Fabienne Roelants

Postoperative analgesic effects of continuous wound infiltration with diclofenac after elective cesarean delivery.

Background:Postoperative pain mostly results from sensitization of afferent fibers at injury sites driving central sensitization. Recently, peripheral processes have gained attention as mechanisms of hyperalgesia, and prostaglandins are among highly sensitizing agents. To date, perioperative administration of a single local dose of nonsteroidal antiinflammatory drugs has shown inconclusive efficacy. Rather than a single bolus, the current study evaluates the postoperative analgesic effect of diclofenac continuous intrawound infusion after elective cesarean delivery. Methods:Ninety-two parturients were randomly allocated to receive a 48-h continuous intrawound infusion with 240 ml containing 300 mg diclofenac, 0.2% ropivacaine, or saline. In the ropivacaine and saline groups, patients also received 75 mg intravenous diclofenac every 12 h for 48 h. Postoperative evaluation included intravenous morphine consumption by patient-controlled analgesia and visual analog pain scores. Punctate mechanical hyperalgesia surrounding the wound and presence of residual pain after 1 and 6 months were also assessed. Results:Continuous diclofenac infusion significantly reduced postoperative morphine consumption (18 mg; 95% confidence interval, 12.7–22.2) in comparison with saline infusion and systemic diclofenac (38 mg; 95% confidence interval, 28.8–43.7) (P = 0.0009) without unique adverse effects. Postoperative analgesia produced by local diclofenac infusion was as effective as local ropivacaine infusion with systemic diclofenac. Conclusions:After elective cesarean delivery, continuous intrawound infusion of diclofenac demonstrates a greater opioid-sparing effect and better postoperative analgesia than the same dose administered as an intermittent intravenous bolus.

Patient-controlled intravenous analgesia using remifentanil in the parturient.

Purpose: To show the use of the short acting opioid remifentanil for labour analgesia when epidural analgesia is considered to be contraindicated.Clinical features: After Ethics Committee approval and informed consent, six patients (36–40 wk gestation), in whom epidural analgesia was considered contraindicated (women refusing regional analgesia, presenting with coagulation or platelet abnormalities or sepsis) benefited from patient-controlled intravenous analgesia (PCIA) with remifentanil. The Abbott Lifecare patient-controlled analgesia (PCA) pump with remifentanil 50 µg·ml−1 was set to deliver remifentanil continuous background infusion of 0.05 µg·kg−1·min−1 and 25 µg boluses with a five minutes lockout period. The PCIA was started when the parturients experienced regular painful contractions (cervical dilatation of at least 4 cm) and stopped just before delivery (cervix fully dilated). Maternal monitoring included non-invasive blood pressure measurements, heart rate, percutaneous arterial oxyhemoglobin saturation and respiratory rate. Percutaneous fetal heart rate was continuously monitored. All patients remained alert or sleepy but easily arousable and were satisfied with their analgesia. No particular side effects have been noticed. Apgar scores were between 6 and 10.Conclusion: Remifentanil PCIA combining low continuous background infusion and small bolus doses is an alternative when epidural analgesia in labour is contraindicated. Under careful anesthesia monitoring, the technique seems to be safe for both mother and baby, at least when delivery occurs at or near the normal term of pregnancy.RésuméObjectif: Décrire l’utilisation de l’opioïde de courte durée, rémifentanil, pour l’analgésie pendant le travail obstétrical lorsque l’analgésie épidurale est contre-indiquée.Éléments cliniques: Six patientes (de 36 à 40 sem de grossesse), chez qui l’analgésie épidurale était contreindiquée (des femmes qui refusaient l’analgésie régionale, présentaient des anomalies de coagulation ou de plaquettes ou de la septicémie), ont consenti à participer à l’étude, approuvée par le Comité d’éthique, et ont bénéficié de l’analgésie intraveineuse autocontrôlée (AIAC) avec du rémifentanil. Une pompe Abbott Lifecare pour l’analgésie autocontrôlée (AAC) a été installée avec 50 µg·ml-1 de rémifentanil administrés en perfusion de fond continue de 0,05 µg·kg-1·min-1 et en bolus de 25 µg entrecoupés de périodes réfractaires de cinq minutes. Le début de l’AIAC correspondait à des contractions douloureuses régulières (dilatation cervicale d’au moins 4 cm) et la fin, avec la naissance du bébé (col complètement dilaté). Le monitorage des mères comprenait la mesure non effractive de la tension artérielle, de la fréquence cardiaque, de la saturation percutanée du sang artériel en oxyhémoglobine et de la fréquence respiratoire. La fréquence cardiaque foetale a été placée aussi sous monitorage continu. Toutes les patientes sont demeurées éveillées ou somnolentes, mais faciles à réveiller et ont été satisfaites de l’analgésie. Aucun effet secondaire particulier n’a été noté. Les indices d’Apgar se situaient entre 6 et 10.Conclusion: Pendant le travail obstétrical, l’administration de rémifentanil en AIAC combinant une faible perfusion de fond continue et de petites doses en bolus peut remplacer une analgésie épidurale contre-indiquée. Utilisée sous monitorage attentif de l’anesthésie, la technique semble sans risque pour la mère et le bébé, du moins lorsque la naissance survient à terme ou près du terme normal de la grossesse.

