Nine Cases of Foodborne Botulism Type B in France and Literature Review

Presented here is an outbreak of nine cases of type B botulism that occurred in France in 2000 followed by a review of the relevant literature. The outbreak resulted from the consumption of home-canned asparagus and required the intubation of six patients. Despite complications, all patients recovered completely. Specific antitoxin treatment was not administered because it is no longer manufactured in France. The literature review covers the epidemiologic data reported from Europe and the USA to date and an assessment of the treatment options for botulism. The usefulness of establishing a European network to provide access to botulism antitoxins is discussed. Although their efficacy is not unanimously accepted, they remain the only specific treatment now known.

Évaluation à distance d'une action de formation médicale continue

OBJECTIVES

To analyse the results of delayed evaluation of European teaching sessions using a questionnaire provided by the French College of Anaesthesiologists.

STUDY DESIGN

Open evaluation.

MATERIAL

Questionnaires were completed 3-6 months after European courses provided in November-December 1999.

METHOD

The types of professional exercise and the medical practice as well as the theme of the courses were pointed out. The evaluation included six items noted from 1 to 10: usefulness of the abstract book, discussion with colleagues, discussion with a manager, decision to modify medical practice, application of that decision, own objectives fulfilled. The global mean score for each item was calculated. Results were compared according to the professional mode of exercise and the theme of the course.

RESULTS

5/7 centres provided information. 91/239 questionnaires were returned to the organizers. The participants were working in different structures (private clinic: 25, university hospital: 31, general hospital: 27, PSPH: 8). The main exercise was anaesthesiology (75/77 answers). Means scores affected to the different items were around 7 for all but one of them. The mean score concerning discussion with a manager was significantly decreased to 3.5 +/- 3.2. Decision to modify their own practise was higher in private clinics compared to PSPH. The abstract book was more consulted after the first course (respiration and thorax).

CONCLUSION

3-6 months following the FEEA courses the participants thought to have fulfil their objectives and declared to have modify their medical practise. The lack of discussion with a manager should be analysed.

[Potential advantages a new syringe pump system]

OBJECTIVES

To evaluate what could be the benefit in terms of alarm suppression, of a new syringe pumps system, which allows automatic relay without alarms.

PATIENTS AND METHODS

We have prospectively recorded the nature and the mode of relay of all syringe pumps for administration of drugs to patients in two ICU. The perfusion regimen was studied in 61 patients over the complete duration of their stay in two ICU. Alarms were also recorded in one ICU room, over 13 days consecutive. The records were processed off-line with an automatic detection-recognition system in order to assess the origin of each alarm. Accordingly, the amount of alarm corresponding to monitor, ventilator and syringe pumps was computed.

RESULTS

We found that syringe pumps, which would provide automatic relays without alarm, would suppress 17% of alarms in ICU and automatize 65% of the relay procedures, which are usually performed often in emergency, on response to the end of perfusion alarm.

CONCLUSION

New syringe pumps allow both reduction of alarms in ICU and a better management of nurse workload. Indeed syringe relay can be planned in advance.

[Multimodal monitoring of head injuries in children]

As in the case of adults, there are three main goals in the monitoring of severe head trauma in children: to prevent or minimize the apparition of secondary lesions, to optimize treatment, to help make precise prognosis. The basic monitoring is composed of repeated clinical examinations, brain radiological imaging and control of vital parameters (blood pressure, temperature, PaO2 (SpO2), PaCO2 (FETCO2), haemoglobin, haematocrit. On the other hand, during specific brain monitoring, the brain perfusion (TCD, intracranial pressure), the electrical activity of the brain and sometimes the brain oxygenation (SvjO2) are controlled. The data obtained from the brain monitoring must always be interpreted carefully. A child with a severe head trauma, in ICU, always requires constant and competent medical attention.

[Intracranial subdural hematoma after obstetric dural puncture]

The authors report a case of subdural haematoma (HSD), which occurred following epidural analgesia for labour, complicated by post dural puncture headache (PDPH). A 26-year-old woman displayed a typical PDPH following epidural anaesthesia. On the sixth day, she was given a blood patch (BP), which was partially efficacious. Because of worsening of the headache, of disappearance of the postural characteristics, and of vomiting without focal neurological signs on the 9th day, a CT-scan was done. The CT-scan showed a small hemispheric subdural haematoma. The recovery was complete with only medical treatment. HSD is a rare serious complication of dural puncture. When the characteristics of PDPH change, HSD should be evoked even without focal neurological signs. An early diagnosis and the small size of the haematoma may allow HSD to be treated medically and avoid surgical evacuation.

[Electroencephalographic effects of sevoflurane in pediatric anesthesia: a prospective study of 20 cases]

OBJECTIVE

To study electroencephalographic (EEG) changes in children during induction of anaesthesia with 8% sevoflurane.

PATIENTS

Twenty patients were consecutively included (ASA I-II; aged: 13-101 months).

MATERIAL AND METHOD

Prospective study; approved by the Ethics Committee; written informed consent obtained from parents; anaesthesia induced with 8% sevoflurane in oxygen; no premedication was given; to collect the EEG data, non-invasive electodes were installed before induction; EEG was recorded continuously and stored on a computer for later analyses (descriptive analysis).

RESULTS

Myoclonics movements were observed during induction of anaesthesia in two boys. Myoclonics movements stopped spontaneously without therapy. Epileptiform EEG activity (spikes and poly-spikes, burst suppression) was observed. In the 18 others cases, during sevoflurane induction, EEG changed rapidly with an increase in the range of beta activity (> 13 Hz) (n = 15) and in slow (< 8 Hz) and delta activity (< 4 Hz). In 14 patients, at time of laryngoscopy, the EEGs showed monophasic slow data activity (sharp high-voltage slow waves). Periods of EEG isoelectrical (burst suppression) were seen without spikes in four cases.

