"You only live twice": multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report.

BACKGROUND: Placenta percreta is associated with high hemorrhagic risk and can be complicated with fatal thromboembolic events. Involving a multidisciplinary team in the treatment of these patients is mandatory to reduce morbidity and mortality. CASE PRESENTATION: This paper reports the case of a 22-year-old patient with placenta percreta who was referred to our tertiary care center for delivery. Few hours after undergoing a successful cesarean hysterectomy, the patient developed a pulmonary embolism and cardiac arrest. A transthoracic echocardiogram done in the intensive care unit (ICU) showed a thrombus in the right ventricle. After cardiac resuscitation, the patient underwent an urgent thoracotomy and a pulmonary artery thrombectomy; many clots were retrieved from the pulmonary artery. After weaning from extracorporeal circulation, an intraoperative transesophageal cardiac ultrasound enabled the medical team to detect a new free-floating thrombus in the right atrium and right ventricle, and consequently to perform an embolectomy and prevent the patient's death. CONCLUSION: This case emphasizes the role of multidisciplinary team in treating high-risk obstetric cases that could be complicated with massive and fatal thromboembolic events. The use of intraoperative transthoracic echocardiography helps in detecting a new thrombus and guides the anesthesiologist in the intra-operative monitoring.

Genotyping test with clinical factors: better management of acute postoperative pain?

Individualization of acute postoperative pain treatment on an evidence-based decision process is a major health concern. The aim of this study is to investigate the influence of genetic and non-genetic factors on the variability of response to morphine in acute postoperative pain. A group of nighty-five patients undergoing major surgery were included prospectively. At 24 h, a logistic regression model was carried out to determine the factors associated with morphine doses given by a Patient Controlled Analgesia device. The dose of morphine was associated with age (p = 0.011), patient weight (p = 0.025) and the duration of operation (p = 0.030). This dose decreased with patient's age and duration of operation and increased with patient's weight. OPRM1 and ABCB1 polymorphisms were significantly associated with administered dose of morphine (p = 0.038 and 0.012 respectively). Patients with at least one G allele for c.118A>G OPRM1 polymorphism (AG/GG) needed 4 times the dose of morphine of AA patients. Additionally, patients with ABCB1 CT and CC genotypes for c.3435C>T polymorphism were 5.6 to 7.1 times more prone to receive higher dose of morphine than TT patients. Our preliminary results support the evidence that OPRM1/ABCB1 genotypes along with age, weight and duration of operation have an impact on morphine consumption for acute postoperative pain treatment.

[History of pain: from Greek antiquity to the 21st century]. / Histoire de la douleur: de l'Antiquité grecque au XXIe siècle.

The history of pain is one of the concepts that have divided Cartesian thinkers and mystical philosophers in the Western civilization over centuries. Depending on the historical period, different dogmas and morals intersect, oppose or attempt conciliation. The attitude towards pain evolved with the evolution of mentalities in the broad sense but also by relying on scientific discoveries in the field. Yesterday, pain was accepted or sublimated. Today, taking care of pain is a patient basic right and an obligation for the practitioner.

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.

Magnesium and Ketamine Reduce Early Morphine Consumption After Open Bariatric Surgery: a Prospective Randomized Double-Blind Study.

BACKGROUNDS: Optimal pain management in bariatric patients is crucial for early recovery. This study aims to evaluate the effects of magnesium and ketamine combination on morphine consumption after open bariatric surgery (primary outcome), as well as on postoperative pain scores and occurrence of side effects. METHOD: A total of 60 patients undergoing elective open gastric bypass were randomized into 3 groups. All patients received the same general anaesthesia protocol. The magnesium and ketamine group (Mg + K) received an IV bolus of magnesium 50 mg/kg and ketamine 0.2 mg/kg followed by continuous infusion of magnesium (8 mg/kg/h) and ketamine (0.15 mg/kg/h) until extubation. The ketamine group (K) received the same bolus and infusion of ketamine, together with a bolus and continuous infusion of normal saline. The placebo group (P) received normal saline. All patients received 48 h of paracetamol 1 g IV q6h and morphine sulphate 0.1 mg/kg subcutaneous q6h PRN. Morphine consumption, VAS pain scores and occurrence of side effects were recorded for 48 h postoperatively. RESULTS: Patients in group (Mg + K) (2.4 ± 2.62 mg) and in group (K) (2.8 ± 2.66 mg) had significantly lower morphine consumption in the PACU compared with the patients in group (P) (4.85 ± 4.51 mg) (p = 0.045). Patients in group (Mg + K) consumed significantly less morphine the first 24 postoperative hours, with a relative reduction of 87% and 21% compared with group (K) and group (P) respectively (p = 0.028). However, this difference was not observed at 48 h. No significant difference was shown between the three groups in terms of nausea and vomiting, time to extubation or excessive sedation. CONCLUSION: The association of magnesium and ketamine bolus followed by infusion in open bariatric surgery appears to be safe and decreases morphine requirements in the first 24 h compared with both ketamine alone and placebo.

