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Cometa MA, Zasimovich Y, Smith CR. Sphenopalatine ganglion block: do not give up on it just yet! Br J Anaesth 2021; 126:e198-e200. [PMID: 33795136 DOI: 10.1016/j.bja.2021.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- M Anthony Cometa
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Yury Zasimovich
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Cameron R Smith
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA.
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Is the Use of Opioids Safe after Primary Cleft Palate Repair? A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3355. [PMID: 33564585 PMCID: PMC7858197 DOI: 10.1097/gox.0000000000003355] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/27/2020] [Indexed: 11/25/2022]
Abstract
Pharmacologic treatment of postoperative pain after cleft palate repair includes opioids and nonopioid analgesics, nerve blocks, and local anesthetic infiltration. Use of opioids in infants has concerns regarding sedation, risk of aspiration, respiratory depression, and respiratory distress. The main objective of this review was to analyze information available on the safety of the use of opioids during perioperative management of pain related to primary cleft palate repair in published studies. Methods A systematic review of the literature for studies published until March 2020 was performed to evaluate the safety of opioid drugs during primary cleft palate repair pain management. The authors chose the following MesH terms for this systematic review: cleft lip and palate AND opioids AND pain management. The investigators performed a systematic literature search using the Pubmed/MEDLINE, Embase, Web of Science, and Cochrane Library databases. Results After a literature search resulting in 70 identified studies, 9 were qualified for the final analysis, which included 772 patients. There was a high level of evidence in the selected studies according to the Oxford CEBM Level of Evidence classification and GRADE scale. The most common adverse event reported was postoperative nausea and vomiting (from 5% to 25%). Episodes of oxygen desaturation have been reported from 2.5% to 7.4% of the studied patients. Conclusion s: Definitive conclusions about the safety of opioid drugs during primary cleft palate repair pain management cannot be drawn. Vomiting and oxygen desaturation have been associated with the use of opioids in the studied population.
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Shafa A, Shetabi H, Adineh-Mehr L, Bahrami K. Selection of the optimal dosage of tranexamic acid to reduce blood loss during pediatric cleft palate surgery. Tzu Chi Med J 2020; 33:181-187. [PMID: 33912417 PMCID: PMC8059463 DOI: 10.4103/tcmj.tcmj_111_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 11/04/2022] Open
Abstract
Objective The aim of the present study was to evaluate and select the optimal dosage of tranexamic acid (TXA) to reduce blood loss during cleft palate surgery in children. Materials and Methods This randomized double-blind clinical trial was performed on 80 children under 3 years of age that were candidates for cleft palate surgery. These children were divided into four groups as follows: the first, second, and third groups received 5, 7.5, and 10 mg/kg of TXA, respectively. Moreover, the fourth group was considered as the control group. Before induction of anesthesia and then every 15 min during the surgery, some parameters such as mean arterial pressure, heart rate, SpO2, and ETCO2 were recorded. Moreover, the amount of blood loss during the surgery, the level of surgeon's satisfaction, and incidence rate of complications were assessed and recorded. Results The amount of blood loss during the surgery in TXA groups receiving dosages of 5, 7.5, and 10 mg/kg with the means of 63.75 ± 10.62, 61.25 ± 15.03, and 61.00 ± 14.29, respectively, was significantly lower than that of the control group with the mean of 92.25 ± 19.83 (P < 0.001). Moreover, no significant difference was found between the three groups receiving TXA dosages in terms of the amount of blood loss, the level of surgeon's satisfaction (P > 0.05). Conclusion According to the results of the present study, all three dosages of TXA had a significant role in reducing blood loss in cleft palate surgery. Given the potential for increased risk of side effects from the drug, it seems safe to use the minimal dosage of this drug to control and reduce blood loss during cleft palate surgery in children <3 years of age.
