Transversus abdominis plane block or intravenous lignocaine in open prostate surgery: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane block (TAP) and intravenous lignocaine are two analgesic techniques frequently used after abdominal surgery. We hypothesized that these two techniques improve post-operative analgesia after open prostate surgery and sought to compare their efficacy on immediate post-operative outcome after open prostate surgery. METHODS: After ethics committee approval, 101 patients were enrolled in this prospective study and randomly allocated to receive bilateral ultrasound-guided TAP (n = 34), intravenous lignocaine (n = 33) or placebo (n = 34). In addition, intravenous paracetamol was given every 6 h. The primary endpoint was the cumulative opioid consumption during the first 48 post-operative hours (median[IQR]). Secondary endpoints included pain scores at rest and upon coughing, need for rescue tramadol, incidence of post-operative nausea and vomiting (PONV), recovery of bowel function and incidence of bladder catheter-related discomfort. RESULTS: Cumulative piritramide consumption after 48 h was 28 [23] mg in the control group, 21 [29] mg in the TAP group and 21 [31] mg in the lignocaine group (P = 0.065). There was no significant difference in post-operative pain scores between groups. The proportions of patients requiring rescue tramadol, experiencing PONV or bladder catheter-related discomfort were similar in each group. Recovery of bowel function was also similar in the three groups. CONCLUSIONS: Our study suggests that TAP block and intravenous lignocaine do not improve the post-operative analgesia provided by systematic administration of paracetamol after open prostatectomy.

Two different techniques of facial mask induction of anesthesia in children provide identical intubation conditions despite different anesthetic depth.

BACKGROUND: Sevoflurane induction in chil- dren is performed using different techniques. Constricted, centered, and symmetrical pupils (CCSP) are classically the endpoint to be achieved before laryngoscopy is performed. OBJECTIVES: We investigated whether two different inhalation induction techniques with the same clinical end- point provided similar intubating conditions and comparable depth of anesthesia as assessed by the Bispectral Index (BIS). METHODS: Following IRB approval, and informed parental consent, 20 children were recruited. They were sched- uled for general anesthesia with tracheal intubation, and randomly assigned to Group 1, where the practitioner used 6% inspired sevoflurane in 50% 02/N20, and no manually assisted ventilation, or Group 2, where inspired sevoflurane was 8% in 50% 02/N20, and ventilation was manually supported upon loss of consciousness. BIS values were blinded. Laryngoscopy was performed after CCSP. Intubation conditions scoring was based on jaw relaxation (mobile = 1, partially mobile = 2, fixed = 3), position of vocal cords (open = 1, half-closed = 2, closed = 3), and cough (no cough = 1, 1 or 2 coughing efforts = 2, persistent coughing = 3). A total score > 3 corresponded to non-optimal conditions. RESULTS: Upon CCSP, BIS values were significantly lower in Group 1 [mean (SD) : 30 (8) - 48 (18), p <0.001], despite significantly higher end-tidal sevoflurane concentration in Group 2 [mean (SD) : 5.0 (0.7) - 6.2 (0.5) ; p <0.001]. Time to CCSP was slightly shorter in Group 2. Intubation conditions were always optimal except for one patient of Group 1. DISCUSSION: Both induction techniques achieve good intubating conditions. Possible explanations for the between-group BIS difference include variable appreciation of the CCSP endpoint, different induction lengths or sevoflurane equilibration times, or sevoflurane-induced increase in electroencephalogram power. A better indicator of the best time to intubate is needed to avoid too deep anesthesia in children.

[Ultra-fast opiate detoxification under general anesthesia: preliminary results of the Liege protocol]. / Le sevrage ultra-rapide des toxicomanes aux opiacés sous anesthésie générale: résultats préliminaires du protocole liégeois.

Many studies support the hypothesis of a substantial benefit in inducing an Opiate Receptor Blockade through a Rapid Opiate Detoxification under general Anaesthesia (RODA) in opiate dependent patients. However, prospective studies and long term evaluation of the technique are lacking. In order to evaluate long-term abstinence rates after a RODA among a sample of opiate addicts, a study was started in March 1999 at the University of Liège. To date, 45 patients were evaluated (mean age: 29 +/- 5 years) with a mean opiate dependence duration of 8 +/- 4 years. Most of them were both heroin and methadone dependent; 42.2% of them were included while 31.1% did not complete the whole inclusion procedure and 26.7% were excluded. None experienced severe withdrawal symptoms. At six months, abstinence rate was 67% and 46% at one year. These preliminary results suggest the interest of the procedure in carefully selected patients.

Sedation, analgesia and anesthesia for interventional radiological procedures in adults. Part II. Recommendations for interventional radiologists.