An evaluation of the postoperative antihyperalgesic and analgesic effects of intrathecal clonidine administered during elective cesarean delivery.

BACKGROUND:Intrathecal clonidine improves intraoperative anesthesia and postoperative analgesia after cesarean delivery. Clonidine also possesses antihyperalgesic properties. Hyperalgesia contributes to postoperative pain and may be associated with increased risk of chronic pain after surgery. In this study, we evaluated the postoperative antihyperalgesic effect of intrathecal clonidine after caesarean delivery. METHODS:Ninety-six parturients undergoing elective cesarean delivery were randomly assigned to receive intrathecal bupivacaine-sufentanil (BS group), bupivacaine-sufentanil-clonidine 75 &mgr;g (BSC group), or bupivacaine-clonidine 150 &mgr;g (BC group). The primary outcome was the extent and the incidence of periincisional punctate mechanical hyperalgesia as assessed by response to application of a von Frey filament at 24 and 48 h after cesarean delivery. Postoperative morphine requirements and pain scores, as well as residual pain at 1, 3, and 6 mo, were also assessed. RESULTS:The BC group had a significantly reduced area of periincisional hyperalgesia at 48 h (median, 25th–75th percentiles): 1.0 (1.0 – 3.3) cm2 vs 9.5 (5.0–14.0) cm2 in the BS group vs 5.0 (2.5–12.3) cm2 in the BSC group (P = 0.02 with the BS group). The incidence of hyperalgesia at 48 h was also lower in the BC group: 16% vs 41% in the BS group vs 34% in the BSC group (P = 0.03 with BS group). Postoperative morphine consumption, pain scores, and incidence and intensity of residual pain did not differ among groups. CONCLUSIONS:Intrathecal clonidine 150 &mgr;g combined with bupivacaine had a postoperative antihyperalgesic effect expressed as a significant reduction in the extent and incidence of periincisional punctate mechanical hyperalgesia at 48 h after elective cesarean delivery compared with intrathecal bupivacaine-sufentanil and intrathecal clonidine 75 &mgr;g-bupivacaine-sufentanil.

Epidural administration of neostigmine and clonidine to induce labor analgesia: evaluation of efficacy and local anesthetic-sparing effect.

