J. Hamza

Parturient's posture during epidural puncture affects the distance from skin to epidural space

STUDY OBJECTIVE To assess the factors affecting the distance from skin to epidural space. DESIGN Prospective observational study of consecutive cases over a 2-year period. SETTING Inpatient obstetric unit in a French university hospital. PATIENTS 2,123 consecutive term parturients who received epidural anesthesia for cesarean section or epidural analgesia for labor and vaginal delivery. INTERVENTIONS At the time of epidural puncture, the interspace used and the patients posture (sitting or left lateral decubitus) were recorded, and the distance from the skin to the epidural space (DS-ES) was measured to the nearest 0.5 cm using a marked epidural needle. MEASUREMENTS AND MAIN RESULTS The relationship between patient factors [height, weight, body mass index (BMI; weight/height2), presence of scoliosis] and technical factors (interspace, patients posture at puncture) versus DS-ES was investigated using multiple regression analysis. DS-ES correlated positively with the parturients weight and BMI. In addition, DS-ES was significantly greater when epidural puncture was performed in the lateral position as compared with the sitting position. CONCLUSION Both the patients weight and position during epidural needle placement are important factors influencing DS-ES. A change from the sitting to the lateral position may increase DS-ES, causing catheter dislodgment and consequent inadequate analgesia. Clinical studies relating DS-ES to inadequate analgesia must take these factors into account.

Premedication for tracheal intubation: a prospective survey in 75 neonatal and pediatric intensive care units.

ObjectiveIn children, like in adults, tracheal intubation is a painful procedure that may induce hypertension, tachycardia, and other undesirable hemodynamic disorders. Although premature neonates are very sensitive to pain and vulnerable to its long-term effects, the need for sedation before tracheal intubation is still discussed in neonatal units. Our objective was to investigate the practice of premedication before tracheal intubation in neonatal and pediatric units and determine the influence of premedication on intubating conditions. DesignWe performed a 10-day prospective survey in 75 neonatal and pediatric intensive care units among the 98 licensed in France. A questionnaire was completed for each intubation performed in each surveyed unit. SubjectsA total of 204 patients were studied: 140 neonates, 52 infants, and 12 children. Main ResultsData on 204 tracheal intubations were collected from 223 that were performed during the study period (participation rate, 91.4%). Premedication was used before intubation for 37.1%, 67.3%, and 91.7% of neonates, infants, and children, respectively (p < .0001). In the subgroup of neonates, premedication was particularly rare for the youngest and the smallest infants. Midazolam was the principle hypnotic used in neonates, whereas propofol was mainly used in children. Opioids or muscle relaxants were used in 16.2% and 4.4% of the patients, respectively. A low success rate and a high incidence of hypoxemia and bradycardia were correlated with the inexperience of the operator. Premedication did not significantly influence either the success rate or the undesirable events associated with tracheal intubation. ConclusionUse of premedication before tracheal intubation is limited in neonates and increases according to the age of the patient. Midazolam does not seem to be an accurate choice to improve intubating conditions in neonates and infants. Because tracheal intubation is a technique that requires a skill only developed by regular practice, operators who have limited experience with intubating children should be supported by senior operators.

Engraftment of Autologous Retrovirally Transduced Hepatocytes after Intraportal Transplantation into Nonhuman Primates: Implication for ex Vivo Gene Therapy

The main impediment to effective ex vivo liver gene therapy of metabolic diseases is the lack of experimental work on large animals to resolve such important issues as effective gene delivery, cell-processing techniques, and the development of appropriate vectors. We have used a nonhuman primate, as a preclinical model, to analyze the limiting steps of this approach using recombinant retroviruses. Seven monkeys (Macaca fascicularis) underwent the complete protocol: their left liver lobe was resected, a catheter was placed in the inferior mesenteric vein and connected to an infusion chamber, and the hepatocytes were isolated, cultured, and transduced with a retroviral vector containing the beta-galactosidase gene. The hepatocytes were harvested and returned to the host via the infusion chamber. Biopsies were taken 4-40 days later. No animal was killed in the course of the experiments. They all tolerated the procedure well. We have developed and defined conditions that permit the proliferation and transduction of up to 90% of the plated hepatocytes. A significant proportion of genetically modified cells, representing up to 3% of the liver mass, were safely delivered to the liver via the chamber. Polymerase chain reaction analysis detected integrated viral DNA sequences and quantitative analysis of the in situ beta-Gal-expressing hepatocytes indicated that a significant amount of transduced hepatocytes, up to 2%, had become integrated into the liver and were functional. These results represent substantial advances in the development of the ex vivo approach and suggest that this approach is of clinical relevance for liver-directed gene therapy.

