Efficacy of bilateral erector spinae block for post-operative analgesia in liver hydatid surgery.

BACKGROUND: Erector spinae plane (ESP) block is a recently described interfacial block, and since 2016, studies have shown that it is a safe technique related to the lower risk of neurovascular and pleural injury comparing to epidural or paravertebral blockade. The application of ESP block in abdominal surgery is relatively limited to case reports and small population studies, which is why we believe every new case of its application should be a valuable contribution. CASE PRESENTATION: With this present case, we explored the efficacy of bilateral ESP block as a post-operative analgesia technique for liver hydatid surgery on a 56-year-old patient. Ultrasound-guided bilateral ESP block was applied at T7 level, while the patient was awake before general anaesthesia induction. The local anaesthetic used was 20 mL ropivacaine (0.375%) and 2 mg dexamethasone on each side. After recovery from anaesthesia, she reported mild pain (visual analogue score of 5 on effort). After 12 hours post-operatively, she received only one dose of paracetamol 1 g considered as rescue analgesic. She did not experience nausea and vomiting episodes. We noted a sensory block extending from T4 to T10. CONCLUSION: To our knowledge, it may be the first adult bilateral single-shot case report for this specific procedure. This technique appears to be safe and effective on post-operative analgesia for this type of surgery; however, prospective studies comparing ESP block to other techniques are needed.

Bilateral Erector Spinae Plane Block for Postoperative Analgesia in Laparoscopic Cholecystectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Erector spinae plane (ESP) block is a novel regional anesthetic technique. Its application for postoperative analgesia has been increasing since 2016; however, its effectiveness remains uncertain and varies according to the type of surgery. This meta-analysis aimed to assess the analgesic efficacy of ESP block in patients undergoing laparoscopic cholecystectomy. METHODS: Literature searches of electronic databases and manual searches up to June 1, 2020 were performed. Review Manager Version 5.3 was used for pooled estimates. We included only randomized controlled trials (RCTs) in this meta-analysis. The random-effects meta-analysis model was used, and metaregression was applied when appropriate. RESULTS: A total of five RCTs consisting of 250 patients were included (124 in the ESP block group vs. 126 in the control group). Bilateral ESP block showed a significant reduction in postoperative intravenous opioid consumption reported up to 24 hours after surgery (mean difference [MD] = -4.46, 95% confidence interval [CI] [-5.50 to -3.42], P < 0.001) and in the time to first rescue analgesic (MD = 73.27 minutes, 95% CI [50.39 to 96.15], P < 0.001). According to the results of four studies, the postoperative pain score was lower in the ESP group compared with the control group at both rest and movement. There were no differences between the two groups as concerns nausea (odds ratio [OR] = 0.45, 95% CI [0.13 to 1.52], P = 0.20) and vomiting (OR = 0.37, 95% CI [0.10 to 1.35], P = 0.13). No block-related complications were noted. CONCLUSION: This meta-analysis showed that bilateral ultrasound-guided ESP block could be considered as an effective option to reduce opioid consumption and the time to first rescue analgesic and seems to be also a safe technique in adults undergoing laparoscopic cholecystectomy.

Personal Protective Equipment: A Cross-Sectional Study in Frontline Healthcare Workers During COVID-19 Outbreak in Tunisia.

BACKGROUND: For frontline healthcare workers (FHW) who are working with Coronavirus Disease-19 (COVID-19) patients, PPE is currently considered as one of the most discussed topics. Recommendation from international organizations concerning the use of PPE are broadly consistent but equipment use is not. No previous studies examined the use of PPE in Tunisia. AIM: Evaluate the availability of personal protective equipment(PPE) in addition to the reality and perception regarding personal safety in workplace. METHODS: We carried out a cross-sectional survey from 15th April to 5th May 2020 across public and private institutions in Tunisia. A 33-item structured questionnaire was developed and administered to FHWs. RESULTS: We received 723 responses. We found that there was a likely overuse of PPE in addition to a high rate of side effects caused by PPE. CONCLUSIONS: Additional training in PPE use might be useful, and sessional work should be considered to decrease the side effects associated with PPE use.

Parecoxib in laparoscopic surgery for simple vesicular lithiasis.

AIM: To evaluate the contribution of parecoxib to the protocol of multimodal analgesia for simple vesicular lithiasis by laparoscopy. METHODS: A prospective, randomized, double-blind study was carried out at Habib Thameur Hospital (Tunis). We included 60 patients, ASA I or II, scheduled for cholecystectomy by laparoscopy. The patients were randomized to 2 groups. The parecoxib group (PG) receiving parecoxib 40 mg 30 minutes before the induction and the control group (CG) receiving physiological saline. Data were collected during hospitalization and a follow-up was done one year after the operation by a questionnaire. RESULTS: The pain scores at rest and at cough were significantly lower in the PG than in the CG during the first postoperative day (p < 10-3). Ten percent of the patients of the CG and no patient of the GP required Morphine in the recovery room (p = 0,07). The requirement of Tramadol was significantly less frequent in the PG (70 % of the PG, 16,6 % of the CG and p < 10-3). A chronic pain was found in 37,5 % and 8 %, respectively, in the GC and GP (p = 0,013). This pain was intense in 2 GC patients requiring analgesics and a work stoppage. CONCLUSIONS: The results of our study are in favor of the use of Parecoxib 40 mg 30 minutes before laparoscopic cholecystectomy for its effects on acute pain, opioid sparing and chronic pain.

