[French scientific contributions to anesthesia. Curares and the neuromuscular junction]. / L'apport des scientifiques français a l'anesthésiologie. Les curares et la jonction neuromusculaire.

In France, a number of scientists from the fields of chemistry, physiology and surgery have been interested in anaesthesiology. Claude Bernard, who published in 1872 the most exhaustive studies on anaesthesia, was also interested from 1844 in drug curare. He created a methodology, studied pharmacology, including pharmacokinetics and demonstrated the specific action on motor nerves while muscle retained its irritability. It was however A. Vulpian who put forward the idea that curare does not affect the nerve itself but may act on a "linking substance" between nerve and muscle. In these times (1862), Rouget described the end apparatus at the nerve-muscle junction in a way which was finally accepted by German authors. Fifty years later, Couteaux achieved the microanatomic study of the end plate (1909). More recently (1972), Changeux and his team isolated the acetylcholine receptor from the electric organ of the torpedo fish.

'Candidatus phytoplasma japonicum', a new phytoplasma taxon associated with Japanese Hydrangea phyllody.

A phytoplasma was discovered in diseased specimens of field-grown hortensia (Hydrangea spp.) exhibiting typical phyllody symptoms. PCR amplification of DNA using phytoplasma specific primers detected phytoplasma DNA in all of the diseased plants examined. No phytoplasma DNA was found in healthy hortensia seedlings. RFLP patterns of amplified 16S rDNA differed from the patterns previously described for other phytoplasmas including six isolates of foreign hortensia phytoplasmas. Based on the RFLP, the Japanese Hydrangea phyllody (JHP) phytoplasma was classified as a representative of a new subgroup in the phytoplasma 16S rRNA group I (aster yellows, onion yellows, all of the previously reported hortensia phytoplasmas, and related phytoplasmas). A phylogenetic analysis of 16S rRNA gene sequences from this and other group I phytoplasmas identified the JHP phytoplasma as a member of a distinct sub-group (sub-group Id) in the phytoplasma clade of the class Mollicutes. The phylogenetic tree constructed from 16S rRNA gene sequences was consistent with the hypothesis that the JHP phytoplasma and its closest known relatives, the Australian grapevine yellows (AUSGY), Phormium yellow leaf (PYL), Stolbur of Capsicum annuum (STOL) and Vergilbungskrankheit of grapevine (VK) share a common ancestor. The unique properties of the DNA from the JHP phytoplasma clearly establish that it represents a new taxon, 'Candidatus Phytoplasma japonicum'.

[A pioneering anesthesiologist, the surgeon Theodore Tuffier]. / Un anesthésiste d'avant garde, le chirurgien Théodore Tuffier.

Théodore Tuffier (1857-1929) was a great surgeon. A part of his interest non well know and reported in this paper was fundamental and technical research in anesthesia.

[Fibrinolytic inhibitors and prevention of bleeding in cardiac valve surgery. Comparison of tranexamic acid and high dose aprotinin]. / Antifibrinolytiques et prévention du saignement en chirurgie cardiaque valvulaire. Comparaison de l'acide tranexamique à l'aprotinine à haute dose.

In order to assess the effects of tranexamic acid in comparison to the high dose regimen of aprotinin recommended by Royston and considered to be the reference in postoperative bleeding in cardiac surgery, 35 consecutive patients were randomised to two groups according to the product prescribed. The global postoperative bleeding was comparable in the two groups (p = 0.49). One surgical reoperation for haemostasis was required in the reference group. There was one case of renal failure in the same group due to cardiac failure. No thrombotic complications were observed. Platelet function, as judged by the bleeding time and platelet aggregation to ristocetin, was the same in the two groups. The D-dimers remained low in both groups, reflecting the absence of intravascular coagulation and fibrinolysis. Tranexamic acid was as effective and as safe as high dose aprotinin. These two substances, in addition to their fibrinolytic inhibitory activity, conserved platelet protection by blocking the action of plasmin. These results seem to justify the preventive use of tranexamic acid from the moment of skin incision, especially in reoperation.

[Natriuresis and atrial natriuretic factors during extracorporeal circulation for cardiac surgery]. / Natriurèse et facteur atrial natriurétique au cours des circulations extracorporelles pour chirurgie cardiaque.

