Maya I. Jalbout

Diclofenac and/or propacetamol for postoperative pain management after cesarean delivery in patients receiving patient controlled analgesia morphine.

Background and Objectives A multimodal approach to postcesarean pain management may enhance analgesia and reduce side effects after surgery. This study evaluates the postoperative analgesic effects of propacetamol and/or diclofenac in parturients undergoing elective cesarean delivery under spinal anesthesia. Methods After randomization, 80 healthy parturients received the following: placebo (group M), 100 mg diclofenac rectally every 8 hours (group MD), 2 g propacetamol intravenously every 6 hours (group MP), or a combination of 2 g propacetamol and 100 mg diclofenac (group MDP) as described above. Drugs were administered for 24 hours after surgery. Postoperative pain was controlled with a patient controlled analgesia pump, using morphine. The visual analog scale (VAS) at rest and on coughing, as well as the morphine consumption, were evaluated at 2, 6, and 24 hours postoperatively. Also, the side effects experienced after undergoing the different regimens were compared. Results The patients’ characteristics did not differ significantly between the 4 groups. VAS score at 2 hours, both at rest and on coughing were lower in group MDP and MD compared with group M (P < .05). At 24 hours, there was still a tendency toward lower pain scores in the groups MDP and MD; however, this difference was only statistically significant at rest between the MDP group and the MP and M groups. Morphine consumption at 2, 6, and 24 hours was lower in the MDP and MD groups compared with the MP and M groups (P < .05). The morphine-sparing effect was higher in groups MDP and MD compared with group MP (57% and 46%, respectively, v 8.2%, P < .05). The incidence of side effects was similar in all groups. However, the power of the study was too low to permit an evaluation of potential side effects. Conclusion Diclofenac after cesarean delivery improves analgesia and has a highly significant morphine-sparing effect. We were unable to demonstrate significant morphine-sparing effect of propacetamol or additive effect of propacetamol and diclofenac in this group of patients.

Does Pregnancy Protect Against Intrathecal Lidocaine-Induced Transient Neurologic Symptoms?

We investigated the incidence of transient neurologic symptoms (TNS) after the use of hyperbaric lidocaine as compared with hyperbaric bupivacaine in patients undergoing cesarean delivery under spinal anesthesia. Two hundred women scheduled for cesarean delivery were randomly allocated to receive spinal anesthesia with 75 mg hyperbaric lidocaine 5% (n = 100) or 12 mg hyperbaric bupivacaine 0.75% (n = 100). Spinal anesthesia was administered to all patients in the sitting position with a 25-gauge Whitacre needle. The level of sensory blockade, time to full recovery, and intraoperative hemodynamic profile were noted in all patients. The patients were interviewed postoperatively for three consecutive days to detect the occurrence of TNS. The incidence of TNS was zero (95% confidence interval 0%–3%) in both the Lidocaine and the Bupivacaine Groups. Our results indicate that the frequency of postoperative TNS does not exceed 3% in patients undergoing cesarean delivery at term using hyperbaric lidocaine 5% or hyperbaric bupivacaine 0.75%. Implications Transient neurologic symptom (TNS) can follow spinal anesthesia and manifests as back pain radiating to the legs, resolving spontaneously. Spinal anesthesia for cesarean delivery was performed with either hyperbaric lidocaine 5% (n = 100) or hyperbaric bupivacaine 0.75% (n = 100). TNS was not noted in any patient.

Intrathecal Versus Intravenous Fentanyl for Supplementation of Subarachnoid Block During Cesarean Delivery

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 &mgr;g of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 &mgr;g of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 ± 35 &mgr;g was required in the IV Fentanyl group, whereas no supple- mentation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 ± 39 min versus 119 ± 44 min;P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25;P = 0.02).

Anesthesia and myopathy.

Purpose of review This report reviews the derangements of neuromuscular transmission in the different types of myopathy. Recent findings The article covers recent literature on myopathy, whether prejunctional, junctional or postjunctional, as well as intensive care unit myopathy, and outlines the influence of myopathy on the action of both depolarizing and non‐depolarizing muscle relaxants. Summary The review classifies myopathy according to its cause, and sheds light on the upregulation and downregulation of endplate acetylcholine receptors. These findings are important for both clinical practice, and for research into neuromuscular transmission.

The pregnant cardiac woman.

&NA; Cardiac diseases are present in 0.5‐4% of pregnancies, and they remain a frequent cause of death during pregnancy. Pregnancy per se imposes significant hemodynamic changes, placing a major burden on the cardiovascular system. The early recognition and close follow‐up of patients with cardiac diseases will improve maternal tolerance to the cardiovascular burden imposed by pregnancy, promote fetal growth and neonatal survival. Rheumatic heart disease remains the most frequent heart disease in the pregnant population with pulmonary edema as the most frequent complication. Atrial septal defect is the most frequent congenital heart disease in the adult population, whereas tetralogy of Fallot is the most common cyanotic congenital heart disease. An improvement in modern techniques of monitoring, a better understanding of the pathophysiology of cardiac disease, as well as multidisciplinary care has led to a substantial improvement in outcome of the pregnant cardiac patient. Management should be initiated before conception as it will provide optimal clinical conditions and sufficient information on the underlying pathophysiology. Curr Opin Anaesthesiol 15:285‐291.