Regional analgesia and breast cancer surgery.

Breast cancer surgery is frequently associated with postoperative nausea, vomiting, pain and painful restricted movement. It is well established that thoracic paravertebral block with or without general anesthesia provides better postoperative analgesia and reduces the risk of nausea and vomiting after breast surgery as well as the incidence of chronic pain. Paravertebral block improves the quality of recovery after breast cancer surgery and provides the patient with the option of ambulatory discharge.

Preoperative fasting: Assessment of the practices of Lebanese Anesthesiologists.

BACKGROUND: Although new guidelines developed by the American Society of Anesthesiologists (ASA) recommend a liberalized preoperative nutrition, authorized clinical practice guidelines or recommendations have not yet been proposed by the Lebanese Society of Anesthesia (LSA). OBJECTIVE: The purpose of this study was to examine Lebanese anesthesiologists' preoperative fasting routines and determine their knowledge and acceptance of the ASA recommendations, their attitude toward liberalized fasting, and the factors favoring their nonadherence to the new recommendations. MATERIALS AND METHODS: This study was conducted in university hospitals, affiliated hospitals, and nonuniversity hospitals located in different regions of Lebanon. The survey was approved by the local ethics committee. A written questionnaire was emailed to all anesthesiologist members of the LSA which was completed anonymously. RESULTS: Out of the 294 anesthesiologists registered in the LSA and who read the email, 118 (40.1%) completed the questionnaire. Of respondents, 90% are aware of the latest ASA practice guidelines for preoperative fasting, and 78.7% claim to apply them in their practices; however, 75% of respondents still require adult patients to stop eating after midnight, and only 45% allow them to drink clear fluids up to 2 h preoperatively. One of the main reasons for not complying with the ASA guidelines was "to allow flexibility for changes in the operating schedule." CONCLUSION: A long preoperative fasting period is still the common practice for Lebanese anesthesiologists. National guideline for preoperative fasting as liberal as that recommended by the ASA should be considered.

Safety and Efficacy of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Used for Analgesia After Bariatric Surgery: A Retrospective Case-Control Study.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia protocols. This point is of great value in morbidly obese patients due to the high prevalence of restrictive pulmonary disease and obstructive sleep apnea. The aim of this study was to test the hypothesis that NSAIDs do not increase acute bariatric surgery complications while optimizing postoperative analgesia. METHODS: Databases of two medical centers were retrospectively reviewed to find all patients who underwent bariatric surgery between 1 January 2017 and 31 December 2017. Inclusion criteria were BMI greater than 30 kg/m2 and age of 16-75 years old. Patients who suffered from severe organ failure or coagulation disorders were excluded. Patient's demographics, obesity-related diseases (diabetes, hypertension, dyslipidemia), postoperative pain scores, and morphine consumption in PACU, as well as early and late surgical complications, were collected. Patients included from the first institution (where NSAIDs analgesia was prohibited: control group) were compared to patients from the second institution (where NSAIDs analgesia was mandatory: case group). RESULTS: The study population included 270 patients, 134 in the control group, and 136 in the case group. NSAIDs usage produced better analgesia with significant reduction in morphine consumption and PACU length of stay. Also, incidence of surgical complications was the same in the two groups. CONCLUSIONS: NSAIDs administration do not increase postoperative complication rate after bariatric surgery. Although NSAID administration provided better analgesia and shorter PACU stay, future prospective studies are needed to confirm these encouraging results and to evaluate their impact on postoperative rehabilitation.

Undergraduate medical education in palliative medicine: the first step in promoting palliative care in Lebanon.

Effective delivery of high-quality palliative care requires effective interprofessional team working by skilled healthcare professionals. Palliative care is therefore highly suitable for sowing the seeds of interprofessional team working in early professional undergraduate medical education. Integrating palliative medicine in undergraduate medical education curricula seems to be a must. In this review, we present as an example the Palliative and End-of-Life Care Curriculum (PEOLC) used in Canada for undergraduate medical education and underline the need for such a national curriculum in Lebanon. One must keep in mind that medical education does not stop at the end of the medical school, ongoing learning needs exist. Continuous medical education in palliative care should also be emphasized; the overall goal is promoting palliative medicine. Respecting and protecting human dignity is the right of every patient.

Pain management and health care policy.

Opioid analgesics are essential for the management of moderate to severe pain. In spite of their documented effectiveness, opioids are often underutilized, a factor which has contributed significantly to the undertreatment of pain. Many countries have developed true national policies on cancer pain and palliative care, and in others only guidelines for care have been developed. Ideally, national policies facilitate and legislate not only a patient's right to care, but also the necessary components of education and drug availability which are so critical for the appropriate achievement of public health programs.

