Christian Loubert

Carbetocin, an oxytocin analog, given as a postpartum hemorrhage prophylaxis in elective Cesarean deliveries, frequently causes tachycardia and hypotension. Phenylephrine infusion has been shown to prevent spinal anesthesia-induced hypotension. The goal of this study was to evaluate if a slow infusion of carbetocin would reduce maternal heart rate variation and hemodynamic disturbances compared with a rapid bolus in parturients receiving a prophylactic phenylephrine infusion during elective Cesarean delivery. In this double-blinded randomized controlled trial, 70 healthy parturients were allocated to either a bolus group or an infusion group. At cord clamping, participants in the bolus group received carbetocin 100 µg as a rapid intravenous bolus, while participants in the infusion group received carbetocin 100 µg over 10 min. The primary outcome was the variation in maternal heart rate from baseline during the 20 min following cord clamping. Secondary outcomes included blood pressure, cardiac output, and stroke volume variations during the study period, measured with the ClearSight™ hemodynamic monitor. Maximum heart rate variation was not different between the groups: bolus group, mean (standard deviation) 29.8 (25.2)% vs infusion group, 27.2 (23.3)%; P = 0.67. The increase in heart rate occurred significantly earlier in the bolus group than in the infusion group (median [interquartile range] time, 105 [69–570] sec vs 485 [255–762] sec; P = 0.02; group × time interaction: two-way repeated measures ANOVA, P = 0.04). There was no significant difference in maximum variations for the other hemodynamic parameters between the groups. Carbetocin infused over ten minutes did not reduce the magnitude of maternal heart rate variation but delayed its occurrence. This finding could be relevant to the anesthesiologist caring for parturients in whom a slight increase in maternal heart rate is clinically undesirable. www.clinicaltrials.gov (NCT03404544); registered 19 January 2018.

*Department of Anesthetics, University College London Hospital, London; †Department of Anesthetics, Royal London Hospital, London; ‡Department of Anesthesia, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe, Manchester; §Department of Anesthetics, The Lister Hospital, London; and ||Department of Anaesthetics, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS trust, London, UK. Copyright * 2012 by Lippincott Williams & Wilkins DOI: 10.1097/SA.0b013e318254da86

BACKGROUND: The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient program for total hip/knee arthroplasty (THA/TKA) are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and satisfaction in patients who experienced both an ERAS-outpatient protocol and standard-inpatient care.METHODS: We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients’ satisfaction wer...

STUDY OBJECTIVE The Nociception Level (NOL) index uses a multiparametric approach to measure the balance between sympathetic and parasympathetic systems activity. Recently, a strong correlation between the NOL index response to nociceptive stimuli and the level of opioid analgesia during surgery was reported. Others observed that intraoperative doses of remifentanil and sufentanil were reduced when the NOL index was used. So far, no study has evaluated the impact of NOL-guided fentanyl antinociception in laparoscopic gynecological surgery. The primary hypothesis of this present study was to evaluate whether intraoperative NOL-guided fentanyl administration would reduce intra-operative opioid consumption. Secondary hypotheses were to assess whether this would lead to lower postoperative opioid consumption and pain scores, as well as improved postoperative outcomes. SETTING University hospital, operating room. PATIENTS 70 adult patients, ASA 1-3, scheduled for total laparoscopic hysterectomy. INTERVENTIONS Patients were randomized into 2 groups: SOC (standardization of care) and NOL (using the NOL index to guide the administration of fentanyl). The depth of anesthesia was monitored with BIS™. Intraoperative fentanyl boluses were administered based on heart rate and mean arterial pressure variations in the SOC group, and NOL index for the NOL group. MEASUREMENTS Fentanyl total intraoperative dose administered was collected and also averaged per hour. Pain scores and hydromorphone consumption were assessed in the post-anesthesia care unit and up to 24 h. MAIN RESULTS Sixty-six patients completed the study, 33 in each group. Total intraoperative fentanyl administration was not different between the two groups (217 (70) in the NOL group vs 280 (210) in the SOC group (P = 0.11)). Nevertheless, intraoperative fentanyl administration per hour was reduced by 25% in the NOL-guided group compared to the SOC group: 81 (24) vs 108 (66) μg.h-1, respectively (P = 0.03). Hydromorphone consumption and pain scores in the post-anesthesia care unit and at 24 h were not significantly different between the two groups. CONCLUSION NOL-guided analgesia allowed for a 22% reduction of the total amount of intraoperative fentanyl which was not significant. Nevertheless, results reported a significant reduction by 25% in the doses of fentanyl averaged per hour of surgery and administered in the NOL-guided group compared with the standardized practice in laparoscopic gynecological surgery. The pain measured postoperatively was similar in the two groups while the average postoperative consumption of opioids to achieve the same level of pain scores in post-anesthesia care unit and at 24 h was not significantly reduced. Further larger multicenter studies centered towards postoperative outcomes are needed.

