Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis.

OBJECTIVE: Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. DESIGN: Multicentric prospective randomized study. PATIENTS: 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. INTERVENTIONS: Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. MEASUREMENTS AND RESULTS: We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686-2.048). Glycemia on day 4 and gamma-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. CONCLUSIONS: In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

[Delayed evaluation of continuous medical education]. / Evaluation à distance d'une action de formation médicale continue.

OBJECTIVES: To analyse the results of delayed evaluation of European teaching sessions using a questionnaire provided by the French College of Anaesthesiologists. STUDY DESIGN: Open evaluation. MATERIAL: Questionnaires were completed 3-6 months after European courses provided in November-December 1999. METHOD: The types of professional exercise and the medical practice as well as the theme of the courses were pointed out. The evaluation included six items noted from 1 to 10: usefulness of the abstract book, discussion with colleagues, discussion with a manager, decision to modify medical practice, application of that decision, own objectives fulfilled. The global mean score for each item was calculated. Results were compared according to the professional mode of exercise and the theme of the course. RESULTS: 5/7 centres provided information. 91/239 questionnaires were returned to the organizers. The participants were working in different structures (private clinic: 25, university hospital: 31, general hospital: 27, PSPH: 8). The main exercise was anaesthesiology (75/77 answers). Means scores affected to the different items were around 7 for all but one of them. The mean score concerning discussion with a manager was significantly decreased to 3.5 +/- 3.2. Decision to modify their own practise was higher in private clinics compared to PSPH. The abstract book was more consulted after the first course (respiration and thorax). CONCLUSION: 3-6 months following the FEEA courses the participants thought to have fulfil their objectives and declared to have modify their medical practise. The lack of discussion with a manager should be analysed.

[Serious cerebral venous thrombosis: can we use fibrinolytic?]. / Thrombophlébite cérébrale grave: peut-on fibrinolyser ?

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.

Electrophysiological effects of morphine in an in vitro model of the 'border zone' between normal and ischaemic-reperfused guinea-pig myocardium.

BACKGROUND: Morphine is commonly used in clinical practice in pain management. Although morphine has been shown to precondition the myocardium, its effects on action potential parameters and ischaemia-reperfusion-induced arrhythmias and conduction blocks remain unknown. METHODS: In a double-chamber bath, guinea-pig right ventricular muscle strips were subjected partly to normal conditions and partly to 30 min of simulated ischaemia (hypoxia, hyperkalaemia, acidosis, and lack of nutritional substrate) followed by 30 min of reperfusion. Action potential parameters were recorded continuously in the normal zone and in the ischaemic- reperfused zone. Spontaneous arrhythmias and conduction blocks were noted. The electro physiological effects of morphine were studied at 0.01 and 0.1 micro M. RESULTS: In control conditions, morphine did not modify action potential parameters of resting membrane potential, maximal upstroke velocity (V(max)), action potential amplitude (APA) and action potential duration at 50 and 90% of repolarization. Morphine reduced ischaemia-induced depolarization and lessened the ischaemia-induced decrease in APA and V(max). Morphine significantly decreased the occurrence of conduction block during simulated ischaemia (20% at 0.01 and 0.1 micro M vs 67% in the control group, P<0.05) and reperfusion-induced arrhythmias (40% at 0.01 micro M and 30% at 0.1 micro M vs 92% in the control group, P<0.05). CONCLUSIONS: In ischaemic-reperfused guinea-pig myocardium, morphine at clinically relevant concentrations decreased ischaemia-induced conduction blocks and reperfusion-induced ventricular arrhythmias.

[Intraoperative memory. A study of its incidence in general anesthesia in 326 patients]. / Mémorisation peropératoire. Evaluation de l'incidence chez 326 patients au décours d'une anesthésie générale.

OBJECTIVES: Measuring the incidence of intraoperative recall in our hospital. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: Three hundred and twenty-six patients who underwent a general anaesthesia for elective surgery on selected sites (general, urology, ORL, gynaecology and obstetrical, vascular and cardiac, thoracic) were interviewed on the first or the second postoperative day using a standard questionnaire. When recall was suspected, the anaesthetist was consulted and the anaesthetic record was looked at in order to evaluate the authenticity of any recollections. RESULTS: Four patients mentioned an anomaly evoking intra-operative recall. The reduction in the anaesthetic level would explain authentic recollection for one patient. The recollection of another patient could not be truly verified. The site was the same for these two cases and the anaesthetic protocol for digestive surgery comprised curare and droperidol. The recollections for the two other patients did not correspond to the intraoperative period. The incidence of this phenomenon on the totality of sites was 0.6 per cent. CONCLUSION: This result conforms to other studies. This phenomenon is a quality indicator, but probably under estimated. Although retrospective, this evaluation is quick and easy. This research in post-operative period should be systematic in order to find the reason and to propose an early course of action for these patients. An analysis of the anaesthetic protocol is necessary when the frequency of intraoperative recall is too high.

