Anesthesie, analgesie, reanimation最新文献

To determine the indications of body position, continuous positive airway pressure and independent lung ventilation in unilateral lung disease, we turned 10 patients with overwhelming unilateral lung disease from supine to lateral position. All patients were breathing spontaneously with a mask, then associated with continuous airway pressure (10 cm H2O PEEP) in five cases. During these spontaneous ventilation methods, hemodynamic parameters did not change, but arterial blood oxygen tension increased and intra-pulmonary shunting decreased significantly. Final recovery was obtained in 7 cases. In the 3 others, mechanical ventilation was needed because spontaneous breathing methods were ineffective in improving blood gases. Lateral position and conventional ventilation with positive airway pressure were also ineffective. Only independent ventilation enhanced arterial blood oxygen tension. But only one patient survived. We conclude that spontaneous breathing methods are able to provide successful treatment in most of patients with unilateral lung disease. In other patients, only independent lung ventilation is effective.

The authors report on a retrospective study of 30 severe acute pancreatitis. The severity of the illness is documented by operative statement and evolution of the disease = 50 p. cent of mortality. A first group of 10 patients (1972-1975) was treated by primary intensive care and rapid ablative surgery with 10 deaths. A second group of 20 patients (1976-1980) was treated by primary intensive care, artificial nutrition and secondary surgical drainage. Mortality is significantly lower in the second group (5 deaths). It is concluded that all severe acute pancreatitis should be initially managed by intensive metabolic care and respiratory support if necessary. The only indication for primary surgery is a diagnostic doubt with peritonitis or bowell infarction. The authors emphasize the improvement of the prognosis of severe acute pancreatitis related to hemodynamic and respiratory measures and to a better nutritionnal support. Surgery should be secondary on a well prepared patient. Drainage or sequestrectomy support a lower mortality than ablative surgery.

The mechanism of microbial colonization and sepsis is disputed. For many authors, catheter contamination results from poor aseptic technic during insertion or removal or from the descent of organisms along the catheter from the skin puncture site; we think with Michel that endogenous colonization of the thrombus at the tip of the catheter must be considered: a statistical correlation between infected foci remote from the catheter allows this hypothesis; tracheostomy may be considered as well as a percutaneous contaminant as a deep infected focus. The correlation between non specific immunity and contamination is another finding which allows the ability of endogenous colonization.

The hemodynamic respiratory results and analgesic quality of ketamine administered as an IV infusion are studied. For the infants weighing less than 10 kg. The increases in arterial pressure and heart rate are not readily acceptable all the less as the ketamine requirement for good analgesia is very important. For the infant weighing more than 10 kg, the procedure of this technique is approximatively the same for the adult. The explanation of these problems is perhaps connected to the larger extra-cellular fluid volumes of young children and to their brain immaturity.

The "ventilatory requirement" can be measured in every conscious subject. But it cannot be appreciated under general anaesthesia. General anaesthesia produce a difference between the amount of spontaneous breathing of the subject and his "ventilatory requirement". A metabolic debt can appear without ventilatory compensation. So spontaneous breathing is never indicated during general anaesthesia. It can be tolerated in some technical situations when controlled breathing is impossible.

Haemodynamic effects of suxamethonium IV 1 mg/kg were studied in eight comatose, mechanicaly ventilated, normotensive patients. Drug interference, including atropine was avoid. A transitory but significant increase in heart rate and cardiac output (CO) was observed, respectively + 27 p. cent (p less than 0.02) and + 29 p. cent (p less than 0.025) at the first minute. Right auricular, pulmonary capillary wedge, and pulmonary arterial pressures increased significantly from the first to the eighth minute. Mean arterial blood pressure unsignificantly increased (+ 5 p. cent) wether systemic arterial resistance decreased from - 11 p. cent (p less than 0.02) at the first minute. No arrhythmia occurred throughout the study. In the conditions of this study suxamethonium induces an early and transient increase in CO. Both tachycardia and increased venous return can explain the rise in CO. Such an increase could be due to the transient abdominal hyperpressure, and can be one of the factors which explain the poor tolerance of suxamethonium in patients with heart failure.

After a review of first two causes of bisalbuminemia: genetic mutation and overdosage during antibiotherapy with beta-lactamines, the authors underline the importance of searching for a bisalbuminemia during the course of pancreatic disease or when confronted with a serous collection, particularly an ascite of undetermined origin. Effectively, the finding of a bisalbuminemia in these two circumstances, after having eliminated the first two etiologies, permits the confirmation of the diagnostic of a pancreatic fistula. This diagnostic should imply exploratory surgery, even without other confirmation, and a per-op. wirsungography if the fistula is not visible macroscopically. The surgical correction of the fistula cures the patient and the bisalbuminemia disappears in several hours.

The authors relate, after 75 cases, their experience of pulmonary artery catheterism carried out in case of cardiac surgery intervention. The Swan-Ganz catheter is exclusively introduced by the percutaneous internal jugular route and generally right (82 p. cent). During the progression of the catheter the radiologic control is not necessary. The complete failures are rare (2,5 p. cent) and the right pulmonary artery is mostly catheterised in every case. Complications are exceptional and often correspond to benign incidents like premature ventricular contractions which always disappear spontaneously, balloon ruptures (three cases) and the isolation of a non-pathogenic organism during the systemic bacteriologic examination without infections reactions. A serious infection complication has been found in one case and a pulmonary infarction is observed in another case. Compared with other venous route the advantages of this method lie in its very easy, simple, fast and trusty execution.