After a review of first two causes of bisalbuminemia: genetic mutation and overdosage during antibiotherapy with beta-lactamines, the authors underline the importance of searching for a bisalbuminemia during the course of pancreatic disease or when confronted with a serous collection, particularly an ascite of undetermined origin. Effectively, the finding of a bisalbuminemia in these two circumstances, after having eliminated the first two etiologies, permits the confirmation of the diagnostic of a pancreatic fistula. This diagnostic should imply exploratory surgery, even without other confirmation, and a per-op. wirsungography if the fistula is not visible macroscopically. The surgical correction of the fistula cures the patient and the bisalbuminemia disappears in several hours.
This retrospective study shows correlations between the occurrence of pulmonary and massive blood transfusion in 50 seriously injured patients. They received massive transfusions on an average of 13 titers (minimum 51, maximum 30 l) including from 0 to 7,51 of macromolecular solutions (average 2,43 1). These seriously injured patients were divided into 4 groups: --20 thoracic injured patients with associated abdominal lesions, --15 thoracic injured patients without any abdominal lesions, --4 peripheral traumatism with abdominal lesions, --11 polytraumatic patients (considering only lesions of the limbs). There is a significant difference between seriously injured patients with associated abdominal lesions who were transfused and the other groups studied. Sixteen patients experienced pulmonary edema the diagnosis of which was reinforced on grounds of clinical, biological and radiological evidences. Significant difference (p:minor 0,05) were noted as regard the incidence of pulmonary edema when comparing the volume of fluids administrated to the different groups. New out of 16 patients died, mainly because of refractory hypoxia. When more than 25 liters of fluids are transfused, the prognosis is poor. Though pulmonary edema may be brought about by transfusion, other etiologic possibilities are to be investigated.
The authors relate their experience of 61 rectal anesthesias with ketamine (10 mg/kg) and diazepam (0.25-0.5 mg/kg). Rectal anesthesia is well accepted by children who are afraid of percutaneous injection. When ketamine is used alone, they obtained only 76 p. cent good result. When diazepam is associated, good results arise to 95 p. cent. Diazepam added to ketamine allows surface surgery during 10 to 15 minutes.
Deliberately lowering blood pressure facilitates middle ear surgery. However, bleeding can persist in spite of hypotension in some tachypneic patients. Fentanyl is a powerful morphinomimetic which decreases ventilatory frequency. This work studies the respiratory effects of fentanyl during spontaneous ventilation in 16 anesthetized patients. Their systemic blood pressure was decreased 40 per cent by trimetaphan. One single injection of fentanyl (0.0125 mg) reduced minute ventilation by 26 per cent, mean inspiratory flow rate (VT/T1) and T1/TTOT, but did not modify the pulmonary dynamic compliance. The acid-base balance parameters changed little toward respiratory alkalosis by trimetaphan and returned to their control values after the injection of fentanyl. Thus, a small dose of fentanyl can be combined with controlled hypotension during anesthesia and spontaneous ventilation without respiratory risk or an acid-base inbalance. With this dose, it has an efficient central influence to reduce the breathing frequency and can be used to lessen bleeding.
The mechanism of microbial colonization and sepsis is disputed. For many authors, catheter contamination results from poor aseptic technic during insertion or removal or from the descent of organisms along the catheter from the skin puncture site; we think with Michel that endogenous colonization of the thrombus at the tip of the catheter must be considered: a statistical correlation between infected foci remote from the catheter allows this hypothesis; tracheostomy may be considered as well as a percutaneous contaminant as a deep infected focus. The correlation between non specific immunity and contamination is another finding which allows the ability of endogenous colonization.
One of these two cases (1 h 30 and 48 hours) was permanent. The cause of the paralysis seems to be either from compression of the nerve between the endotracheal tube cuff and the cricoid, or from compression between the thyroid ala and a dislocated arytenoid cartilage from use of an unnecessarily large tube. An anatomical study has helped to confirm this hypothesis and shows the presence of an ischaemic aera overlying the nerve at the level of its entrance into the larynx due to the endotracheal cuff.
Haemodynamic function was assessed in twenty patients with severe pre-eclampsia or eclampsia. In front of the earlier well-known data hypercinetic circulatory status was found with vascular resistance almost unchanged. As some investigators found two levels placental blood flow, haemodynamic status may be different in some cases. Consequences on therapy are discussed especially beta-bloquers and potential deleterious effects of anti-hypertensive treatments.
The authors relate, after 75 cases, their experience of pulmonary artery catheterism carried out in case of cardiac surgery intervention. The Swan-Ganz catheter is exclusively introduced by the percutaneous internal jugular route and generally right (82 p. cent). During the progression of the catheter the radiologic control is not necessary. The complete failures are rare (2,5 p. cent) and the right pulmonary artery is mostly catheterised in every case. Complications are exceptional and often correspond to benign incidents like premature ventricular contractions which always disappear spontaneously, balloon ruptures (three cases) and the isolation of a non-pathogenic organism during the systemic bacteriologic examination without infections reactions. A serious infection complication has been found in one case and a pulmonary infarction is observed in another case. Compared with other venous route the advantages of this method lie in its very easy, simple, fast and trusty execution.
