Preliminary results of prolonged target controlled infusion of sufentanil adjusted to an effort pain score after cardiac surgery.

Repeated boluses of i.v. morphine are often used for analgesia after cardiac surgery, but this procedure frequently provides inadequate pain relief. Target controlled infusion (TCI) of opioid drugs has been proposed as an alternative. The objective of this study was to evaluate the effects of prolonged sufentanil TCI adjusted to an effort pain score on the postoperative course after cardiac surgery. Twenty-six patients scheduled for cardiac surgery were anaesthetised using TCI of propofol and sufentanil, followed by early extubation. In the postoperative period, patients were randomly allocated to receive either boluses of i.v. morphine (Bolus group), adapted to a pain score at rest, or sufentanil TCI with a low target concentration (0.08-0.1 ng/ml), adapted to a pain score during deep inspiration (TCI group). Postoperative pain was assessed using a Verbal Numerical Score (VNS) before and during three stimuli: extubation, lateral positioning and physiotherapy. In 15 patients, inspiratory capacity was evaluated by incentive spirometry (IS) on postoperative day 1. Three patients in each group were withdrawn because of delayed extubation. Clinical characteristics, mean time to extubation and PaCO2 were similar in both groups. Analgesia was adequate at rest in both groups as indicated by low pain scores. Pain intensity increased significantly during the three stimuli (p < 0.01). VNS were lower in the TCI than in the Bolus group (3.8 +/- 0.5 versus 4.8 +/- 0.5, p = 0.03). Nine of 10 patients in the TCI group but only 4 of 10 patients in the bolus group gave a VNS below 5 during the stimuli. IS performance was better preserved in the TCI than in the Bolus group (53 +/- 5% versus 35 +/- 5% of preoperative values, p < 0.05). These observations indicate that after cardiac surgery, postoperative pain management with prolonged TCI of sufentanil adapted to a pain score during deep inspiration can achieve better analgesia during routine bedside procedures and higher pulmonary volumes than on-demand boluses of morphine.

Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy?

OBJECTIVES: The purpose of our study was to validate the incentive spirometry (IS) as a simple mean to follow pulmonary function at the bedside after lung surgery. MATERIALS AND METHODS: We studied prospectively 19 patients (16 men, 3 women; mean +/- SE age, 60 +/- 2.8 years) undergoing lobectomy for lung cancer. All the patients had an obstructive pattern with FEV1/FVC below 75%. Lung volumes, including functional residual capacity (FRC) and residual volume (RV), measured using spirometry and the helium dilution technique, and IS were measured preoperatively and postoperatively at days 1, 2, 3, and 8, and at 2 months. RESULTS: Our results showed that in the postoperative period after lung resection, IS performance was well correlated (R) during the first 8 postoperative days with vital capacity (VC) (R between 0.667 and 0.870) mainly due to the excellent correlation with the inspiratory reserve volume (IRV, R between 0.680 and 0.895) but was poorly correlated with expiratory reserve volume (R below 0.340), RV (R below 0.180), and FRC (R below 0.470). CONCLUSIONS: IS can be used as a simple mean to follow lung function, especially VC and IRV, in the postoperative period in spontaneously breathing patients. IS is noninvasive and can be performed repeatedly at the bedside in the intensive care setting.

Exploration of the cellular mediated immunity by the blastogenesis test during chronic brucellosis in human.

The diagnosis of the chronic, human brucellosis is frequently difficult and usually needs experimental methods. This paper describes a lymphocyte stimulation test with a Brucella antigen and the results of this test concerning 45 brucellic or not brucellic patients. It is concluded that this test is interesting, especially for the chronic and sero-negative Brucellosis diagnosis.

Late prosthetic valve endocarditis. Bacteriological findings and prognosis in 29 cases.

Of 296 incidences of infectious endocarditis seen between 1971 and 1980, 29 cases of late prosthetic valve endocarditis (10%) occurred in 26 patients who had undergone valve replacement more than two months previously. The prosthesis was mitral in 8 cases, aortic in 9 cases, and multiple in 12 cases. The clinical picture consistently associated fever together with a regurgitation murmur in 12 cases (41%), a splenomegaly in 7 cases, a neurologic accident in 13 cases and other signs of endocarditis in 10 cases. Blood cultures were positive in 28 cases. The diagnosis was confirmed anatomically in 11 cases. Thirty-one causative agents were identified: 15 streptococci (48%), most of them were group D (11/15), 11 staphylococci (35%) 6 Staphylococcus aureus, 5 Staphylococcus coagulase negative and 5 other species. Two relapses and 3 recurrent infections were noted. The death rate was 58% with some factors being associated with a higher death rate: non-streptococcal micro-organism (87%) regurgitation murmur (83%) cardiac failure with dysfunction of the prosthesis (89%) neurologic complication (91%). Eight valve replacements were performed within a mean period of 32 days after the onset of the antibiotherapy with a death rate of 75%. It decreased to 50% for patients treated with antibiotic alone, and as low as 23% for Streptococcal endocarditis. These results suggest that earlier and more frequent indications for cardiac valve replacement could be an alternative to improve the prognosis.