Are our stethoscopes contaminated ?

BACKGROUND: Health care-associated infections are a real public health problem. Contaminated medical equipments such as stethoscopes are often an overlooked vector. In our study, we were interested in proving our doctors stethoscopes contamination and in studying the microbiological profile of isolated germs. METHODS: This was about a cross-sectional study that lasted 2 months (May and June 2014) including 39 personal stethoscopes of all grade doctors working in 8 different departments in Habib Thameur Hospital. The swabs were taken from the membranes of the stethoscopes and sent quickly to our bacteriology service. Then, the bacteriological samples were subcultivated on blood agar. The reading tooks place 24 hours later. Were considered positive the cultures that contained more than 104 colony forming units/ml. Then we proceeded to the identification of the germ. RESULTS: Fifteen samples from 39 were positive that was 38 %. The coagulase- negative Staphylococcus was the predominant germ. The pathogenic germs were found in 5 positive samples that was 12 % from all the samples. They were distributed as follows: 2 Methicillin-susceptible Staphylococci Aureus, 2 methicillin-resistant coagulase- negative Staphylococci and one Pseudomonas aerogenusa. The pathogenic germs were found in stethoscopes taken from cardiology and intensive care unit (ICU). In cardiology, 7/9 stethoscopes were positive (5 coagulase- negative Staphylococcus among them 2 resistant methicillin and 2 Staphylococcus aureus.) In ICU, 6/13 stethoscopes were positive among them one Pseudomonas aerogenusa. CONCLUSION: The stethoscopes constitute bacterial reservoirs. It is necessary to perform a procedure for the good practices of disinfection.

[Effectiveness of intravenous magnesium on postoperative pain after abdominal surgery versus placebo: double blind randomized controlled trial]. / Effet du magnésium intraveineux sur la douleur postopératoire en chirurgie abdominale versus placebo : Essai thérapeutique randomisé, en double aveugle.

PURPOSE: the purpose of our trial is to evaluate the impact of the intravenous perfusion of magnesium on the morphin consumption and on the controle of the stress neuro-endocrin and metabolic reaction in major digestive surgery. METHODS: prospective, randomized, double blinded study versus placebo.Including 42 ASA I patients, scheduled for major digestive surgery, randomized into two groups : Magnesium, receiving a bolus of magnesium sulfate; 50 mg/kg, followed by a continuous perfusion; 10 mg/kg/h for the 24 postoperative hours. The control group received the same volume of an isotonic saline solution.Postoperative analgesia was assured by morphin PCA. The patients were evaluated by the pain visual analogic scale (VAs), the total dose of morphine consumed and the evolution of the biological markers of stress (glycemia, cortisol, ATH, prolactine and IL6) during the first 24 postoperative hours. Hemodynamic and respiratory parameters, side effects and patient satisfaction were recorded. RESULTS: the total dose of morphine consumed during the first 24 postoperative hours,was equivalent in the two groups (44,49+/-6,4 vs 45,26+/-9,1 mg; p= 0,59).the initial pain VAS means were equivalent (68 mm +/- 15 vs 71 mm+/-14). Ulterior pain VAS means, after morphin titration then with PCA were also equivalent and less to 40 mm. the global amplitude and the evolution of the stress markers evaluated by the surface under curbs were comparable in the two groups, despite a magnesemia twice higher than the normal values in the magnesium group.the satisfaction and the incidence of side effects were similar. CONCLUSION: association of magnesium to morphin PCA does not help to reduce morphin consumption, and does not affect the control of the stress reaction in major digestive surgery.

Sternal cleft, a rare congenital anomaly. Report of the first Tunisian case.

BACKGROUND: Sternal cleft is an uncommon visually dramatic congenital anomaly of the chest wall. It is resulting of failure of the two lateral mesodermal sternal bars fusion by the eight weeks of gestation. Superior defects are the commonest forms, usually isolated. AIM: Clinical and surgical aspects of sternal cleft are presented. The advantages of early surgery in the neonatal period are developed. CASE REPORT: We report the first Tunisian case of a superior sternal cleft associated to haemangioma in a newborn boy. Scanning shows non-appearance of manubrium at the upper part of sternum. Sternal bars showing a U-shaped incomplete sternal cleft. Surgical repair consisted of reconstructing a new sternum from sternal bars and resection of haemangioma. The patient had good aesthetic and functional results. CONCLUSION: The appearance of a child with its heart bulging through its chest wall is very disturbing to parents. Early surgery is most easy and most comforting.