Nefopam after total hip arthroplasty: role in multimodal analgesia.

BACKGROUND: Multimodal analgesia combining several non-opioid analgesics is recommended for pain control after surgery. In one study of total hip arthroplasty (THA), pain relief achieved by adding ketamine to the paracetamol-ketoprofen combination was statistically significant but remained inadequate in most patients. In two other studies, the analgesic effect of nefopam was synergistic with that of ketoprofen and additive with that of paracetamol. Adding nefopam to the paracetamol-ketoprofen-ketamine combination has not been evaluated. HYPOTHESIS: Adding nefopam to the paracetamol-ketoprofen-ketamine combination significantly improves analgesia after THA. MATERIAL AND METHODS: A prospective single-centre comparative non-randomised study (control group then nefopam group) was conducted in patients undergoing THA under general anaesthesia. All patients received paracetamol-ketoprofen-ketamine and morphine/droperidol patient-controlled analgesia. The nefopam group also received a continuous infusion of nefopam (120 mg/d for 48 h). Pain was evaluated daily for 7 days. The main evaluation criteria were morphine consumption, and pain intensity evaluated using a numerical rating scale and a validated questionnaire. To detect a 40% morphine-sparing effect by H24 (α=0.05 and ß=0.2), 85 patients were needed in each group. RESULTS: The two groups (90 patients/group) had no significant differences for perioperative characteristics, pain scores, morphine consumption at H24 (nefopam, 13 ± 12 mg and control, 14 ± 13 mg, P=0.39), or functional recovery. Compared to the control group, the nefopam group had lower rates of nausea/vomiting (P<0.0001), pruritus (P=0.002), and visual disturbances (P=0.02). DISCUSSION: Nefopam failed to improve pain relief when added to a multimodal analgesia regimen but alleviated several morphine-induced side effects. Redundancy between nefopam and ketamine may explain the absence of greater pain relief. This study emphasises the need for clinical evaluations of every analgesic regimen, as the available data were not sufficient to predict these results. LEVEL OF EVIDENCE: Level III, case-control study.

[Identification and analysis of errors in prescription, preparation and administration of drugs in intensive care, medicine and surgery at the University Hospital Center of Tours]. / Identification et analyse des erreurs de prescription, de préparation et d'administration des médicaments en réanimation, médecine et chirurgie au CHU de Tours.

OBJECTIVE: Within the framework of a project to establish "the safety of drug use and the prevention of iatrogenic risks", the pharmaceutical team conducted a review on the errors in drug prescription in order to implicate the medical professionals in its development. In collaboration with the medical teams, the pharmacy organised a series of therapeutic surveys aimed at quantifying and qualifying the errors related to the prescription, preparation and administration of medicinal products. METHODS: A prospective survey was conducted in three types of care units (Medicine, surgical intensive care and paediatric vascular surgery) over a 30-day period in each unit. A resident pharmacist studied the preparations and administration of drugs and compared them to the prescriptions and recommendations of in the literature. The investigator also conducted the pharmaceutical analysis of the prescriptions (dose, drug interactions, administration timetable...). The clinical impact of the errors on the patient were scored 0 (none) to 3 (lethal) by a duo composed of an external physician and the resident physician in charge of the study on site. RESULTS: Among the 3,023 drugs prescribed, the error rate was of 0.04 [0.033; 0.047], 44% of which scored 2. The errors in preparation or administration were of 0.134 [0.117; 0.151] among the 1,632 drug administrations observed, 19% of which scored 2. Regarding errors in prescription and administration, no significant difference was revealed between the three units [p > 0.09]. DISCUSSION: This study enhanced the awareness of the nursing and medical staff and the hospital management with regards to the reality of medical errors. Our data were comparable to the results of other studies published elsewhere.

[Generalized tonic-clonic status epilepticus: therapeutic strategy]. / L'état de mal épileptique généralisé tonico-clonique: stratégie thérapeutique.

BASIC STRATEGY: Generalized tonic-clonic status epilepticus is a medical emergency requiring very rapid administration of anti-epilepsy drugs to avoid or prevent neurological damage. First intention treatment is based on rapid-action intravenous benzodiazepine (BZD) associated with another long-action anti-epilepsy drug. General anesthesia with respiratory assistance may be needed if the seizures are refractory. We considered the pharmacodynamic, pharmacokinetic and pharmacoeconomic properties of drugs proposed for the treatment of status epilepticus. TREATMENT EFFICACY: An analysis of the literature and clinical practice show that, used alone, BZDs have a rapid effect and are effective in 54 to 84% of the cases. When hydantoins are combined with BZD, cessation of seizures can be achieved in 94% of the patients compared with 82% when phenobarbital is used alone. However, the administration of hydantoins requires 15 to 30 min whereas phenobarbital is effective in 5 minutes. Irrespective of the type of BZD combined with hydantoins, no difference has been observed concerning clinical efficacy. Midazolam appears to be as effective as barbiturics. Cardiac function must be monitored when hydantoins are used although admission in an intensive care unit may not be required, unlike the situation with phenobarbital that may lead to intubation. IN CLINICAL PRACTICE: Considering non-refractory status epilepticus, a comparison of the efficacy of the proposed drugs, their side effects and their cost demonstrates a good cost/benefit ratio for phenobarbital and good tolerance for fosphenytoin. If cessation of the seizures cannot be achieved, other therapeutic strategies may have be to used: induction of barbituric coma with thiopental, general anesthesia using propofol, or midazolam or lidocaine.