CONCLUSION

At 2 MAC, epileptiform EEG activity has been observed during sevoflurane anaesthesia. In a short group of patients, this raises the question of avoiding sevoflurane in patients who have a history of epilepsy.

Ketamine: new uses for an old drug

Over the years, ketamine has found many applications in paediatric anaesthesiology. Recent insights into the mechanism of its central action, and the pharmacology of its isomers have led to a re-evaluation of this drug, expanding the range of indications in adults. The best examples of the uses of ketamine as an analgesic are: in brief diagnostic or therapeutic procedures, during the post-operative period in neonates and infants as well as in paediatric anaesthesia and intensive care.

[Pediatric anesthesia practice in France: a survey of 1,526 anesthesiologists]

OBJECTIVES

To assess the individual activity of anaesthetists in paediatric anaesthesia (PA), and collect their wishes about continuing education and recommendations in PA.

STUDY DESIGN

Transversal, prospective study.

METHODS

A questionnaire of 33 items, sent to 4,360 anaesthetists, spread over 15 health districts, working in a public or private institution.

RESULTS

We gathered 1,526 replies (35%) of which 34% university hospitals, 32% public institutions and 31% private institutions. 943 physicians (63%) had no specific structure, and 1,119 (87%) considered a specialized nurse to be essential for PA. 1,127 physicians (74%) had undertaken a specific session during their formation. The practice of PA depends upon age and context. Above 1 year old, the surgery that is performed weekly was ENT (38%), abdominal and urologic surgery (28%). Mask induction was performed by 60% of the physicians in children under 5 years. 63% of the anaesthetists dreaded a laryngospasm during induction. 625 physicians undertook regional anaesthesia in children under 5 years (87% caudal anaesthesia, 48% peripheral nerve blocks). 1,029 physicians (67%) wished for recommendations in PA in children under 12 months.

CONCLUSIONS

This survey showed that most of the anaesthetists wished for recommendations in their paediatric anaesthesia practice.

[Evaluation of transfusion strategies during craniosynostosis repairs]

OBJECTIVE

To evaluate the changes in transfusion practices during craniosynostosis surgery in children, with consideration of the transfusion-associated risks.

STUDY DESIGN

Retrospective study.

PATIENTS

The study included 64 consecutive craniosynostosis repairs by the same neurosurgical and anaesthetic team, over a period of 17 years.

METHODS

The children were allocated into two groups. In group I (1980-1991), blood loss was compensated precisely from scalp incision on. In group II (1992-1996), transfusion was only started when blood loss crossed a calculated limit considered as acceptable. The mean criterion of judgment was the quantity of transfused blood in comparison with the theoretical blood volume. Mean preoperative and postoperative haemoglobin concentrations, estimated blood losses, volume of replaced blood and number of transfused patients were compared between the two groups with a two tailed Student's t test.

RESULTS

The rate of non transfused children increased from 6% before 1991 to 39% after 1992%; conservely the rate of postoperative transfusions increased from 3 to 39%.

CONCLUSION

The risks of blood transfusion favoured the development of new of more restrictive transfusion practices, even in haemorrhagic surgery. To limit blood transfusion in craniosynostosis surgery, a harmonious cooperation between surgeons and anaesthetists is essential and blood replacement must be based on a definite determination of the acceptable blood losses.

Use of intravenous ketamine-midazolam association for pain procedures in children with cancer. A prospective study

We evaluated the safety and efficacy of midazolam-ketamine association to control pain induced by diagnostic procedures in paediatric oncology patients. 226 procedures were carried out in 92 patients aged three days to 18 years. Drugs were given i.v. by an anaesthesiologist. Midazolam dose was 25 microg.kg-1 and ketamine 0. 5 to 2 mg.kg-1, depending on number and invasiveness of procedures. The mean dose of ketamine was 1 mg.kg-1. Mean duration of sedation was ten min. No complication was observed and analgesia was considered satisfactory in 89 out of 92 patients. These results indicate that midazolam-ketamine is a safe and effective association in pain management for paediatric oncology patients and efficiently induces brief unconscious sedation with analgesia.

Correlation between cerebral oxygen saturation measured by near-infrared spectroscopy and jugular oxygen saturation in patients with severe closed head injury

Near-infrared spectroscopy has been used to monitor cerebral oxygen saturation during cerebral circulatory arrest and carotid clamping. However, its utility has not been demonstrated in more complex situations, such as in patients with head injuries. The authors tested this method during conditions that may alter the arteriovenous partition of cerebral blood in different ways.

METHODS

The authors compared changes in measured cerebral oxygen saturation and other hemodynamic parameters, including jugular venous oxygen saturation, in nine patients with severe closed head injury during manipulation of arterial carbon dioxide partial pressure and after mean arterial pressure was altered by vasopressors.

RESULTS

The Bland and Altman representation of cerebral oxygen saturation versus jugular oxygen saturation showed a uniform scatter. Values for changing arterial carbon dioxide partial pressure were: bias = 1.1%, 2 SD = +/-21%, absolute value; and those for alterations in mean arterial pressure: bias = 3.7%, 2 SD = +/-24%, absolute value. However, a Bland and Altman plot of changes in cerebral oxygen saturation versus changes in jugular oxygen saturation had a negative slope (alteration in arterial carbon dioxide partial pressure: bias = 2.4%, 2 SD = +/-17%, absolute value; alteration in mean arterial pressure: bias = -4.9%, 2 SD = +/-31%, absolute value). Regression analysis showed that changes in cerebral oxygen saturation were positively correlated with changes in jugular venous oxygen saturation during the carbon dioxide challenge, whereas correlation was negative during the arterial pressure challenge.

CONCLUSIONS

Cerebral oxygen saturation assessed by near-infrared spectroscopy does not adequately reflect changes in jugular venous oxygen saturation in patients with severe head injury. Changes in arteriovenous partitioning, infrared-spectroscopy contamination by extracerebral signal, algorithm errors, and dissimilar tissue sampling may explain these findings.

