Marie-Claire Antakly

General anesthesia with remifentanil for Cesarean section in a patient with HELLP syndrome

HELLP syndrome is a severe complication of pre‐eclampsia characterised by hemolysis, elevated liver enzymes and a low platelet count. It is associated with an increased risk of adverse outcome for both the mother and the fetus ( 1 ). Patients with HELLP syndrome are also at greater risk of pulmonary edema, adult respiratory distress syndrome, abruptio placentae, intracerebral hemorrhage, eclamptic convulsions, disseminated intravascular coagulation, ruptured liver hematomas and acute renal failure. Perinatal mortality is equally high. Before delivery, aggressive obstetric management is directed toward stabilization of the affected organ systems, if possible, and interruption of the pregnancy in the early phase of the accelerated disease progression. Definitive therapy is delivery ( 2, 3 ).

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.

Relocation of a Double-lumen Tube During Surgical Dissection

We read with interest the report by Drs. Riley and Marples (1) concerning relocation of a double-lumen tube (DLT) during patient positioning. We recently encountered a similar case that we hereby report. A 60-yr-old man with T3NlMO epidermoid carcinoma of the right lung (RL) was scheduled for right thoracotomy. He was in ASA physical status 11. Anesthesia was induced with intravenous pentothal and was continued with pancuronium, fentanyl, and halothane. A 39 Fr left DLT (Mallinckrodt) was inserted using direct laryngoscopy. Ventilation was normal, and a ”leak test” (2 ) showed successful lung isolation. The tube was secured in place, and mechanical ventilation was started. The patient was then turned to the left lateral position, and adequate positioning of the tube was checked again to eliminate secondary displacement. After thoracotomy, the right lung was deflated to facilitate surgical dissection. Twenty minutes later, and while the surgeon was manipulating the hilar region, the RL started inflating. Thinking that this was due to tube withdrawal, the surgeon pushed the DLT downward to reintubate the left bronchus. This resulted in an increase of the inflation of the RL. Immediately, rotation of the DLT and selective intubation of the right main stem bronchus were suspected. Ventilation was switched from endobronchial to endotracheal, which led instantaneously to RL deflation and adequate patient ventilation. The suspected diagnosis of complete rotation of the DLT was confirmed at the time of bronchial resection, which showed the tube inside the right main stem bronchus. The DLT was then withdrawn to allow bronchial closure. As suggested by Drs. Riley and Marples, the reason for this complication was probably that the tip of the DLT was not inserted far enough into the left main stem bronchus. While in their case it was the patient positioning that displaced the cannula, in our patient manipulation of the carina during surgery displaced the DLT. Another predisposing factor might be the fact that, in the left lateral position, the carina is displaced downward and, since the tube is secured in place, it cannot follow. Another point of interest is that usually in a right selective intubation the orifice of the tracheal lumen is in the right main stem bronchus (3) and is obstructed by the cuff of the endobronchial tube, whereas in our case the tracheal lumen orifice probably remained in the trachea, which explains why switching from endobronchial to endotracheal ventilation allowed adequate ventilation, lung deflation, and resuming the surgical procedure. Finally, as suggested by the authors, this complication might have been avoided if a pediatric fiberoptic bronchoscope had been used to check the tube position before thoracotomy. Alexander Yazigi, MD Samia Madi-Jebara, MD Fadia Haddad, MD Marie-Claire Antakly, MD Department of Anesthesiology Division of Cardiovascular and Thoracic Anesthesia H&el Dieu de France Hospital Beirut, Lebanon

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.

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.

Opioid drugs: what is next for Lebanon?

Opioids remain essential drugs for the treatment of severe cancerous pain. However, many countries have developed new regulations and policies for a better availability and accessibility of these drugs. Lebanon is not too far from these advanced strategies. The Ministry of Health and specifically the Narcotic Department have adjusted regulations related to opioid prescriptions and have registered many new opioid drugs in 2012 for a better pain-free life for our patients. However, there is still a lot to do in this field.

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.