Tiberiu Ezri

The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection: a randomized trial

STUDY OBJECTIVE To assess the effect of intermittent versus continuous bladder catheterization on labor duration and local anesthetic consumption. DESIGN Randomized, controlled, prospective, single-blind trial. SETTING University-affiliated hospital. PATIENTS 209 ASA physical status I and II, primiparous parturients who received patient-controlled epidural analgesia for labor. INTERVENTIONS Patients were randomly allocated to either the intermittent bladder catheterization group (Group IC; n = 109) or the continuous catheterization group (Group CC; n = 100). MEASUREMENTS Duration of the second stage of labor, dose of local anesthetics given, and primary outcomes were compared by group using the t-test for independent samples. Main secondary outcomes were postpartum urinary retention and rate of postpartum urinary tract infection (UTI; asymptomatic bacteruria). MAIN RESULTS Duration of the second stage of labor was longer in Group CC than Group IC: 105 +/- 72 vs. 75 +/- 52 min (P = 0.002). This finding was associated with increased local anesthetic dose requirement in Group CC during both stages of labor (73 +/- 25 mL vs. 63 +/- 26 mL; P = 0.005). The rate of UTI was similar (30%) in both study groups. CONCLUSION Intermittent bladder catheterization was associated with shorter second-stage labor and less local anesthetic, but the same frequency of postpartum urinary retention and UTI was seen with both catheterization groups.

A prospective, randomized comparison of cobra perilaryngeal airway and laryngeal mask airway unique in pediatric patients

BACKGROUND: The Cobra Perilaryngeal Airway (PLA) provides better sealing pressure than the Laryngeal Mask Airway Unique (LMAU) during positive-pressure ventilation in adults. We compared the performance of the CobraPLA and LMAU in infants and children. METHODS: Two-hundred pediatric patients were randomly assigned to a CobraPLA or an Laryngeal Mask Airway (LMA). We measured airway sealing at cuff inflation pressures of 40 and 60 cm H2O; ease and time of insertion; device stability; efficacy of ventilation; number of insertion attempts; incidence of postoperative sore throat, dysphonia, laryngospasm, bronchospasm, and gastric gas insufflation. Steady-state end-tidalCO2 was measured at the head of the CobraPLA and at the “Y-piece” piece of the anesthetic circuit. For the major outcomes, the airway groups were subdivided post hoc into small and large CobraPLA and small and large LMA subgroups. Results are presented as means ± sds; P < 0.05 was considered statistically significant. RESULTS: Airway sealing pressure with the cuff inflated to 60 cm H2O in the large CobraPLA subgroup (22 ± 7 cm H2O) was significantly more than that of the small CobraPLA subgroup (18 ± 5 cm H2O) and large LMA subgroup (16 ± 5 cm H2O; P < 0.001). The CobraPLA was more stable than the LMA (same anatomic fit score before and after surgery) and produced less gastric insufflation. Head CobraPLA end-tidalCO2 values were 6.4 ± 6 mm Hg more than those of the Y piece of the circle circuit. CONCLUSIONS: The CobraPLA airway performed as well as the LMAU during anesthesia in pediatric patients for a large range of outcomes and was superior for some.

Gastroesophageal regurgitation during anesthesia and controlled ventilation with six airway devices

STUDY OBJECTIVE To investigate the frequency of gastroesophageal regurgitation and respiratory mechanics during positive pressure ventilation using 5 supraglottic devices or an endotracheal tube (ETT). DESIGN Prospective, randomized study. SETTING Operating rooms in a university-affiliated hospital. PATIENTS 180 ASA physical status I and II patients, aged 18 to 65 years old, who underwent elective orthopedic, minor vascular, peripheral plastic, or urologic surgery during general anesthesia. INTERVENTIONS Patients were randomly allocated to one of 6 airway device groups (n = 30 each): (1) Cobra Perilaryngeal Airway; (2) Laryngeal Mask Airway (LMA) Classic; (3) LMA Fastrach; (4) LMA ProSeal; (5) laryngeal tube; and (6) ETT (SIMS Portex, Ltd, Hythe, Kent, UK). After insertion of the designated device, the lungs of each nonparalyzed patient were mechanically ventilated. MEASUREMENTS Hypopharyngeal pH, peak inspiratory pressures, sealing pressures, and lung compliance were measured. Hypopharyngeal pH lower than 4 was considered a regurgitation event. MAIN RESULTS Regurgitation (episodes of pH <4) occurred in between one and 5 patients of each study group, with no statistical difference. Sealing pressures were similar among all the airway device groups. CONCLUSIONS The frequency of gastroesophageal regurgitation in anesthetized, unparalyzed, mechanically ventilated patients was similar in patients whose lungs were ventilated with either the Cobra Perilaryngeal Airway, LMA Classic, Fastrach, ProSeal, laryngeal tube, or ETT.

Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance

BackgroundHyperphosphatemic acidosis and severe electrolyte disturbances caused by phosphate salts (PO) used for mechanical bowel preparation have been described in occasional case reports prior to bowel resection surgery. We hypothesized that PO used preoperatively for bowel preparation may cause more pronounced acid base and electrolyte changes than polyethylene glycol (PG).MethodsForty American Society of Anesthesiologists physical status II–III patients were randomly allocated to receive either PO or PG for bowel preparation before intra-abdominal surgery (bowel resection or other major elective intra-abdominal surgeries). Measurements of pH, base deficit, blood gases, lactate, hemoglobin, calcium, magnesium, potassium and phosphorus were undertaken before the laxative administration, intraoperatively, and postoperatively.ResultsPreoperative demographic, hemodynamic and laboratory data were similar in the two groups. Intraoperative calcium (8.4 [0.6] vs 9 [0.5] mg·dL-1) and pH (7.35 [0.04] vs 7.41 [0.03]) were lower, while lactate (1.3 [0.4] vs 0.9 [0.3] mmol·L-1) was higher with PO. Postoperative calcium, magnesium and potassium were lower (8 [0.5] vs 8.9 [0.2] mg·dL-1, 1.68 [0.3] vs 1.8 [0.4] and 3.5 [0.36] vs 3.7 [0.33] mEq·L-1 respectively) while phosphorus (4.1 [0.3] vs 3.3 [0.2] mEq·L-1) was higher with PO. A higher percentage of abnormal values for calcium, potassium, phosphorus and base deficit (66% vs 33%, 25% vs 10%, 19% vs 2% and 28.3% vs 5% respectively) were observed with PO.ConclusionsCalcium and magnesium changes were more pronounced in patients who received PO for bowel preparation.AbstractObjectifĽacidose hyperphosphatémique et des troubles sévères des électrolytes causés par les sels phosphatés (PO) utilisés pour la préparation intestinale mécanique ont été décrits à ľoccasion dans des présentations de cas avant la résection de ľintestin. Nous avons supposé que les PO utilisés avant ľopération pour la préparation intestinale pouvaient causer plus de changements acide base et électrolytiques que le polyéthylèneglycol (PG).MéthodeQuarante patients ďétat physique ASA II–III ont reçu au hasard soit des PO, soit du PG pour la préparation de ľintestin à la chirurgie intra-abdominale comme la résection de ľintestin ou ďautres opérations majeures réglées. Les mesures du pH, du déficit basique, des gaz sanguins, du lactate, de ľhémoglobine, du calcium, du magnésium, du potassium et du phosphore ont été faites avant ľadministration du laxatif, pendant et après ľopération.RésultatsLes données démographiques, hémodynamiques et de laboratoire étaient similaires dans les deux groupes. Le calcium (8,4 [0,6] vs 9 [0,5] mg·dL-1) et le pH (7,35 [0,04] vs 7,41 [0,03]) peropératoires étaient plus bas, mais le lactate (1,3 [0,4] vs 0,9 [0,3] mmol·L-1) était plus élevé avec le PO. Le calcium, le magnésium et le potassium postopératoires ont été plus bas (8 [0,5] vs 8,9 [0,2] mg·dL-1, 1,68 [0,3] vs 1,8 [0,4] et 3,5 [0,36] vs 3,7 [0,33] mEq·L-1) tandis que le phosphore (4,1 [0,3] vs 3,3 [0,2] mEq·L-1) a été plus élevé avec le PO. Un plus fort pourcentage de valeurs anormales pour le calcium, le potassium, le phosphore et le déficit basique (66 % vs 33 %, 25 % vs 10 %, 19 % vs 2 % et 28,3 % vs 5 %) a été observé avec le PO.ConclusionLes changements notés pour le calcium et le magnésium étaient plus prononcés chez les patients qui ont reçu des PO pour une préparation intestinale.

Listening to music during anesthesia does not reduce the sevoflurane concentration needed to maintain a constant bispectral index.

