The recurrent laryngeal nerve (RLN): application to transhiatal oesophagectomy

To emphasize the risks of recurrent laryngeal nerve lesions during transhiatal oesophagectomy an anatomical study of the course of the recurrent laryngeal nerve (RLN) was performed. Twenty RLN were dissected in their thoracic portion. This work showed the constancy of the low origin of the nerve in the adult under the aortic arch, and its course in the tracheal angle. It confirmed the close connections of the nerve with the posterior mediastinal viscera. Lastly, it displayed oesophageal nerve branches arising from the RLN and a few anastomoses between them and the tracheal nerve branches. This anatomical disposition resulted into the difficulty of transhiatal oesophaphagectomies and the risk of injury of the recurrent laryngeal nerve. The possibility of nerve lesions can explain the respiratory complications of this surgical approach.

[Prolonged apnea after suxamethonium administration during staphylococcal toxic shock]

A toxic shock syndrome occurred after a femoral nail removal requiring revision surgery. After administration of suxamethonium (1 mg.kg-1), an apnoea prolonged over 45 minutes was observed. The trachea was extubated 105 minutes after suxamethonium administration. For the nail removal, two days before, the anaesthetic had been given by the same anaesthesiologist, with a similar protocol. Apnoea extended over 20 minutes. The day of the revision surgery, plasma cholinesterase activity was 410 UI.L-1 and reached 910 UI.L-1, 9 months later. Dibucaine number was 20 and fluorure number 17. The apnoea was in relation with a genetic plasma cholinesterase deficiency increased by the toxic shock syndrome. Shock and hepatic insufficiency were suspected to contribute to the decrease in plasma cholinesterase. Suxamethonium should be avoided in case of toxic shock syndrome.

Post-operative intravenous continuous analgesia: comparison of buprenorphine, fentanyl and nalbuphine

Continuous intravenous infusions of fentanyl, buprenorphine or nalbuphine were investigated to provide pain relief for patients after major abdominal surgery. Buprenorphine (n = 23) was given as a loading dose of 5 micrograms kg-1 and infused at 0.8 micrograms kg-1 h-1. Fentanyl (n = 20) was given as a loading dose of 2 micrograms kg-1 and infused at 0.7 micrograms kg-1 h-1. Nalbuphine (n = 21) was given as a loading dose of 200 micrograms kg-1 and infused at 80 micrograms kg-1 h-1. The infusion rate was increased when analgesia was inadequate, and decreased if respiratory depression occurred. Mean doses were respectively 0.74 +/- 0.15 microgram kg-1 h-1 buprenorphine, 0.68 +/- 0.18 microgram kg-1 h-1 fentanyl, 83 +/- 21 micrograms kg-1 h-1 nalbuphine. Titration of continuous intravenous infusion of buprenorphine and fentanyl provided better analgesia than nalbuphine with smaller doses than those reported in similar studies allowing spontaneous breathing.

[Invasive aspergillosis in surgical intensive care patients]

Aspergillosis is a rare event in intensive care patients. Three cases of invasive aspergillosis due to Aspergillus fumigatus were diagnosed in a surgical critical care unit. Risk factors for aspergillosis were found in two liver transplanted patients. One of them had a primitive cutaneous aspergillosis, and the other, treatment difficulties due to the unavailability of an injectable preparation of itraconazole, a new triazole antifungal agent efficient against Aspergillus species. The third case occurred in a patient who had had surgery for gastric carcinoma with liver metastasis. The mycological examination of the air and workbench in the patients' rooms disclosed between 2 and 13 CFU.mm-3 of different Aspergillus species. Plasma itraconazole concentrations were measured in one patient only. They were below the therapeutic range, probably because of intestinal disturbances. The oral administration of itraconazole capsules through gastro-intestinal feeding tubes results in a poor availability of the drug. Such a technique of administration should therefore be undertaken with larger doses than those commonly recommended. Moreover, itraconazole plasma concentrations should be monitored. The association with amphotericin B is recommended until normal intestinal absorption has been obtained.

[Value of Tissucol in cervical anastomosis of esophagoplasty]

There is an important fistula rate associated with the cervical anastomosis of oesophagoplasties. The authors report their experience with reinforcement of these anastomoses by adhesion using a fibrinogen based biological tissue glue. They propose that this technique be used in all high risk anastomoses, in particular, for those affecting a non peritonealized section of the digestive tract.

