Emmanuel Marret

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

Background: The optimal effective dose of epidural morphine that provides postoperative analgesia after caesarean section with minimal side effects remains debated.

Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials

IntroductionThe efficacy of steroid administration before planned tracheal extubation in critical care patients remains controversial with respect to the selection of patients most likely to benefit from this treatment.MethodsWe performed an extensive literature search for adult trials testing steroids versus placebo to prevent reintubation or laryngeal dyspnoea. Studies were evaluated on a five-point scale based on randomisation, double-blinding and follow-up. Our analysis included trials having a score three or higher with patients mechanically ventilated for at least 24 hours and treated with steroids before extubation, taking into account the time of their administration (early vs late) and if the population selected was at risk or not.ResultsSeven prospective, randomised, double-blinded trials, including 1846 patients, (949 of which received steroids) were selected. Overall, steroids significantly decreased the risk of reintubation (relative risk (RR) = 0.58, 95% confidence interval (CI) = 0.41 to 0.81; number-needed-to-treat (NNT) = 28, 95% CI = 20 to 61) and stridor (RR = 0.48, 95% CI = 0.26 to 0.87; NNT = 11, 95% CI = 8 to 42). The effect of steroids on reintubation and stridor was more pronounced for selected high-risk patients, as determined by a reduced cuff leak volume (RR = 0.38, 95% CI = 0.21 to 0.72; NNT = 9, 95% CI = 7 to 19; and RR = 0.40, 95% CI = 0.25 to 0.63; NNT = 5, 95% CI = 4 to 8, respectively). In contrast, steroid benefit was unclear when trials did not select patients for their risk of reintubation (RR = 0.67, 95% CI = 0.45 to 1.00; NNT = 44, 95% CI ≥ 26 to infinity) or stridor (RR = 0.56, 95% CI = 0.20 to 1.55).ConclusionsThe efficacy of steroids to prevent stridor and reintubation was only observed in a high-risk population, as identified by the cuff-leak test and when it was administered at least four hours before extubation. The benefit of steroids remains unclear when patients at high risk are not selected.

Performance of the Airtraq laryngoscope after failed conventional tracheal intubation: a case series.

Background: The Airtraq™, a new disposable indirect laryngoscope, was evaluated in patients with difficult intubation.

A comparison of ropivacaine and bupivacaine for cervical plexus block.

We compared bupivacaine 0.5% and ropivacaine 0.75% for cervical plexus block (CB). Forty patients scheduled for carotid artery surgery were allocated randomly to undergo superficial and deep CB with 30 mL of one of the two anesthetic solutions. We evaluated the onset of anesthetic block; the requirement for supplementation during the surgery; the patients’ satisfaction; postoperative pain on a visual analog scale at 1, 2, and 3 h; and the use of paracetamol as a rescue analgesic medication. Arterial blood was sampled immediately and 1, 3, 5, 10, 15, 30, 45, and 60 min after CB for measurements of bupivacaine or ropivacaine concentrations. Patients in both groups had equivalent onset of CB, local infiltration with lidocaine during surgery, and satisfaction scores. In the Bupivacaine group, visual analog scale scores were lower at 2 and 3 h, and the delay before paracetamol administration was prolonged. Observed peak concentrations were larger in the Ropivacaine group (4.25 [2.07–6.59 mg/L] vs 3.02 [0.98–5.82 mg/L]), but time to reach peak concentrations was comparable (5 [1–15 min] vs 5 [0–45 min] in the Ropivacaine and Bupivacaine groups, respectively). We conclude that ropivacaine has no advantage over bupivacaine for CB.

Accelerated idioventricular rhythm associated with desflurane administration

IMPLICATIONSnThe rapid administration of desflurane results in transient hypertension and tachycardia, especially in the presence of sympathetic imbalance. We report a case in which rapid administration of desflurane precipitated an accelerated idioventricular rhythm in a patient. This may have been related to a period of inadequate anesthesia.

Hypnosis increases heat detection and heat pain thresholds in healthy volunteers

Background and Objectives Hypnosis has been reported to induce analgesia and to facilitate anesthesia. To date, hypnotic-induced analgesia has had little explanation and it has even been questioned. The current study was thus designed to investigate the effect of hypnotic suggestion on thermal-detection thresholds, heat pain, and heat-pain tolerance thresholds. Methods In 15 healthy volunteers, enrolled in a randomized cross-over study, thermal thresholds were investigated in 2 sequences of measurements, under waking and hypnotic states, using a thermal stimulator. Results Heat detection and heat-pain thresholds were increased under hypnosis (from 34.3 ± .9°C to 36.0 ± 2.9°C and 45.0 ± 3.7°C to 46.7 ± 2.7°C, respectively, P < .05), whereas heat-pain tolerance and cold-detection thresholds were not statistically changed. Conclusion These results indicate that hypnosis may partly impair the detection of Aδ and C fibers stimulation, potentially explaining its analgesic effect.

Lobectomy and postoperative thromboprophylaxis with enoxaparin improve blood hypercoagulability in patients with localized primary lung adenocarcinoma

BACKGROUNDnPatients with lung adenocarcinoma undergoing surgery are in high risk for VTE and receive routine post-operative thromboprophylaxis with LWMH.nnnAIMnWe investigated markers of hypercoagulability in patients with primary localized adenocarcinoma and the modifications induced by lobectomy and postoperative administration of enoxaparin.nnnMATERIALS AND METHODSnPatients suffering from localised primary lung adenocarcinoma (n=15) scheduled for lobectomy were studied. The control group consisted of 15 healthy age and sex-matched individuals. Blood was collected before anaesthesia induction and after surgery, at several intervals until the 7th post-operative day. Samples were assessed for thrombin generation, phosphatidylserin expressing platelet derived microparticles expressing (Pd-MP/PS(+)), tissue factor activity (TFa), FVIIa and TFPI levels, procoagulant phospholipid dependent clotting time and anti-Xa activity.nnnRESULTSnAt baseline, patients showed increased thrombin generation and Pd-MP/PS(+). After lobectomy thrombin generation significantly decreased. Administration of enoxaparin attenuated thrombin generation. In about 50% of samples collected post-operatively an increase of thrombin generation occurred despite the presence of the expected anti-Xa activity in plasma. At the 7th post-operative day, 3 out of 15 patients showed a significant increase of thrombin generation.nnnCONCLUSIONnIn patients with localized lung adenocarcinoma, hypercoagulability is characterized by high thrombin generation and increased concentration of Pd-MP/PS(+). Tumor mass resection is related with attenuation of thrombin generation, which is inhibited by postoperative thromboprophylaxis with enoxaparin. The response to enoxaparin is not predicted by the concentration of the anti-Xa activity in plasma. The assessment of thrombin generation during prophylaxis with enoxaparin allows to identify patients with high residual plasma hypercoagulability.

Comparison of intrathecal bupivacaine and ropivacaine with different doses of sufentanil

Background: Spinal bupivacaine produces a complete anaesthetic block of a longer duration than ropivacaine, which leads to a potentially increased risk of failure. A combination of sufentanil to ropivacaine may improve the blocks reliability.