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The analgesic and ventilatory depressant effects of epidural and intramuscular alfentanil (15 micrograms/kg) were compared in two groups of seven healthy unpremedicated subjects. Fifteen minutes after IM injection, the slope of the ventilatory response to CO2 decreased significantly (from 2.72 +/- 0.34 to 1.8 +/- 0.20 L.min-1.mmHg-1) while assessment of periosteal analgesia showed no change. After epidural injection, the slope of the ventilatory response to CO2 decreased significantly (from 2.32 +/- 0.42 to 1.61 +/- 0.29, 1.51 +/- 0.29, and 1.53 +/- 0.21 L.min-1.mm Hg-1) at 15, 45, and 90 minutes (x +/- SD, P less than 0.05), and there was significant periosteal analgesia of the tibia (15 and 30 minutes after injection) and of the radius (30 to 90 minutes after injection). Throughout the study, plasma alfentanil levels were similar after intramuscular and epidural injection. These results suggest that epidural alfentanil induces ventilatory depression due to the rostral spread of the drug rather than to systemic absorption.

The authors studied the effects of epidural sufentanil (0.75 microgram.kg-1) after urologic surgery in 15 children ranging in age from 4 to 12 yr, and in weight from 14 to 47 kg. The onset and duration of analgesia were 3.0 +/- 0.3 and 198 +/- 19 min, respectively (mean +/- SEM). Side effects included pruritus (3/15), nausea and vomiting (5/15), drowsiness (10/15), and urinary retention (1/11). No apnea was observed. Periosteal analgesia and ventilation were studied in eight of the children (mean age 8.6 +/- 0.8 yr). There was significant periosteal analgesia of the tibia (30, 60, 90, and 120 min after injection) and of the radius (60, 90, and 120 min after injection). Resting respiratory rate and tidal volume did not change during the study. Resting minute-ventilation decreased from 6.3 +/- 0.5 l.min-1 preoperatively to 5.6 +/- 0.6 l.min-1 (P less than 0.05) postoperatively, before epidural sufentanil injection; it did not decrease further after epidural sufentanil. Similarly, end-tidal CO2 tension increased significantly from 37.2 +/- 0.7 mmHg preoperatively to 39.9 +/- 1.2 mmHg (P less than 0.05) postoperatively, before epidural sufentanil; epidural sufentanil did not cause a further significant increase in end-tidal CO2 tension. The slope of the CO2 ventilatory response curve decreased significantly from 1.68 +/- 0.12 l.min-1. mmHg-1 preoperatively to 1.10 +/- 0.13 l.min-1.mmHg-1 (P less than 0.01) postoperatively. There were further significant decreases to 0.68 +/- 0.10 and 0.89 +/- 0.16 l.min-1.mmHg-1 30 and 60 min after epidural sufentanil.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors determined the effects of intravenous infusion and epidural administration of lidocaine on the control of ventilation in two groups of eight healthy unpremedicated subjects. In the intravenous group, an injection of 1.5 mg/kg lidocaine was followed by an infusion at a rate of 60 micrograms X kg-1 X min-1 for 30 min. The slope of the ventilatory response to CO2 was significantly increased (P less than 0.05) from its control value (2.65 +/- 1.22 1 X min-1 X mmHg-1 [mean +/- SD]) at the end of the infusion (58%), while plasma lidocaine level was at 3.14 +/- 0.82 microgram/ml. The correlation between individual plasma lidocaine levels and the changes in the slope of the ventilatory response to CO2 was significant (r = 0.58, n = 24, P less than 0.01). In the epidural group, after the administration of 5 mg/kg of lidocaine, the slope of the ventilatory response to CO2 increased significantly (P less than 0.05) from its control value (1.52 +/- 0.75 1 X min-1 X mmHg-1) at 15 (+22%) and 25 min (+42%), while plasma lidocaine levels were at 1.79 +/- 0.42 and 2.22 +/- 0.47 microgram/ml, respectively. In both groups, resting minute ventilation and end-tidal CO2 values remained unchanged. These results suggest that epidural lidocaine has a stimulating effect on the ventilatory control mechanisms that results from the systemic effect of the drug.

The authors compared the effects of administration of fentanyl 200 μg on the Ventilatory response to carbon dioxide in two groups of nine healthy unpremedicated subjects: one group received fentanyl as an intramuscular injection; in the other group, fentanyl was injected into the epidural space. In the intra muscular group, the slope of the venti-latory response to CO2 did not decrease significantly. In the epidural group, the slope of the Ventilatory response to CO2 decreased significantly from 2.48 ± 1.05 to 1.77 ± 0.7, 1.74 ± 0.7, and 2.07 ± 0.74 L·min-1·mm Hg−1 at 30, 60, and 120 min after injection (x ± SD, P ≤ 0.05), respectively. At each time of the study, plasma fentanyl levels were significantly lower in the epidural group than in the intramuscular group (P ≤ 0.05). These results suggest that epidural fentanyl induces a non systemic Ventilatory depression that may be due to the rostral spread of the drug.