Cerebral blood flow and cerebral oxygen consumption during nitroprusside-induced hypotension to less than 50 mmHg

The authors determined the effect of profound induced hypotension (i.e., mean arterial blood pressure less than 50 mmHg) during craniotomy for cerebral aneurysm on cerebral blood flow and cerebral metabolic rate for oxygen before, during, and after (20 min and 40 min after) the hypotensive period. The study was performed on nine adults (mean age, 29.2 yr) who were awake and conscious without peripheral neurologic deficits at the time of surgery. The study was conducted with the dura open with the use of a radial artery cannula, a 7-Fr thermodilution flow-directed pulmonary artery catheter, and an internal jugular vein catheter. The 133xenon intraarterial injection technique was used to determine regional cerebral blood flow (rCBF) in the nonoperated hemisphere. rCBF remained unchanged (from 22.8 +/- 4.1 ml.100 g-1.min-1 to 23.8 +/- 4.6 ml.100 g-1.min-1) during the hypotensive period (MAP from 87.8 +/- 10.4 mmHg to 40.0 +/- 4.4 mmHg; P less than 0.001) despite an increase in cardiac index since cerebral perfusion pressure and cerebrovascular resistance decreased to a similar degree. No gross cerebral metabolic disturbances were observed. A period of decreased cerebrovascular resistance and increased rCBF followed induced hypotension. rCBF increased from 23.8 +/- 4.6 ml.100 g-1.min-1 to 30.0 +/- 5.8 ml.100 g-1.min-1 (P less than 0.001) 20 min after sodium nitroprusside (SNP) was stopped without rebound hypertension. These modifications disappeared 20 min later. Reduction of mean arterial blood pressure to 40 mmHg by SNP was apparently safe for the brain, although the possibility of low perfused regions and local brain and cerebrospinal fluid lactoacidosis, particularly in the retracted hemisphere, cannot be excluded.

[Postoperative thyrotoxic crisis during beta blockade: an atypical picture of generalized muscle deficiency]

The case is reported of a 42 year old female patient with Graves disease who presented with an atypical thyroid storm after subtotal thyroidectomy. Surgery was indicated because of poor patient compliance with the medical treatment, and its partial failure. High doses of propranolol (240 mg a day) were given for 5 days preoperatively. Anaesthesia and surgery were uneventful however, towards the end of the first postoperative day, a severe myopathic syndrome started, with neither fever nor tachycardia. Respiratory failure and pneumonia occurred 24 h later. This was deemed to be due to an atypical thyroid storm. The patient was intubated and ventilated, and treated with high doses of propranolol (320 mg a day). Muscle strength began returning to normal on the 4th postoperative day, being completely normal 2 months later. Even though a particularly severe form of thyrotoxic myopathy appeared to be the most likely cause of this temporary muscle disorder, beta-blockers may have been involved. Their potential role is discussed.

[Hemodynamic study during the postoperative period in coronary patients undergoing non-cardiac surgery. The role of mechanical ventilation and sedation]

The initial period of postoperative rewarming is frequently marked by rapid increases in metabolic rate and myocardial work leading to haemodynamic instability. In order to test the beneficial effect of mechanical respiratory support with sedation in the postoperative period, 18 patients with coronary artery disease operated upon for abdominal or orthopedic surgery were submitted to a hemodynamic study. The patients were divided in two groups. In group II intravenous nitrates were administered perioperatively. Postoperative hemodynamic profiles were similar in both group. No perioperative signs of myocardial ischemia were detected. Prolonged ventilation with sedation can prevent the hemodynamic stress of recovery.

[Lung infection and acute adult respiratory distress syndrome during surgical resuscitation]

Non cardiogenic pulmonary edema (PE) is frequently observed during the postoperative period. 56 patients with postoperative PE were divided into two groups: ARDS, acute respiratory distress syndrom and NHPE, non hemodynamic PE. The incidence of primary pulmonary infection and pulmonary superinfection were investigated. Both groups were not different except for the level of PaO2 lower in ARDS. Mortality was higher in ARDS (80%) than in NHPE (42%). Pulmonary primary infection and superinfection were respectively observed in 33 and 10%, and 23 and 15% of ARDS and NHPE. Blood cultures were more frequently positive during abdominal sepsis than during pneumonia. Viral etiology was thrice noted in 13 pneumonitis. Value of diagnostic methods for respiratory infections is discussed.

