Gemma Hayek

Prophylactic ondansetron is effective in the treatment of nausea and vomiting but not on pruritus after cesarean delivery with intrathecal sufentanil-morphine

STUDY OBJECTIVES To assess the safety and efficacy of ondansetron for prevention of pruritus, nausea and vomiting after cesarean delivery with intrathecal sufentanil-morphine. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Referral center, institutional practice. PATIENTS 100 nonbreastfeeding women undergoing elective cesarean delivery with sufentanil-morphine-bupivacaine anesthesia. INTERVENTIONS After the umbilical cord was clamped, patients in Group 1 received ondansetron 8 mg intravenously (IV) and patients in Group 2 received placebo. MEASUREMENTS Frequency and severity of postoperative (24-hour) pruritus, nausea and vomiting, surgical pain, and side effects related to ondansetron were recorded. MAIN RESULTS In the ondansetron group, 38 patients had pruritus (16 mild and 22 severe) and 9 patients had nausea and vomiting (5 mild and 4 severe). In the placebo group, 41 patients had pruritus (21 mild and 20 severe) and 29 patients had nausea and vomiting (9 mild and 15 severe). The frequency and severity of the nausea and vomiting episodes were significantly reduced in the ondansetron group. Pain scores were comparable between groups. No side effects related to ondansetron were reported. CONCLUSIONS Prophylactic IV ondansetron 8 mg is safe and effective in reducing the frequency and the severity of nausea and vomiting, but not pruritus, following cesarean delivery with intrathecal sufentanil-morphine.

Pulse Pressure Variation Predicts Fluid Responsiveness in Elderly Patients After Coronary Artery Bypass Graft Surgery

OBJECTIVE To assess the ability of pulse pressure variation to predict fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery. DESIGN A prospective, interventional study. SETTING An academic, tertiary referral hospital. PARTICIPANTS Sixty patients >70 years old and mechanically ventilated after coronary artery bypass graft surgery. INTERVENTIONS Intravascular volume expansion using 6% hydroxyethyl starch solution, 7 mL/kg over 20 minutes. MEASUREMENTS AND MAIN RESULTS Heart rate, arterial blood pressure, pulse pressure variation, central venous pressure, pulmonary artery occlusion pressure, and stroke volume index were measured immediately before and after volume expansion. Fluid responsiveness was defined as an increase in stroke volume index ≥ 15% after volume expansion. Forty-one patients were fluid responders and 19 patients were nonresponders. In contrast to central venous pressure or pulmonary artery occlusion pressure, pulse pressure variation was higher in the responders than in the nonresponders (22 ± 6% v 9.3 ± 3%, p = 0.001) and correlated with the percent changes in the stroke volume index after volume expansion (r = 0.47, p = 0.001). The area under the receiver operating characteristic curve for pulse pressure variation was 0.85 (95% confidence interval 0.75-0.94). The threshold value of 11.5% allowed the discrimination between responders and nonresponders with a sensitivity of 80% and a specificity of 74%. CONCLUSIONS Pulse pressure variation is a reliable predictor of fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

Correlation between central venous oxygen saturation and oxygen delivery changes following fluid therapy

Background: The rationale for using central venous oxygen saturation (ScvO2) in various clinical scenarios is that it reflects the balance between oxygen delivery (DO2) and demands. In this study, we evaluated the correlation between ScvO2 and DO2 changes (ΔDo2, ΔScvO2) in patients receiving fluid therapy following coronary surgery. We also correlated the changes of mean arterial pressure (ΔMAP) and central venous pressure (ΔCVP), with ΔDO2.

Prognostic importance of automated ST-segment monitoring after coronary artery bypass graft surgery

Background: Automated ST‐segment monitors are widely used in cardiac surgery units. The purpose of this study was to determine if cardiac morbidity and mortality, after CABG surgery, are predicted by ECG ST‐segment changes on automated monitors.

Accuracy of radial arterial pressure measurement during surgery under controlled hypotension

Background: Radial arterial pressure underestimates the pressure in the aorta in several clinical situations. A central‐to‐radial pressure gradient was attributed to intense vasodilation. The aim of this study was to evaluate the accuracy of radial pressure monitoring during controlled hypotension achieved with profound arterial vasodilation.

