Mechanism and treatment of shock associated with acute pancreatitis

Dépendance aux benzodiazépines et syndrome de sevrage. Revue de la littérature

Ce travail rapporte les résultats d'une revue de la littérature mondiale (247 publications), concernant les syndromes de sevrage et la dépendance aux benzodiazépines, réalisant ainsi une mise à jour de l'tude eifectuée par Marks (1986) pour la période 1961-1984. Quatre-vingts cas publiés individuellement et 269 cas publiés par séries ont été recensés pour la période 1984-1988 (janvier), soit en ajoutant ces chiffres à ceux de Marks (1986): 928 cas individuels et 969 cas publiés par séries, soit encore au total: 1 897 cas publiés. L'analyse détaillée de ces cas, leur signification en termes de risque sont rapportées et discutées.

Au plan pratique, il apparaît que toutes les benzodiazépines peuvent être à l'origine de syndrome de sevrage, y compris celles à demi-vie courte. Le risque de dépendance est d'autant plus important que la durée de la prescription et les posologies employées sont élevées. Il est donc nécessaire de préconiser un sevragesystématiquementprogressif, quelles que soient la molécule et la durée de prescription, d'éviter l'administration aux sujets ayant des antécédents d'abus de toxiques ou de médicaments, de réserver l'usage à long terme aux pathologies anxieuses chroniques, en réévaluant régulièrement l'indication, de prescrire le moins longtemps possible et à la dose la plus faible possible dans tous les autres cas, en faisant varier la posologie selon l'évolution de l'intensité des symptômes.

The intensive care of acute pancreatitis

The results of medical and surgical treatment of 115 cases of acute pancreatitis treated in the surgical intensive care unit over a period of 8 years are reviewed. The death rate from acute pancreatitis fell during the period of study in the intensive care unit from 42.6% between 1969 and 1973, when drainage was used, to 22.9% between 1974 and 1976 when resection was performed, and in hospital from 8.2% to 5.8% respectively. The results improved as a consequence of adequate treatment of shock, complete intravenous feeding, accurate timing of surgery and the successful choice of operative procedures.

Acute pancreatitis: analysis of factors influencing survival

Of patients with acute pancreatitis (AP), there remains a group who suffer life-threatening complications despite current modes of therapy. To identify factors which distinguish this group from the entire patient population, a retrospectiva analysis of 519 cases of AP occurring over a 5-year period was undertaken. Thirty-one per cent of these patients had a history of alcoholism and 47% had a history of biliary disease. The overall mortality was 12.9%. Of symptoms and signs recorded at the time of admission, hypotension, tachycardia, fever, abdominal mass, and abnormal examination of the lung fields correlated positively with increased mortality. Seven features of the initial laboratory examination correlated with increased mortality. Shock, massive colloid requirement, hypocalcemia, renal failure, and respiratory failure requiring endotracheal intubation were complications associated with the poorest prognosis. Among patients in this series with three or more of these clinical characteristics, maximal nonoperative treatment yielded a survival rate of 29%, compared to the 64% survival rate for a group of patients treated operatively with cholecystostomy, gastrostomy, feeding jejunostomy, and sump drainage of the lesser sac and retroperitoneum.

Temperature of the great toe as an indication of the severity of shock

To establish whether changes in skin temperature would provide objective indication of the presence and severity of shock, hemodynamic and temperature measurements were obtained with the aid of a digital computer. Values obtained 3 hours after admission and 3 hours prior to discharge or death in 100 patients who presented with clinical signs of circulatory shock were analyzed. Temperature was measured with standard thermistor probes at five sites: the digital pad of the third finger, the large toe, the deltoid region of the arm, the lateral portion of the thigh, and the rectum.

A significant correlation was demonstrated between the cardiac output and temperature of the toe (r = 0.71). Correlations were increased to 0.73 when corrections were made for changes in ambient temperature. A stepwise regression analysis provided no significant improvement in the predictability of cardiac index when the values for temperatures of other skin sites were included. Discriminant function analysis showed that an early measurement of toe temperature correctly predicts patient outcome 67% of the time.