à 24 h était de 26,5 % et 21,5 % dans les groupes Cisatracurium et Placebo, respectivement. Quarante-huit heures après l’anesthésie, l’incidence était de 7,8 % et 6,1 %, respectivement (P=0,32 et P=0,50 entre les groupes, respectivement). Dans la population évaluable cliniquement, l’incidence de lésions laryngées symptomatiques, évaluée à 48 h par nasofibrosco-pie, était équivalente dans les deux groupes, soit 1,6 % et 1,5 % dans le groupe Placebo et le groupe Cisatracurium, respectivement (P<0,001 pour le test d’équivalence), tout comme l’occurrence avec des conditions d’intubation acceptable (95,4 % vs 100 %, P<0,05 pour le test d’équivalence). Toutefois, l’occurrence dans les situations où les conditions d’intubation étaient excellentes était plus fréquente dans le groupe Cisatracurium que dans le groupe Placebo (P=0,0003).Conclusion: À la suite d’une induction de l’anesthésie à l’aide de propofol et de rémifentanil en dose modérée, le cisatracurium n’a pas procuré un taux plus élevé de conditions bonnes à excellentes pour l’intubation trachéale ; en outre, la relaxation musculaire procurée par le cisatracurium n’a pas non plus réduit le taux de lésions laryngées symptomatiques après l’intubation trachéale.

Optimal remifentanil dosage for providing excellent intubating conditions when co-administered with a single standard dose of propofol.

This dose–response study aimed to determine the dose of remifentanil combined with propofol 2.5 mg.kg−1 which provided excellent intubation conditions in 95% of patients. Ninety premedicated female ASA 1 and 2 patients were randomly allocated to five remifentanil dose groups (1, 2, 3, 4 or 5 μg.kg−1). Induction of anaesthesia was performed with a blinded dose of remifentanil infused over 60 s simultaneously co‐administered with propofol 2.5 mg.kg−1 infused over 45 s. Tracheal intubation was attempted 150 s after the beginning of induction. Intubating conditions were assessed with the Copenhagen score. A probit analysis was performed to calculate the intubating efficient doses (IED) of remifentanil in 95% of patients (IED95). Our data revealed that the IED95 of remifentanil was 4.0 (95% CI: 3.4–5.6) μg.kg−1, which was associated with a maximum decrease in heart rate and mean arterial pressure of < 30%, a finding which also applied to the other groups.

Effects of intravenous medium-chain triglycerides on pulmonary gas exchanges in mechanically ventilated patients

ObjectiveIn mechanically ventilated patients, pulmonary gas exchange was investigated during the administration of total parenteral nutrition containing medium-chain triglycerides or long-chain triglycerides as fat emulsions. DesignProspective, randomized, crossover trial (two lipid infusion periods of 8 hrs). SettingIntensive care unit in a university hospital. PatientsSix mechanically ventilated patients, using the pressure-support mode. InterventionsTotal caloric intake was adapted according to measured energy expenditure. Fat emulsion provided 50% of the energy expenditure. Patients were infused with 50% medium-chain/50% long-chain triglycerides or 100% long-chain triglycerides in a random sequence. Measurements and Main ResultsOxygen consumption, CO2 production, and minute ventilation were measured by indirect calorimetry. Pao2 and Paco2 were determined in blood samples. Medium-chain triglycerides increased oxygen consumption by 27.8% and minute ventilation by 14.3% at the end of the protocol. CO2 production, Pao2, and Paco2 were not different between groups. ConclusionsMedium-chain triglycerides cause an increase in metabolic demand in mechanically ventilated patients when they are infused over a short period. Postoperative or intensive care unit patients with a low pulmonary reserve should receive infusions of medium-chain triglycerides over a more prolonged period than long-chain triglycerides. (Crit Care Med 1994; 22:248–251)

Metabolic effects of a D-β-hydroxybutyrate infusion in septic patients: Inhibition of lipolysis and glucose production but not leucine oxidation

