Annales de l'anesthesiologie francaise最新文献

The rapid idioventricular rhythm (RIVR) seen most frequently during the acute phase of myocardial infarction is considered to be a benign arrhythmia which has only a moderate haemodynamic effect on the healthy heart. In a patient with chronic bronchitis and emphysema and ischaemic heart disease, haemodynamic studies during an episode of poorly tolerated RIVR showed a 22 per cent decrease in cardiac output secondary to a decrease in stroke volume. The authors emphasise the need for the correction of factors capable of increasing myocardial oxygen debt rather than the use of anti-arrhythmic agents.

The criteria for intravenous administration of anesthetics or their adjunctives in continuous and constant flow remain imprecise and incompletely understood. Drugs with a very short half-life are usually preferred, without this being a restrictive notion. The theoretical bases for the kinetics of constant flow intravenous infusion are well known but not the practical carrying out, and the practitioner remains confronted with various fundamental questions. Indeed, the quantity administered must take in account it's elimination, but what happens in cases of destructive metabolism, above all when the metabolites are toxic? On the other hand, can the kinetics observed for a given dose be extrapolated to any dose that is administered? Using real examples during constant-flow anestesia, we reconsider a simple calculation method based on the total clearance for a given substance and providing the theoretical constant-concentration level. This study shows how complex the kinetics of constant-flow administration area. All these techniques should be preceded before human application, by serious research on adequate experimental models.

A multiple puncture procedure was employed to determine delayed skin hypersensitivity in 76 patients admitted to an Intensive Care Unit. This new method enables the responses to 7 antigens to be measured after a single application. Patient reactivity was assessed on admission (D0) and during hospitalisation (D7 and D14). Results were analysed as a function of modifications in antigenic response during hospitalisation, and its incidence on subsequent infection and mortality. Mortality in anergic patients was 85.71 p. cent, infection being the cause in 90 p. cent of these cases. A very association was found between anergy and mortality (p less than 0.001). These results suggest that cell immunity skin tests in patients admitted for intensive care treatment can be of some value for assessing prognosis. Tests must be repeated during hospitalisation, however, as immunity defences progress, in fact--in one direction or another--up to the 14th day or even beyond, an a single test on the day of admission is insufficient for prognostic purposes.

Anesthetic drugs have multiple effects on cellular structures and functions. Among these are membrane perturbations, cell division, DNA synthesis, disruption of microtubules and microfilaments, phagocytosis and cell locomotion. Some of these effects are reversible, and directly correlated to concentration and length of exposure; other, however, seriously compromise cellular integrity and vital functions. A review of the literature and current work are presented.

It is fundamental importance to have available a simple method for testing the resistance of patients admitted to an intensive care unit in order to modify treatment and, where applicable, monitor its effects. This study evaluated the response to intradermal injections of Phytohaemagglutinin (PHA) (Difco: 7.5 micrograms in 0.1 ml) in 71 patients. The principal results were as follows: In forty patients, reactive on admission, mortality was 17.5 per cent, whilst it was 71 per cent in thirty one non reacting patients (p less than 0.0001). Taking into consideration only the last tests performed, the relationship between non-reaction/death became even more significant: 10 per cent of the 40 reacting patients, as against 81 per cent in the 31 non-reacting patients (p less than 0.00000001). Association with study of the tuberculin test did not notably improve the sensitivity of the test (75% mortality in the case of non-reaction to both tests). By contrast, there was a correlation with serum albumin levels measured at the time of admission (33.4 plus or minus 2.6 for 29 survivors; 28.4 plus or minus 3.9 for the 19 patients who died) (p less than 001). Continuation of the study emphasised the importance of the technical protocol in the value of the results and the major influence of nutrition intake on the positivisation of tests. In conclusion, intradermal injections of PHA offer a simple and reliable method for the assessment of immune defences.

The existence of opiate receptors in the spinal cord led the authors to seek a clinical application. 1 - A peroperative injection of morphine was administered in 170 cases: 0.005 mg/kg of fentanyl in 105 cases and 0.05 mg/kg of morphine in 65 cases. In addition to usual surveillance (blood pressure, heart rate and central venous pressure), more extensive haemodynamic investigations were undertaken in 20 patients using a Swan-Ganz catheter. Blood concentrations (11 cases) and CSF concentrations (2 cases for each time of measurement) were determined in the case of fentanyl. In 20 patients (10 of whom had received fentanyl and 10 morphine) there was sophisticated cardio-respiratory surveillance postoperatively. 2 - 0.05 mg/kg or morphine (404 cases), 50 mg of pethidine (10 cases) and 0.1 mg of fentanyl (10 cases) were injected postoperatively. A comparison was made of the analgesia obtained. After three types of anaesthesia: epidural with bupivacaine with intubation (10 cases), halothane with intubation (10 cases) and neuroleptanaesthesia (10 cases), an injection was given of 0.05 mg/kg of morphine, with cardiorespiratory surveillance. Results were as follows: 1 - There were no significant variations in haemodynamic parameters peroperatively, indicative of adequate analgesia. Blood concentrations of fentanyl were as follows: 3.2 +/- 2.1 ng/ml after 10 minutes, 2 +/- 1.7 ng/ml after one hour, 1.4 +/- 1 ng/ml after two hours and 0.4 +/- 0.3 ng/ml after four hours. CSF concentrations were much higher; 34 ng/ml after one hour, 30 ng/ml after two and three hours and 25 ng/ml after four hours. No cardio-respiratory depression was seen after the peroperative injection of morphine. 2- The duration of analgesia following a postoperative injection of a morphine derivative was as follows: morphine 17.3 +/- 3.9 hours, pethidine 3.5 +/- 0.5 hours, and fentanyl 5.1 +/- 0.7 hours. The epidural injection of morphine after neuroleptoanaesthesia caused respiratory depression in two of the 10 cases, with a rise in pCO2 of 0.45 and 0.52 KPa. The results are discussed and compared with those of other authors. In conclusion, the authors emphasize the advantages of this method which makes it possible to obtain with smaller doses analgesia of longer duration than following a systemic injection of morphine, whilst at the same time decreasing the side effects.

In order to compare the assimilation of the three most widely used amino acid solutions: Azonutril 25 (R), Totamine concentré glucidique (Carbohydrate concentrated Totamine) and Vamine (R), a study was undertaken of daily and cumulative nitrogen balances during the first five postoperative days in 120 patients after digestive surgery, divided into three groups and receiving parenteral alimentation only. The three groups were identical in terms of age, weight and sex, as well as the type of surgery performed. Daily calorie and nitrogen intake was identical in the three series. Daily nitrogen balance was calculated using the approximation method described by Apfelbaum based upon urinary urea excretion and by estimation of digestive nitrogen losses. Daily nitrogen balance showed a significant difference on D4 between the Azonutril (R) series (+ 1.8 g +/- 2.9) and the Totamine (R) (+ 3.3 g +/- 2.2) and Vamine (+ 3.1 g +/- 3.3 g) groups, On D5, the difference was statistically very significant between the Azonutril (R) group (+ 1.1 g +/- 3.3) and the Totamine (R) (+ 2.9 g +/- 2.7) and Vamine (R) (+ 3 g +/- 2.6) groups. Study of cumulative balances for four then five days confirmed statistically the better assimilation of Totamine (R) and of Vamine (R) which in the opinion of the authors are better balanced from a quantitative standpoint.