Thomas Lieutaud

Muscle relaxation and increasing doses of propofol improve intubating conditions.

PurposeMuscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not dearly defined. This study was designed to determine, during intubation: i) the relative role of anesthetics and atracurium-induced neuromuscular block and; ii) the effect of different doses of propofol in the presence of complete muscle block.MethodsPatients were randomized to four groups and received fentanyl and a standardized anesthetic procedure. Patients from groups high (H;n = 45), medium (M;n = 48) and low(L;n = 47) received 2.5 mg· kg−1, 2.0 mg· kg−1, and 1.5 mg· kg−1 of propofol respectively, Atracurium (0.5 mg· kg−1) was then injected and tracheal intubation performed once complete block was achieved at the orbicularis oculi. Patients from group without atracurium (WA;n = 20) received propofol as in group H. Intubation was performed at the expected onset time of action of atracurium.ResulteUsing the same dose of propofol, the incidence of good or excellent intubating conditions was 35% without atracurium and 95% with atracurium (P < 0,0001), In patients receiving atracurium, clinically acceptable intubating conditions were more frequently achieved in groups receiving the highest propofol doses (group H or M vs group L;P < 0.03).ConclusionOur study confirms the interaction between anesthesia and muscle relaxation to produce adequate intubating conditions. In the conditions described, intubating conditions were more dependent on atracurium-induced neuromuscular blockade than on anesthetics, but both atracurium and propofol improved intubating conditions.RésuméObjectifAgents d’anesthésie et curares sont souvent associés pour l’intubation. Cependant, leurs rôles respectifs pendant l’intubation ne sont pas clairement définis. Cette étude a pour objectif de différencier pour l’intubation i) l’effet des agents d’anesthésie de ceux du bloc moteur induit par l’atracurium et ii) le rôle de différentes doses de propofol couplées à un bloc moteur complet induit par l’atracurium.MéthodeLes patients étaient randomisés en quatre groupes. Tous recevaient du fentanyl et une procédure d’anesthésie standardisée. Les patients des groupes high (H; n = 45), medium (M; n = 48), et low (L; n = 47) recevaient respectivement 2,5 mg· kg−1, 2,0 mg· kg−1 et 1,5 mg· kg−1 de propofol puis atracurium 0,5 mg· kg−1. Lintubation était réalisée et cotée après qu’un bloc complet avait été obtenu à l’orbiculaire de l’œil. Les patients du groupe n’ayant pas reçu l’atracurium (WA) recevaient le propofol comme dans le groupe H, et étaient intubés après un intervalle de temps correspondant à celui du délai d’action supposé de l’atracurium.RésultatsChez les patients recevant des doses d’anesthésie équivalentes, les conditions d’intubation étaient significativement meilleures chez ceux recevant l’atracurium (groupe H) par rapport aux patients WA (P < 0,0001). Pour les patients recevant de l’atracurium, les conditions d’intubation étaient significativement meilleures chez les patients du groupe H ou M par rapport aux patients du groupe L (P < 0,03).ConclusionLes conditions d’intubation dépendent plus du bloc neuromusculaire que des agents d’anesthésie lorsque l’on attend l’installation complète du bloc. Cependant, les conditions d’intubation dépendent aussi du rôle des agents d’anesthésie lors de l’intubation avec une curarisation complète.

Preemptive Intravenous Morphine-6-glucuronide Is Ineffective for Postoperative Pain Relief

Background Morphine-6-glucuronide (M-6-G), a major metabolite of morphine, is reported to be more potent than morphine when administered intrathecally; however, its efficiency remains under debate when administered intravenously. This study was designed to assess the analgesic efficiency of intravenous M-6-G for the treatment of acute postoperative pain. Methods After informed consent was obtained, 37 adults (American Society of Anesthesiologists physical status I–II) who were scheduled for elective open knee surgery were enrolled in the study. General anesthesia was induced with thiopental, alfentanil, and vecuronium and was maintained with a mixture of nitrous oxide/isoflurane and bolus doses of alfentanil. At skin closure, patients were randomized into three groups: (1) morphine group (n = 13), which received morphine 0.15 mg/kg; (2) M-6-G group (n = 12), which received M-6-G 0.1 mg/kg; and (3) placebo group (n = 12), which received saline. At the time of extubation, plasma concentration of morphine and M-6-G was measured. Postoperative analgesic efficiency was assessed by the cumulative dose of morphine delivered by patient-controlled analgesia. Opioid-related side effects were also evaluated. Results No difference was noted in patient characteristics and opioid-related side effects. Morphine requirements (mean ± SD) during the first 24 h in the M-6-G group (41 ± 9 mg) and the placebo group (49 ± 8 mg) were significantly greater (P < 0.05) compared with the morphine group (29 ± 8 mg). Conclusion A single intravenous bolus dose of M-6-G was found to be ineffective in the treatment of acute postoperative pain. This might be related to the low permeability of the blood–brain barrier for M-6-G.

