Jean Jacques Eledjam

Brachial plexus block with bupivacaine : effects of added alpha-adrenergic agonists : comparison between clonidine and epinephrine

The effects of clonidine and epinephrine, administered into the brachial plexus sheath, were evaluated in 60 patients who underwent surgery of the upper limb. All patients received 40 to 50 ml of 0.25% bupivacaine, injected into the brachial plexus sheath, using the supraclavicular technique. The patients were randomly allocated to two groups so that 30 patients received 150 μg clonidine hydrochloride (Group I), and 30 received 200 μg epinephrine (Group II). The quality and the duration of analgesia were assessed as well as, the possible side-effects. The block produced with the addition of clonidine was longer (994.2±34.2 vs 728.3±35.8 min) and superior to that with epinephrine (P<0.001). No major side-effects were recorded. We conclude that the injection of clonidine into the brachial plexus sheath is an attractive alternative to epinephrine to prolong the duration of analgesia following upper limb surgery under conduction anaesthesia.RésuméLes effets de l’addition d’agents agonistes alpha-adrénergiques à la bupivacaïne lors de blocs du plexus brachial ont été évalués chez soixante patients ayant une intervention chirurgicale sur le membre supérieur. L’ensemble des patients a reçu 40 à 50 ml de bupivacaïne à 0.25% pour réaliser un bloc du plexus brachial par voie sus-claviculaire. Les patients du groupe I (n=30) recevaient par la même voie 150 μg de clonidine, ceux du groupe II (n=30) 200 μg d’ adrénaline. La durée et la qualité de l’analgésie sont ensuite étudiées ainsi que les éventuels effets adverses. Une différence statistiquement significative a été retrouvée en ce qui concerne la durée d’analgésie qui était supérieure dans le groupe clonidine (994,2±34,2 min vs 728,3 ±35,8 min; P<0.001). Aucun effet adverse majeur n’est retrouvé. Les auteurs concluent à l’intérêt particulier de la clonidine pour prolonger la durée d’ analgésie après chirurgie du membre supérieur réalisée sous anesthésie régionale.

Neurolytic blockade of the obturator nerve for intractable spasticity of adductor thigh muscles.

Neurolytic blockade is one of the therapeutic possibilities to treat spasticity of various muscles. In patients with spasticity of the adductor thigh muscles, a percutaneous approach to the obturator nerve is often difficult. We describe a new approach to the obturator nerve and we examine its feasibility. The second objective was to assess the efficacy of obturator neurolysis for the management of adductor thigh muscle pain and spasticity associated with hemiplegia or paraplegia. Nerve blocks were performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. Neurolysis was performed by injection of 65% ethanol. We performed 27 blocks in 23 patients. Technical evaluation was achieved in terms of number of attempted needle insertions, time to accurate location of the nerve and success rate. The efficacy of the block was assessed using four scores: degree of alleviation of muscle spasm and triple flexion of the lower limb, improvement of gait and facilitation of hygienic care. Success rate of the technique was 100% with a time to accurate nerve location of 130 ± 35 s. Compared with scores measured immediately before the block, all studied parameters were significantly improved. Efficiency was significant on adductor muscle spasticity (p < 0.001 at 1 day and p < 0.01 at 60 and 120 months). Triple flexion was also significantly improved (p < 0.05 from 1 to 120 days), as well as gait (p < 0.02) and hygiene (p < 0.01) scores. No complications occurred. The combined approach of the obturator nerve represents a new technique which proved to be accurate, fast, simple, highly successful and reproducible. Obturator neurolysis was confirmed as an efficient and cost‐effective technique to reduce adductor muscle spasm and related pain and to improve gait and hygienic care in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurone.

Evolution des concentrations sanguines du propofol administré à débit constant en association avec le fentanyl

The blood concentration of propofol was studied in 14 ASA 1 informed patients, who were to undergo orthopaedic or plastic surgery lasting at least 90 min. Anacsthesia was induced with a 2 mg · kg−1 bolus of propofol together with 0.86 μg · kg−1 fentanyl. This was followed by a constant rate infusion of propofol and fentanyl, 5 mg · kg−1 · h−1 and 3 μg · kg−1 · h−1 respectively. The mean duration of propofol infusion was 153 ± 63 min, with extremes of 90 and 315 min. Propofol concentration was measured using gas phase chromatography on total arterial blood ; the lower limit of detection was 0.05 mg · l−1. During the infusion, blood concentrations were found between 2 and 4 mg · 1−1. It was 2.25 mg · l−1 at the fifth min ; this was 80 % of the concentration found at the 120th min. There was in fact no statistically significant difference between the values found at the 90th, 120th and 150th min. On stopping the infusion, the concentrations fell rapidly during the first 5 min, and then more slowly. By the 30th min, it had reached a value 4.5 times less than that at the end of the infusion. However, individual variations were found, which could explain delayed recovery. The calculated pharmacokinetic parameters were : elimination half-life = 41.7 ± 20 min, clearance = 2.14 ± 0.55 l · min−1 and equilibrium distribution volume = 43.4 ± 15.21. These results are discussed. It is therefore possible to give propofol continuously at a constant rate without having any accumulative effect.

Comparaison du propofol au propanidide administrés à débit constant

So as to compare the anaesthesia obtained using propofol with that obtained using propanidid, 40 ASA I patients, aged between 18 and 50 years, who were to undergo elective orthopaedic or plastic surgery lasting more than 60 min, were randomly divided into two equal groups, one receiving propofol (PF) and the other propanidid (PD). All the patients received 0.5 mg atropinc, 100 mg pethidine and 7.5 mg droperidol (10 mg if weight > 60 kg) intramuscularly 45 min before induction. Patients in group PF were then given 2 mg · kg−1 propofol over 1 min and 0.9 μg · kg−1 fentanyl over 3 min, followed by a constant rate infusion of 5 mg · kg−1 · h−1 propofol and 3 μg · kg−1 · h−1 fentanyl. For PD patients, the doses of fentanyl were identical ; they were given 10.6 mg · kg−1 propanidid over 3 min for induction, and 37 mg · kg−1 · h−1 for maintenance. All the patients were intubated and ventilated mechanically. The usual anaesthetic parameters were monitored at induction, during surgery, and during recovery. Consciousness was lost more quickly with propofol (p < 0.05), but the corneal reflex returned more rapidly in group PD (p < 0.02). The time required for a full return to normal consciousness was identical in both groups. The fall, during induction, and the increase, during recovery, of Pasys were greater in group PD (p < 0.05 and < 0.001 respectively). Padia and heart rate were lower in group PF after the 30th min (p < 0.05 and < 0.01 respectively). In PD group, the return to spontaneous breathing was faster (p < 0.01), Paco2 lower (p < 0.01) and bicarbonate level much lower (p < 0.001). Conjunctival hyperhaemia was seen more frequently in group PF. In favour of propofol, there was the greater haemodynamic stability and the lesser lowering of the bicarbonate level. The data thus obtained confirmed the closely similar characteristics of both anaesthetics. In favour of propanidid, there was the lesser respiratory depression during induction and recovery.