ObjectiveTo study the effect of a D-P-hydrox-ybutyrate infusion on protein metabolism, lipolysis, and endogenous glucose production in septic patients. DesignProspective, randomized trial. SettingIntensive care unit (ICU) and metabolic unit at a university hospital. PatientsTwelve ICU patients with sepsis and six healthy normal subjects. InterventionsSeptic patients were administered 4-hr infusions of either D-β-hydroxybutyrate or a control solution, 12 hrs after parenteral nutrition was replaced with an isotonic saline infusion. Measurements and Main ResultsThe appearance and oxidation rates of leucine (L[l-13C]leucine) and endogenous glucose production (D[6,6-2H2]glucose), plasma fatty acids, and glycerol values were measured before and at the end of infusion of D-β-hydroxybutyrate or control solution. Unlike the control test, the D-β-hydroxybutyrate infusion decreased glucose production, fatty acids, and glycerol concentrations, but failed to decrease the leucine oxidation rate. ConclusionExogenous ketone-bodies infusion decreased lipolysis and glucose production in septic patients but had no beneficial effect on protein metabolism, as evaluated with L[l-13C]leucine. (Crit Care Med 1994; 22:1091–1098)

Antibioprophylaxie pour césarienne avant incision ou après clampage du cordon ? Méta-analyse

OBJECTIVE The objective of this systematic review was to assess the effect of preoperative rather than after umbilical cord clamping antimicrobial prophylaxis for caesarean delivery on maternal and neonatal infectious postoperative morbidity. STUDY DESIGN Meta-analysis. METHODS Three electronic databases (Pubmed, Cochrane Central Register of Randomized Controlled Trials and Embase) were searched without language restriction and retrieved 201 potentially relevant trials. Five randomized controlled trials (n=1108) studying the timing of antimicrobial prophylaxis for caesarean section were included. The quality of included trials was assessed on the modified Oxford validity scale. RESULTS Preoperative administration of antibiotics (n=456) rather than after cord clamping (n=563) provides a significant reduction in the incidence of endometritis (Odds Ratio (OR) 0.59 [95% Confidence Interval (CI) 0.35-0.98]) and of total maternal infectious morbidity (OR 0.51 [95% CI 0.32-0.82]). This benefit was not observed regarding the incidence of wound infection (Peto OR 0.58 [95% CI 0.29-1.16]), neonatal infection (Peto OR 1.06 [95% CI 0.57-1.96]), neonatal sepsis workup (OR 1.02 [95% CI 0.67-1.54]), neonatal documented sepsis (Peto OR 0.93 [95% CI 0.43-2.02]) or neonatal intensive care unit admission (OR 0.97 [95% CI 0.61-1.56]). No significant heterogeneity was observed between the included studies. CONCLUSION This meta-analysis provides strong evidence that the preoperative rather than after cord clamping administration of antimicrobial prophylaxis for caesarean delivery provides a reduction in the incidence of endometritis and maternal total infectious morbidity without affecting the incidence of wound infection and neonatal infectious morbidity.

Ultrasonographic measurement of antral area for estimating gastric fluid volume in parturients

BACKGROUND The aim of this prospective observational study was to assess the performance of ultrasonographic gastric antral area (GAA) to predict gastric fluid volumes of >0.4, >0.8 and >1.5 ml kg(-1), in fasted women in established labour. METHODS A first ultrasound examination of the antrum was performed, in order to confirm gastric vacuity by using a qualitative score. Baselines GAA measurements were obtained in both supine and right lateral decubitus positions. Thereafter, parturients were allowed to drink clear fluids only. Measurement of GAA was repeated 15 min after last fluid intake, in both supine and right lateral positions. Receiver operating characteristics (ROC) curves were constructed to determine the accuracy of GAA to diagnose ingested volumes of >0.4, >0.8 and >1.5 ml kg(-1). RESULTS Data from forty parturients were analysed. The areas under the ROC curves ranged from 80% to 86%. The cut-off value for antral area measured in supine position, to detect a volume >0.4 ml kg(-1), was 387 mm(2), with a sensitivity of 87%, a specificity of 70% and a negative predictive value of 85%. A cut-off value of 608 mm(2) predicted a fluid volume >1.5 ml kg(-1), with a specificity of 94%, a sensitivity of 75% and a negative predictive value of 92%. CONCLUSIONS This study provides cut-off values for GAA that could be used in addition to the qualitative assessment of the antrum to define a full stomach in labouring patients.

Changes in qualitative and quantitative ultrasound assessment of the gastric antrum before and after elective caesarean section in term pregnant women: a prospective cohort study.