The in vitro effects of remifentanil, sufentanil, fentanyl, and alfentanil on isolated human right atria.

Because some clinical studies have suggested that opioids used in anesthesia may have different deleterious hemodynamic effects, we compared the direct myocardial effects of cumulative concentrations of remifentanil, sufentanil, fentanyl, and alfentanil on inotropic and lusitropic variables of isolated human myocardium in vitro. Human right atrial trabeculae, obtained from patients scheduled for coronary bypass surgery or aortic valve replacement, were suspended vertically in an oxygenated (95% oxygen/5% CO(2)) Tyrode's modified solution ([Ca(2+)](o) = 2.0 mM, 37 degrees C, pH 7.40, stimulation frequency 1 Hz). The effects of cumulative concentrations (10(-11), 10(-10), 10(-9), 10(-8), 10(-7), and 10(-6) M) of remifentanil (n = 8), sufentanil (n = 8), fentanyl (n = 8), and alfentanil (n = 8) on inotropic and lusitropic variables of isometric twitches were measured. Remifentanil, sufentanil, and fentanyl did not modify active isometric force and peak of the positive force derivative as compared with the Control group. Alfentanil induced a dose-dependent decrease in active isometric force and peak of the positive force derivative. This effect was abolished in the presence of [Ca(2+)](o) = 4.0 mM. None of these opioids altered lusitropic variables.

Delayed diagnosis of vascular injuries during lumbar discectomy.

We report an accidental perforation of the left iliac artery and vein during lumbar discectomy in the kneeling position. During the surgical procedure, a brief and transient hypotension occurred, although the surgeon did not observe any abnormal bleeding in the operating field. In the recovery room, arterial blood pressure decreased, and tachycardia, pallor, and abdominal pain occurred. Retroperitoneal bleeding was suspected. Immediate fluid resuscitation was initiated, anesthesia was continued, and red blood cells were ordered. The use of medical antishock trousers enabled temporization until vascular surgeons were ready. An emergent laparotomy was performed to repair vascular injuries. The delayed symptoms, use of medical antishock trousers, and implications for anesthetists are discussed.

In vitro effects of desflurane, sevoflurane, isoflurane, and halothane in isolated human right atria.

BACKGROUND: Direct myocardial effects of volatile anesthetics have been studied in various animal species in vitro. This study evaluated the effects of equianesthetic concentrations of desflurane, sevoflurane, isoflurane, and halothane on contractile parameters of isolated human atria in vitro. METHODS: Human right atrial trabeculae, obtained from patients undergoing coronary bypass surgery, were studied in an oxygenated (95% O2-5% CO2) Tyrode's modified solution ([Ca2+]o = 2.0 mM, 30 degrees C, stimulation frequency 0.5 Hz). The effects of equianesthetic concentrations (0.5, 1, 1.5, 2, and 2.5 minimum alveolar concentration [MAC]) of desflurane, sevoflurane, isoflurane, and halothane on inotropic and lusitropic parameters of isometric twitches were measured. RESULTS: Isoflurane, sevoflurane, and desflurane induced a moderate concentration-dependent decrease in active isometric force, which was significantly lower than that induced by halothane. In the presence of adrenoceptor blockade, the desflurane-induced decrease in peak of the positive force derivative and time to peak force became comparable to those induced by isoflurane. Halothane induced a concentration-dependent decrease in time to half-relaxation and a contraction-relaxation coupling parameter significantly greater than those induced by isoflurane, sevoflurane and desflurane. CONCLUSIONS: In isolated human atrial myocardium, desflurane, sevoflurane, and isoflurane induced a moderate concentration-dependent negative inotropic effect. The effect of desflurane on time to peak force and peak of the positive force derivative could be related to intramyocardial catecholamine release. At clinically relevant concentrations, desflurane, sevoflurane, and isoflurane did not modify isometric relaxation.

[Mesenteric vein and inferior vena cava thrombosis: disseminated intravascular coagulation and/or G 20210 A mutation of the prothrombin gene?]. / Thrombose veineuse mésentérique et cave inférieure: CIVD et/ou mutation G 20210 A du gène de la prothrombine?

The authors report the case of a 30-year-old man who died from pulmonary embolism and multiorgan failure caused by mesenteric and inferior vena cava thrombosis. The patient was found heterozygous for the prothrombin gene variant (G 20210 A). The family study showed the same asymptomatic anomaly in his brother. This recently described mutation is associated with an increased risk for venous thrombosis. The investigations and treatment of mesenteric venous thrombosis are discussed.

Mechanisms of severe, immediate reactions to iodinated contrast material.

