Hypersensitivity reactions to Patent Blue V in breast cancer surgery: a prospective multicentre study.

BACKGROUND: An increasing number of immediate hypersensitivity reactions (HSR) have been reported after the use of Patent Blue V (PBV) for breast cancer surgery. This is the first study to publish prospective data with systematic allergological assessment. METHODS: We conducted a multicentre study in 10 French cancer centres for over 6 months. All patients scheduled for breast surgery with injection of PBV were included in the study. Patients were screened for past medical history, atopy, and known food and drug allergies. When suspected HSR or unexplained reactions occurred after injection of PBV, blood samples were taken, and plasma histamine and serum tryptase concentrations were measured. HSR to PBV was suggested if skin tests performed 6 weeks later were positive. RESULTS: Nine suspected HSR to PBV were observed in 1742 patients. Skin tests were positive in six patients, giving an incidence of 0.34%. Four grade I and two grade III HSR were observed, both requiring intensive care unit treatment. Mean onset time of the reaction was 55 ± 37 min. Plasma histamine was elevated in four patients, while serum tryptase was normal. We found no risk factors associated with HSR to PBV. CONCLUSION: An incidence rate of one in 300 HSR to PBV was observed for patients exposed to PBV during sentinel lymph node detection. This rate is higher than rates reported after the use of neuromuscular blocking agents, latex or antibiotics.

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.

Assessment of hemodynamic and gastric mucosal acidosis with modified fluid versus 6% hydroxyethyl starch: a prospective, randomized study.

OBJECTIVE: To investigate the effect of 4 % succinylated modified fluid gelatin (MFG) versus mean weight, highly substituted 6% hydroxyethyl starch (HES) on hemodynamic and gastric mucosal acidosis variables, in septic hypovolemic patients. DESIGN: Prospective, randomized, clinical investigation. SETTING: University hospital intensive care unit. PATIENTS: Thirty-four septic hypovolemic ventilated and hemodynamically controlled patients. INTERVENTIONS: Invasive hemodynamic and gastric tonometric measurements. MEASUREMENTS AND RESULTS: Hemodynamic and tonometric parameters were recorded at baseline and 60 min after infusion of 500 ml of each colloid. In all patients central venous pressure, pulmonary artery occlusion pressure, cardiac index and mean arterial pressure increased significantly with both colloids, and hemoglobin concentration decreased by the same amount while oxygen delivery remained stable. Gastric intramucosal pH increased from 7.27 +/- 0.08 to 7.31 +/- 0.07 (p < 0.001) with MFG and decreased non-significantly from 7.26 +/- 0.11 to 7.22 +/- 0.08 (ns) with HES. Carbon dioxide gastric mucosal arterial gradient decreased from 18 +/- 9 to 13 +/- 9 mmHg (p < 0.0005) in the MFG group and rose non-significantly from 18 +/- 11 to 21 +/- 11 mmHg with HES. CONCLUSIONS: Although MFG and 6% HES have the same hemodynamic effects, their physicochemical properties induce different responses on gastric mucosal acidosis in septic, hypovolemic and ventilated patients. These effects of MFG and HES on gastric mucosa need to be considered in patient management.

Nosocomial endocarditis in the intensive care unit: an analysis of 22 cases.

OBJECTIVES: To review the intensive care unit experience of patients with admitted or acquired nosocomial endocarditis (NE) defined according to the Duke criteria. DESIGN: Prospective, cohort study. SETTING: University teaching hospital. PATIENTS: We reviewed the records of 22 patients documented with NE during a 6-yr period from 1992 to 1997. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients (9 women/13 men) aged 38-83 yrs (mean 65+/-9 yrs) had a NE (prevalence of 5 per 1,000 admissions). For six patients, NE was the reason for the admission to the intensive care unit. For 17 patients, the time elapsed between admission and diagnosis of NE was 39+/-25 days. Sixteen patients were predisposed to infection and seven had underlying heart conditions that put them at risk for acute endocarditis: three prosthetic valves, two valvular diseases, and two cardiac pacemakers. In 21 cases (one unknown portal of entry), NE was the consequence of bacteremia related to a medical or surgical procedure: 11 intravascular devices, eight surgical wounds, one tracheal procedure, and one leg ulceration. The bacteriologic agents detected in blood cultures were: staphylococci (n = 17), Streptococcus (n = 2), Pseudomonas aeruginosa (n = 2), and Candida (n = 2). Fourteen patients underwent echocardiography according to cardiac signs (cardiac failure, new cardiac murmur, or embolic event). For the eight remainders, echocardiography was performed systematically because of fever and positive blood cultures. The lesions detected by 21 transthoracic and 17 transesophageal echocardiographs were the following: vegetations (n = 19), myocardial abscesses (n = 5), and valvular perforation (n = 1). On 16 surgical indications, only five patients underwent surgery because the others were in too poor of a condition. The overall mortality was 68% (n = 15) and was directly associated with NE in 36% of cases (n = 8). Seven patients (28%) were discharged 34 days after the diagnosis of endocarditis. CONCLUSIONS: NE is a frequent nosocomial infection that occurs late during hospitalization. Persistent fever with positive blood cultures is sufficient symptomology to promptly perform an echocardiogram. The poor prognosis is related to the poor condition of those patients who cannot be referred for surgical treatment.