BACKGROUND: Music reduces stress responses in awake subjects. However, there remains controversy about the role of music or therapeutic suggestions during general anesthesia and postoperative recovery. We thus tested the hypothesis that intraoperative exposure to soothing music reduces the end-tidal concentration of sevoflurane (ETSevo) necessary to maintain bispectral index (BIS) near 50 during laparoscopic surgery. METHODS: Forty patients, aged 40–60 yrs, ASA I and II, undergoing laparoscopic hernias or cholecystectomy under general anesthesia were studied. All patients were connected to a BIS monitor. Anesthesia was induced with fentanyl 2 &mgr;g/kg, sevoflurane in oxygen, rocuronium (0.6 mg/kg), and maintained with sevoflurane in oxygen and 50% nitrous oxide, with an infusion of fentanyl (1 &mgr;g · kg−1 · h−1). Sevoflurane was titrated to maintain BIS near 50 throughout the procedure. Patients were randomly assigned to either listen to music or not. RESULTS: The ETSevo necessary to maintain a BIS near 50 was virtually identical in patients who listened to music (1.29 ± 0.33%) and those who did not (1.27 ± 0.33%, P = 0.84). Patients who listened to music reported slightly less pain, but the difference was not statistically significant. Mean arterial blood pressure was slightly higher in patients who listened to music (101 ± 11 mm Hg) than in those who did not (94 ± 10 mm Hg, P = 0.040). CONCLUSIONS: The end-tidal concentration of sevoflurane required to maintain BIS near 50 during laparoscopic cholecystectomy was virtually identical in patients exposed to music or not. Although previous work suggests that music reduces preoperative stress and may be useful during sedation, our results do not support the use of music during surgery.

Morbidly Obese Patients are Hemodynamically Stable During Laparoscopic Surgery: A Thoracic Bioimpedance Study

Purpose. Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable. Methods. In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI ≥ 35 kg/m2) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40–50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP ≤ 60 and MAP ≥ 130 mmHg or HR ≤ 50 and HR ≥ 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI. Results. Heart rate was higher in obese patients in head-up position (79 ± 15 mmHg vs. 65 ± 12 mmHg – P=0.011). SVR was higher in the nonobese group with head-up position (1978 ± 665 dynes s cm−5 vs. 1394 ± 496 dynes s cm−5P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP ≤ 60 and ≥130 mmHg or HR ≤ 50 and ≥110 bpm in either of the groups. Conclusion. Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

The outcome of preterm neonates with intraventricular hemorrhage delivered with intravenous meperidine or epidural analgesia

We aimed to study, retrospectively, the neonatal outcome of 45 preterm neonates with intraventricular hemorrhage (IVH) who were delivered vaginally with intravenous meperidine (n = 23) or epidural analgesia (n = 22). Neonates in the epidural group had a better outcome in terms of a first-minute Apgar score of 7 or less, in 31% vs 69% (P = 0.001); 5-min Apgar score of 7 or less, in 18% vs 82% (P = 0.003); a lower incidence of respiratory distress syndrome (RDS; 23% vs 30%; P = 0.03); a lower dopamine requirement during the first neonatal week (13% vs 72%; P = 0.01); and a higher survival rate (91% vs 58%, respectively; P = 0.008). It is concluded that preterm neonates with IVH had a better outcome when delivered to mothers receiving epidural analgesia as compared to those receiving intravenous meperidine.

Activin ??A in Term Placenta and Its Correlation With Placental Inflammation in Parturients Having Epidural or Systemic Meperidine Analgesia: A Randomized Study

STUDY OBJECTIVE To investigate the immunohistochemical localization of betaA subunit of activin A in human term placenta, as a marker for placental infection/inflammation and elevated temperature, in parturients laboring during two analgesic regimens. DESIGN Prospective, randomized controlled study. SETTING Delivery room. PATIENTS 56 healthy, ASA physical status I and II primiparous women in labor. INTERVENTIONS Parturients were assigned to receive patient-controlled epidural analgesia (PCEA) with 0.2% ropivacaine or patient-controlled intravenous analgesia PCA with meperidine. MEASUREMENTS Histologic and immunohistochemical placental evaluation for white blood cell infiltration and activin betaA staining were made. Maternal temperature elevation above 37.6 degrees C and leukocytosis above 15,000/microL were recorded. MAIN RESULTS Temperature was not significantly increased in parturients receiving PCEA over those who received (PCA) with meperidine (31% vs 11%, respectively; P = 0.1). There was also no association between temperature elevation during epidural analgesia and increased white blood cell count (>15,000/microL) or presence of polymorphonuclear and/or lymphocyte aggregation in the placenta. Immunohistochemical staining with antisera against the betaA subunit of activin was present mainly in the placental cytotrophoblast, syncytiotrophoblast, and vascular endothelium, and was not associated with an increase in maternal temperature. No significant difference was noted between the two analgesic techniques with regard to maternal temperature elevation. Intrapartum temperature elevation was not associated with histologic signs of placental inflammation or with expression of activin betaA in the placenta. CONCLUSION Other mechanisms may be involved in the etiology of temperature elevation during labor.