Clonidine, an alpha2 adrenoceptor agonist, has anti-hypertensive and anti-nociceptive effects. It is commonly used in association with local anaesthetics and opioids to enhance the quality and duration of extradural analgesia in the postoperative period, and to decrease the incidence of side effects. As a sole analgesic, it has seldom been used to relieve postoperative pain. The dose of extradural clonidine to achieve good pain relief without deleterious side effects remains undetermined. In order to address this problem, we performed a computer search via two well-known databases, Medline and Excerpta Medica, covering the period from 1985 to September 1997. One hundred and fifty-nine articles were retrieved of which 38 dealt with extradural clonidine and postoperative pain. All but 16 studies suffered from serious design flaws, such as lack of controls and/or randomization, or inadequate statistical analysis. The data from these studies were difficult to interpret because of the tremendous variation in variables, especially dose of clonidine, level of extradural injection, time of administration, type of anaesthesia, type of surgery, and reference and rescue drugs. The simultaneous extradural use of local anaesthetics and opioids further hindered data interpretation, and precluded any meta-analysis. Proposals for a standard study design are made to help comparison between studies involving extradural clonidine and postoperative pain.
L'étude des causes de la morbidité sévère conduit à identifier des actions destinées à améliorer la sécurité et la qualité des soins. Elle permet d'identifier des cas de soins suboptimaux, notamment dans les domaines des hémorra-gies de la délivrance et des hypertensions, sévères. L'établis-sement de recommandations nationales et de protocoles locaux, l'amélioration de la cohésion de l'équipe, la formation de chacun de ses membres permettent d'approcher les buts poursuivis. Une évaluation des actions est nécessaire.Mots clés Morbidité maternelle sévère · Near misses · Soins suboptimaux · Travail en équipe Abstract Confidential enquiries into severe maternal morbidity lead to identification of actions taken to implement security and adequacy of care, which is an institutional target. Identifying the cases of sub-optimal cares, mainly in the fields of post-partum hemorrhages and of severe hypertensions, collecting data, and analyzing the results lead to national guidelines and local protocols. Staff cohesion and initial and postgraduate training of the care team are important steps to conduct the actions and to reach goals. Audits to evaluate and refine actions have to be regularly performed.
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