[Post-transfusion purpura: and cause of severe postoperative thrombopenia]. / Purpura post-transfusionnel: une cause de thrombopénie postopératoire grave.

A 59-year-old woman developed an acute and severe thrombocytopenia (platelet count below 10.10(9).L-1) with active bleeding, 6 days after a massive transfusion for intraoperative haemorrhagic shock. The diagnosis of post-transfusion purpura (PTP) was confirmed by the presence of an allo-antibody directed against HPA-1a platelet antigen. The patient and her daughter had a rare HPA-1b platelet phenotype, but also belonged to the HLA DR3 phenotype, frequently associated with PTP. This case shows the therapeutic difficulties of postoperative PTP. Despite active bleeding, this syndrome requires the discontinuation of transfusions of incompatible platelets. Transfusion of phenotyped platelets is often inefficient. Red cell concentrates must be platelet and plasma free. Immunomodulating therapy can shorten the time course. Preventive measures, particularly autologous transfusions, are necessary for subsequent haemorrhagic surgery or parturition.

-The effect of desflurane on cerebral blood flow velocity and cerebrovascular reactivity to CO2 in children-. / Effets du desflurane sur les vélocités sanguines cérébrales et la réactivité cérébrovasculaire au CO2 chez l'enfant.

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.

[Postoperative analgesia after ligamentoplasty of the knee. Comparison of epidural morphine and intravenous nalbuphine]. / Analgésie postopératoire après ligamentoplastie de genou. Comparaison de la morphine péridurale et de la nalbuphine intraveineuse.

Surgery of the anterior cruciate ligament causes severe postoperative pain. This study aimed to compare efficacy and side effects of two postoperative analgesia methods, during 24 hours. Twenty healthy patients were assigned to two groups (n = 10): the patients of the first group were given by an epidural catheter 3 mg of morphine hydrochloride, every twelve hours. The patients of the second group received 2 mg h-1 of intravenous nalbuphine. The degree of pain was studied with a visual analogue scale. After the third postoperative hour, it was significantly higher in the second group, but the nalbuphine dose was low. The incidence of respiratory depression, nausea, pruritus was not statistically different between the groups, but 7/10 patients in the first group suffered of urinary retention (the first micturition was obtained 10.5 hours after the end of surgery in the first group and 5.3 h in the second one). Two patients needed an uretral catheter. These results might tend to show a greater efficactly of epidural morphine, with a higher incidence of urinary side effects.

[Anaphylactic shock during the use of high doses of aprotinin in cardiac surgery]. / Choc anaphylactique lors de l'utilisation de l'aprotinine à fortes doses en chirurgie cardiaque.

A 77-year-old man was admitted for mitral valve replacement, 46 days after a failed conservative mitral surgery where he received high-dose aprotinin. Twenty minutes after induction of anaesthesia, 250 UPh E of aprotinin were infused intravenously; before the end of this infusion, bronchospasm, systemic hypotension and generalized rash were noted. Immediate treatment included intravenous adrenaline and methylprednisolone; cardiovascular stability was restored after 10 minutes. Immediate histamine liberation was confirmed by the analysis of the time course of the clinical events, a previous contact and positive skin tests. Aprotinin has the antigenic molecular structure of natural proteins. Since 1987, it is used in cardiac surgery to reduce postoperative blood loss: to prevent serious allergic reactions to aprotinin, it is necessary, in patients known to have had previous aprotinin therapy, to perform skin testing with diluted aprotinin before infusion.