[Viral hepatitis B. Risk for the anesthetist]

The risk of hepatitis B, previously reported in other countries, has never been investigated in French anaesthetic medical staff. The prevalence of hepatitis B viral markers has been calculated among the medical staff of the Department of Anaesthesiology, the hospital health care personnel, patients before surgical procedure and renal transplantation patients. The frequency in anaesthesiologists (18.75%; 12 out of 64) was significantly greater (p less than 0.05) than in health care personnel (10.5%; 91 out of 863). Prevalence increased with the length of practice in anaesthesiology. Prevalence of markers is 8.7% (27 out of 196) in patients undergoing surgery and 82% (27 out of 33) in patients operated on for renal transplantation in 1981. Frequency of carriers of the hepatitis B surface antigen is 0% in medical staff, 0.2% in health care personnel and 0.5% in patients before surgery. Among the health care staff, anaesthesiologists belong to a high risk population for hepatitis B. Prevention by administration of hepatitis B vaccine is recommended to protect the anaesthesiologist, his relatives and his patients.

[Acute renal failure after extracorporeal circulation with aortic counterpulsation in surgically treated patients]

In a series of 604 adults operated on for cardiac surgery with cardiopulmonary bypass (CPB), 21 (3.5%) underwent circulatory assistance by intra-aortic balloon pump (IABP); in 5 of them (24%), acute renal failure (ARF) was observed. ARF occurred in only 26 (4.4%) of the other patients who did not require IABP. Evolution of ARF and its factors were therefore investigated in those patients having received IABP. ARF was defined as serum blood urea nitrogen (BUN) greater than or equal to 16 mmol X 1(-1), urinary urea/BUN less than 10, creatinine clearance less than 40 ml X min-1 X 1.73 m-2. Some perioperative features were compared between patients with postoperative ARF and those without ARF. ARF occurred in the 5 patients with IABP during, or immediately after, weaning from IABP. ARF was more frequent in patients operated on for mechanical complications of myocardial infarction with a significant more severe haemodynamic status. They had significantly longer CPB and aortic clamping times. The prognosis depended on the cardiac failure and not on the ARF. In patients with mechanical complications of infarction, early IABP seemed to be the predominant preventive measure. Other therapeutic implications are suggested, particularly the use of dopamine (1 to 3 micrograms X kg-1 X min-1) because of its renal vasodilating action which can contribute to the maintenance of urinary flow.

[Infections in surgery under extracorporeal circulation. Results of 3 years of antibioprophylaxis]

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.

[Incidence and prognosis of acute renal failure after cardiac surgery with extracorporeal circulation]

Acute renal failure occurred in 21 patients after 311 cardiac operations with cardiopulmonary bypass in adults (6,75%). It was non oliguric in 20 cases. It is related to per and postoperative hemodynamic depression. Patients operated for valvular replacement seemed most at risk if severe cardiac failure existed with or without preoperative renal dysfunction. Similarly those operated upon for mechanical complications of myocardial infarction were often affected. The prognosis depends on the degree of cardiac failure. Strict patient selection, myocardial protection during bypass and measures to increase low cardiac output are recommended. Intra-aortic balloon pump for patients with myocardial infarction and dopamine in the early postoperative period seem helpful.

[Prophylactic antibiotic therapy with cefamandole in total hip surgery replacement using Charnley's tent. A randomized study]

A randomized study of one-day prophylactic antibiotic therapy in total hip arthroplasty was performed in 93 procedures in 84 patients. All patients were operated by the same surgeons with use of a clean air system. They were divided into two groups: K- without antibiotic, and K+ with intravenous cefamandole, 1.5 g before incision followed by 1.5 g every four hours up to the 24th postoperative hour. Clinical follow up by the surgeons included four examinations within the first year. There was no significant difference in age, repartition of sexes or acquired physical defects between the two groups. Major deep infections requiring revision surgery occurred early in one case in K+ and early in four cases and late in one in K6. Nine patients had bilateral hip replacement. Only one infection was observed, in the only patient who did not receive cefamandole for either procedure. Physical disability had no influence on infection. Microbial organisms isolated from deep infection foci were not consistently identical with pathogens previously identified in wound drainage fluid. Staphylococcus aureus was responsible for 4 of 6 deep infections. One-day prophylactic antibiotic therapy by cefamandole decreases the incidence of deep infection at the surgical site in total hip arthroplasty with use of a clean air system.