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Affiliation(s)
- Amir Shafa
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Shetabi
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Lili Adineh-Mehr
- Department of Anesthesiology, Anesthesiology and Critical Care Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Keivan Bahrami
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Barbero GE, de Miguel M, Sierra P, Merritt G, Bora P, Borah N, Ciarallo C, Ing R, Bosenberg A, de Nadal M. Clonidine as an Adjuvant to Bupivacaine for Suprazygomatic Maxillary Nerve Blocks in Cleft lip and Palate Repair: A Randomized, Prospective, Double-Blind Study. Cleft Palate Craniofac J 2020; 58:755-762. [PMID: 33043691 DOI: 10.1177/1055665620964141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Does clonidine, as adjuvant to bupivacaine for suprazygomatic maxillary nerve blocks, reduce emergence agitation in patients undergoing cleft lip and cleft palate surgery? DESIGN Randomized, controlled, and double-blind study. SETTING Guwahati Comprehensive Cleft Care Center, Guwahati (Assam, India). PARTICIPANTS A total of 124 patients; with a median age of 5 years in the clonidine group (CLG) and 7 years in the control group (CG), who underwent cleft lip or cleft palate surgery were included. Exclusion criteria included lack of consent from patients or their guardians, allergy to local anesthetics, coagulation disorders, local infection at the puncture site before performing the block, and language difficulties or cognitive disorders. INTERVENTIONS Patients were randomized into 2 groups to receive bilateral suprazygomatic maxillary nerve blocks with either a bupivacaine/clonidine mixture for the CLG or bupivacaine alone in the CG. MAIN OUTCOME MEASURE The primary end point was the incidence of emergence agitation. RESULTS There was a statistically significant difference in the incidence of emergence agitation (30.2% in the CG compared to 15.2% in the CLG; difference of incidences: 15%, 95% CI: 0.1-30.1). The percentage of patients requiring intraoperative Fentanyl was lower in the CLG (10.6% compared to 26.4%; difference of incidences: 15.8%, 95% CI: 1.8-29). No other differences were observed. Further research in a more typically aged children population undergoing cleft surgery is needed. CONCLUSIONS The use of clonidine as an adjuvant to bupivacaine in maxillary nerve block reduces the incidence of emergence agitation and intraoperative opioid consumption without hemodynamic or sedative side effects in patients undergoing cleft lip and palate surgery.
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Affiliation(s)
- Gaston Echaniz Barbero
- Department of Anesthesiology, 16810Vall d'Hebron Hospital, Barcelona, Spain.,Department of Surgery, 16810Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcos de Miguel
- Department of Anesthesiology, 16810Vall d'Hebron Hospital, Barcelona, Spain.,Department of Surgery, 16810Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Plinio Sierra
- Department of Pediatric Anesthesia, 425365King Abdullah Hospital, Riyadh, Saudi Arabia
| | - Glenn Merritt
- Department of Anesthesiology, 2932Children's Hospital Colorado, Denver, Colorado, USA
| | - Pranjal Bora
- Department of Anesthesiology, Guwahati Comprehensive Cleft Care Center, Guwahati, India
| | - Nabamallika Borah
- Department of Anesthesiology, Guwahati Comprehensive Cleft Care Center, Guwahati, India
| | - Christopher Ciarallo
- Department of Anesthesiology, 2932Children's Hospital Colorado, Denver, Colorado, USA
| | - Richard Ing
- Department of Anesthesiology, 2932Children's Hospital Colorado, Denver, Colorado, USA
| | - Adrian Bosenberg
- Department Anesthesiology and Pain Management, Seattle Children's Hospital and 7284University of Washington, Seattle, Washington, USA
| | - Miriam de Nadal
- Department of Anesthesiology, 16810Vall d'Hebron Hospital, Barcelona, Spain.,Department of Surgery, 16810Universitat Autònoma de Barcelona, Barcelona, Spain
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Kearney AM, Gart MS, Brandt KE, Gosain AK. Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair. Plast Reconstr Surg 2020; 146:371-379. [PMID: 32740590 DOI: 10.1097/prs.0000000000007018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States. METHODS Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles. RESULTS Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics. CONCLUSIONS This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.