Background:Epidural clonidine produces analgesia without motor impairment, and is associated with a local anesthetic–sparing effect during labor. The authors have recently demonstrated that epidural neostigmine initiates selective labor analgesia devoid of adverse effects. Both drugs possess common analgesic mechanisms mediated through spinal acetylcholine release. This study evaluates their epidural combination in parturients. Methods:At the beginning of labor, parturients were randomly allocated to one of five groups to receive one of the following after a test dose: 150 &mgr;g epidural clonidine, 750 &mgr;g neostigmine, or 75 &mgr;g clonidine combined with 250, 500, or 750 &mgr;g neostigmine. A pain score (visual analog scale, 0–100) was recorded before administration and at regular intervals until request for a supplemental injection. Subsequent analgesia was provided by continuous epidural infusion of ropivacaine. Results:Parturients did not differ regarding demographic data and initial pain score. Clonidine 150 &mgr;g, neostigmine 750 &mgr;g, and 75 &mgr;g clonidine plus 250 &mgr;g neostigmine produced ineffective and short-lasting effects. Clonidine 75 &mgr;g plus 500 &mgr;g neostigmine and 75 &mgr;g clonidine plus 750 &mgr;g neostigmine presented comparable durations of 90 ± 32 and 108 ± 38 min (mean ± SD), respectively, and final analgesic efficacies, with 72.2% and 84%, respectively, of the parturients reporting a visual analog scale score of less than 30 out of 100 after 30 min. Ropivacaine use was significantly reduced in all clonidine groups (average, 9.5 mg/h) in comparison with neostigmine alone (17 ± 3 mg/h). No adverse effects were observed for 75 &mgr;g clonidine combined with any dose of neostigmine while maternal sedation (20%) and hypotension (33%) occurred with 150 &mgr;g clonidine alone. Conclusions:Epidural clonidine, 75 &mgr;g, with 750 &mgr;g neostigmine is an effective combination to initiate selective labor analgesia without adverse effects. Clonidine use further reduces local anesthetic consumption throughout the course of labor.

Epidural neostigmine combined with sufentanil provides balanced and selective analgesia in early labor.

Background:This study evaluated the efficacy of an epidural single dose of neostigmine combined with sufentanil to provide selective and balanced analgesia at the beginning of labor. Methods:After informed consent, 125 healthy parturients were randomly allocated to receive, after a test dose, a single injection of either epidural sufentanil 20 &mgr;g (minimal analgesic dose) or 10 &mgr;g or a combination of sufentanil 10 &mgr;g with neostigmine 250, 500, or 750 &mgr;g in a total volume of 12 ml. Pain scores were recorded at regular intervals to determine onset and duration of analgesia. Maternal and fetal vital parameters as well as side effects were closely monitored. Results:Parturients did not differ concerning demographic data. Epidural neostigmine 500 &mgr;g with sufentanil 10 &mgr;g produced effective analgesia (visual analog scale <30 mm within 10 min in 72% parturients and within 15 min in 85% parturients; average duration of 119 min, confidence interval 96–142 min) that was as effective as epidural sufentanil 20 &mgr;g. Epidural combination with neostigmine 250 &mgr;g was ineffective, whereas 750 &mgr;g did not produce higher effect than 500 &mgr;g. No motor block was recorded. Maternal and fetal vital parameters remained stable during labor. Conclusions:Epidural combination of neostigmine 500 &mgr;g (e.g., 6–7 &mgr;g/kg) with sufentanil 10 &mgr;g provides similar duration of analgesia as epidural sufentanil 20 &mgr;g and allows effective and selective analgesia devoid of side effects in the first stage of labor.

The effect of epidural neostigmine combined with ropivacaine and sufentanil on neuraxial analgesia during labor.