[Sheehan's syndrome: a recurrent obstetrical complication]

Case report of a 25-year-old primigravida who sustained a necrosis of the anterior pituitary gland after a haemorrhagic Caesarean section. The diagnosis was delayed, as the early symptoms (apathy, anorexia, nausea, orthostatic hypotension and hypoglycaemia) were imputed to more usual causes.

[Interactions between naltrexone, an opioid antagonist, and opioids administered during general anesthesia]

We report a case of a probable interaction between sufentanil and naltrexone, an oral long acting opioid antagonist, prescribed for maintenance of abstinence in alcoholics and opioid addicts. The interaction resulted in an antagonisation of the effects of sufentanil and the necessity to increase the dosage. Anaesthetists should be aware of this potential drug interaction.

Autoregulation of human inner ear blood flow during middle ear surgery with propofol or isoflurane anesthesia during controlled hypotension

We used controlled hypotension to obtain a bloodless cavity during middle ear surgery under an optical microscope. No previous study has assessed the effect of controlled hypotension on inner ear blood flow (IEF) autoregulation in humans receiving propofol or isoflurane anesthesia. In the present study, the IEF autoregulation was determined using laser Doppler flowmetry in combination with transient evoked otoacoustic emissions (TEOAEs) during controlled hypotension with sodium nitroprusside in 20 patients randomly anesthetized with propofol or isoflurane. A coefficient of IEF autoregulation (Ga) was determined during controlled hypotension, with a Ga value ranging between 0 (no autoregulation) and 1 (perfect autoregulation). During controlled hypotension with propofol, IEF remained stable (1%+/-6%; P > 0.05) but decreased by 25%+/-8% with isoflurane (P < 0.05). The Ga was higher during propofol anesthesia (0.62+/-0.03) than during isoflurane anesthesia (0.22+/-0.03; P < 0.0001). Under propofol anesthesia, there were individual relationships between TEOAE amplitude and change in IEF in four patients. Such a correlation was not observed under isoflurane anesthesia. These results suggest that human IEF is autoregulated in response to decreased systemic pressure. Furthermore, isoflurane has a greater propensity to decrease cochlear autoregulation and function than propofol.

IMPLICATIONS

The present study shows that inner ear blood flow is autoregulated under propofol, but not isoflurane, anesthesia during controlled hypotension in humans during middle ear surgery. Further studies are needed to explore the postoperative auditory functional consequences of the choice of the anesthetic drug used in middle ear surgery.

-The effect of desflurane on cerebral blood flow velocity and cerebrovascular reactivity to CO2 in children-

OBJECTIVE

To assess in children with a transcranial Doppler the effect on cerebral blood flow velocities of desflurane, whose cerebral vasodilator effects have been studied in animals and in adults with intracranial lesions.

STUDY DESIGN

Prospective clinical study.

PATIENTS

Ten healthy children, mean age: 3.4 yr, ASA physical class 1, undergoing minor urologic surgery, were included in this study.

METHOD

Induction was obtained with atropine 10 micrograms.kg-1, fentanyl 3 micrograms.kg-1 and propofol 3 mg.kg-1. Endotracheal intubation was facilitated by atracurium 0.3 mg.kg-1. Mechanical ventilation, with a 50% air/oxygen mixture was adjusted to achieve an end-tidal CO2 (PETCO2) level of 38 +/- 2 mmHg. Monitoring included measurement of mean arterial blood pressure (MAP), heart rate, PETCO2, SpO2 and end-tidal desflurane concentrations (FETDes). Mean blood flow velocities (Vmean) were measured in the middle cerebral artery using a bi-directional 2 MHz TCD system (EME-TC 2000 S). A first TCD measurement followed intubation (T1). Thereafter, desflurane was adjusted to 1 MAC. Six other TCDs were recorded each minute until FETDes reached the inspired fraction (T2-T7). Thereafter, CO2 reactivity was assessed with a hypocapnia test, induced by hyperventilation. Measures were done at T8 (PETCO2: 33 +/- 1 mmHg), T9 (PETCO2: 29 +/- 1 mmHg), and T10 (initial PETCO2: 38 +/- 1 mmHg). All these measurements were made before starting surgery. Analysis of variance (ANOVA) was used to analyse the data (P < 0.05 was considered as significant).

RESULTS

The Vmean and heart rate increased significantly with increasing concentrations of desflurane (Vmean from 68 +/- 27 to 106 +/- 30 cm.s-1 and heart rate from 109 +/- 17 to 136 +/- 15 b.min-1 between T1 and T7). During hypocapnia, Vmean decreased to 68 +/- 23 cm.s-1 at T9, and returned to normal values with PETCO2 at 38 mmHg at T10. SpO2 remained unchanged. Mean arterial pressure was stable from T1 to T7, but decreased significantly at T9 and T10.

CONCLUSION

Desflurane elicits a dose-dependent increase in cerebral blood flow velocities and heart rate, but does not change mean arterial pressure, suggesting that its cerebrovascular action is independent of its systemic vascular action. CO2 reactivity is maintained at one MAC. The results in children are similar to those seen in adults.

Airway compression in children due to congenital heart disease: value of flexible fiberoptic bronchoscopic assessment

OBJECTIVE

To evaluate the frequency and severity of airway compression due to congenital heart disease in children and validate the use of the fiberoptic bronchoscope to assess them.

DESIGN

A retrospective study.

SETTING

A single-institutional study in a university hospital.

PARTICIPANTS

Seventy-two children with congenital heart disease.

INTERVENTIONS

Airway endoscopy was performed in an awake child in cases of clinical and/or radiologic respiratory signs or in cases of preoperative assessment of a cardiac abnormality that is known to accompany airway compression.

MEASUREMENTS AND MAIN RESULTS

Endoscopy was well tolerated; 71% of the children had endoscopic abnormalities and 50% had airway compression. The locations of these compressions are the same as those described in the literature in the cases of vascular rings and left-to-right shunts. The other endoscopic findings were laryngeal and bronchial abnormalities, tracheobronchial malacia, respiratory signs of gastroesophageal reflux, and positive bacteriologic sputum samples.