ORG 9487 Neuromuscular Block at the Adductor Pollicis and the Laryngeal Adductor Muscles in Humans

Background: ORG 9487 is a new steroidal nondepolarizing muscle relaxant with a rapid onset of action. This study was designed to determine the neuromuscular blocking profile of ORG 9487 at the adductor muscles of the larynx and the adductor pollicis. Methods: In 30 adults, anesthesia was induced with propofol (2–5 mg/kg) and fentanyl (2–3 micro gram/kg). After train‐of‐four stimulation, the block of the laryngeal adductor muscles was evaluated by measuring the pressure changes in the cuff of the tracheal tube placed between the vocal cords, and the force of the contraction of the adductor pollicis was measured with a force transducer. Patients were randomly allocated to receive ORG 9487 at intravenous bolus doses of 0.75, 1.5 or 2 mg/kg (n = 10 in each group). Results: Time to peak effect was significantly shorter at the vocal cords than at the adductor pollicis muscle (P < 0.001). Onset time at the vocal cords was 62 +/‐ 16 s, 62 +/‐ 13 s, and 52 +/‐ 14 s (mean +/‐ SD) after doses of 0.75, 1.5, and 2 mg/kg, respectively (not significant). Onset time at the adductor pollicis muscle was 126 +/‐ 33 s, 96 +/‐ 20 s, and 82 +/‐ 21 s after 0.75, 1.5, and 2 mg/kg doses, respectively (P <0.001). Maximum block was significantly less intense at the vocal cords than at the adductor pollicis muscle (69 +/‐ 15% vs. 94 +/‐ 4% after 0.75 mg/kg; 86 +/‐ 7% vs. 97 +/‐ 4% after 1.5 mg/kg; and 91 +/‐ 5% vs. 99 +/‐ 1% after 2 mg/kg). After 1.5 mg/kg duration to 25%, recovery was 3.7 +/‐ 2.2 min versus 10.2 +/‐ 2.5 min at the vocal cords and the adductor pollicis muscle, respectively, and 75% recovery occurred at 9.7 +/‐ 3.7 min at the vocal cords and at 18.3 +/‐ 5.2 min at the adductor pollicis muscle. Conclusions: ORG 9487 has a rapid onset of action at the laryngeal adductor and the adductor pollicis muscles. Onset and duration of action are faster at the vocal cords than at the adductor pollicis muscle. However, the maximum block obtained at the laryngeal muscles was less than at the adductor pollicis, regardless of the dose of ORG 9487.

Syndrome coronarien aigu après injection de carbétocine 100 µg au cours d’une césarienne en urgence

RésuméObjectifL’hémorragie du post-partum affecte 5 % des parturientes. Sa prévention repose entre autres, sur l’administration de dérivés ocytociques. La carbétocine est une molécule analogue de l’ocytocine, récemment disponible mais qui présente une fréquence d’évènements secondaires importante.Éléments cliniquesNous rapportons le cas d’une patiente, sans facteur de risque cardiovasculaire, ayant souffert dans les suites immédiates d’une injection de carbétocine lors d’une césarienne en urgence, d’une symptomatologie coronaire aiguë avec modifications transitoires du tracé électrocardioscopique per-opératoire. Aucune modification des enzymes cardiaques ou de l’échographie cardiaque n’a été enregistrée lors du suivi post-opératoire.ConclusionL’analyse rétrospective de l’utilisation de carbétocine dans notre établissement sur l’année 2012 permet de suspecter une incidence d’événement coronaire de 1/245 (0,34 %) proche de celles rapportées dans différentes études. Nous discutons la prise en charge de douleurs angineuses chez les patientes au cours des césariennes et la prise en charge ultérieure de cette patiente.AbstractPurposePostpartum hemorrhage affects 5% of parturients. Its prevention relies mainly on the administration of oxytocin derivatives. Carbetocin is a newly available analogue of oxytocin but has a considerable incidence of side effects.Clinical featuresWe report the case of a woman with no cardiovascular risk factors experiencing an acute coronary syndrome with significant electrocardiogram changes perioperatively after a single injection of carbetocin during an emergency Cesarean delivery. Postoperative cardiac enzyme levels and transthoracic echocardiogram results were normal.ConclusionA 2012 retrospective analysis of the use of carbetocin in our institution revealed an incidence rate for coronary events of 1/245 (0.34%), a rate similar to the ones reported in previous studies. We discuss the management of patients with angina during a Cesarean delivery as well as the plans to care for these patients in the future.

