Anesthesie, analgesie, reanimation最新文献

A retrospective study of the anaesthetic records in cardiac surgical patients was undertaken: massive doses of fentanyl were used according to Stanley (29). The rate of drug administration was fentanyl 150 micrograms/kg for induction and 15 to 25 micrograms/kg/hour for maintenance, pancuronium bromide 0,1 mg/kg for induction and 0,015 mg/kg/hour for maintenance. Myocardial oxygen consumption (estimated by rate-pressure-product) during induction period remains constant. The oesophago-rectal temperature gradient is smaller than with other anaesthetic techniques, showing a very good perfusion homogeneity without the need of vasodilatator drugs. The temperature after-drop in the post bypass period is also reduced (less than 1,2 degrees C). The incidence of hemodynamic and rhythmic disturbances during operations and during the first post-operative day is lowered. Delayed respiratory autonomy appears to be the major drawback of this method (group 1: 25,30 h +/- 7,30 h; 30,20 h +/- 12,25 h; group 3: 21,15 h +/- 6,25 h).

The authors compare the protein sparing effect of two diets, exclusively intravenous, including the same protein intake, but a different caloric intake, 21 calories/gm nitrogen for diet "A" (20 cases); 138 calories/gm nitrogen for diet "B" (20 cases). This has been observed during the six post-operative days of major visceral surgery: oesophagectomy, total gastrectomy, colic or rectocolic exeresis, sequestrectomy for acute pancreatitis, lots having been drawn for the diets. Daily nitrogen balances have been made and plasmatic and urinary levels of amino-acids have been measured before surgery and on the third and fifth post-operative days. Statistical exploitation is done by variance analysis (linear model of three factors) with a 99% confidence ratio: 1) Patient factor has no influence whatsoever on cumulative nitrogen balance. 2) Time factor arises only on the fourth post-operative day and only in the hypocaloric diet, leading to catabolism. 3) Metabolic condition is determinant. On no cancerous disease, superiority of hypercaloric diet is well demonstrated. On cancerous disease, nitrogen loss is only significantly different on 4th and 5th post-operative day: hypercaloric diet gives a better nitrogen balance.

41 babies were operated upon in emergency in the cardiac surgery department. 11 of them were submitted to open heart surgery and 30 were operated without extra corporeal circulation. Amongst them, there were 21 coarctations of thoracic aorta either isolated or associated with other cardiac malformations. 13 of them, presented a pericardial effusion, and the mean age was 3 months. First of all, the notion of emergency in cardiac surgery of the new-born is stressed. Then, premedication and technic of anaesthesia are shortly described. The authors insist on the frequency of lethal cardiac fibrillation occurring at the opening of pericardium in case of coarctations of aorta complicated by pericardial effusion. Prevention of this accident is possible if at the beginning of anaesthesia the baby lies in a proclive position. On the opposite, bradycardia occurring at the opening of the pericardium or during pulmonary artery banding have a good prognosis. Lastly, the authors insist on the high risk of this surgery in the baby (25 p. cent of mortality) and 80 p. cent under 6 months of age and the high mortality of iterative operations.

Fifty-eight coelio-splanchnic nerve blocks by alcoholisation were done for thirty-two patients at the regional Center of the Fight against Cancer at Montpellier for persistent neoplastic pain of the pancreatico-solar type. In 15 cases (46,6 p. cent), the pancreatico-solar syndrome is the initial sign of a primitive or secondary supra-mesocolic cancer. In 12 cases, the hyperalgic syndrome discloses the extension or recidive of the tumor. According to etiologies, the illnesses were as follows: --pancreatic neoplasias I or II: 13 cases, --hepato-biliary lesions I or II: 11 cases, --peritoneal carcinosis: 4 cases, --invasion of retro-peritoneal nodes: 4 cases. Epigastric pain irradiating to the left para-vertebral area are resistant to analgesias; 95 p. cent of these patients received morphinic drugs for several days, if not weeks. The splanchnic nerves were reached by a posterior high lumbar injection according to the Kappis and Labat technic. A block with 2 p. cent lidocaine is immediately followed by alcoholisation by 99,8 p. cent ethanol. According to patient status, the blocks to the left and right were done at once or at several visits. The block by lidocaine gives immediate analgesia thereby indicating the proper placement of the injection. The coeliac alcoholisation assures the neurolysis of the splanchnic nerves. The antalgic effect lasts a variable time, averaging 42 days (varying from 2 to 240 days). The antalgic action always allows the discontinuation of morphinic drugs and increases the efficacy of minor analgesics, if necessary. All the same, 18/25 received morphine during their last few days before death.

The consequences of continuous positive airway pressure (CPAP) on left ventricular function are uncertain. Left ventricular function was assessed by M-mode echocardiography in 8 young normal subjects during CPAP via face mask. Heart rate and arterial pressure did not change. End-diastolic volume and stroke volume significantly decreased. Ejection fraction remained unchanged. The slight decrease of stroke volume induced by increasing positive airway pressure is in relation to decreased left ventricular preload.

Glucose intolerance occurring in injured patients is known to be a part of the general response to injury described by Cuthbbertson: early "ebb phase" with a decrease of energy production, then "flow phase" with hypermetabolism. Several processes can be responsible for the abnormalities observed: 1) Alterations in peripheral glucose uptake. 2) Absolute or relative insulin lack in connection with increased catecholamine release which is know to inhibit insulin secretion. 3) Decreased sensitivity and responsiveness to insulin in connection with increased levels of counter regulatory hormones (catecholamines, glucagon, growth hormone). 4) Non-suppressibility of hepatic gluconeogenesis by glucose. Glucose intolerance decreases glucose utilisation and leads to increased proteolysis always unfavorable for patients.

Thirty-one patients undergoing neuro-radiological investigations were anesthetized by methohexital-fentanyl association. Induction of anesthesia was performed by I. V. bolus of these two agents. Anesthesia was maintained by a constant rate perfusion of methohexital and fentanyl, prepared according to body weight. Posology can be reduced hourly by modifying the perfusion rate. First hour: methohexital 2 mg/kg/hour fentanyl 5 microgram/kg/hour; second hour: methohexital 0.4 mg/kg/hour, fentanyl 2 microgram/kg/hour; third hour: methohexital 0,4 mg/kg/hour, fentanyl 1 microgram/kg/hour. If necessary this dosage was modified according to isolate reactions and thus total real consumption was 25 to 30 p. cent higher to estimated theoretical requirements. This protocol of anesthesia with controlled ventilation was well cardiocirculatory tolerated and adapted to these radiological investigations.