CONCLUSION

Endoscopy in an awake patient is the only way to evaluate the functional component of a compression due to malacia; the resulting collapse of the airway can cause trapping of air and secretions. Furthermore, fiberoptic bronchoscopy offers a complete examination of the airways and can help detect airway abnormalities that are potential causes of complications. Fiberoptic bronchoscopy is a suitable and well-tolerated examination that is easy to perform at the bedside of the child. This technique optimizes the preoperative assessment of children with congenital heart disease.

The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery

The analgesic efficacy and safety of propacetamol, an injectable prodrug of acetaminophen, (paracetamol) were studied in 87 children (36 boys, 51 girls; age 6-13; mean age 9.5 years) immediately after limb surgery. Using a double-blind, randomized, parallel group design, the effects of a single IV infusion of 30 mg.kg-1 propacetamol (i.e. 15 mg.kg-1 acetaminophen) were compared with a single injection of placebo (PL). Efficacy was assessed on pain scores rated on a four-point verbal scale, a five-point visual scale (faces) and on a four-point relief verbal scale before administration (T0) and 0.25, 0.5, 1, 2, 3, 4, 5, 6 h after administration. At the end the global efficacy was rated by the physician on a five-point verbal scale. Propacetamol was statistically superior to placebo on all assessment criteria. Seven side-effects were recorded: five in the propacetamol group and two in the placebo group. 30 mg.kg-1 propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery.

The benefit of using a heat and moisture exchanger during short operations in young children

We studied the efficiency of a heat and moisture exchanging filter (HMEF; Pall BB25) as a means of compensating for the heat and moisture loss during anaesthesia in young children using cold and dry gas supplied from open circuits. Forty ASA I children (mean age: 48 months +/- 20; mean weight: 16 +/- 3.5 kg) were randomized into two groups: Group I without HMEF/Group II with HMEF. The two groups did not show any significant differences for morphometric data or ventilation parameters. Relative humidity and temperature measurements in anaesthetic gases were taken using a combined temperature/humidity probe introduced into the circuit. Absolute humidity in the circuit was calculated from these measurements. In Group II, a significant increase (P < 0.001) in absolute humidity was demonstrated (Group I: 12 mg H2O.1(-1) vs Group II: 22 mg H2O.1(-1). This increase appeared immediately after introduction of the HMEF in the circuit and remained constant throughout the duration of the operation. Thus, the use of the device is recommended for young children, even for operations of short duration.

Excision of bronchogenic cysts in children using an ultrathin fibreoptic bronchoscope

PURPOSE

We report the use of an ultrathin fibreoptic bronchoscope (Olympus N20: external diameter: 2.2 mm) as the means of airway endoscopic monitoring during anaesthesia for the excision of mediastinal bronchogenic cysts in two young children.

CLINICAL FEATURES

The first, a four-month old boy, presented with stridor and wheezing due to a subcarinal bronchogenic cyst compressing the two main bronchi. The second, an eight-day-old girl whose trachea was intubated, presented with respiratory noise in relation to a bronchogenic cyst compressing the end of the trachea. In both cases, airway endoscopy was performed during anaesthesia with the ultra thin fibreoptic bronchoscope. Endoscopic monitoring allowed, first, a good evaluation of the degree of cyst compression on the airways. Second, the endotracheal tube could be positioned or repositioned with precision in order to avoid severe compression or spilling of liquid into the airways and to allow protection of the suture. Finally, video transmission helped the surgeon to visualize the surgical repair from the inside.

CONCLUSION

When added to the classical monitoring using SpO2, PETCO2 and airway pressure, peroperative endoscopic control provides complementary information which can help to detect possible complications more rapidly. This technique could be extended to all airway surgery on very young children.

[Programmed autologous blood transfusion in children. Results of a national survey]

OBJECTIVE

To assess the development and the current practice of predeposit autologous blood transfusion (PABT) in children in France.

STUDY DESIGN

Nationwide survey with a questionnaire.

METHOD

Survey conducted in January 1995, including 121 blood transfusion centres (BTC) out of which 101 replied.

RESULTS

Initiated in 1979, PABT is practiced at present in 66% of BTC. This figure increased by 12% from 1993 to 1994. Orthopaedic surgery was the main indication. Other indications included bone marrow harvesting for allogenic transplantation. Concerning the inclusion criteria, the lower limit of age was 9 +/- 4 years and weight 26 +/- 10 kg. The youngest child was one-year-old and his body weight was 8 kg.

CONCLUSION

The production of codified protocols would probably favour the development of PABT in children and increase its safety and its efficiency.

[Familial form of pyknodysostosis with hematologic manifestations in a child]

BACKGROUND

Pyknodysostosis is characterized by post-natal onset of short-limbed short stature and generalized hyperostosis. It must be differentiated from osteopetrosis with precocious manifestations in which hyperostosis may crowd the marrow cavity with extramedullary hematopoiesis.

CASE REPORTS

A boy, born from consanguineous parents presented with classical features of pyknodysostosis: short-limbed stature, large skull, frontal bossing, wide anterior fontanelle and tendency to fracture. His sister had the same features at the age of 3 months; she had hepatosplenomegaly at the age of 5 months with anemia, erythroblastosis (13%), myelemia and, at 10 months, thrombocytopenia.

CONCLUSION

Hyperosostis can be complicated by development of such severe hematological manifestations as classically seen in osteopetrosis. Differential diagnosis between both entities is based upon radioclinical investigation.