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Affiliation(s)
- Aaron M Kearney
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Michael S Gart
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Keith E Brandt
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, and Northwestern University Feinberg School of Medicine; OrthoCarolina; and the American Board of Plastic Surgery
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Gude P, Gustedt F, Bellgardt M, Vogelsang H, Herzog-Niescery J, Dazert S, Weber TP, Volkenstein S. High dose ibuprofen as a monotherapy on an around-the-clock basis fails to control pain in children undergoing tonsil surgery: a prospective observational cohort study. Eur Arch Otorhinolaryngol 2020; 277:2115-2124. [DOI: 10.1007/s00405-020-05929-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
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Bilateral suprazygomatic maxillary nerve blocks vs. infraorbital and palatine nerve blocks in cleft lip and palate repair. Eur J Anaesthesiol 2019; 36:40-47. [DOI: 10.1097/eja.0000000000000900] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mostafa MF, Herdan R, Elshazly M. Comparative study of levobupivacaine and bupivacaine for bilateral maxillary nerve block during pediatric primary cleft palate surgery: a randomized double-blind controlled study. Korean J Anesthesiol 2018; 71:135-140. [PMID: 29619786 PMCID: PMC5903109 DOI: 10.4097/kjae.2018.71.2.135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 11/23/2022] Open
Abstract
Background Cleft lip and palate are common major congenital anomalies. Cleft palate (CP) repair causes pain and needs large doses of intravenous opioids. The risk of postoperative airway obstruction or respiratory depression is high, requiring continuous and vigilant monitoring. The primary outcome was to evaluate the efficacy of using different local anesthetics during bilateral maxillary nerve block (MNB) with general anesthesia on quality of recovery after primary CP repair. We hypothesized that levobupivacaine would be better than bupivacaine. Also, to investigate the potency of bilateral MNB in improving quality of postoperative analgesia. Methods Sixty children undergoing primary CP repair surgery were enrolled in the study. Combined general anesthesia and regional bilateral MNB were used for all patients. Group L (n = 30): children received 0.15 ml/kg of 0.2% levobupivacaine, while in Group B (n = 30): children received 0.15 ml/kg of 0.2% bupivacaine. Results Face, Legs, Activity, Cry, and Consolability pain score readings were 0 score in 7 cases of the Group L and 10 cases of Group B, 1 score in 14 cases of the Group L and 12 cases of Group B, and 2 score in 9 cases of the Group L and 8 cases of Group B. We found no statistically significant difference between the two study groups as regarding pain score or serious complications. Conclusions Levobupivacaine is as effective and safe as bupivacaine to be used for MNB block with a lower incidence of complications. Bilateral suprazygomatic MNB is an effective, easy, and safe method for pain relief in children undergoing primary cleft palate repair surgeries.
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Affiliation(s)
- Mohamed F Mostafa
- Department of Anesthesia and Intensive Care, Assiut University Faculty of Medicine, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Assiut University Faculty of Medicine, Assiut, Egypt
| | - Mohamed Elshazly
- Department of Plastic Surgery, Assiut University Faculty of Medicine, Assiut, Egypt
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Fenlon S, Somerville N. Comparison of Codeine Phosphate and Morphine Sulphate in Infants Undergoing Cleft Palate Repair. Cleft Palate Craniofac J 2017; 44:528-31. [PMID: 17760494 DOI: 10.1597/06-206.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To ascertain the quality of analgesia provided by morphine in comparison to codeine. Design: The study is a prospective, randomized, double-blind trial of analgesic effect employing validated pain scores. Patients: Infants having primary cleft palate repair with informed parental consent to enter the study. Interventions: Infants received one of two analgesics intraoperatively for immediate postoperative pain relief. Morphine was given by intravenous injection and codeine by the intramuscular route. Main Outcome Measure: Pain scores in the immediate postoperative period for 2 hours following surgery; this outcome measure was decided prior to data collection. Results: The pain score and other outcome measures were all blinded. Measurements are all evident from the nature of the results. Conclusions: There was no clinically significant difference observed in the analgesic effect of either drug on the two groups studied.
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Affiliation(s)
- S Fenlon
- Department of Anesthesia, Queen Victoria Hospital, West Sussex, UK
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Surana P, Parikh DA, Patkar GA, Tendolkar BA. A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery. Korean J Anesthesiol 2017; 70:633-641. [PMID: 29225747 PMCID: PMC5716822 DOI: 10.4097/kjae.2017.70.6.633] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/11/2017] [Accepted: 04/18/2017] [Indexed: 11/10/2022] Open
Abstract
Background We investigated whether the intraoperative administration of dexmedetomidine would attenuate the profound sympathoadrenal response associated with cleft palate (CP) surgery. Methods Sixty children aged 6 months to 12 years undergoing CP surgery under general anesthesia were randomly assigned to the control (C) or dexmedetomidine (D) groups. Group C received benzodiazepine (0.05 mg/kg midazolam followed by infusion of normal saline) fentanyl isoflurane anesthesia, and Group D received dexmedetomidine (loading 1 µg/kg followed by infusion of 0.5 µg/kg/h) fentanyl isoflurane anesthesia. Heart rate (HR), mean blood pressure (MBP), intraoperative fentanyl and isoflurane requirements, recovery scores, emergence agitation, pain scores, time and requirement of rescue analgesic, and surgeon satisfaction were noted. Results Intraoperative HR and MBP in Group D were significantly lower than the corresponding values in Group C (P < 0.001). HR decreased up to 16% in Group D. By contrast, HR increased up to 20% in Group C. Group D had comparable MBP to its baseline, whereas Group C had higher MBP until extubation (P = 0.015). Two children in Group D developed bradycardia and hypotension, which was successfully treated. The fentanyl and isoflurane requirements decreased by 43% and 30%, respectively, in Group D patients compared to those in Group C (P < 0.001). Group D had lower pain scores and less emergence agitation (P < 0.001). Time until requirement of first rescue analgesic was longer in Group D than that in Group C (P < 0.001). Surgeon satisfaction was higher in Group D than that in Group C. Conclusions Intravenous dexmedetomidine during CP surgery attenuated hemodynamic responses with excellent surgeon satisfaction. Close monitoring of hemodynamics is recommended.