The effect of low-dose intravenous ketamine on continuous intercostal analgesia following thoracotomy.

Ketamine, a noncompetitive N-methyl-d-aspartate antagonist, provides analgesia and prevents chronic pain following thoracotomy. The study was aimed to assess the effect of intravenous low-dose ketamine on continuous intercostal nerve block analgesia following thoracotomy. The study was a prospective, randomized, double-blinded, and placebo-controlled clinical study, performed in a single university hospital. Sixty patients, undergoing elective lobectomy through an open posterolateral thoracotomy, were included. For postoperative pain, all patients received a continuous intercostal nerve block with bupivacaine plus intravenous paracetamol and ketoprofen. In addition, patients were randomized to have intravenous ketamine (0.1 mg/kg as a preincisional bolus followed by a continuous infusion of 0.05 mg/kg/h) in group 1 or intravenous placebo in group 2. Patients reporting a visual analog scale pain score at rest ≥40 mm received intravenous morphine sulfate as rescue analgesia. The following parameters were assessed every 6 hours for 3 postoperative days: Visual analog scale pain scores at rest and during coughing, requirement of rescue analgesia with morphine, Ramsay sedation scores and psychomimetic adverse effects. Both the groups were statistically comparable regarding visual analog scale pain scores at rest (P=0.75) and during coughing (P=0.70), number of morphine deliveries (P=0.17), cumulative dose of rescue morphine (P=0.2), sedation scores (P=0.4), and psychomimetic adverse effects (P=0.09). Intravenous low-dose ketamine, when combined with continuous intercostal nerve block, did not decrease acute pain scores and supplemental morphine consumption following thoracotomy.

Stereotactic functional mapping of the cat motor cortex.

Epidural motor cortex stimulation is an increasingly used method to control refractory neuropathic pain although its mechanisms of action remain poorly understood. Animal models are currently developed that allow reproducing the conditions of this neurosurgical approach and clarifying its mechanisms. In this study we validate a new stereotactic functional map of the cat motor cortex carried out in epidural conditions, thus allowing future experimentations that closely mimic the technique used in humans.

Morbidity and mortality of thyroidectomy for substernal goiter.

BACKGROUND: Our objective was to evaluate morbidity and mortality of thyroidectomy in substernal goiters and identify patients at risk for these events. METHODS: The medical records of 127 patients with substernal goiters were retrospectively reviewed. RESULTS: The most common preoperative symptom was shortness of breath (48%). 13% of the 127 patients were asymptomatic. Preoperative imaging identified tracheal deviation in 69% and tracheal compression in 41% of the cases. Substernal goiters were resected via a cervical approach in 100% of the cases. Six patients (5%) had postoperative hoarseness, 1 had permanent vocal cord paralysis, and 19 (15%) had transient postoperative hypocalcemia. The mortality and permanent hypoparathyroidism were null. Patients with postoperative complications had larger goiters and were more likely to have tracheal compression. CONCLUSIONS: Thyroid resection via a cervical approach for substernal goiters is associated with low rate of morbidity and no mortality. Patients with large tumors and tracheal compression are more likely to develop postoperative complications.

Ultrasonography: highly accuracy technique for preoperative localization of parathyroid adenoma.

OBJECTIVES/HYPOTHESIS: This study evaluates the accuracy of ultrasonography in guided unilateral parathyroidectomy to treat primary hyperparathyroidism. STUDY DESIGN: Retrospective study. METHODS: Two hundred fifty-three patients with primary hyperparathyroidism underwent preoperative ultrasonography. Two groups were defined. Group 1 included the patients in whom the preoperative cervical ultrasound localized one abnormal parathyroid gland; these patients underwent unilateral surgical exploration of the neck under local anesthesia. Group 2 included the patients who had a bilateral neck exploration under general anesthesia when the preoperative examination was equivocal or failed to localize the lesion, when concomitant thyroid pathology indicated thyroidectomy, and when justified by the surgical findings. RESULTS: Sensitivity and positive predictive value of ultrasonography in detecting abnormal parathyroid gland were 96% and 98%, respectively. Cervical ultrasound correctly identified, 96% and 85% of abnormal glands in groups 1 and 2, respectively. The presence of thyroid nodular disease did not affect ultrasonographic accuracy. Sonographic examination decreased the operative time of parathyroidectomy to an average of 15 minutes. Mediastinal and retroesophageal localizations of abnormal parathyroid gland adversely affected the accuracy of the ultrasound. No cervical hematoma was noted. Transient recurrent laryngeal nerve palsy occurred in four patients. Twenty-three patients required postoperative calcium supplementation for 2 to 4 months, and all were normocalcemic at follow-up. CONCLUSIONS: Cervical ultrasound is a reliable preoperative exploration allowing parathyroidectomy via unilateral approach under local anesthesia.