[Indications for the use of magnesium in anesthesia and intensive care]

Magnesium (Mg), a cofactor in numerous enzymatic reactions, is often ignored by clinicians, as the symptomatology of Mg depletion is not specific and usually associated with that of the cause of the depletion. Furthermore, the plasma Mg concentration (0.8 to 1.1 mmol.L-1) is only equivalent to one percent of the total body content. A Mg deficit may exist while plasma Mg concentration is normal. Therefore other techniques for Mg assessment, such as the repletion test, as well as red blood cell and lymphocyte concentrations have been used. A renewed interest for Mg occurred as numerous studies have shown the therapeutic efficiency of Mg and as the mechanisms of its haemodynamic effects have been recognized. Mg regulates Na-K-ATPase activity, K channels activity and, most of all, it is a natural calcium channel blocking agent. These properties explain its important place in electrophysiology of myocardial cells and the effects on the tension of smooth muscles, resulting in a vasodilation and a bronchodilation respectively. The antagonistic effect of Mg on calcium decreases the presynaptic release of acetylcholine at the neuromuscular junction and the release of epinephrine at the peripheral sympathetic nerves and the adrenals. Mg potentiates the effect of non-depolarizing muscle relaxants. A Mg deficiency occurs often in ICU patients, in alcoholics and during use of diuretics. Simultaneous administration of Mg is often required for treatment of potassium deficiency. Mg has an anti-arrhythmic effect towards digoxin-mediated dysrhythmias and torsades de pointes, and can be efficient in other arrhythmias. Systematic use of Mg seems to decrease mortality of acute myocardial infarction and is justified during cardiac surgery, often associated with hypomagnesemia, because of vasodilation of coronary arteries and in order to prevent occurrence of arrhythmias. Mg, because of its calcium channel blocking properties and as it lowers the release of epinephrine, is indicated for surgery of pheochromocytoma. In eclamptic and pre-eclamptic patients, the use of Mg is valuable, but not as an anti-epileptic agent. Other clinical uses of Mg have been proposed, but they are either anecdotal or of uncertain efficiency.

[Value of fiberoptic bronchoscope in children with epiglottitis]

Acute epiglottitis is an infectious disease causing a severe respiratory distress. Any attempt to move the child in the horizontal position or to examine his throat can result in cardiac arrest. Diagnosis, endotracheal intubation as well as decision making of the optimal time for extubation are greatly facilitated by the use of a fiberoptic bronchoscope. The device is a paediatric model (external diameter 3.6 mm with an operating channel). It is inserted through the nare in the child in the sitting position. Oxygen is delivered through a nasal tube. The examination is performed under local anaesthesia (lidocaine 0.5%). Midazolam is sometimes added via the rectal or i.v. route. The clinical signs are monitored as well as the heart rate and SpO2. The diagnosis of epiglottitis as it is visual, is very easy and rapid once the epiglottis is observed through the fibreoptic bronchoscope. The advantage of the examination under fibreoptic bronchoscope is to allow visualization without aggression or stimulation of the pharyngolaryngeal structures and without modification of the child's position. Endotracheal intubation, which is always required, is facilitated as the child is breathing spontaneously. The expiratory flow blows bubbles of saliva, which guide the bronchoscope to the glottis. When the internal diameter of the endotracheal tube is larger than 4 mm, the bronchoscope is used as a guide. When it is less than 4 mm. the bronchoscope is inserted in the trachea with a guide wire slipped in the operating channel; the bronchoscope, but not the wire is withdrawn and the endotracheal tube is inserted over the guide wire.(ABSTRACT TRUNCATED AT 250 WORDS)

[Is hemodilution sufficient to avoid homologous blood transfusion in reduction mammaplasties?]

The unpredictability of blood loss during reductive mammoplasties induced the authors to use a blood-sparing technique so as to avoid homologous transfusions. Intentional isovolaemic haemodilution (IIH) was performed in 38 patients. Clinical and biological criteria were used for analyzing the results. In this prospective study, IIH could not prevent the necessity of homologous transfusion for 3 patients, in the early postoperative period. In one of these cases, clotting of blood prevented its utilization. Therefore IIH appears to be an interesting alternative blood-sparing method in patients who cannot benefit easily from preoperative programmed blood auto-donation.

[Comparison of the analgesic efficacy of nalbuphine and its combination with propacetamol during the immediate postoperative period in gynecologic-obstetric surgery]

This prospective randomized single-blind study compared the efficacy of a combination of propacetamol (2 g) and a low dose of nalbuphine hydrochloride (10 mg) with nalbuphine hydrochloride (20 mg) alone, in a population of 152 white female patients after gynaecologic or obstetrical surgery, for alleviation of postoperative pain in recovery room. The drugs were administered intravenously in case of pain. The population was divided into two groups: group 1 received 20 mg of nalbuphine hydrochloride and group 2 received 2 g of propacetamol combined with 10 mg of nalbuphine hydrochloride. The pain intensity was studied with the visual analogue scale and comparisons use no parametric tests (Mann and Whitney test, Kruskall and Wallis test) and Chi2 test. Groups were similar for age, surgical and anaesthesia procedures and initial pain level. The propacetamol-nalbuphine hydrochloride 10 mg association provided a significantly better analgesia than nalbuphine 20 mg during the first two postoperative hours (p < 0.05). In group 1, the analgesia score decrease was respectively 28 +/- 25 mm (range: 33-75 mm) after 1 h and 31 +/- 25 mm (range: 26-84 mm) after 2 h. In group 2, the decrease was more important: 37 +/- 21 mm (range: 5-84 mm) after 1 h and 42 +/- 23 mm (range: 20-84 mm) after 2 h. Side effects were minimal and similar in both groups (nausea, drowsiness). It is concluded that a propacetamol-nalbuphine hydrochloride 10 mg association provides better analgesia than single dose of 20 mg of nalbuphine. This association convenient analgesia with a decreased dose of nalbuphine.