Ultrasound measurement of the antral cross‐sectional area allows a quantitative estimate of gastric contents in non‐pregnant adults, but this relationship may be affected by compression of the stomach exerted by the gravid uterus during pregnancy. This study aimed to assess differences in quantitative (Perlas score) and qualitative (antral cross‐sectional area) ultrasound assessments of the gastric antrum performed immediately before and after caesarean section. Forty‐three women having elective caesarean section performed under spinal anaesthesia were studied in the semirecumbent and semirecumbent‐right lateral positions. Thirty‐nine women showed no change in stomach contents using the Perlas score between the two measurement periods; four women showed a change, but by one grade only. The median (IQR [range]) antral cross‐sectional area was 323 (243–495 [103–908]) mm2 before, and 237 (165–377 [112–762]) mm2 after, caesarean section in the semirecumbent position (p = 0.001); the comparable values in the semirecumbent‐right lateral position were 418 (310–640 [161–1238]) mm2 and 362 (280–491 [137–1231]) mm2 (p = 0.09). The distance between the skin and the antrum, and the aorta and the antrum, decreased significantly in both positions after surgery. We suggest that our results indicate that stomach contents remain largely unchanged in women having elective caesarean section, but antral cross‐sectional area decreases, especially in the semirecumbent position, related to a change in the position of the stomach within the abdomen. This implies that the relationship of antral cross‐sectional area to volume of stomach contents, which has been determined for non‐pregnant subjects, may not apply in term pregnant women.

Resuscitation with lipid, epinephrine, or both in levobupivacaine-induced cardiac toxicity in newborn piglets

BACKGROUND The optimal dosing regimens of lipid emulsion, epinephrine, or both are not yet determined in neonates in cases of local anaesthetic systemic toxicity (LAST). METHODS Newborn piglets received levobupivacaine until cardiovascular collapse occurred. Standard cardiopulmonary resuscitation was started and electrocardiogram (ECG) was monitored for ventricular tachycardia, fibrillation, or QRS prolongation. Piglets were then randomly allocated to four groups: control (saline), Intralipid(®) alone, epinephrine alone, or a combination of Intralipd plus epinephrine. Resuscitation continued for 30 min or until there was a return of spontaneous circulation (ROSC) accompanied by a mean arterial pressure at or superior to the baseline pressure and normal sinus rhythm for a period of 30 min. RESULTS ROSC was achieved in only one of the control piglets compared with most of the treated piglets. Mortality was not significantly different between the three treatment groups, but was significantly lower in all the treatment groups compared with control. The number of ECG abnormalities was zero in the Intralipid only group, but 14 and 17, respectively, in the epinephrine and epinephrine plus lipid groups (P<0.05). CONCLUSIONS Lipid emulsion with or without epinephrine, or epinephrine alone were equally effective in achieving a return to spontaneous circulation in this model of LAST. Epinephrine alone or in combination with lipid was associated with an increased number of ECG abnormalities compared with lipid emulsion alone.

Ultrasound assessment of the gastric contents for the guidance of the anaesthetic strategy in infants with hypertrophic pyloric stenosis: a prospective cohort study

BACKGROUND Evacuation of gastric content through a nasogastric tube, followed by rapid sequence induction, is usually recommended in infants undergoing pyloromyotomy. However, rapid sequence induction may be challenging, and is therefore controversial. Some anaesthetists regularly perform classical non-rapid induction technique, after blind aspiration of the gastric contents, although this aspiration may have been incomplete. This prospective observational study aimed to assess whether the ultrasound monitoring of the aspiration of the stomach contents, may be useful to appropriately guide the choice of the anaesthetic induction technique, in infants undergoing pyloromyotomy. METHODS Infants undergoing pyloromyotomy were consecutively included. Ultrasound assessment of the antrum was performed before and after the aspiration of the gastric contents through a 10 French gastric tube. The stomach was defined as empty when no content was seen in both supine and right lateral positions. The correlation between antral area and the aspirated gastric volume was also tested. RESULTS We analysed 34 infants. Ultrasound examination of the antrum failed in three infants. The stomach was empty in 30/34 infants (nine before aspiration, 21 after aspiration), allowing to perform a non-rapid induction technique in 88.2% of the infants. There was a significant correlation between antral area measured in right lateral decubitus and the aspirated gastric volume. CONCLUSIONS Our results suggest that the qualitative ultrasound assessment of the antral content may be a simple and useful point-of-care tool, for the choice of the most appropriate anaesthetic technique for pyloromyotomy according to the estimated risk of pulmonary aspiration of gastric contents.