Thoracic epidural and intrathecal analgesia have similar effects on pain relief and respiratory function after thoracic surgery

PURPOSE To compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy. PATIENTS AND METHODS 55 patients undergoing an elective postero-lateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 microg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 microg.mL(-1) via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 microg.mL(-1) with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO(2), PaCO(2), respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough. RESULTS No significant difference was noted between both groups concerning VAS, HR, MAP, SpO(2), PaCO(2) and RR. Variations of the respiratory function tests were identical in both groups. CONCLUSION This study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.RésuméObjectifComparer ľeffet de la rachianalgésie à la morphine (M) et au sufentanil (S) à la péridurale thoracique sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.Matériel et méthodesQuarante-cinq patients de 58,4 ± 13 ans ďâge moyen subissant une thoracotomie postéro-latérale ont été divisés en deux groupes. Les patients du Groupe I (n = 27) ont reçu une rachianalgésie lombaire (5 μg de S et 0,5 mg de M) une heure avant ľinduction. Groupe II (n = 28) a reçu après ľinduction, 10 à 20 mL ďune solution de bupivacaine (B) 0.25 % et fentanyl (F) 2 μg·mL-1 à travers un cathéter péridural installé entre T5 et T8 avant ľinduction. Une perfusion continue de cette solution a été administrée en période peropératoire. Après chirurgie et pendant 48 h, une perfusion de B 0.1 % et F 2 μg·mL-1 a été administrée avec des bolus toutes les 15 min si nécessaire. Les variables étudiées sont: la fréquence cardiaque (FC), la pression artérielle moyenne (PAM), la saturation périphérique en O2 (SpO2), la fréquence respiratoire (FR), la pression artérielle en O2 (PaCO2), le volume expiratoire maximal à la première seconde, la capacité vitale fonctionnelle, le débit expiratoire maximal et ľéchelle visuelle analogique (EVA) de la douleur au repos et au mouvement et ceci à différents temps allant de la veille de la chirurgie à T48 = 48 h après chirurgie.RésultatsĽEVA au repos et au mouvement, la FC, la PAM, la SpO2, la PaCO2, la FR et les variations des tests pulmonaires sont comparables dans les deux groupes.ConclusionLa rachianalgésie à la M et au S a des effets comparables à la péridurale thoracique à la B et au F sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.AbstractPurposeTo compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy.Patients and methods55 patients undergoing an elective posterolateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 μg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 μg·mL-1 via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 μg·mL-1 with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO2, PaCO2, respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough.ResultsNo significant difference was noted between both groups concerning VAS, HR, MAP, SpO2, PaCO2 and RR. Variations of the respiratory function tests were identical in both groups.ConclusionThis study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.

Correlation between Central Venous - Arterial Carbon Dioxide Tension Gradient and Oxygen Delivery Changes Following Fluid Therapy

Background: Central venous-arterial carbon dioxide (CVA-CO2) tension gradient was related to low cardiac output after coronary surgery. The objective of this study was to assess the correlation between CVA-CO2 tension gradient and oxygen delivery (DO2) changes following fluid therapy in coronary surgery. Methods: A prospective interventional study was conducted in a cardiac surgery intensive care unit. Forty consecutive sedated and mechanically ventilated adult patients, with a cardiac index < 2.3 L/min/m² and a pulmonary artery occlusion pressure ≤ 12 mmHg following coronary surgery, were included. All patients received a 500 ml bolus of an isotonic crystalloid solution over 20 min. Concomitant hemodynamic parameters, arterial and central venous blood gases were measured before (T0) and after (T1) volume loading. Means were compared by Student’s test and correlations by Spearmen coefficient”. P ≤ 0.05 was considered to be significant. Results: CVA-CO2 gradient decreased (12.6 ± 3.0 vs 10.2 ± 3.7 mmHg; p = 0.01) and DO2 increased (312 ± 57 vs 357 ± 81 l/min/m²; p = 0.001) significantly from T0 to T1. The correlation between CVA-CO2 gradient changes and DO2 changes was negative and statistically significant (r = -0.38; p=0.015). Conclusion: CVA-CO2 gradient and DO2 changes were inversely and significantly correlated in patients receiving fluid therapy following coronary surgery. In this context, CVA-CO2 gradient changes could be used as an indicator to guide volume loading and to assess its effect on DO2.