[Shaken baby syndrome]

The shaken baby syndrome is a relatively recent concept concerning mishandled children and characterized by cerebral lesions (subarachnoid haemorrhage, oedema, axonal injuries). A case is reported of a 11-month-old female infant, who was admitted in a paediatric intensive care unit with clinical signs of brain death after cardiopulmonary resuscitation. The CT scan showed subdural haemorrhage. Pathological examination confirmed the major blunt head trauma. The father admitted that he had shaken his daughter as "she cried too often". The mechanism of the lesions is a combination of several factors, especially the large size of infant's head and the weakness of the neck muscles. It is possible to recognize still in the perinatal period children at risk of mishandling, allowing an efficient prevention of the shaken baby syndrome.

[Value of transcranial Doppler ultrasonography in the management of severe head injuries]

Transcranial doppler ultrasonography (TCD) is a non invasive technique for the assessment of cerebral blood flow (CBF). The aim of this prospective study was to evaluate the benefit of TCD for the monitoring of major head trauma patients. Therefore 10 of such patients, aged 17 to 37 years, had a TCD at admission and subsequently at least twice a day. Following data were measured simultaneously at the site of the right and the left middle cerebral arteries: the systolic (SV), diastolic (DV) and mean (MV) blood velocity, the resistance index (RI) of Pourcelot (RI = SV-DV/SV) and the pulsatility index (PI) of Gosling (PI = SV-DV/MV). Simultaneously, the mean intracranial pressure (ICP) obtained with a subarachnoid probe, the PaCO2 and the mean arterial pressure (Pa) were measured. The cerebral perfusion pressure (CPP) was calculated with the formula: CPP = Pa-ICP. A total of 132 measures were analysed. There was a linear relation between RI and CPP (r = 0.566; p < 0.001), between RI and ICP (r = 0.822; p < 0.001), as well as between PI and CPP (r = 0.563; p < 0.001) and between PI and ICP (r = 0.837; p < 0.001). In the opposite there was no statistically significant relation between ICP and MV (r = 0.18) nor between CPP and MV (r = 0.23). However, a MV over 100 cm.s-1 was regularly associated with a ICP over 60 mmHg. The close correlation between RI, PI and ICP allows to use RI or PI to estimate ICP.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of thiopental on middle cerebral artery blood velocities: a transcranial Doppler study in children

The effect of an intravenous injection of thiopental on middle cerebral artery blood velocities was assessed by transcranial pulsed Doppler monitoring in 20 children: ten head-injured patients and ten control subjects. Thiopental induced a moderate but immediate decrease of middle cerebral artery blood velocities in both groups; this variation was significant (P < 0.01) and more prolonged in the head-injured than in control patients. Transcranial Doppler ultrasonography thus appears to be suitable for monitoring children in intensive care units and could help to avoid the use of thiopental in patients with low cerebral artery blood flow velocity.

[Pharmacokinetics of paracetamol in the cerebrospinal fluid in the elderly]

We investigated acetaminophen pharmacokinetics in CSF in twelve operated arteritics patients with continuous spinal anesthesia. Nine men and three women aged 77 +/- 7 years and weighing 66 +/- 15 kg entered in the study after expressing verbal informed consent. They received intravenously a single dose of acetominophen (equivalent to 1 g). Fifteen minutes to six hours after the intravenous injection, blood and CSF samples were withdrawn every thirty minutes, except during the second to the third hour were it was every fifteen minutes. Acetaminophen concentrations in blood and in CSF were assayed by HPLC. Acetaminophen was detected in the earliest samples (1.32 +/- 1.32 micrograms.ml-1) and then increased up to 8.16 +/- 3.04 micrograms.ml-1 at 186 +/- 56 minutes. From 135th to 345th minute, acetaminophen concentration in CSF stay at about 6 micrograms.ml-1, which is the duration of its maximal analgesic central effect.

[Transcranial Doppler in anesthesia and intensive care]

Transcranial Doppler sonography (TCD) is a non invasive technique whereby ultrasonic signals may be recorded from the basal cerebral arteries by using a low frequency probe. Three routes can be used: the transtemporal approach, which studies the anterior, middle and posterior cerebral arteries; the transorbital approach, which evaluates the ophthalmic artery and the carotid canal; and the sub-occipital approach, which assesses the basilar, posterior cerebral and intracranial vertebral arteries. Normal reference values for Doppler parameters have been established for these arteries. Many factors influence them, such as the diameter of the examined blood vessel, PaCO2, cerebral blood flow and cerebrovascular resistances. There are numerous clinical applications of TCD. In anaesthesia, monitoring with this method is useful during cardiopulmonary bypass, controlled hypotension, or carotid endarterectomy. After subarachnoid haemorrhage, the degree of vasospasm can be assessed by TCD. Monitoring cerebral blood flow velocities in intensive care provides important information for the treatment of patients suffering from meningitis, or experienced a head injury, or another ischaemic-anoxic disease. The field of clinical applications of TCD is increasing greatly, but the results must always be carefully interpreted, taking into account the data of other investigations.

[The physiopathology and medical treatment of acute traumatic occlusion of the popliteal artery. The point of view of the anesthesiologist-resuscitator]

The acute occlusion of the popliteal artery involves: 1. A regional disease: muscular ischaemia with an increase of capillary permeability and oedema. The recovery of the circulation brings with it the formation of free radicals. 2. Sometimes, a general and metabolic illness complicates the muscular ischaemia. It associates to varying degrees: hypovolemic shock, metabolic troubles, acute renal failure, disseminated intravascular coagulation, infection. It can compromise the vital prognosis. The reanimation which completes the surgical treatment includes two stages: 1. The prehospital stage when the first imperative is to commit the patient to the vascular surgeon's care as soon as possible and in the best hemodynamic conditions. 2. The hospital stage when the therapeutic objectives are represented by: a) the treatment of hypovolemia; b) the curing of acute renal failure (bicarbonates 2 mmol.kg-1, hypertonic mannitol 1 g.kg-1; c) fight against infection; d) Heparin: 1 to 2 mg.kg-1 (if there is no counterindication); e) hyperbaric oxygen treatment in some situations. Despite the progress of reanimation, the initially intended amputation is subject to discussion in the following circumstances: crushing which in fact accomplishes an amputation, prolonged and complete ischemia lasting more than 10 to 12 hours, severe I.V.D.C., associated serious lesions (cranial traumatism, pelvis crushing).

