Peroperative catecholamine levels were taken as a method for the assessment of automatic protection. Plasma adrenalin and nonadrenalin levels (spectro-fluometric technique) were measured at different pre-, per- and postoperative times in twenty eight surgical patientS: fifteen undergoing cardiac surgery and ten surgery involving the aortic bifurcation. Anaesthesia included high doses of fentanyl associated with droperidol. During aortic grafts variations in catecholamine levels were not significant, whilst during and after ECC there was a significant increase in the values. These variations were slight in comparison with those which may be seen during the excision of a phaeochromocytoma and were very similar to those obtained during effort. There were wide individual variations.
The authors report twenty two cases of post-operative gas gangrene. In the series studied mortality was 40.9 p. 100, independent of age and sex. Rapidly progressive forms were the most severe. The delay before effective treatment was prescribed influenced prognosis. In clinical terms, shock and associated renal insufficiency were grave, as well as a picture of respiratory distress which led, in certain cases, to contra-indication of one of the therapeutic possibilities, i.e. that of hyperbaric oxygen. Responsible organisms could be isolated in nineteen cases from local samples. There was a marked predominance (15 cases) of clostridium perfringens. Contamination with aerobic flora was common. Examination to assess favourizing circumstances led essentially to a conclusion of the role of microbial contamination, ischemia, broad spectrum antibiotics, absence of appropriate antibiotics and underlying immuno-depression. Treatment was based in the majority of cases on the triple combination of antibiotics, surgery and hyperbaric oxygen, as well as the correction of any general systemic disorders. Mortality was markedly reduced (31 p. 100) in patients receiving complete and early treatment. The gravity and recrudescence of disorders due to anaerobic organisms lead the authors to review current therapeutic possibilities. Appropriate treatment should be prescribed in all situations where an infection due to anaerobic organisms is feared, and should cover the risk of clostridial infection (penicillin 200,000 mu/kg/24 h) as well as the risk of bacteroides (metronidazole 25 mg/kg/24 h). Curative treatment should be prescribed, even in the absence of bacteriological proof, on the basis of presumptive clinical evidence, this being a true emergency which should not be delayed under any circumstances.
Cellular immunity is studied by intradermal reaction to phytohaemagglutinin (four concentrations: 1, 2, 5 and 10 infinity g), the response to which at the 24th hour gives information concerning macrophage power and at the 48th hour the functional value of the T lymphocytes. Such a study was carried out in three groups of patients: 1st group (n = 20): general anaesthesia without surgery, duration less than 30 minutes; 2nd group (n = 10): general anaesthesia without surgery, duration greater than 2 hours; 3rd group (n = 20): general anaesthesia with surgical procedure, duration greater than 2 hours. In all groups, the results showed highly significant immune depression at the 24th hour, certainly linked to a depression of macrophage power. This depression persisted at the 48th hour, but less markedly and less significantly, which could not be interpreted as definite evidence of depression of the T lymphocytes. Surgery would not appear to have played any additional role to anaesthesia in this immune depression, nor did the duration of anaesthesia. In a 4th group (n = 10) treated with vitamin A and undergoing anaesthesia with surgery lasting for more than two hours, no immune depression was seen.
Amikacin serum levels were measured 256 times in 65 patients admitted into the intensive care unit for various reasons over 18 months. These measurements confirmed the dosage of 5 micrograms per kg repeated every 8 hours in patients with normal renal function. Forty eight hours before the first measurement, a control assay is essential to check that there is no residual antibiotic and that the antibacterial activity of the serum is zero. After this a single weekly control is sufficient to check that the residual level is effective and non toxic, i.e. between 2 and 6 micrograms per ml. However, in patients with acute renal insufficiency, there are three dosage schemas which should be used depending on the creatinine level. These three schemas are nevertheless not sufficient to continue effective therapy without a risk of toxic side effects. It is therefore necessary to check both the pack levels and the residual levels regularly from the beginning of treatment. Two to three weekly controls are essential to avoid a risk of toxic side effects.