Spinal neostigmine produces analgesia without respiratory depression or hypotension but provokes major gastrointestinal side effects. Epidural injection of this drug, however, appears to induce analgesia devoid of such side effects. In this study, we evaluated the effect of a bolus of epidural neostigmine on the duration and magnitude of analgesia in early labor and assessed its eventual sparing effect on subsequent local anesthetic requirements. Epidural neostigmine methylsulfate (maximal dose 4 &mgr;g/kg) was added to 10 mL of ropivacaine 0.1%, with and without sufentanil 10 &mgr;g, to initiate analgesia. Twenty minutes after injection, pain score, sensory level, and motor block were assessed. Time until request for supplemental epidural medication was also recorded. Patient-controlled epidural analgesia with ropivacaine 0.1% was used for epidural supplementation. Maternal and fetal side effects were closely recorded. Neostigmine (4 &mgr;g/kg), when added to ropivacaine 10 mg, provided equivalent analgesia to ropivacaine 20 mg but was less effective than sufentanil 10 &mgr;g for the initiation of labor epidural analgesia. Further, neostigmine did not modify the subsequent patient-controlled epidural analgesia local anesthetic requirements during labor. No hemodynamic instability, additional motor block, or bothersome side effects were recorded.

Loss of resistance to saline with a bubble of air to identify the epidural space in infants and children: a prospective study.

S ince 1986, epidural analgesia has been routinely used in our hospital to provide postoperative analgesia for children undergoing major surgery. Identification of the epidural space is accomplished by using the loss of resistance to saline with a bubble of air. This technique is used in our hospital to identify the epidural space in adults, and its use in children has already been suggested (1). As this technique has not yet been described in pediatric patients, we prospectively collected data to evaluate the incidence of technical problems at the time of identification of the epidural space and of subsequent insertion of an epidural catheter in infants and children.

In children, the addition of epinephrine modifies the pharmacokinetics of ropivacaine injected caudally.

PurposeTo describe the modification of the ropivacaine (R) pharmacokinetics produced by the addition of epinephrine (E).MethodsAfter Institutional Review Board approval, 18 ASA I boys received a caudal block (1 mL·kg−1) with either plain 0.2% R (Group E-) or with 0.2% R containing E (5 μg·mL−1; Group E+). Venous blood samples were taken at zero, 15, 30, 60, 90, 120, 180, 240, 420, 720, 1440 min after caudal injection. Total R concentration in plasma was determined by high pressure liquid chromatography. Maximal concentration (Cmax) and time to peak concentration (Tmax) were obtained from the data, terminal half-life (T1/2z), clearance (Cl) and volume of distribution (Vd) were estimated by a non-compartmental approach. Subsequently, in order to determine the absorption rate (Ka) and to reduce to number of blood samples, 25 other children, receiving plain R and another group of 25 receiving the E solution were studied using a population approach (NONMEM). A one compartment model with first order absorption was used. The effect of weight, age and E on Cl, Vd and Ka was estimated.ResultsCmax was significantly lower in Group E+ (0.93 mg·L−1 ±0.29vs 0.61 mg·L−1 ± 0.28,P = 0.05) and Tmax occurred later (124 min ± 53vs 47 min ± 16,P = 0.003). Weight was a significant covariate for Cl and Vd while E significantly slowed R Ka [Group I Ka 0.025 min−1 [coefficient of variation (CV) 21 %] vs 0.078 min−1 (CV 25%) in Group II].ConclusionThe addition of E significantly modifies the pharmacokinetics of R injected caudally.RésuméObjectifDécrire la modification de la pharmacocinétique de la ropivacaïne (R) induite par l’addition d’épinéphrine (E).MéthodeAyant reçu l’approbation du Comité d’examen, nous avons administré un bloc caudal à 18 garçons d’état physique ASA I (1 mL·kg−1) avec, soit de la R simple à 0,2 % (Groupe E-), soit dela R à 0,2 % contenant de l’E (5 μg·mL−1; Group E+). Des échantillons de sang veineux ont été prélevés à zéro, 15, 30, 60, 90, 120, 180, 240, 420, 720, 1 440 min après l’injection caudale. La concentration plasmatique totale de Ra été déterminée par chromatographie liquide haute pression. La concentration maximale (Cmax) et le temps d’atteindre la concentration maximale (Tmax) ont été obtenus des données; la demivie terminale (T1/2z), la clairance (Cl) et le volume de distribution (Vd) ont été évalués par une méthode non compartimentale. Par la suite, dans le but de déterminer la vitesse d’absorption (Ka) et de réduire le nombre d’échantillons sanguins, 25 enfants, recevant de la R simple et un autre groupe de 25, la solution d’E, ont été étudiés par une approche de population (NONMEM). Un modèle monocompartimental avec absorption du premier ordre a été utilisé. L’effet du poids, de l’âge et de l’E sur la Cl, le Vd et la Ka a été évalué.RésultatsLa Cmax a été significativement plus faible dans le Groupe E+ (0,93 mg·L−1 ± 0,29 vs 0,61 mg·L−1 ± 0,28, P = 0,05) et le Tmax a été plus tardif (124 min ± 53 vs 47min ± 16, P = 0,003). Lepoids a été une covariable significative pour la Cl et le Vd tandis que l’E a significativement ralenti la Kadela R [Groupe I, Ka 0,025 min−1 [coefficient de variation (CV) 21 %] vs 0,078 min−1 (CV 25 %) dans le Groupe II].ConclusionL’addition d’E modifie de façon significative la pharmacocinétique de la R en injection caudale.