Resume Introduction Appliquer les principes de recuperation optimisee apres une chirurgie (Enhanced Recovery After Surgery: ERAS) est une option interessante pouvant reduire la duree de sejour apres un remplacement articulaire de la hanche ou du genou (PTH, PTG). Cette methode permettrait d’ameliorer l’experience clinique du patient, afin qu’il soit dispose a retourner plus tot a la maison. Hypothese Nous prevoyons que notre groupe ERAS, PTH et PTG en court sejour presentera un taux de complication inferieur et une duree de sejour hospitalier reduite, se traduisant par des couts directs inferieurs en comparaison a la procedure standard. Materiel et methode Nous avons compare le taux de complication selon la classification de Clavien-Dindo, la duree de sejour et les couts d’une hospitalisation entre une cohorte prospective de 120 PTH et PTG ERAS en court sejour et un groupe controle historique de 150 PTH et PTG hospitalisees plus de 24 h. Resultats Le groupe ERAS court sejour a presente un taux significativement inferieur de complications de grade 1 ou 2 par patient en comparaison au groupe controle (moy. 0,8 vs 3,0, p  Discussion Plusieurs programmes de chirurgie ambulatoire mettent l’accent sur le retour a domicile comme principal facteur de succes, repoussant au second plan a qualite de la recuperation et la reduction des complications post-operatoires. L’instauration d’un protocole ERAS court-sejour PTH et PTG dans notre etablissement a non seulement permis une diminution de la duree de sejour mais aussi d’ameliorer le bien-etre du patient et diminuer les couts directs engendres par ces procedures. Niveau de preuve Niveau II.

The aim of this study was to de termine the minimum effective fluid volume (MEFV) of hydroxyethyl starch 130/0.4 (HES) infused in a preload fashion which would prevent hypotension in 50% of parturients undergoing caesarean section. A secondary objective was to measure the hemodynamic effect of fluid loading on the subjects. This is a prospective, double-blinded, dose-finding study using an up-down sequential allocation design. In the operating room. Thirty healthy parturients undergoing caesarean section under spinal anesthesia using a prophylactic phenylephrine infusion were included in this study. The initial HES volume infused in the first patient was 500 mL. A failure of treatment to HES preload was defined as a single episode of systolic hypotension below 20% of baseline value. The next patient in the sequence was given a volume of HES adjusted by either an increment or a decrement of 100 mL according to the previous subject response to fluid preload. Stroke volume and cardiac ...

Obesity is a worldwide health problem and its prevalence is reaching epidemic proportions. As obesity does not spare women of childbearing age, obstetric anesthesiologists will increasingly be exposed to the challenges of anesthesia in this population. The purpose of this article is to give the reader a thorough understanding of the anesthetic implications of obesity relating to cesarean deliveries. Obesity is associated with hypertension, diabetes, obstructive sleep apnea and other comorbidities. It increases the risk of cesarean delivery, postpartum wound infections and deep venous thromboembolism. Obese parturients are prone to anesthetic complications such as aspiration of gastric contents, difficult monitoring, positioning, airway management and challenging neuraxial techniques. A thorough precesarean delivery preparation should include an evaluation by an anesthesiologist for women with a BMI over 40 kg/m2 and institution of an antacid prophylaxis protocol, thromboprophylaxis ...

ackground and Aims: Blockade of nociceptive afferents by the se ofcontinuous wound infiltration with local anesthetics may be eneficial in a postoperative multimodal pain management after otal abdominal hysterectomy (TAH) with bilateral salpingo-oohorectomy (BSO). The efficiency of continuous wound infusion ith local anesthetic is still controversial. The role of continuous ound infusion of levobupivacaine for pain relief and postoperaive recovery was evaluated.