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Affiliation(s)
- Priyanka Surana
- Department of Anesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, India
| | - Devangi A Parikh
- Department of Anesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, India
| | - Geeta A Patkar
- Department of Anesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, India
| | - Bharati A Tendolkar
- Department of Anesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Mumbai, India
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Abstract
Abstract
Background:
The authors investigated the efficacy of bilateral suprazygomatic maxillary nerve block (SMB) for postoperative pain relief in infants undergoing cleft palate repair.
Methods:
In this prospective, double-blind, single-site, randomized, and parallel-arm controlled trial, 60 children were assigned to undergo bilateral SMB with general anesthesia with either 0.15 ml/kg of 0.2% ropivacaine (Ropi group) or 0.15 ml/kg of isotonic saline (Saline group) on each side. The primary endpoint was total postoperative morphine consumption at 48 h. Pain scores and respiratory- and SMB-related complications were noted.
Results:
The overall dose of intravenous morphine after 48 h (mean [95% CI]) was lower in the Ropi group compared with that in the Saline group (104.3 [68.9 to 139.6] vs. 205.2 [130.7 to 279.7] μg/kg; P = 0.033). Continuous morphine infusion was less frequent in the Ropi group compared with that in the Saline group (1 patient [3.6%] vs. 9 patients [31%]; P = 0.006). Three patients in the Saline group had an episode of oxygen desaturation requiring oxygen therapy. There were no technical failures or immediate complications of the SMB. Intraoperative hemodynamic parameters, doses of sufentanil, pain scores, and postoperative hydroxyzine requirements were not different between the two groups.
Conclusion:
Bilateral SMB is an easy regional anesthesia technique that reduces total morphine consumption at 48 h after cleft palate repair in children and the use of continuous infusion of morphine and may decrease postoperative respiratory complications.
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Opioid tolerance or opioid withdrawal? Anesthesiology 2013; 119:1229-30. [PMID: 24195952 DOI: 10.1097/aln.0b013e3182a76f92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intraoperative Infusion of 0.6–0.9 µg · kg−1 · min−1 Remifentanil Induces Acute Tolerance in Young Children after Laparoscopic Ureteroneocystostomy. Anesthesiology 2013; 118:337-43. [DOI: 10.1097/aln.0b013e31827bd108] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background:
Intraoperative infusion of opioids has been associated with increased postoperative pain and analgesic requirements, but the development of tolerance in young children is less clear. This prospective, randomized, double-blinded study was designed to test the hypothesis that the intraoperative administration of remifentanil results in postoperative opioid tolerance in a dose-related manner in young children.
Methods:
We enrolled 60 children (aged 1–5 yr) who were undergoing elective laparoscopic ureteroneocystostomy. Patients were randomized and received an intraoperative infusion of 0, 0.3, 0.6, or 0.9 µg·kg−1·min−1 remifentanil. Postoperative pain was managed by a parent/nurse-controlled analgesia pump using fentanyl. The primary outcome included the total fentanyl consumptions at 24 and 48 h postsurgery. Secondary outcomes were the postoperative pain scores and adverse effects.
Results:
The children who received 0.6 and 0.9 µg·kg−1·min−1 remifentanil required more postoperative fentanyl than the children who received saline or 0.3 µg·kg−1·min−1 remifentanil (all P < 0.001) for 24 h after surgery. The children who received 0.3–0.9 µg·kg−1·min−1 intraoperative remifentanil reported higher pain scores at 1 h after surgery than the children who received saline (P = 0.002, P = 0.023, and P = 0.006, respectively). No significant intergroup differences in recovery variables were observed, but vomiting was more frequent in the 0.9 µg·kg−1·min−1 remifentanil group than in the other groups (P = 0.027).
Conclusions:
The intraoperative use of 0.3 µg·kg−1·min−1 remifentanil for approximately 3 h (range: 140–265 min) did not induce acute tolerance, but the administration of 0.6 and 0.9 µg·kg−1·min−1 remifentanil to young children resulted in acute tolerance for 24 h after surgery in an apparently dose-related manner.
