SummaryWe have measured the metabolic response to sequential administration of propacetamol, metamizol and/or external cooling in 20 febrile patients under sedation and analgesia and during mechanical ventilation. There was no change in temperature (TЊ) after propacetamol therapy, whereas after metamizol only a small decrease was noted (from 38.9 (SEM 0.2) to 38.5 (0.3) ЊC; P:0.02). External cooling produced a significant decrease in TЊ (39.1 (0.2) to 37.1 (0.2) ЊC; P:0.0001) accompanied by a decrease in energy expenditure (EE) (2034 (73) to 1791 (88) kcal day 91 ; P:0.004). Heart rate and minute ventilation decreased significantly in parallel. There were no other changes in haemodynamics or pulmonary gas exchanges. We conclude that propacetamol and metamizol did not produce a clinically significant decrease in TЊ in febrile ICU patients whereas external cooling decreased both TЊ and EE. The parallel decrease in body temperature and EE seemed to be related to opioid administration or sedation, or both. (Br. J. Anaesth. 1997; 78: 23-127 Fever in critically ill patients is related frequently to either the systemic inflammatory response syndrome (SIRS) or infection. Usually fever is treated with antipyretic drugs, often paracetamol or metamizol. External cooling by different methods, such as sponging the body surface with ice-cooled water, is also used. 1 Even if reducing fever is still controversial from an immunological point of view, there is little doubt that patient comfort and metabolic demand can be improved by this procedure. 2 Indeed, a previous study in critically ill patients demonstrated diminished oxygen consumption related to decreased body temperature improving the oxygen demand-delivery ratio. 3 However, body cooling in healthy humans results in shivering which increases energy expenditure (EE).The aim of this study was to measure EE as an integrated indicator of body metabolic activity after reduction in temperature. Our hypothesis was that external cooling may induce an increase in EE, in contrast with drugs which, by resetting the thermoregulatory set point, decrease EE. Therefore, we designed a prospective, unblinded, crossover study to evaluate the respective effects of centrally acting drugs (propacetamol or metamizol) or external physical cooling in febrile ICU patients. Patients and methodsThe study was approved by the Ethics Committee of our institution. The requirement for informed consent was waived by the committee who judged that the therapies were applied independently by the attending physician and were accepted in clinical practice, and no invasive measurements were made. We studied 20 patients undergoing mechanical ventilation via a tracheal tube, with a rectal temperature greater than 38.5 ЊC and in whom the physician in charge wished to decrease fever. No patient had an inspired oxygen fraction greater than 0.6, a pneumothorax or a broncho-pleural fistula. Patients' lungs were ventilated with a Veolar-Hamilton (Hamilton Bonaduz, Switzerland) or Engström-Erica ventilator (Engström,...

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Objectives: To identify perioperative practice patterns that predictably impact postoperative pain. Background: Despite significant advances in perioperative medicine, a significant portion of patients still experience severe pain after major surgery. Postoperative pain is associated with serious adverse outcomes that are costly to patients and society. Methods: The presented analysis took advantage of a unique observational data set providing unprecedented detailed pharmacological information. The data were collected by PAIN OUT, a multinational registry project established by the European Commission to improve postoperative pain outcomes. A multivariate approach was used to derive and validate a model predictive of pain on postoperative day 1 (POD1) in 1008 patients undergoing back surgery. Results: The predictive and validated model was highly significant (P = 8.9E-15) and identified modifiable practice patterns. Importantly, the number of nonopioid analgesic drug classes administered during surgery predicted decreased pain on POD1. At least 2 different nonopioid analgesic drug classes (cyclooxygenase inhibitors, acetaminophen, nefopam, or metamizol) were required to provide meaningful pain relief (>30%). However, only a quarter of patients received at least 2 nonanalgesic drug classes during surgery. In addition, the use of very short-acting opioids predicted increased pain on POD1, suggesting room for improvement in the perioperative management of these patients. Although the model was highly significant, it only accounted for a relatively small fraction of the observed variance. Conclusion: The presented analysis offers detailed insight into current practice patterns and reveals modifications that can be implemented in today's clinical practice. Our results also suggest that parameters other than those currently studied are relevant for postoperative pain including biological and psychological variables.