Syndrome coronarien aigu après injection de carbétocine 100 µg au cours d’une césarienne en urgence@@@Acute coronary syndrome following a 100 µg carbetocin injection during an emergency Cesarean delivery

RésuméObjectifL’hémorragie du post-partum affecte 5 % des parturientes. Sa prévention repose entre autres, sur l’administration de dérivés ocytociques. La carbétocine est une molécule analogue de l’ocytocine, récemment disponible mais qui présente une fréquence d’évènements secondaires importante.Éléments cliniquesNous rapportons le cas d’une patiente, sans facteur de risque cardiovasculaire, ayant souffert dans les suites immédiates d’une injection de carbétocine lors d’une césarienne en urgence, d’une symptomatologie coronaire aiguë avec modifications transitoires du tracé électrocardioscopique per-opératoire. Aucune modification des enzymes cardiaques ou de l’échographie cardiaque n’a été enregistrée lors du suivi post-opératoire.ConclusionL’analyse rétrospective de l’utilisation de carbétocine dans notre établissement sur l’année 2012 permet de suspecter une incidence d’événement coronaire de 1/245 (0,34 %) proche de celles rapportées dans différentes études. Nous discutons la prise en charge de douleurs angineuses chez les patientes au cours des césariennes et la prise en charge ultérieure de cette patiente.AbstractPurposePostpartum hemorrhage affects 5% of parturients. Its prevention relies mainly on the administration of oxytocin derivatives. Carbetocin is a newly available analogue of oxytocin but has a considerable incidence of side effects.Clinical featuresWe report the case of a woman with no cardiovascular risk factors experiencing an acute coronary syndrome with significant electrocardiogram changes perioperatively after a single injection of carbetocin during an emergency Cesarean delivery. Postoperative cardiac enzyme levels and transthoracic echocardiogram results were normal.ConclusionA 2012 retrospective analysis of the use of carbetocin in our institution revealed an incidence rate for coronary events of 1/245 (0.34%), a rate similar to the ones reported in previous studies. We discuss the management of patients with angina during a Cesarean delivery as well as the plans to care for these patients in the future.

Acute coronary syndrome following a 100 µg carbetocin injection during an emergency Cesarean delivery

RésuméObjectifL’hémorragie du post-partum affecte 5 % des parturientes. Sa prévention repose entre autres, sur l’administration de dérivés ocytociques. La carbétocine est une molécule analogue de l’ocytocine, récemment disponible mais qui présente une fréquence d’évènements secondaires importante.Éléments cliniquesNous rapportons le cas d’une patiente, sans facteur de risque cardiovasculaire, ayant souffert dans les suites immédiates d’une injection de carbétocine lors d’une césarienne en urgence, d’une symptomatologie coronaire aiguë avec modifications transitoires du tracé électrocardioscopique per-opératoire. Aucune modification des enzymes cardiaques ou de l’échographie cardiaque n’a été enregistrée lors du suivi post-opératoire.ConclusionL’analyse rétrospective de l’utilisation de carbétocine dans notre établissement sur l’année 2012 permet de suspecter une incidence d’événement coronaire de 1/245 (0,34 %) proche de celles rapportées dans différentes études. Nous discutons la prise en charge de douleurs angineuses chez les patientes au cours des césariennes et la prise en charge ultérieure de cette patiente.AbstractPurposePostpartum hemorrhage affects 5% of parturients. Its prevention relies mainly on the administration of oxytocin derivatives. Carbetocin is a newly available analogue of oxytocin but has a considerable incidence of side effects.Clinical featuresWe report the case of a woman with no cardiovascular risk factors experiencing an acute coronary syndrome with significant electrocardiogram changes perioperatively after a single injection of carbetocin during an emergency Cesarean delivery. Postoperative cardiac enzyme levels and transthoracic echocardiogram results were normal.ConclusionA 2012 retrospective analysis of the use of carbetocin in our institution revealed an incidence rate for coronary events of 1/245 (0.34%), a rate similar to the ones reported in previous studies. We discuss the management of patients with angina during a Cesarean delivery as well as the plans to care for these patients in the future.