The efficacy of two dosage regimens of intravenous naloxone were compared to avoid nonrespiratory side effects and respiratory depression and yet to preserve analgesia (maximum tolerance to periostial pressure over the tibia) after administration of 200 micrograms epidural fentanyl. Three groups of eight patients were studied: group 1 patients received a loading dose of 0.4 mg IV naloxone followed by naloxone infusion at a rate of 10 micrograms.kg-1.hr-1. Group II patients received a loading dose of 0.2 micrograms naloxone followed by a naloxone infusion at a rate of 5 micrograms.kg-1.hr-1. Group III patients received a saline infusion at a rate of 20 ml/hr. Epidural fentanyl significantly increased tolerance to periostial pain in all three groups (respectively, +38 +/- 20%, +36 +/- 16%, and +35 +/- 14%) (mean +/- SD; P less than 0.05). The naloxone infusion significantly reduced this effect in groups I and II, respectively, -40 +/- 20% and -37 +/- 28% below prenaloxone levels) (P less than 0.05). Nonrespiratory side effects were also reversed in groups I and II. In group III, neither periostial analgesia nor nonrespiratory side effects were affected. The baseline slopes of VE/PETCO2 were 2.34 +/- 1.01, 2.14 +/- 0.66, and 2.68 +/- 1.14 L.min-1.mm Hg-1, respectively, in groups I, II, and III. Epidural fentanyl significantly decreased the slope below baseline levels in each group: -21 +/- 16%, -22 +/- 17%, and -19 +/- 32%, respectively, in groups I, II and III.(ABSTRACT TRUNCATED AT 250 WORDS)

The plasma protein binding of sufentanil has been studied in newborns, infants (0.5 +/- 0.3 yr), children (6.8 +/- 3.0 yr), and adults (39.5 +/- 9.0 yr). Binding of sufentanil was determined in vitro by equilibrium dialysis, and radioactive tritiated sufentanil was used for the determination of drug concentrations in plasma and buffer. The free fraction of sufentanil was significantly higher in the newborn (19.5 +/- 2.7%; P less than 0.01) than in the other age groups. The free fraction was also significantly higher in infants (11.5 +/- 3.2%; P less than 0.01) than in children (8.1 +/- 1.4%) or in adults (7.8 +/- 1.5%) but did not differ significantly between children and adults. The free fraction of sufentanil was strongly correlated with the alpha 1-acid glycoprotein plasma concentration (r = -0.73; P less than 0.001) whereas it was weakly correlated with albumin plasma concentration (r = -0.35; P less than 0.05). These data suggest that the lower concentration of alpha 1-acid glycoprotein in newborns and infants probably accounts for the decrease in protein binding of sufentanil in these age groups when compared with that in older children or adults. The increased free fraction in the neonate might contribute to the enhanced effects of lipophilic opioids in the neonate.

Introduction : Dans un contexte de modernisation et de réorganisation du système de soins français dans le cadre de la permanence de soins, des effecteurs mobiles parcourent le territoire depuis 2012. En Ille-et-Vilaine, ce dispositif essaye entre autre d’endiguer la foule de patients présents aux urgences. Cette étude vise à définir la population bénéficiant du passage d’un effecteur mobile et de travailler sur le devenir des patients concernés. Matériels et méthodes : étude transversale et descriptive. Travail réalisé sur l’ensemble des appels passés au CRRA du SAMU 35 du 1er janvier 2016 au 31 décembre 2016, ayant été orientés vers la permanence des soins. Résultats : 58 707 appels ont été étudiés, dont 1 591 ont bénéficié du passage d’un effecteur mobile. Dans cette population bénéficiant du passage de l’effecteur mobile, la moyenne d’âge était de 73 ± 22 ans avec une prédominance féminine (56%). Les EM étaient principalement mobilisés le week-end et jours fériés (71% de leur activité) sur des horaires de journée pour 55% et de 20h à minuit pour 28%. Dans 36% des cas, l’appel provenait d’un EHPAD et un personnel paramédical en était à l’origine dans 44%. L’EM est principalement mobilisé sur deux grands cadres de pathologies : la médecine de la personne âgée (29%) avec notamment la prise en charge de la fin de vie, et les pathologies traumatiques (20%). En analyse univariée, les patients étaient plus souvent transportés sur un service d’urgence s’ils étaient des hommes (p