Evaluation of pregabalin as an adjuvant to patient-controlled epidural analgesia during late termination of pregnancy

Introduction:Late termination of pregnancy combines psychological distress with severe physical pain. The present study evaluated the benefit of adding oral pregabalin to epidural analgesia during this procedure. Methods:Healthy women were randomly allocated to receive either oral pregabalin 150 mg/12 h or prazepam 10 mg/12 h at the induction of the late termination of pregnancy procedure. When they felt abdominal pain (numerical rating scale ranging from 0 [no pain] to 100 [worst pain possible]), patient-controlled epidural analgesia was activated and set to deliver ropivacaine 0.1% with sufentanil 0.25 &mgr;g/ml, 5 ml/h with a bolus dose of 5 ml/30 min. Rescue analgesia was available as needed by administration of 10 ml ropivacaine 0.1% (pain score less than 60/100) or 0.2% (at least 60/100). The primary outcome was the consumption of epidural analgesics. Results:Forty-eight patients participated in the study. Demographic and obstetric data were similar. Pregabalin reduced total ropivacaine consumption 11.3 ± 3.2 mg/h (mean ± SD) versus 15.1 ± 4.9 mg/h in the prazepam group (P = 0.005), an effect related to a decrease in the need for rescue analgesia. In the pregabalin group, fewer women asked for rescue dose (75 vs. 96%; P = 0.048), and the number of rescue doses per patient was reduced (1 [0–2] vs. 2 [1–3]); median [interquartile range], P = 0.005), particularly the need for ropivacaine 0.2%. Discussion:This is the first study considering the use of pregabalin for labor pain associated with late termination of pregnancy, showing that pregabalin 150 mg/12 h is a helpful adjuvant to epidural analgesia. Modulation of both visceral sensitization and affective component of pain may contribute to the benefits observed.

Hypnosis in the Perioperative Management of Breast Cancer Surgery: Clinical Benefits and Potential Implications

The aim of this review is to summarize data published on the use of perioperative hypnosis in patients undergoing breast cancer surgery (BCS). Indeed, the majority of BCS patients experience stress, anxiety, nausea, vomiting, and pain. Correct management of the perioperative period and surgical removal of the primary tumor are clearly essential but can affect patients on different levels and hence have a negative impact on oncological outcomes. This review examines the effect of clinical hypnosis performed during the perioperative period. Thanks to its specific properties and techniques allowing it to be used as complementary treatment preoperatively, hypnosis has an impact most notably on distress and postoperative pain. During surgery, hypnosis may be applied to limit immunosuppression, while, in the postoperative period, it can reduce pain, anxiety, and fatigue and improve wound healing. Moreover, hypnosis is inexpensive, an important consideration given current financial concerns in healthcare. Of course, large randomized prospective studies are now needed to confirm the observed advantages of hypnosis in the field of oncology.