[Fluctuation charts and monitoring in pediatric anesthesia]

Automated anesthesia record with trend curves is a real progress for the anesthetist, offering complete and rigorous documentation. The medico-legal aspects are important and justify a non discussed technology.

[Treatment of postoperative pain in children in the recovery room. Use of morphine and propacetamol by the intravenous route]

The analgesic efficiency of morphine and propacetamol for postoperative pain, in the recovery room, was studied in two groups of children, who had undergone either orthopedic or visceral surgery. An injection of 50 mcg/kg of morphine chlorhydrate was given to the first group of 239 children ASA I, who were admitted to the recovery room and who presented signs of severe pain (agitation, crying, complaining). The analgesic efficiency of morphine was judged on physiological criteria (blood pressure, heart rate) and on behavioral criteria (calming of the child). No incidents were noticed. A second study was then performed on a second group of 100 children ASA I, who received 15 mg.kg-1 of propacetamol as an intravenous perfusion for 15 minutes. The analgesic efficiency of propacetamol was judged on behavioral criteria alone. In the morphine group, 67% of the children was calmed following one injection (94% after a second injection given 15 minutes after the first). In the propacetamol group, 77% of the children were calmed. Propacetamol was insufficient for the pain in 23% of the cases but one subsequent injection of morphine was always sufficient to calm the child. These two successive studies show the need for an analgesic protocol for children in the recovery room. Propacetamol should be administered first and then, if insufficient, followed by only one injection of morphine. This protocol of propacetamol and morphine seems to be satisfactory and thus avoids all pernicious side effects.

The effects of captopril and enalapril on tissue levels of various elements in spontaneously hypertensive rats

The effects of two inhibitors of angiotensin I converting enzyme, captopril and enalapril, on the concentrations of Na, K, Ca, Mg, Fe, S, P, Sr, Mn, Cu and Zn ions in blood, plasma, heart, skeletal muscle, liver and kidney of spontaneously hypertensive rats (SHR) were studied. Captopril and enalapril were given by the intraperitoneal route for 15 days, at 160 mumols/kg/d and 40 mumols/kg/d, respectively. Elements in tissues were determined by inductively coupled plasma emission spectrometry with a JY 48 instrument. The common changes produced with the two drugs were: a decrease of Na in muscle (-10%), a decrease of Ca in plasma and kidney (less than -10%) and a decrease of Mn in liver (-15%). The main effects observed with only one of the two drugs were: an increase of Cu in plasma (+26%) with captopril, and increases of Sr in heart (+56%), muscle (+79%) and liver (+74%) with enalapril. Zinc concentration in tissues was not modified, except for an increase in liver with captopril (+13%) and a decrease in heart with enalapril (-11%).

[Munchausen's syndrome by proxy and chronic intestinal pseudo-obstruction]

A case of intestinal pseudo-obstruction in a 4 1/2 year-old boy is reported. All etiologic investigations remained negative. Management successively required continuous enteral feeding, ileostomy then total parental nutrition. The proof of a chronic barbiturate intoxication, induced by the mother, was made only after 2 1/2 years of follow-up, when the patient was in a critical condition. Separation of the child from his family led to complete disappearance of symptoms within a few days.

[Plasma concentrations of ornidazole in newborn infants and infants after iterative administration]

Ornidazole was administered for ten days to twelve hospitalized neonates at the same daily dose of 20 mg/kg either by one or two IV infusions. Minimum steady-state concentrations measured between the 4th and 10th day ranged from 7.8 to 17.3 (mean = 11.8 +/- 3.2 mg/l) for one daily infusion and from 10.9 to 26.6 (mean = 20.5 +/- 6 mg/l) for two infusions. These minimum concentrations were all above the minimum inhibitory concentration for the most clinically significant anaerobic bacteria. So the single daily administration of ornidazole at the dose of 20 mg/kg is sufficient to obtain therapeutic efficiency.

[Hematoma of the adrenal glands and heparin]

The diagnosis of adrenal haemorrhage complicating heparin therapy is often delayed, despite computed tomography (CT). Moreover, its pathogenesis is not clear. Adrenal haemorrhages are often seen in cases where there is no unduly excessive anticoagulation, and can be accompanied by a paradoxical thrombosis of the central adrenal vein. Symptoms usually occur within the first 8 to 12 days after starting heparin. The difficulty in establishing the diagnosis stems from the fact that symptoms are rather nonspecific: abdominal pain and backache, nausea, vomiting, lethargy, weakness, hypotension, hyperpyrexia. To confirm the diagnosis, both hormonal proof of adrenal failure and anatomic evidence of haemorrhage must be found. Early CT scans may show the haemorrhage. Several possible causes have been put forward to account for these adrenal haemorrhages. The degree of anticoagulation did not seem to be a prerequisite, 30 to 50% of patients showing no evidence of other bleeding or coagulation tests outside the therapeutic range. Capillary fragility of old age might be a factor. Stress would seem to be an important factor predisposing to adrenal haemorrhage. Many authors consider the paradoxical central vein thrombosis as a result of the haemorrhage rather than its cause, whereas other conclude the opposite. Unfortunately, to date coagulation studies are often incomplete; platelet counts were missing in most reports published before 1985. Since that date, a heparin induced thrombosis-thrombocytopaenia syndrome (HITTS), in which thrombosis may occur in any vascular bed, has been recognized with increasing frequency. Nine cases of adrenal haemorrhage associated with HITTS have been reported. It seems highly likely that a proportion of cases of heparin-related adrenal destruction are due to HITTS.(ABSTRACT TRUNCATED AT 250 WORDS)

[A rare hemostatic disorder: pseudo von Willebrand's disease]