PURPOSE: To measure and elucidate the mechanisms of presumed mediators of unexpected severe, immediate reactions to iodinated contrast materials. MATERIALS AND METHODS: In a multicenter study, 20 patients with mild to severe reactions to iodinated contrast material and 20 control subjects without reactions were evaluated. Ionic contrast material was associated with 18 (90%) of 20 reactions. Concentrations of plasma histamine, tryptase, urinary methylhistamine, specific immunoglobulin E (IgE) against ioxitalamate or ioxaglate, and the anaphylatoxins C3a and C4a were measured with radioimmunoassays; complement C3 and C4 levels were measured with nephelometry. RESULTS: Histamine levels were increased in 14 patients; tryptase levels, in 16; and methylhistamine levels, in six. Histamine and tryptase values correlated with the severity of the reaction (P < .02 and P < .004, respectively). Significantly higher levels of specific IgE against ioxaglate (P < .005) and ioxitalamate (P = .045) were found in patients. No differences were found for complement fractions. Skin test results in two patients with life-threatening reactions were positive for the administered contrast material. CONCLUSION: Histamine release and mast cell triggering are related to severe reactions. An IgE-related mechanism is strongly suspected. Radiologists should be trained to identify and treat anaphylactic shock in patients who react to iodinated contrast material.

Proarrhythmic and antiarrhythmic effects of bupivacaine in an in vitro model of myocardial ischemia and reperfusion.

BACKGROUND: Bupivacaine may have toxic cardiovascular effects when accidentally administered by intravascular injection. However, its electrophysiologic effects in the presence of myocardial ischemia remain unknown. The authors evaluated the electrophysiologic and anti- and proarrhythmic effects of bupivacaine in an in vitro model of the ischemic and reperfused myocardium. METHODS: In a double-chamber bath, a guinea pig right ventricular muscle strip was subjected partly to normal conditions and partly to simulated ischemia followed by reperfusion. The electrophysiologic effects of bupivacaine were studied at 1, 5, and 10 microM concentrations. RESULTS: Bupivacaine (5 and 10 microM) decreased the maximal upstroke velocity of the action potential (Vmax) in normoxic conditions and further decreased (10 microM) the Vmax decrease induced by ischemic conditions. Bupivacaine reduced the mean occurrence time to the onset of myocardial conduction blocks (9 +/- 3 min; mean +/- SD; P < 0.005 with 5 and 10 microM, compared with 17 +/- 6 min during simulated ischemia with no drug or control), and it increased the number of preparations that became inexcitable to pacing (55% of preparations, with 1 microM and 100% with 5 and 10 microM, compared with 17% for the control group). The incidence of spontaneous arrhythmias was reduced by 5 and 10 microM bupivacaine during ischemia and reperfusion and was enhanced by 1 microM bupivacaine during the ischemic phase. CONCLUSIONS: In guinea pig myocardium under ischemic conditions, bupivacaine induced a loss of excitability at concentrations of 5 and 10 microM. Proarrhythmic effects observed at 1 microM were considered as lower than the cardiotoxic range in normoxic conditions. The incidence of reperfusion arrhythmias was decreased at all concentrations.

[Traumatic rupture of the pericardium. A rare diagnosis]. / Rupture traumatique du péricarde. Un diagnostic rare.

Rupture of the pericardium is a rare complication of blunt chest trauma. The diagnosis is difficult and if it remains unrecognized, severe complications such as heart herniation may occur. We report the case of a 19-year-old patient with a traumatic rupture of the pericardium. The diagnosis was suggested by a pneumopericardium seen on the chest radiograph and CT-scan. Emergency thoracotomy enabled localisation of the tear, assessment of its size, and reparation of the tear to prevent heart herniation.

[Severe type 7 Adenovirus pneumoniae in an immunocompetent adult]. / Pneumopathie sévère à Adénovirus type 7 chez un adulte immunocompétent.

We report a case of severe Adenovirus type 7 pleuropneumonia in an immunocompetent adult. The treatment required a mechanical ventilation with tracheostomy. The sequelae was a restrictive respiratory insufficiency. Adenovirus is a common cause of pneumonia in children, in military recruits or in immunocompromised adults. However, it is an infrequent cause of such a severe complication in a healthy adult.

[Indications and role of albumin for vascular loading in the operating room]. / Indications et place de l'albumine dans le cadre du remplissage vasculaire au bloc opératoire.

Prospective clinical studies on albumin and non human colloids, administered peroperatively, were analysed. Only those with a level of evidence I or II were considered. On the basis of the cost-effectiveness ratio, albumin should not be the first choice treatment for peroperative plasma volume expansion. Low molecular weight hydroxyethylstarch is as efficient for restoration and maintenance of volaemia and colloid osmotic pressure. Albumin is administered when other colloids are contra-indicated or when their upper limit of volume has been reached.