L’analgésie péridurale thoracique et rachidienne ont des effets comparables sur la douleur et la fonction respiratoire après chirurgie thoracique

PURPOSE To compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy. PATIENTS AND METHODS 55 patients undergoing an elective postero-lateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 microg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 microg.mL(-1) via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 microg.mL(-1) with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO(2), PaCO(2), respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough. RESULTS No significant difference was noted between both groups concerning VAS, HR, MAP, SpO(2), PaCO(2) and RR. Variations of the respiratory function tests were identical in both groups. CONCLUSION This study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.RésuméObjectifComparer ľeffet de la rachianalgésie à la morphine (M) et au sufentanil (S) à la péridurale thoracique sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.Matériel et méthodesQuarante-cinq patients de 58,4 ± 13 ans ďâge moyen subissant une thoracotomie postéro-latérale ont été divisés en deux groupes. Les patients du Groupe I (n = 27) ont reçu une rachianalgésie lombaire (5 μg de S et 0,5 mg de M) une heure avant ľinduction. Groupe II (n = 28) a reçu après ľinduction, 10 à 20 mL ďune solution de bupivacaine (B) 0.25 % et fentanyl (F) 2 μg·mL-1 à travers un cathéter péridural installé entre T5 et T8 avant ľinduction. Une perfusion continue de cette solution a été administrée en période peropératoire. Après chirurgie et pendant 48 h, une perfusion de B 0.1 % et F 2 μg·mL-1 a été administrée avec des bolus toutes les 15 min si nécessaire. Les variables étudiées sont: la fréquence cardiaque (FC), la pression artérielle moyenne (PAM), la saturation périphérique en O2 (SpO2), la fréquence respiratoire (FR), la pression artérielle en O2 (PaCO2), le volume expiratoire maximal à la première seconde, la capacité vitale fonctionnelle, le débit expiratoire maximal et ľéchelle visuelle analogique (EVA) de la douleur au repos et au mouvement et ceci à différents temps allant de la veille de la chirurgie à T48 = 48 h après chirurgie.RésultatsĽEVA au repos et au mouvement, la FC, la PAM, la SpO2, la PaCO2, la FR et les variations des tests pulmonaires sont comparables dans les deux groupes.ConclusionLa rachianalgésie à la M et au S a des effets comparables à la péridurale thoracique à la B et au F sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.AbstractPurposeTo compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy.Patients and methods55 patients undergoing an elective posterolateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 μg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 μg·mL-1 via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 μg·mL-1 with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO2, PaCO2, respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough.ResultsNo significant difference was noted between both groups concerning VAS, HR, MAP, SpO2, PaCO2 and RR. Variations of the respiratory function tests were identical in both groups.ConclusionThis study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.

Combined sciatic, femoral and obturator nerve blocks for an infra-inguinal arterial bypass graft surgery

Sir, Acute transient swelling of the parotid gland after general anesthesia, referred to as anesthesia mumps, is a rare clinical entity. It is a benign and noninfectious complication. A 26-year-old male was operated due to a T4 burst fracture. General anesthesia was induced, and the patient was placed in the prone position. The head was turned to the right side and the left side of the face was placed on a soft pad. Posterior stabilization, which lasted about 5 h, was performed and the patient was extubated without any problem. Four hours after the surgery, a painful swelling on the left pre-auricular and post-auricular areas extending to the angle of the mandible was noted. Clinical examination showed diffuse edema and induration over the parotid gland. We performed ultrasonography, which showed enlargement of the left parotid gland and dilatation of the parotid duct. The swelling started to resolve at 48 h and subsided completely on day 6. The etiology of anesthesia mumps is unclear. Among the implicated mechanisms are the increase in intra-oral pressure due to straining and/or coughing during anesthesia and retrograde passage of air into the parotid gland via the Stenon duct, obstruction of the Stenon duct due to head positioning, retention of secretions and dehydration. In our case, not only mechanical compression but also manipulation of the oropharyngeal cavity due to endotracheal intubation may be considered. When we first saw the case, we thought that the swelling might be subcutaneous emphysema. However, there was no crepitation by palpation. Besides, chest roentgenogram had no evidence of pneumothorax. What can be done to prevent such a problem? The most important measure is to use soft pads to prevent the parotid gland from being subjected to direct compression when the patients undergo a lengthy surgery and lie in the prone position. Furthermore, it is critical to keep the patient normovolemic. In conclusion, anesthesia mumps may occur in the first few hours of the post-operative period. It has no clinical significance and patients fully recover within a few days without any treatment. The main priority should be to eliminate the anxieties of both the patient and the family.