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Welzing L, Link F, Junghaenel S, Oberthuer A, Harnischmacher U, Stuetzer H, Roth B. Remifentanil-induced tolerance, withdrawal or hyperalgesia in infants: a randomized controlled trial. RAPIP trial: remifentanil-based analgesia and sedation of paediatric intensive care patients. Neonatology 2013; 104:34-41. [PMID: 23635551 DOI: 10.1159/000348790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 02/07/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Short-acting opioids like remifentanil are suspected of an increased risk for tolerance, withdrawal and opioid-induced hyperalgesia (OIH). These potential adverse effects have never been investigated in neonates. OBJECTIVES To compare remifentanil and fentanyl concerning the incidence of tolerance, withdrawal and OIH. METHODS 23 mechanically ventilated infants received up to 96 h either a remifentanil- or fentanyl-based analgesia and sedation regimen with low-dose midazolam. We compared the required opioid doses and the number of opioid dose adjustments. Following extubation, withdrawal symptoms were assessed by a modification of the Finnegan score. OIH was evaluated by the CHIPPS scale and by testing the threshold of the flexion withdrawal reflex with calibrated von Frey filaments. RESULTS Remifentanil had to be increased by 24% and fentanyl by 47% to keep the infants adequately sedated during mechanical ventilation. Following extubation, infants revealed no pronounced opioid withdrawal and low average Finnegan scores in both groups. Only 1 infant of the fentanyl group and 1 infant of the remifentanil group required methadone for treatment of withdrawal symptoms. Infants also revealed no signs of OIH and low CHIPPS scores in both groups. The median threshold of the flexion withdrawal reflex was 4.5 g (IQR = 2.3) in the fentanyl group and 2.7 g (IQR = 3.3) in the remifentanil group (p = 0.312), which is within the physiologic range of healthy infants. CONCLUSIONS Remifentanil does not seem to be associated with an increased risk for tolerance, withdrawal or OIH.
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Affiliation(s)
- Lars Welzing
- Department of Neonatology, Children's Hospital, University Hospital of Bonn, Bonn, Germany.
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Welzing L, Oberthuer A, Junghaenel S, Harnischmacher U, Stützer H, Roth B. Remifentanil/midazolam versus fentanyl/midazolam for analgesia and sedation of mechanically ventilated neonates and young infants: a randomized controlled trial. Intensive Care Med 2012; 38:1017-24. [PMID: 22456770 DOI: 10.1007/s00134-012-2532-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 03/05/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE Common opioids for analgesia and sedation of mechanically ventilated infants may tend to accumulate and cause prolonged sedation with an unpredictable extubation time. Remifentanil is a promising option due to its unique pharmacokinetic properties, which seem to be valid in adults as well as in infants. METHODS In this double-blind, randomized, controlled trial mechanically ventilated neonates and young infants (<60 days) received either a remifentanil or fentanyl-based analgesia and sedation regimen with low dose midazolam. The primary endpoint of the trial was the extubation time following discontinuation of the opioid infusion. Secondary endpoints included efficacy and safety aspects. RESULTS Between November 2006 and March 2010, we screened 431 mechanically ventilated infants for eligibility. The intention to treat group included 23 infants who were assigned to receive either remifentanil (n = 11) or fentanyl (n = 12). Although this was designed as a pilot study, median extubation time was significantly shorter in the remifentanil group (80.0 min, IQR = 15.0-165.0) compared to the fentanyl group (782.5 min, IQR = 250.8-1,875.0) (p = 0.005). Remifentanil and fentanyl provided comparable efficacy with more than two-thirds of the measurements indicating optimal analgesia and sedation (66.4 and 70.2 %, respectively; p = 0.743). Overall, both groups had good hemodynamic stability and a comparably low incidence of adverse events. CONCLUSIONS As neonates and young infants have a decreased metabolism of common opioids like fentanyl and are more prone to respiratory depression, remifentanil could be the ideal opioid for analgesia and sedation of mechanically ventilated infants.
