[Staphylococcus nasal carriage and infection of central venous ports in oncology]

OBJECTIVE

To assess the risk of infection of either subcutaneously implanted central venous access devices or percutaneous central venous catheters inserted via a subcutaneous tunnel in cancer patients with a positive staphylococcal nasal carriage.

STUDY DESIGN

Prospective study.

PATIENTS

The study included 266 patients undergoing cancer chemotherapy.

METHOD

A nasal swab was taken prior to insertion of the venous access device and the patients were followed over 30 days for the occurrence of a staphylococcal infection (hemoculture and device or site of insertion).

RESULTS

A nasal staphylococcal nasal carriage was found in 227 patients. Out of the 15 developing a device infection, a staphylococcal nasal colonization was existing in nine patients. Bacteriological screening a sensitivity of 60% and a specificity of 13%.

CONCLUSION

Bacteriological screening at the time of device insertion of a central venous access device is of no value for the detection of patients at risk of staphylococcal infection of the device.

[Factor VII deficiency and surgery]

Factor VII deficiency is a rare disorder (1/500,000), with manifestations similar to those experienced by patients with haemophilia. Excessive bleeding during surgical procedure is prevented by factor VII administration. We report two cases of patients presenting a factor VII deficiency who were treated for oncological surgery. In the first patient with a severe congenital factor VII deficiency (8%), a continuous infusion of factor VII prevented the development of perioperative bleeding. In the second case, with a probably acquired factor VII deficiency (33%) related to a leiomyosarcoma, bleeding was prevented by a single preoperative factor VII injection.

[Peripheral venous catheter embolism]

The accidental embolization of peripheral venous catheter fragments seems to be a rare event. Removal of the catheter embolus is usually recommended, because of the high morbidity and mortality rates from sepsis, perforation, thrombosis and arrhythmias. We report a case, in which the diagnosis was made 17 years after the embolization by the means of a systematic chest X-ray. The use of spiral CT scan with computerized post-processing 3D reconstruction confirmed the diagnosis. Because of good tolerance during this very long term, a not-to-treat decision was taken.

Amphotericin B intralipid formulation: stability and particle size

Amphotericin B remains the drug of choice for treating systemic fungal infections, although toxicity limits its clinical use. Some studies reported the use of Intralipid deoxycholate amphotericin B as an alternative delivery system. An in-vitro study was performed to assess the compatibility of deoxycholate amphotericin B in Intralipid. With two types of dilution of deoxycholate amphotericin B (in 5% dextrose and Intralipid or in Intralipid alone) the solution stability was not constant with a clear yellow precipitate. We observed an increase in the size of the particles (1.5-4-fold). In light of these results Intralipid deoxycholate amphotericin B should not be routinely administered.

A comparative study of controlled-release morphine (CRM) suspension and CRM tablets in chronic cancer pain

This study compared the efficacy and the adverse effects of controlled-release morphine (CRM) suspension (SAR 213) and CRM tablets (Moscontin) in the treatment of cancer pain. This multicenter, randomized, double-blind, double-dummy, crossover study was carried out on 52 patients. Each patient received both study treatments given at an equivalent dosage of morphine during each of two 7-day periods. The primary outcome variable was the severity of pain assessed three times daily by means of a visual analogue scale. Secondary criteria of efficacy were the severity of pain assessed by verbal rating scale, the need for "rescue" doses of immediate-release morphine, treatment preference, and indices of quality of life (activity, mood, sleep). There were no statistically significant differences in the parameters assessed when comparing the two groups. This study shows that, when prescribed at the same doses, CRM suspension and CRM tablets have similar efficacy and adverse effects, as well as the same duration of action. The results of this first clinical study carried out on CRM suspension are especially relevant for patients with cancer pain who have difficulty swallowing.

[Perforation of the esophagus during attempted endotracheal intubation]

A case is reported of oesophageal perforation which occurred during an attempt to carry out endotracheal intubation. A 54-year-old female patient was scheduled for mastectomy. She had no clinical features likely to predict a difficult endotracheal intubation. After induction with thiopentone, phenoperidine and suxamethonium, three attempts were made to carry out tracheal intubation with a Mallinckrodt Lo-pro tube, internal diameter 7.5 mm. During the third attempt, the oesophagus was accidentally intubated. The diagnosis was made before any insufflation was carried out. Another anaesthetist took over, and intubated the patient. At that time, there was left-sided cervical emphysema which quickly spread. An oesophageal perforation was suspected, and the patient was given 500 mg of metronidazole and 1 g of cefotetan. Postoperatively, the antibiotics were continued, and the patient had nothing by mouth. Oesophagography showed a posterior fistula in the upper third. Conservative treatment was continued until the seventh day, when another oesophagography was carried out. This showed that the perforation had completely healed. This rather rare complication of endotracheal intubation may have a poor prognosis if it results in mediastinitis. The diagnosis and prognosis of this complication and its treatment, whether conservative or surgical, are discussed.