Low frequency jet ventilation for stent insertion in a patient with tracheal stenosis

PurposeEvaluate oxygen jet ventilation in a patient with tracheal stenosis undergoing stent insertion.Clinical featuresManual intermittent low frequency oxygen jet ventilation was used during general anesthesia for fibreoptic bronchoscopy and stent insertion in a patient with tracheal stenosis. Oxygen jets were delivered via a Sander’s injector adapted to the proximal end of the endotracheal tube on one side, and open to room air on the other side. Adequate oxygenation and carbon dioxide removal were ensured throughout the procedure.ConclusionLow frequency jet ventilation in a patient with tracheal stenosis provided adequate ventilation as well as a nonobstructed field during fibreoptic bronchoscopy and stent insertion.RésuméObjectifÉvaluer la ventilation en jet avec de l’oxygène chez un patient qui présente une sténose trachéale et qui doit subir la mise en place d’un tuteur.Éléments cliniquesLa ventilation en jet, manuelle et intermittente, avec de l’oxygène, a été utilisée pendant l’anesthésie générale pour la fibroscopie et l’insertion d’un tuteur chez un sujet souffrant de sténose trachéale. L’oxygène a été administré par un injecteur de Sander fixé à la partie proximale de la sonde endotrachéale, d’un côté, et ouvert à l’air ambiant, de l’autre côté. L’oxygénation et l’élimination du gaz carbonique ont été adéquates pendant toute l’intervention.ConclusionLa ventilation en jet à basse fréquence, utilisée dans un cas de sténose trachéale, a fourni une ventilation suffisante et un champ libre pour la fibroscopie et l’insertion d’un tuteur.

Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas

PurposeTo report the perioperative management and the serious hemodynamic fluctuations during manipulation of an organ of Zuckerkandl tumour in a patient undergoing resection of multicentric extraadrenal pheochromocytomas.Clinical findingsA 28-yr-old man who had undergone at age 12 a laparotomy for excision of an extraadrenal pheochromocytoma complained of paroxysmal headache, occasional sweating and palpitations. The arterial blood pressure (BP) was 200/100 mmHg. A 24-hr-urine collection showed catecholamines 5076 μg·24 hr−1 (normal < 25 μg·24 hr−1). Computed tomography of the abdomen revealed two retroperitoneal masses, one adjacent to the lower pole of the right kidney and a second larger mass located at the aortic bifurcation in the region of the organ of Zuckerkandl. The patient was scheduled for excision of multiple extraadrenal pheochromocytomas. He was prepared preoperatively for two weeks with prazosin 1 mgpo q six hours and propranolol 10 mgtid. Manipulation of the infrarenal tumour was uneventful but manipulation of the Zuckerkandl tumour resulted in severe hypertensive episodes with BP ranging from 200/100 to 320/120 mmHg. Surgery was interrupted temporarily; the hypertensive crisis was controlled by the infusion of sodium nitroprusside and byiv phentolamine and esmolol.ConclusionIn a patient undergoing resection of recurrent multicentric extraadrenal pheochromoctyomas, severe hypertensive episodes occurred during manipulation of one tumour but not during manipulation of the other. This may be attributed to inadequate preparation of the patient, difficult surgical dissection of the large Zuckerkandl pheochromocytoma, and/or secondary to an excessive and different pattern of release of catecholamines during manipulation of the Zuckerkandl tumour.RésuméObjectifPrésenter le traitement périopératoire et les fluctuations hémodynamiques inquiétantes survenues pendant la manipulation d’une tumeur de l’organe de Zuckerkandl chez un patient qui devait subir la résection de phéochromocytomes extrasurrénaliens multicentriques.Constatations cliniquesUn homme de 28 ans qui, à 12 ans, avait subi l’excision laparoscopique d’un phéochromocytome extrasurrénalien, se plaignait de céphalées paroxystiques, de sueurs et de palpitations occasionnelles. La tension artérielle (TA) était de 200/100 mmHg. Un prélèvement d’urine sur 24 h a montré une concentration de catécholamines de 5076 μg·24 h−1 (la normale étant < 25 μg·24 h−1). La tomodensitométrie de l’abdomen a montré deux masses rétropéritonéales, l’une adjacente au pôle inférieur du rein droit et une seconde, plus grosse, localisée à la bifurcation aortique dans la région de l’organe de Zuckerkandl. L’excision des multiples phéochromocytomes extrasurrénaliens a été planifiée. Le patient a été préparé en recevant, deux semaines avant l’opération 1 mg de prazosin po q à prendre aux six heures et 10 mg de propranolol tid. La manipulation de la tumeur infrarénale s’est faite sans incident, mais celle de la tumeur de Zuckerkandl a entraîné des épisodes d’hypertension sévère, la TA allant de 200/100 à 320/120 mmHg. L’intervention chirurgicale a été interrompue temporairement pour permettre de traiter la crise d’hypertension par une perfusion de nitroprussiate de sodium et par de la phentolamine et de l’esmolol iv.ConclusionDes épisodes d’hypertension sévères sont survenus chez un patient subissant la résection de phéochromocytomes multicentriques récurrents pendant la manipulation d’une des deux tumeurs. Cette situation peut relever d’une préparation inadéquate du patient, de la difficulté de la dissection chirurgicale du plus gros phéochromocytome de Zuckerkandl et/ou elle peut être secondaire à une sécrétion excessive et différente de catécholamines pendant la manipulation de la tumeur de Zuckerkandl.