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Affiliation(s)
- Lars Welzing
- Department of Neonatology and Paediatric Intensive Care, Childrens Hospital, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
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Dadure C, Sola C, Choquet O, Capdevila X. Les blocs nerveux périphériques de la face chez l’enfant. ACTA ACUST UNITED AC 2012; 31:e17-20. [DOI: 10.1016/j.annfar.2011.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Effect of Rectal Diclofenac and Acetaminophen Alone and in Combination on Postoperative Pain After Cleft Palate Repair in Children. J Craniofac Surg 2011; 22:1955-9. [DOI: 10.1097/scs.0b013e31822ea7fd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Does Use of Bupivacaine-Soaked Pledgets Aid in the Care of Postoperative Cleft Palate Patients? Ann Plast Surg 2011; 66:528-9. [DOI: 10.1097/sap.0b013e3182059be8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mak WY, Yuen V, Irwin M, Hui T. Pharmacotherapy for acute pain in children: current practice and recent advances. Expert Opin Pharmacother 2011; 12:865-81. [PMID: 21254863 DOI: 10.1517/14656566.2011.542751] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Acute pain in children may be undertreated. Improved understanding of developmental neurobiology and paediatric pharmacokinetics should facilitate better management of pharmacotherapy. The objective of this review is to discuss current paediatric practice and recent advances with these analgesic agents by using an evidence-based approach. AREAS COVERED Using PubMed an extensive literature review was conducted on the commonly used analgesic agents in children from 2000 to April 2010. EXPERT OPINION A multimodal analgesic regimen provides better pain control and functional outcome in children. The choice of pharmacological treatment is determined by the severity and type of pain. However, more research and evidence is required to determine the optimal drug combinations.
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Affiliation(s)
- Wai Yin Mak
- Queen Mary Hospital-Anaesthesiology, F2 Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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Abstract
Remifentanil has gained the confidence of anesthesiologists and has given a real opportunity to change the way anesthesia is given. It can be considered the ideal opioid despite many obstacles to pediatric use: the condition of 'off-label', the lack of wide randomized clinical trials, and the fear of adverse events because of its high potency. Experiences in the field with this opioid over the years encouraged its use. Use has been associated with N(2)0 and volatile agents for general anesthesia and with propofol for total intravenous anesthesia (TIVA). It seems very useful for sedation inside and outside the operating room and in intensive care for both short painful procedures and synchronization with mechanical ventilation. However, its unique pharmacokinetic characteristics causing rapid onset and offset of effect appear unchanged in small children and even in premature neonates and need to be really confirmed by further pharmacokinetic studies. Moreover, the real risks of tolerance and hyperalgesia should be evaluated in the pediatric population. In this review, we go through the newer aspects of this versatile drug that has been proposed as 'the pediatric anesthetist's opiate'.
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Affiliation(s)
- Maria Sammartino
- Department of Anaesthesia and Intensive Care, Catholic University of Sacred Heart, Rome, Italy.
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Milić M, Goranović T, Knežević P. Complications of sevoflurane–fentanyl versus midazolam–fentanyl anesthesia in pediatric cleft lip and palate surgery: a randomized comparison study. Int J Oral Maxillofac Surg 2010; 39:5-9. [DOI: 10.1016/j.ijom.2009.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 07/12/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
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Choi SH, Lee WK, Lee SJ, Bai SJ, Lee SH, Park BY, Min KT. Parent-controlled analgesia in children undergoing cleft palate repair. J Korean Med Sci 2008; 23:122-5. [PMID: 18303211 PMCID: PMC2526495 DOI: 10.3346/jkms.2008.23.1.122] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aims of this study were to find an optimal basal infusion dose of fentanyl for parent-controlled analgesia (PrCA) in children undergoing cleft palate repair and the degree of parents' satisfaction with PrCA. Thirty consecutive children between 6 months and 2 yr of age were enrolled. At the end of surgery, a PrCA device with a basal infusion rate of 2 mL/hr and bolus of 0.5 mL with lockout time of 15 min was applied. Parents were educated in patient-controlled analgesia (PCA) devices, the Wong Baker face pain scoring system, and monitoring of adverse effects of fentanyl. Fentanyl was infused 0.3 microgram/kg/hr at first, and we obtained a predetermined fentanyl regimen by the response of the previous patient to a larger or smaller dose of fentanyl (0.1 microgram/kg/hr as the step size), using an up-and-down method. ED50 and ED95 by probit analysis were 0.63 microgram/kg/hr (95% confidence limits, 0.55-0.73 microgram/kg/hr) and 0.83 microgram/kg/hr (95% confidence limits, 0.73-1.47 microgram/kg/hr), respectively. Eighty seven percent of the parents were satisfied with participating in the PrCA modality. PrCA using fentanyl with a basal infusion rate of 0.63 microgram/kg/hr can be applied effectively for postoperative pain management in children undergoing cleft palate repair with a high level of parents' satisfaction.