Ventilatory effects of epidural clonidine during the first 3 hours after caesarean section

Many authors have shown the analgesic efficacy of 150–800 μg of epidural clonidine in the postoperative period. Its use as an analgesic after caesarean section has recently been studied with higher dosages (400–800 μg). Our study aimed at assessing the analgesic and ventilatory effects of two smaller doses of epidural clonidine (150 and 300 μg), which were compared to the effects of 10 mg of parenteral morphine (M) during the first 3 h after caesarean section. The duration of the analgesic effect was longest with 150 μg of epidural clonidine. Arterial blood pressure decreased from 30 min after the injection to the end of the study in both epidural clonidine groups. A marked sedation was observed in patients receiving 300 μg of epidural clonidine and was frequently associated with snoring, obstructive apnoea and episodes of arterial oxygen desaturation. We conclude that 150 μg of epidural clonidine provides better and longer analgesia after caesarean section than 10 mg of parenteral morphine, and seems preferable to higher doses (300 μg) in this setting, since 300 μg of epidural clonidine may produce unacceptable respiratory obstructive disturbances.

Dose of prophylactic intravenous ephedrine during spinal anesthesia for cesarean section

STUDY OBJECTIVE To compare the incidence of maternal hypotension associated with spinal anesthesia for cesarean section when 10-, 15-, or 20-mg prophylactic boluses of intravenous (IV) ephedrine are used. DESIGN Prospective observational study. SETTING Teaching hospital. PATIENTS 108 women admitted for elective cesarean section. INTERVENTIONS Spinal anesthesia was performed using hyperbaric bupivacaine 10 mg, sufentanil 2 microg, and morphine 0.2 mg (volume 4 mL). Ephedrine (10, 15, or 20 mg) was administered 2 minutes after the intrathecal injection. Maternal blood pressure was checked every 2 minutes. Hypotension was promptly treated with 5-mg ephedrine boluses. MAIN RESULTS Incidence of hypotension was significantly higher in women receiving a 10-mg prophylactic dose of ephedrine than in those receiving either a 15-mg or a 20-mg prophylactic dose of ephedrine [23/36 in the 10-mg ephedrine group vs. 13/36 and 10/36 in the 15-mg and 20-mg ephedrine groups, respectively (p< 0.05)]. CONCLUSION In the conditions of this study, a single bolus of IV ephedrine with doses of either 15 or 20 mg decreased significantly the incidence of maternal hypotension as compared to a single 10-mg bolus of ephedrine.

Preoperative coagulation tests in former preterm infants undergoing spinal anaesthesia.

Background: Clinical history is insufficient to detect disorders of haemostasis in infants aged less than 1 year and laboratory coagulation testing is recommended in infants before perimedullar anaesthesia.

Traitement par le danaparoïde de sodium au cours de la grossesse chez une patiente présentant une allergie cutanée aux héparinesde bas poids moléculaire

The authors describe a case of heparin-induced skin reaction due to two preparations of low molecular weight heparin in a pregnant woman. The main characteristics of heparin-related cutaneous allergy are reported. The use of an heparinoid, usually indicated for patients with heparin-induced thrombocytopenia, appeared to be efficient and safe for the mother and her fetus. An epidural analgesia was performed for labor analgesia, 24 hours after the last injection of danaparid of sodium.

Reanimación del recién nacido en la sala de partos

Resumen Menos del 10 % de los recien nacidos requieren una reanimacion activa. La rapidez y la calidad de los cuidados iniciales condicionan el pronostico del bebe y la aparicion de un sufrimiento vital neonatal es a menudo imprevisible. La reanimacion del recien nacido esta bien estandarizada y debe ser realizada por un equipo profesional calificado que disponga del material necesario en todos los partos. La apreciacion de la gravedad de la situacion del recien nacido se basa esencialmente en parametros clinicos sencillos. La aspiracion precoz de la faringe y la desobstruccion de las vias respiratorias constituyen a menudo los primeros elementos del tratamiento de las insuficiencias respiratorias del recien nacido, en particular cuando el liquido amniotico aspirado esta tenido de meconio. Los progresos de la reanimacion permiten indices importantes de supervivencia sin secuelas mayores en caso de gran prematuro o hipotrofia mayor. En este contexto suele proponerse el empleo de tecnicas menos invasivas. La existencia de malformaciones debe conducir a un tratamiento rapido por parte de un personal especializado.

Hemodynamic disorders associated with target-controlled infusion (TCI) using remifentanil in children with cerebral palsy undergoing dental procedure: A-652

hypothesized that general balanced anaesthesia compared to sevoflurane inhalation anaesthesia is associated with lower rate of complications. Materials and Methods: After written parental informed consent, 117 consecutive children (aged 5 days to 3 years with body weight 3–21 kg) were randomly allocated to two groups. Children in Group I were induced with sevoflurane (5–8 vol%) and maintained with fentanyl (0.005 mg kg 1), vecuronium (0.1 mg kg 1) and midazolam (0.05 mg kg 1). Children in Group II were induced with sevoflurane (5–8 vol%) and maintained with sevoflurane/ oxygen/air mixture supplemented with fentanyl (0.005 mg kg 1). Results and Discussions: Table shows intraoperative and postoperative complications.

Analgesia y anestesia en el parto

Resumen Algunas de las considerables modificaciones fisiologicas que se producen durante el embarazo y el parto tienen consecuencias muy precisas con respecto a la anestesia de la madre. Realizando sistematicamente una consulta con el anestesista hacia el final del embarazo es posible evaluar el riesgo anestesico y considerar las ventajas e inconvenientes de cada tecnica. En este fasciculo se describe la analgesia y la anestesia perimedular durante el trabajo y el parto y asimismo la anestesia para la cesarea.