[Heart surgery with extracorporeal circulation in hemodialyzed patients with renal insufficiency]

The authors report 4 valvular replacements under cardiopulmonary bypass in chronic hemodialysis-dependent patients. The peri-operative management was the same in every case. The recent improvements of intensive care medicine amend this protocol. Considering the analysis of data from the literature and the results of our 4 valvular replacements these operations and coronary artery-bypass graft, can be scheduled with an acceptable risk in these patients. Because of the hemodynamic improvement secondary to the cardiac operation, which allows a better tolerance of hemodialysis, this surgery must not be delayed.

[Postoperative respiratory complications of myotonia dystrophica (Steinert's disease)]

Respiratory difficulties have long been recognized to be a major risk in patients with myotonia dystrophica, but postoperative pulmonary complications have only rarely been considered. Two cases of postoperative pulmonary complications which led to the patients's death stressed the severity and difficulty of treatment of these complications. A third case of postoperative respiratory failure revealed the underlying disease. These cases showed all the more the importance of preventing pulmonary complications. Pre-, per- and postoperative measures, chosen with respect to the severity of the myotonia and the seat of the surgical procedure, are suggested.

[Peroperative circulatory arrest caused by a tumoral pulmonary embolism following hepatectomy for tumor. Apropos of a case]

The authors report a case of pulmonary tumor embolism during a hepatectomy for hepatoma, leading to a fatal cardiac arrest. This cause of cardiac arrest during operation has never been reported in the literature, but systematic autopsies of patients dying from liver cancer, especially primary or metastatic tumors, shows that the incidence of these embolisms is frequently underestimated. Any anomaly of the hepatic vein appearing in the X-rays implies a danger of intra- or post-operative embolism. Allowance must therefore be made for this in the surgical technique, which should include complete or partial cross-clamping of the vena cava.

[Acute respiratory distress syndrome after accidental inhalation of a hydrosoluble contrast medium]

Acute respiratory distress syndrome after accidental aspiration of hydrosoluble contrast medium is reported. In spite of pulmonary superinfection, the outcome was favorable after mechanical ventilation with permanent positive pressure. This case confirms previous reports and invites to extreme caution when such agents are used in patients with swallowing disorders and preexisting pulmonary disease.

Intraoperative pulmonary tumor embolism after hepatectomy for liver carcinoma

Intraoperative pulmonary tumor embolism occurred during right hepatectomy for primary hepatic carcinoma. The tumor embolus produced abrupt arterial hypotension, tachycardia, an increased central venous pressure, intense cyanosis, followed by cardiac arrest. Pulmonary tumor embolism resulting from hepatic tumors is rare and has not been reported to have occurred intraoperatively. When tumor thrombosis has been detected or suspected, hepatic vascular exclusion should be considered for the prevention of intraoperative embolism.

[Hemodynamic effects of a new antidepolarizing agent: fazadinium bromide]

Studies concerning the hemodynamic effects of this new antidepolarizing agent are scarce and difficult to interpret because of drug interactions, and of an accentuation of vagal tonus related to the use of morphinomimetic analgesics. For a better approach of the effects proper to fazadinium, we have tried to perform a study freed, to a maximum, from any drug interference. We studied the hemodynamic effects to a single dose of 1 mg.kg-1 of fazadinium bromide during 35 minutes in coronary patients normal hemodynamically or rhythmically, non-premedicated, ventilated with 50 p. 100 nitrous oxide in oxygen, and bebore any surgical procedure. All hemodynamic modifications are moderate and maximal 10 minutes after injection. The stroke index decreases 16 p. 100, heart rate increases 6 p. 100 and cardiac index falls 10 p. 100. Total peripheral resistance remains unchanged and mean arterial pressure drops 10 p. 100. Finally pulmonary wedge pressure decreases slightly. None of these modifications are statistically significant. One may, therefore, conclude that fazadinium tolerance, when the drug is freed from any drug interference, in coronary patients normal hemodynamically and free from rhythm disorders is excellent from a hemodynamic and rhythmic point of view. However, other isolated observations of hypovolemic subjects, or patients with atrial fibrillation receiving fazadinium and studied hemodynamically suggest a poorer tolerance in these cases.