Benzodiazepines are given orally as a premedication before an interventional radiological procedure. Local analgesia is achieved by drugs such as lidocaine, bupivacaine or ropivacaine. General analgesia is obtained by non opioid analgesics and opioid narcotics. For intravenous sedation, benzodiazepines such as ketamine or propofol should be administered under the supervision of an anesthesiologist. A preprocedure consultation with the anesthesiologist is recommended. Monitoring equipments, drugs and nursing staff assistance should be provided in the interventional suite. Vital signs should be monitored for several hours until patient's discharge. Close collaboration between anesthesiologists and interventional radiologists is a prerequisite for achieving high standard sedation and analgesia.

The efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery.

OBJECTIVE: The primary objective was to evaluate the efficacy of propafenone compared with amiodarone in the reversion of atrial fibrillation or flutter. The secondary objective was the assessment of the tolerance of propafenone versus amiodarone. DESIGN: An open, randomized trial. SETTING: A single university hospital. PARTICIPANTS: Forty patients who gave their informed consent. INTERVENTIONS: These patients underwent cardiac bypass surgery or aortic valvular replacement. For treatment of postsurgical arrhythmias, they either received intravenous propafenone, 1 to 2 mg/kg in a 10-minute bolus, followed by an infusion of 420 mg in 24 hours, or amiodarone, 2.5 to 5 mg/kg, in a 10-minute bolus followed by an infusion of 900 mg in 24 hours. MEASUREMENTS AND MAIN RESULTS: Sinus rhythm was restored in 12 of 18 (67%) propafenone patients and in 17 of 22 (77%) amiodarone patients. If the early success time-limit had been fixed at 60 minutes, the proportion would have been 41% (7/17) for propafenone versus 14% (3/22) for amiodarone, and that difference is nearly significant (p = 0.07 Fisher's exact test). However, after 210 minutes, 50% of the propafenone patients regained sinus rhythm versus only 25% of the amiodarone patients. Hemodynamic parameters improved with time in both groups without showing any statistically significant difference. CONCLUSIONS: The results suggest that propafenone produces a more prompt effect in converting patients from atrial fibrillation or flutter to normal sinus rhythm.

Contribution of angiotensin-converting enzyme to the cardiac metabolism of bradykinin: an interspecies study.

The role of angiotensin-converting enzyme (ACE) in the metabolism of bradykinin (BK) has been studied in several tissues. However, and contrary to angiotensin I, the metabolism of BK at the cardiac level has not been investigated. In this study, we define the participation of ACE in the carboxy-terminal degradation of BK in heart membranes of the dog, human, rabbit, and rat. The calculation of the kinetic parameters characterizing the metabolism of BK and the generated des-Arg9-BK can be summarized as follows: the half-life (t1/2) of BK [dog (218 +/- 32 s) > human (143 +/- 9 s) = rat (150 +/- 4 s) > rabbit (22 +/- 2 s)] and of des-Arg9-BK [dog (1,042 +/- 40 s) > human (891 +/- 87 s) > rat (621 +/- 65 s) > rabbit (89 +/- 8 s)] both showed significant differences according to species. Enalaprilat, an ACE inhibitor, significantly prevented the rapid degradation of BK and des-Arg9-BK in all species studied, whereas retrothiorphan, a neutral endopeptidase inhibitor, and losartan, an angiotensin II type I receptor antagonist, did not affect this metabolism. The relative importance of ACE in the cardiac metabolism of BK was species related: dog (68.4 +/- 3.2%) = human (72.2 +/- 2.0%) > rabbit (47.7 +/- 5.0%) = rat (45.3 +/- 3.9%). ACE participation in the metabolism of des-Arg9-BK was as follows: rabbit (57.0 +/- 4.0%) > dog (39.9 +/- 8.8%) = human (25.4 +/- 5.5%) = rat (36.0 +/- 7.0%). The participation of cardiac kininase I (carboxypeptidase M) in the transformation of BK into des-Arg9-BK was minor: human (2.6 +/- 0.1%) > dog (0.9 +/- 0.1%) = rabbit (1.0 +/- 0.1%) = rat (1.0 +/- 0.1%). These results demonstrate that ACE is the major BK-degrading enzyme in cardiac membranes. However, the metabolism of exogenous BK by heart membranes is species dependent. Our observations could explain some discrepancies regarding the contribution of kinins in the cardioprotective effects of ACE inhibitors.

Endotoxaemia, production of tumour necrosis factor alpha and polymorphonuclear neutrophil activation following strenuous exercise in humans.