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Affiliation(s)
- Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Kwandong University College of Medicine, Goyang, Korea
| | - Sung Jin Lee
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Jun Bai
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Su Hyun Lee
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Beyoung Yun Park
- Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, Seoul, Korea
| | - Kyeong Tae Min
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Steinmetz J, Holm-Knudsen R, Sørensen MK, Eriksen K, Rasmussen LS. Hemodynamic differences between propofol-remifentanil and sevoflurane anesthesia for repair of cleft lip and palate in infants. Paediatr Anaesth 2007; 17:32-7. [PMID: 17184429 DOI: 10.1111/j.1460-9592.2006.01999.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Propofol-remifentanil anesthesia is widely used in adults but few studies are available in infants. We aimed at comparing the hemodynamic effects of propofol-remifentanil vs sevoflurane-fentanyl anesthesia. In addition, we sought to investigate recovery and whether remifentanil induced acute opioid tolerance. METHODS In total, 39 infants 4-6 months old were prospectively enrolled and randomized to receive either a combination of remifentanil and propofol (n = 17) or a sevoflurane-fentanyl anesthesia (n = 22) for surgical repair of cleft lip and palate. In both groups, sevoflurane was used for induction of anesthesia and fentanyl was administered before tracheal extubation. Mean arterial blood pressure and heart rate were recorded every 5 min after induction. We also recorded time from termination of surgery to tracheal extubation, postoperative behavior and the need for analgesia for the first 24 h after surgery. Postoperative observations were blinded. RESULTS In the remifentanil-propofol group, the mean arterial blood pressure was higher [58 (51-65) vs 51 (45-55), P = 0.02] and the mean heart rate was lower [111 (108-113) vs 128 (122-143), P < 0.0001]. There were no differences in recovery time or behavior after surgery. In the remifentanil group, a median fentanyl dose of 4 microg x kg(-1) was required to insure a smooth recovery, but there was no difference in morphine consumption during the first 24 h after surgery. CONCLUSIONS A high-dose remifentanil-propofol infusion was associated with a higher blood pressure and lower heart rate than sevoflurane-fentanyl anesthesia in infants. Postoperative morphine consumption, recovery time and quality were similar.
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Affiliation(s)
- Jacob Steinmetz
- Department of Anesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital, Copenhagen, Denmark.
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Abstract
Remifentanil is a relatively new synthetic opioid, which is not licensed worldwide for neonates and infants. Because of its unique pharmacokinetic properties with a short recovery profile, it could be the ideal opioid for neonates and infants, who are especially sensitive to respiratory depression by opioids. Therefore, we conducted a MEDLINE search on all articles dealing with the use of remifentanil in this important subgroup of patients. Most experience with remifentanil in neonates and infants is as maintenance anaesthesia during surgery. In approximately 300 neonates and infants, remifentanil proved to be an effective and safely used opioid for this indication. However, very limited data exist on remifentanil for analgesia and sedation of mechanically ventilated paediatric intensive care patients. Further research with remifentanil in neonates and infants should focus on this group of patients because remifentanil, with its very short context-sensitive half-life, could result in shorter extubation times compared with commonly used opioids such as morphine or fentanyl.
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Affiliation(s)
- Lars Welzing
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital University of Cologne, Cologne, Germany.
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Santos CF, Calvo AM, Sakai VT, Dionísio TJ, Lauris JRP, Carvalho RM, Trindade AS. The changing pattern of analgesic and anti-inflammatory drug use in cleft lip and palate repair. ACTA ACUST UNITED AC 2006; 102:e16-20. [PMID: 16997088 DOI: 10.1016/j.tripleo.2005.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 11/09/2005] [Accepted: 12/09/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This work aimed at performing a retrospective and comparative investigation of pharmacological therapeutic approach for pain and inflammation control for cleft lip and/or palate repair. STUDY DESIGN Medical charts from 2000 patients who underwent surgical procedures at the Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC-USP), Brazil, were assessed to obtain information regarding type of cleft, surgical procedure, and analgesic and anti-inflammatory drugs prescribed. The first 1000 consecutive surgeries performed in 1992 and 2002 were assessed. RESULTS Different analgesic and anti-inflammatory agents-nonsteroidal anti-inflammatory drugs (NSAIDS), steroids, and opioids-were given to patients perioperatively and postoperatively. NSAIDS were given to almost all patients (97.03% in 1992 and 99.88% in 2002, P > .05). Steroid administration increased in 2002 (8.66% versus 17.71%, P < .05). Opioids were administered only in 2002 (50.31%, P < .05). CONCLUSION NSAIDS, steroids, and opioids were used for pain and inflammation control in cleft lip and palate repair at HRAC-USP. A change in the pattern of analgesic and anti-inflammatory drug use was observed when comparing 1992 and 2002. More potent compounds, such as opioids, were used in 2002 in a significant percentage of all the surgical procedures.
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Affiliation(s)
- Carlos F Santos
- Discipline of Pharmacology, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil.