Object The aim of this study was to provide evidence for the effect of intrathecal morphine application after spinal cord tumor resection. Methods Twenty patients participated in a prospective open proof-of-concept study. During dural closure, morphine (7 μg/kg) was injected into the subarachnoid space. All patients were monitored in an intensive care setting postoperatively. Pain, additional opioids given, and vital parameters were recorded. Results Six patients received a mean morphine dose of 365 μg between C-3 and C-7 and 14 patients received a mean dose of 436 μg between T-2 and T-12. In the cervical and thoracic groups, the mean Numeric Rating Scale score was highest upon intensive care unit admission (1.2 and 2.5, respectively) and declined at 12 hours (0.5 and 0.8, respectively). Minimal extra morphine was required. Minor side effects occurred without consequence. Conclusions Intrathecal morphine for postoperative analgesia after resection of cervical and thoracic spinal cord tumors is effective and safe. These preliminary results require confirmation by larger comparative studies and further clinical experience.

Purpose Hip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients. Methods Single-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain—as measured in perioperative morphine use—hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality. Results 407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality. Conclusions This article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

Purpose: To determine among three currently used epidural test doses which is the most reliable for the detection of accidental intrathecal misplacement of an epidural catheter, and which clinical sign is to be used as a marker. Methods: Ninety orthopedic patients were allocated to either the continuous epidural or the continuous spinal group according to age, < or > 70 yr. They received, in a randomised, double-blind fashion, one of the three solutions: 60 mg lidocaine 2% (L2%), 7.5 mg bupivacaine 0.25% (B0.25%), or 15 mg bupivacaine 0.5% (B0.5%); all three solutions contained epinephrine. Objective variables studied every two minutes over the first ten minutes after injection included: presence of a sensory level >_ TI2, presence of a motor block ~ I, and anesthesia of segments L I, L 2, S 2 and S s. Subjective variables studied over the same period included paresthesias, sensation of warmth or cold, and muscle weakness. ~ts:When using presence of motor block ~ I on the Bromage scale, the administration of 60 mg L2% with epinephrine identified all patients having an intrathecal catheter six minutes after injection, whereas none of the patients receiving the same solution through the epidural catheter presented a motor block. This was not the case for the other two solutions studied. Cond~on: Lidocaine 2% with epinephrine at a dose of 60 mg is the test dose of choice to detect the intrathecal misplacement of an epidural catheter. The presence of motor block ~ I is the only reliable clinical sign.Obje~ff : D&erminer, parmi trois dose-tests couramment utilisEes en anesth&ie p&idurale, laquelle est la plus fiable dans la d&ection d'une position intrath&ale accidentelle d'un cath&er p&idural, et quel signe clinique dolt &re utilisE comme marqueur. M&hode : Quatre-vingt-dix patients orthopEdiques ont EtE attribu& en fonction de leur ~ge, < ou > 70 ans, soit au groupe d'anesth&ie p&idurale continue soit au groupe d'anesth&ie spinale continue ; ils ont ensuite &E randomis& pour recevoir en double-aveugle l'une des trois solutions suivantes : 60 mg de lidocaine 2 % (L 2 %), 7,5 mg de bupivacaine 0,25 % (B 0,25 %), et 15 mg de bupivacaine 0,5 % (B 0,5 %) ; les 3 solutions Etaient adrEnalinEes. Les variable objectives &udi&s toutes les deux minutes pendant les deux premieres minutes apt& l'injection comprenaient : la presence d'un bloc sensitif_> TI2, la pr&ence d'un bloc moteur _> I sur l'&helle de Bromage, et la perte de sensation ~ la piqfire dans les segments L l , L 2, S 2 and S s. Les variables subjectives &udiEes pendant la m~me p&iode comprenaient : la presence de paresth~sies, de sensation de chaud ou de froid, et de faiblesse musculaire. ~s~ltal~ : En utilisant la presence d'un bloc moteur >_ I, l'administration de 60 mg de L 2 % adrEnalinEe a permis d'identifier tousles patients avec un catheter intrath&al, six minutes aprEs l'injection, alors qu'aucun des patients recevant la m~me solution au travers du catheter p&idural n'a pr&ent~ de bloc moteur. Ceci n'a pas ~tE le cas avec les 2 autres solutions &udi~es. ...

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