A case of pseudo von Willebrand's disease occurring in a 26 year old pregnant woman is reported. The diagnosis was made during the 33rd week of pregnancy. The patient had excessive bleeding of minor wounds, and biological tests revealed a bleeding time exceeding 20 min, a greatly reduced level of Rco fraction of von Willebrand's factor (27%), the absence of high molecular weight von Willebrand's factor multimers, and a greatly increased platelet aggregation in small doses of ristocetin. The patient was allowed to give birth by the vaginal route, receiving 30 IU.kg-1 highly purified concentrated factor VIII, once cervical dilatation was complete. Uterine revision was carried out for safety's sake because of prolonged post-partum bleeding. Two red cell packs were transfused as haemoglobin concentration decreased from 106 g.l-1 to 80 g.l-1. The newborn also presented with biological signs of pseudo von Willebrand's disease, with a bleeding time exceeding 15 min, hypothrombocytopaenia, and a level of Rco fraction of von Willebrand's factor of 9%. Preoperative assessment should always include an investigation of primary haemostatic mechanisms. In case of pseudo von Willebrand's disease, platelet transfusion combined or not with the transfusion of highly purified factor VIII seems to be useful. Investigation of other family members for a pseudo von Willebrand's disease trait is essential.

[Heparin-induced thrombocytopenia complicated by hematoma of the adrenal glands and acute adrenal insufficiency]

Three cases of acute adrenal haemorrhage complicating heparin induced thrombocytopaenia are described. The patients were 2 men and 1 woman, respectively 62, 74 and 76-year old. They all had orthopaedic problems requiring a treatment by subcutaneous calcium heparinate. Thrombocytopaenia occurred 7 to 10 days after the beginning of treatment, with a progressive return to normal of platelet count on stopping heparin. A syndrome suggestive of adrenal failure appeared on the 10 th to 12 th day consisting of abdominal pain, hyperpyrexia, arterial hypotension, asthenia, altered consciousness. Adrenal hormone levels were decreased. Abdominal scanography demonstrated adrenal haemorrhage in 2 patients. The third patient died before further investigations could be carried out. Hormonal replacement therapy brought things back to normal. Six other similar cases have already been published. The heparin induced thrombocytopaenia probably explains the two paradoxes of adrenal haemorrhage complicating heparin therapy: its occurrence in the absence of excessive anticoagulation, and adrenal venous thrombosis. The presence of abdominal pain, fever, collapse, or hyponatraemia with heparin induced thrombocytopaenia should suggest a possible adrenal haemorrhage. Adrenal CT scans should be carried out rapidly, so that hormone treatment can be initiated without delay.

[Propofol in urological endoscopy in elderly patients. Comparison with methohexital]

Twenty patients undergoing cystoscopy (group A) and forty patients undergoing transurethral resection (group B), aged more than 65 years, were anaesthetized. Duration of anaesthesia was less than 15 min for cystoscopy, and more than 30 min for transurethral resection. No premedication was given. The patients were ASA I or ASA II. Group A patients were allocated randomly to receive either 1.5 mg . kg-1 propofol (n = 10) or 2 mg . kg-1 methohexitone (n = 10) for induction of anaesthesia. Anaesthesia was maintained using incremental doses of propofol or methohexitone and 60% N2O with a face-mask. Forty group B patients undergoing transurethral resection were randomly assigned to four equal groups (PB: propofol 1.5 mg . kg-1; MB: methohexitone 2 mg . kg-1; PF: propofol and 1.5 micrograms . kg-1 fentanyl; PFV: propofol, 2 micrograms . kg-1 fentanyl and 0.1 mg . kg-1 vecuronium). Suxamethonium (1 mg . kg-1; groups PB, MB and PF) and vecuronium (0.1 mg . kg-1; group PFV) were given to facilitate endotracheal intubation. Anaesthesia was maintained by infusion of propofol or methohexitone, using a calibrated pump started immediately after intubation. Ventilation was controlled only in group PFV. Induction with 1.5 mg . kg-1 propofol resulted in stopping counting after 62 s and loss of the eye-lash reflex after 84 s versus 47 and 67 s respectively with methohexitone. The anaesthesist's assessment was favourable for cystoscopy with propofol and methohexitone; recovery times were similar for the two drugs in cystoscopy lasting less than 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of intranasal nifedipine during clamping of the abdominal aorta]

The haemodynamic changes due to cross-clamping of the abdominal aorta below the renal arteries were studied in ten patients. Anaesthesia was induced with thiopentone and maintained with fentanyl and vecuronium and inhalation of 60% nitrous oxide in oxygen. At the fifth minute, clamping increased mean arterial pressure (Pa) by 11%, systemic vascular resistance (Rsa) by 26% and decreased cardiac output (CO) by 20%. Nifedipine was administered intranasally at this time. Heart rate remained unchanged; mean pulmonary arterial and mean pulmonary wedge pressures were slightly decreased. Pa and Rsa fell to significantly lower levels between the fifth and fifteenth minutes (24 and 43% respectively). Although CO increased by 28%, this was not significant. The administration of intranasal nifedipine during anaesthesia was well tolerated. This study demonstrated that intranasal nifedipine prevented adverse haemodynamic effects of cross-clamping of the aorta below the renal arteries.

[Determination of thresholds of external cardiac pacing during anesthesia]

The efficacy of transcutaneous pacing was studied in 33 patients during general anaesthesia. The temporary pacing was effective in all cases. Stimulation thresholds ranged from 85 to 150 mA (mean : 110 +/- 17). In all 33 patients, external pacing was effective in producing a pulse without significantly reducing arterial pressure. Stimulation thresholds were only influenced by electrode position; age, weight, thoracic diameter and cardiothoracic ratio did not have any effect on them. No adverse effects of transcutaneous pacing were recorded. Transcutaneous pacing can be an alternative to transvenous right ventricular endocardiac pacing in the operating room in some circumstances.