To examine whether endotoxaemia accompanying long-term, strenuous physical exercise is involved in exercise-induced increase in plasma tumour necrosis factor alpha (TNF-alpha) concentration and polymorphonuclear neutrophil (PMN) activation, 14 male recreational athletes [mean age 28 (SEM 1) years] were studied. Exercise consisted of a 1.5-km river swim, a 40-km bicycle race, and a 10-km road race. Mean time to complete the race was 149.8 (SEM 4.8) min. The plasma concentrations of granulocyte myeloperoxidase (MPO) and TNF-alpha were significantly higher than baseline values immediately and 1 h after exercise (P<0.001). Both variables returned to pre-race levels the day after exercise. Marked, transient decreases in plasma concentrations of anti-lipopolysaccharide (LPS) immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies directed against a panel of selected smooth gram-negative LPS were observed after the race, reaching in most cases minimal values in the blood sample drawn immediately following the completion of the triathlon. There was no significant correlation between the magnitude of PMN activation, as assessed by the increase in plasma concentrations of MPO, and the humoral markers of endotoxaemia and TNF-alpha. An inverse, highly significant relationship between the increase in plasma TNF-alpha concentrations and the changes in circulating anti-LPS IgM antibodies concentrations was observed (r = -0.7; P<0.01). These findings suggest that exercise-induced endotoxaemia was involved in the release of TNF-alpha, that the magnitude of the TNF-alpha response to exercise was down-regulated by anti-LPS antibodies of the IgM class, and that the production of TNF-alpha and endotoxaemia did not seem to play a role in the activation of circulating PMN in the exercising subjects.

Effects of training on exercise-induced muscle damage and interleukin 6 production.

To address the question of whether the increased plasma concentration of interleukin 6 (IL-6) following strenuous muscular work could be related to exercise-induced muscle damage, 5 moderately active male volunteers underwent two isokinetic exercise sessions in the eccentric mode, separated by a period of 3 weeks during which the subjects underwent five training sessions. Before training, exercise was followed by severe muscle pain (delayed-onset muscle soreness; DOMS), and by significant increases in plasma IL-6 level and serum myoglobin concentration (SMb) (P < 0.001). After training, postexercise DOMS and SMb values were significantly lower than those measured before training. There was no significant difference between plasma IL-6 levels measured at the same time points before and after training. We conclude that the hypothetical relationship between exercise-induced muscle damage and increased postexercise levels of circulating IL-6 is not substantiated by the present results.

Possible in vivo tolerance of human polymorphonuclear neutrophil to low-grade exercise-induced endotoxaemia.

To address the question of whether translocation of bacterial lipopolysaccharide (LPS) into the blood could be involved in the process of exercise-induced polymorphonuclear neutrophil (PMN) activation, 12 healthy male subjects who took part in a sprint triathlon (1.5 km river swim, 40 km bicycle race, 10 km road race) were studied. While there was no detectable amount of endotoxin in the blood samples drawn at rest, exercise was followed by the appearance of circulating endotoxin molecules at the end of competition in four subjects, and after one and 24 h recovery in three and seven athletes, respectively. The concentrations of plasma granulocyte myeloperoxidase ([MPO]), were significantly higher immediately after exercise and one hour later-than baseline values (P<0.001). This variable returned to pre-race levels the day after exercise, despite the presence of detectable amounts of LPS, at that time, in seven athletes. The absence of significant correlation (r=0.26; P=0.383) and temporal association between [MPO] and plasma endotoxin levels led us to conclude that endotoxaemia was not involved in the process of exercise-induced PMN degranulation observed in our subjects.

Piroxicam fails to reduce myocellular enzyme leakage and delayed onset muscle soreness induced by isokinetic eccentric exercise.

To test the hypothesis that delayed onset muscular soreness (DOMS) following intense eccentric muscle contraction could be due to increased production of prostaglandin E(2) (PGE(2)), ten healthy male subjects were studied. Using a double-blind randomized crossover design, each subject performed two isokinetic tests separated by a period of at least 6 weeks: once with placebo, and once with piroxicam (Feldene((R))). They were given one capsule containing either placebo or piroxicam (20 mg) per day for 6 days with initial doses given starting 3 days prior to isokinetic testing. Exercise consisted of eight stages of five maximal contractions of the knee extensor and flexor muscle groups of both legs separated by 1 min rest phases, on a Kin Trex device at 60( degrees )/s angular velocity. The subjective presence and intensity of DOMS were evaluated using a visual analogue scale immediately after, and 24 and 48 h after each test. The mean plasma concentration of PGE(2) measured at rest and after exercise was significantly lower in the group treated with piroxicam (p < 0.05). However, statistical analysis (two-way ANOVA test) revealed that exercise did not cause any significant change of mean plasma PGE(2) over time in either of the two groups. Eccentric work was followed by severe muscle pain in extensor and flexor muscle groups. Maximal soreness was noted 48 h postexercise. Serum creatine kinase activity and the serum concentration of myoglobin increased significantly, and reached peak values 48 h after exercise in both experimental conditions (p < 0.001). By paired t-test, it appeared that there were no significant differences in the serum levels of these two markers of muscle damage between the two groups at any time point. We conclude that: (1) oral administration of piroxicam fails to reduce muscle damage and DOMS caused by strenuous eccentric exercise; and (2) the hypothetical role of increased PGE(2) production in eccentric exercise-induced muscle damage, DOMS, and reduced isokinetic performance is not substantiated by the present results.