The external cardiac massage mechanism is commonly related to the ventricles compression between the vertebral block and the sternum. This over-simple explanation must be reconsidered. Following recent data, the intra thoracic pressure changes take probably a major part in it efficiency. Six patients have been studied by hemodynamic intra aortic measurements and Doppler carotidian velocimetry. Intra thoracic pressure have been recorded by an oesophageal catheter. Results are in agreement with the prominent part of the intra thoracic pressure variations. Various external cardiac methods are investigated following this monitoring. Some aspects of the classical management of the cardiac arrest have to be discussed.
This infusion used instead of whole blood has become increasingly common. However in our, as in other french institutions, the volume and the hematocrit of blood contained in each unit varies often notably. In addition, because of their high viscosity packed erythrocytes cannot be transfused rapidly enough. For transfusion in emergency situations and transfusion in operating room, following suggestions could be made to blood banks: --each unit should provide information on its content (volume and hematocrit or hemoglobin content); --units with low blood content should be transfused outside the operating room, whereas units containing high volumes should be reserved for peroperative transfusion in order to reduce charge of manipulation; --packed erythrocytes units should be prepared in order to allow same transfusion rates as whole blood (i.e. an average of 100 ml per minute for one transfusion line); --packed erythrocytes units should contain about 80 ml of plasma for an average total concentrate volume of 260 ml in order to provide enough antibacterial defense components; --units of fresh whole blood should be provided when approximately 150 p. cent of recipient's blood volume has been replaced in order to maintain the critical platelet level.
Glucose intolerance occurring in injured patients is known to be a part of the general response to injury described by Cuthbbertson: early "ebb phase" with a decrease of energy production, then "flow phase" with hypermetabolism. Several processes can be responsible for the abnormalities observed: 1) Alterations in peripheral glucose uptake. 2) Absolute or relative insulin lack in connection with increased catecholamine release which is know to inhibit insulin secretion. 3) Decreased sensitivity and responsiveness to insulin in connection with increased levels of counter regulatory hormones (catecholamines, glucagon, growth hormone). 4) Non-suppressibility of hepatic gluconeogenesis by glucose. Glucose intolerance decreases glucose utilisation and leads to increased proteolysis always unfavorable for patients.
An accidental case of delayed haemolytic reaction due to an anti-D allo-immunization in a patient suffering from multiple traumatic injuries allows us to define a procedure of emergency treatment towards non iso-Rhesus transfusions and the problems posed by the detection of acquired allo-antibodies.
The authors use the Bain Circuit with spontaneous breathing during head surgery (neurosurgery and ophthalmological procedures). Suitable for both adult and pediatric use, it seems to be, due to its unique characteristics, the choice circuit for all anaesthesia procedures in which the physician does not have direct control over the patient's head. Comparative analysis of blood gas levels is effected, on the one hand in children connected to a Digby-Leigh system and Bain Circuit, and on the other hand in adults, some of whom are connected to a two-way system and the other under a filter circuit; all of the patients are then connected to the Bain Circuit. In children the analysis of results shows that for an identical protocol of anaesthesia the quality of spontaneous breathing obtained using the Bain Circuit is the same as that obtained using the Digby-Leigh. In adults anaesthetized using fluothane and with spontaneous breathing, the average level of hypercapnia under filter circuit and Bain Circuit is identical. Also, the same level of alveolar hypoventilation is obtained under spontaneous breathing with the two-way and Bain Circuit systems when there are properly provisioned. Thus this work confirms other studies by showing that the Bain Circuit is particularly well adapted to head surgery because of its low weight and easy manageability. On the other hand, when using spontaneous breathing the level of alveolar hypoventilation, and thus the degree of hypercapnia, is directly related to the level of anaesthesia and independent of the circuit chosen. Only the setting up of controlled breathing would allow the physician to work under the desired level of normo or hypocapnia.
The performance of a calculator was studied on 19 patients requiring therapy with mechanical ventilation. Values of total compliance displayed by this calculator device were compared with values obtained with the syringe method. The determination of compliance were made at a series of values for Tidal volume (T. V.): 3, 4, 5, 6, 8, 10, 12, 15, 18, 20, 23 and 26 ml.kg-1. Measurements were performed while patients were paralysed by pancuronium bromide. In each patient the calculator device displayed values that correlate closely with the value obtained by the syringe method. Compliance increased between 3 and 26 ml.kg-1 of T. D. Between 4 and 15 ml.kg-1 of TD the changes of compliance were nearly identical whatever the method of measurement used. The calculator can be used for reliable monitoring or recordings of total compliance.
Hemodynamic data of 8 patients undergoing planned resection of abdominal aortic aneurysm are statistically analyzed by variance analysis ("patient" factor and "time" factor). The results are: 1. "Patient" factor exists for all the variables studied. 2. "Time" factor is present for some of them. After aortic clamping, there is a significant decrease of the systolic index (p less than 0.05) and of the left ventricular systolic work index (p less than 0.01). After aorting declamping, a high significant increase of the mean right auricular pressure (p less than 0.001) and of mean capillary wedge pressure (p less than 0.001) are seen. Similar results are observed at the end of surgery. The results are commented with regard of the literature.
Fifty one patients with terminal cancer suffering severe pains reluctant to other treatment have received morphine by mouth, in a regular regimen. The doses range between 5 and 50 mg every 4 hours. 60% of our patients have their pain alleviated without any side effect impeding the treatment.