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Abstract
We have developed a modern strategy for the anesthetic management of pediatric cleft lip and cleft palate repair using anesthetic drugs such as sevoflurane, desflurane, acetaminophen, remifentanil, and pirtitramide together with new techniques. It provides best conditions for the surgeon and maximum safety for the pediatric patient. A team of pediatricians, neonatologists, pediatric surgeons, and pediatric anesthetists have tackled the problem of management of children with craniofacial abnormalities such as cleft lip and cleft palate. The best and safest anesthetic techniques are outlined and the most frequent complications are discussed, e.g. management of the difficult airway, the airway in patients with complex craniofacial abnormalities, fiberoptic endotracheal intubation through a laryngeal mask, intraoperative dislocation of the endotracheal tube, postoperative airway obstruction and perioperative bleeding.
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Affiliation(s)
- Andreas Machotta
- Klinik für Anästhesiologie und operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum
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Chanavaz C, Tirel O, Wodey E, Bansard JY, Senhadji L, Robert JC, Ecoffey C. Haemodynamic effects of remifentanil in children with and without intravenous atropine. An echocardiographic study. Br J Anaesth 2004; 94:74-9. [PMID: 15486003 PMCID: PMC4767884 DOI: 10.1093/bja/aeh293] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Remifentanil is known to cause bradycardia and hypotension. We aimed to characterize the haemodynamic profile of remifentanil during sevoflurane anaesthesia in children with or without atropine. METHODS Forty children who required elective surgery received inhalational induction of anaesthesia using 8% sevoflurane. They were allocated randomly to receive either atropine, 20 microg kg(-1) (atropine group) or Ringer's lactate (control group) after 10 min of steady-state 1 MAC sevoflurane anaesthesia (baseline). Three minutes later (T0), all children received remifentanil 1 microg kg(-1) injected over a 60 s period, followed by an infusion of 0.25 microg kg(-1) min(-1) for 10 min then 0.5 microg kg(-1) min(-1) for 10 min. Haemodynamic variables and echocardiographic data were determined at baseline, T0, T5, T10, T15 and T20 min. RESULTS Remifentanil caused a significant decrease in heart rate compared with the T0 value, which was greater at T20 than T10 in the two groups: however, the values at T10 and T20 were not significantly different from baseline in the atropine group. In comparison with T0, there was a significant fall in blood pressure in the two groups. Remifentanil caused a significant decrease in the cardiac index with or without atropine. Remifentanil did not cause variation in stroke volume (SV). In both groups, a significant increase in systemic vascular resistance occurred after administration of remifentanil. Contractility decreased significantly in the two groups, but this decrease remained moderate (between -2 and +2 sd). CONCLUSION Remifentanil produced a fall in blood pressure and cardiac index, mainly as a result of a fall in heart rate. Although atropine was able to reduce the fall in heart rate, it did not completely prevent the reduction in cardiac index.
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Affiliation(s)
- Charles Chanavaz
- Service d'anesthésie réanimation chirurgicale
Hôpital PontchaillouUniversité de Rennes 12 Rue Henri Le Guilloux 35033 Rennes Cedex 9
| | - Olivier Tirel
- Service d'anesthésie réanimation chirurgicale
Hôpital PontchaillouUniversité de Rennes 12 Rue Henri Le Guilloux 35033 Rennes Cedex 9
| | - Eric Wodey
- Service d'anesthésie réanimation chirurgicale
Hôpital PontchaillouUniversité de Rennes 12 Rue Henri Le Guilloux 35033 Rennes Cedex 9
- Groupe de Recherche Cardio-vasculaire
Université de Rennes 1CNRSRennes
- * Correspondence should be addressed to Eric Wodey
| | - Jean-Yves Bansard
- LTSI, Laboratoire Traitement du Signal et de l'Image
Université de Rennes 1INSERMCampus de Beaulieu, 263 Avenue du Général Leclerc - CS 74205 - 35042 Rennes Cedex
| | - Lotfi Senhadji
- LTSI, Laboratoire Traitement du Signal et de l'Image
Université de Rennes 1INSERMCampus de Beaulieu, 263 Avenue du Général Leclerc - CS 74205 - 35042 Rennes Cedex
| | - Jean-Claude Robert
- Service de Chirurgie Dentaire Pédiatrique et Physiologie
Hôpital Pontchaillou
| | - Claude Ecoffey
- Service d'anesthésie réanimation chirurgicale
Hôpital PontchaillouUniversité de Rennes 12 Rue Henri Le Guilloux 35033 Rennes Cedex 9
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