[Hemodilution and peroperative autotransfusion during harvest for bone marrow graft]

In order to avoid the infectious and immunological complications of homologous blood given to autologous bone marrow graft recipients, intraoperative haemodilution together with delayed salvage of the red blood cells contaminating the marrow graft were used prospectively over a period of 6 months. This was carried out in 74 patients, i.e. 2 allogenic and 72 autologous donors (mean age 27.2 +/- 19.7 years). A mean of 13.66 +/- 7.10 ml.kg-1 bone marrow were harvested. Fluid replacement was carried out, volume for volume, with a modified fluid gelatin (Plasmion) (n = 73; 14.6 +/- 6.6 ml.kg-1), glucose 5% (n = 54; 9.64 +/- 4.88 ml.kg-1) and Ringer solution (n = 33; 8.1 +/- 3.3 ml.kg-1). No haemodynamic problems occurred. Autologous blood transfusion was possible in 54 patients; mean volume of bone marrow harvested was 631 +/- 298 ml, and a mean of 293 +/- 154 ml of blood was retransfused to the patients (mean haematocrit of the blood units: 0.536 +/- 0.048). Nine of these patients were also given homologous blood. In the other 20, the volume of bone harvested marrow was significantly lower than in the autologous transfusion group (430 +/- 202 ml; p less than 0.05), and red blood cell salvage was not possible; only 3 patients received homologous blood. Finally only 16.2% of the patients in this series were given homologous blood. It is concluded that intentional isovolaemic haemodilution together with autotransfusion of salvaged blood can reduce the need for homologous blood during bone marrow harvesting.

[Polyurethane catheters and antineoplastic chemotherapy. An experimental study]

An in vitro study of the effect of cytotoxic drugs on polyurethane catheters was carried out. The drugs used--vincristine, doxorubicin, cisplatin and carmustine--damage the surface of silicone elastomer catheters. The irregularities produced seem to be preferential sites for thrombus formation and adhesion of bacterial microcolonies. Electron microscopy examination of the catheters dipped in the drug solutions for different time intervals revealed the appearance of different patterns of damage. The irregularities produced seemed to be less pronounced than for silicone catheters. Polyurethane was highly sensitive to doxorubicin. These changes could well have clinical repercussions. The compatibility of catheters and drugs should be routinely tested before being put on the market.

[Surface changes of intravenous catheters after antineoplastic chemotherapy]

During long-term venous catheter implantation, septic and thrombotic complications are quite frequent. In the case reported, the failure of systemic and local antibiotic therapy during repeated septicaemia due to Bacillus cereus at the time of intensive chemotherapy led to a scanning electron microscopy study of the used silicone catheter. There were marked changes of the inner surface with a lot of cellular remains, in contrast with the usual non thrombogenic property of the silicone. An in vitro study was carried out with antitumour agents. Duration of exposure and drug concentration were identical to those used in in vivo perfusions. There were marked changes of the inner surface, which could lead to important modifications of the properties of the silicone. The damage depended on the drug. Silicone was slightly sensitive to vicristin and carmustin, but highly sensitive to cisplatin and doxorubicin. The compatibility of catheter material with the drugs used, especially for oncologic chemotherapy, must be tested systematically.

[Isolated increase in the bleeding time: the hemorrhagic risk and therapeutic problems]

An isolated increase of the bleeding time is rare. In the young, there may exist a history of bleeding disorders such as epistaxis. In middle age, the increased risk of bleeding during surgery is low but real, and depending on the type of surgery. There are many drugs responsible for increased bleeding time; these must be avoided: the principle that one haemostatic defect is often well tolerated whereas two are not is very real. So the management of such patients during surgery must be meticulous and the use of some drugs must be avoided. Careful surgical management with regard to haemostasis undoubtedly allows many patients with this sort of defect to undergo surgery without excessive bleeding. Some treatments are possible (e.g. steroids, DDAVP), but their routine use is not warranted.

[Bacterial meningitis and intrathecal treatment of chronic pain]

A case is reported of bacterial meningitis related to an intradural implant used in the treatment of pain into which morphine was administered daily. The infection began on the third day after implantation of the system. Because of its efficiency in controlling pain, it was not removed; the infection was successfully treated with local and general antibiotic treatments only. The system was used 121 days.

[Preoperative chemotherapy of ovarian cancer in anesthesia and resuscitation]

Anti-mitotic chemotherapy has become more efficient but also more toxic. This toxicity complicates later operations. Sixty cases of ovarian cancer one analysed and the various complications related to chemotherapy described.