L’analgésie péridurale thoracique et rachidienne ont des effets comparables sur la douleur et la fonction respiratoire après chirurgie thoracique@@@Thoracic epidural and intrathecal analgesia have similar effects on pain relief and respiratory function after thoracic surgery

PURPOSE To compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy. PATIENTS AND METHODS 55 patients undergoing an elective postero-lateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 microg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 microg.mL(-1) via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 microg.mL(-1) with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO(2), PaCO(2), respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough. RESULTS No significant difference was noted between both groups concerning VAS, HR, MAP, SpO(2), PaCO(2) and RR. Variations of the respiratory function tests were identical in both groups. CONCLUSION This study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.RésuméObjectifComparer ľeffet de la rachianalgésie à la morphine (M) et au sufentanil (S) à la péridurale thoracique sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.Matériel et méthodesQuarante-cinq patients de 58,4 ± 13 ans ďâge moyen subissant une thoracotomie postéro-latérale ont été divisés en deux groupes. Les patients du Groupe I (n = 27) ont reçu une rachianalgésie lombaire (5 μg de S et 0,5 mg de M) une heure avant ľinduction. Groupe II (n = 28) a reçu après ľinduction, 10 à 20 mL ďune solution de bupivacaine (B) 0.25 % et fentanyl (F) 2 μg·mL-1 à travers un cathéter péridural installé entre T5 et T8 avant ľinduction. Une perfusion continue de cette solution a été administrée en période peropératoire. Après chirurgie et pendant 48 h, une perfusion de B 0.1 % et F 2 μg·mL-1 a été administrée avec des bolus toutes les 15 min si nécessaire. Les variables étudiées sont: la fréquence cardiaque (FC), la pression artérielle moyenne (PAM), la saturation périphérique en O2 (SpO2), la fréquence respiratoire (FR), la pression artérielle en O2 (PaCO2), le volume expiratoire maximal à la première seconde, la capacité vitale fonctionnelle, le débit expiratoire maximal et ľéchelle visuelle analogique (EVA) de la douleur au repos et au mouvement et ceci à différents temps allant de la veille de la chirurgie à T48 = 48 h après chirurgie.RésultatsĽEVA au repos et au mouvement, la FC, la PAM, la SpO2, la PaCO2, la FR et les variations des tests pulmonaires sont comparables dans les deux groupes.ConclusionLa rachianalgésie à la M et au S a des effets comparables à la péridurale thoracique à la B et au F sur ľanalgésie et la fonction respiratoire après chirurgie thoracique.AbstractPurposeTo compare in a prospective randomized trial the effects of thoracic epidural infusions of fentanyl (F) and bupivacaine (B) to intrathecal morphine (M) and sufentanil (S) on analgesia and respiratory function following thoracotomy.Patients and methods55 patients undergoing an elective posterolateral thoracotomy were randomly assigned to one of two groups: Group I (n = 27): received intrathecal S (5 μg) and M (0.5 mg) one hour before surgery. Group II (n = 28) received, after induction of anesthesia, an initial dose of 10 to 20 mL of a solution of B 0.25% and F 2 μg·mL-1 via an epidural thoracic catheter previously inserted between T5 and T8. The same solution was infused during surgery. After surgery, patients received a continuous infusion of B 0.1% and F 2 μg·mL-1 with a bolus every 15 min if needed. Heart rate (HR), mean arterial pressure (MAP), SpO2, PaCO2, respiratory rate (RR), forced expiratory volume in one second, peak expiratory flow rate and forced vital capacity were recorded at different times from the day before surgery till T48 = 48 hr after surgery. Subjective pain was assessed using a 10 cm visual analogue scale (VAS) scoring at rest and during cough.ResultsNo significant difference was noted between both groups concerning VAS, HR, MAP, SpO2, PaCO2 and RR. Variations of the respiratory function tests were identical in both groups.ConclusionThis study shows that intrathecal M and S offer analgesia comparable to thoracic epidural infusion of B and F.