At the end of cardiopulmonary bypass (CPB) diuresis and natriuresis are widely modified. Those are classically due to the CPB conditions (mean arterial pressure, non pulsatile flow, hypothermia, long duration ...). Previous studies showed no evidence of these modifications being due to variations of hormones such as vasopressin, renin or aldosterone. The atrial natriuretic factor, cardiac hormone mainly known for its natriuretic effect, would contribute to explain these facts. This study includes 17 patients NYHA I or II without any renal dysfunction or diabetes mellitus. They were scheduled for cardiac surgery under CPB (valvular replacement or aortocoronary bypass). Sampling times were: TO: after induction of anaesthesia and before surgical incision; T1: during steady CPB; T2: 30 min after CPB release. At each time were obtained: diuresis, osmolar and free water clearance, fractional excretion of sodium, haematocrit, plasma concentration of ANF (pANF), and right atrial pressure and capillar wedge pressure in case of aortocoronary graft. FeNa at the end of CPB is significantly linked to the osmolar clearance and the CPB duration. FeNa evolution is parallel with pFAN evolution. At the end of CPB pFAN is first linked to cardiac rate, then to CPB duration. Cardiac filling pressures after and before CPB are not different. pANF after CPB cannot be attributed to these pressures. Numerous factors are involved in the renal sodium elimination. An evident statistic link between pANF and FeNa is then difficult to demonstrate. Their parallel evolution is coherent and suggests that ANF is the main hormone of natriuresis at the end of CPB. ANF secretion factors at the end of CPB remain unclear. This study emphasizes the involvement of cardiac rate and CPB duration in pANF increase at the end of CPB.

[Bacterial infections after heart surgery under extracorporeal circulation. Effects of autologous and homologous transfusions]. / Infections bactériennes après chirurgie cardiaque sous circulation extra-corporelle. Effets des transfusions autologues et homologues.

To verify that the rate of post operative infections is higher with homologous transfusion rather than without, 86 coronary artery bypass patient charts were retrospectively studied. Inclusion criteria were those of the autologous transfusion group. Four groups were defined : Gr 1 : No transfusion. Gr 2: Autotransfusion. Gr 3: Allotransfusion. Gr 4: Autotransfusion who also received homologous blood products. Although not significant, the bacterial infection rate was twofold higher in the Gr 3, than in the autologous group and was almost four times higher and significant (p < 0.01) when patients who received homologous blood products were compared to those who did not. These preliminary results lead us to enlarge our autotransfusion program and us encourage, to search for the cause of the decreased infection rate after autologous transfusion by prospective studies.

[Cardiac failure caused by cardiomyopathy disclosing pheochromocytoma. Perioperative treatment]. / Défaillance cardiaque par cardiomyopathie révélatrice d'un phéochromocytome. Traitement péri-opératoire.

A case of cardiomyopathy secondary to an unrecognised pheochromocytoma is reported. It was cured by successful outset with congestive cardiac failure with an ejection fraction of 11%. Following medical treatment including a beta-blocker and converting enzyme inhibitors, the situation remained so disturbing that cardiac transplant was envisaged. It was nevertheless decided to first remove the tumour, with mechanical circulatory assistance cover if necessary. Surgical excision proved to be relatively easy. Cardiac failure disappeared clinically within a few days, though a degree of myocardial impairment revealed by paraclinical investigations persisted after ten months. The pathophysiology, beneficial effect of beta-blockers and the SvO2 usefulness blood during the perioperative period are discussed. The prognosis of the cardiomyopathy, considered up to the present to be uncertain, new seems favourable once it is possible to completely excise the tumour.

[The use of antifibrinolytics in heart surgery. 3 prospective studies]. / Emploi des antifibrinolytiques en chirurgie cardiaque. Trois études prospectives.

In order to assess the validity of antifibrinolytic treatments in cardiac surgery, three successive controlled randomized double-blind studies were carried out in patients undergoing a first (n = 60) or repeat surgical procedure because of a valvular or coronary disease. The first study aimed at stating the value of low doses of aprotinin compared with "classical" ones and a placebo. The second study was planned to compare tranexamic acid with low-dosed aprotinin and a placebo. The last study applied to reiterated procedures and compared tranexamic acid with classical and reduced aprotinin dosages, without a placebo group. Effects were estimated on postoperative bleeding, blood transfusions, platelets function and possible complications such as thrombosis or seric creatinine elevation. A reduced bleeding was observed in the non-placebo groups of studies I and II. The 3d study did not show any significant differences in this respect between the three methods. Tranexamic acid was found as effective as aprotinin on platelets function. No significant changes of seric creatinine was observed from preoperative to 4th postoperative day. A valvular non-obstructive thrombosis occurred on the second postoperative week in the tranexamic acid group.

[Evolution of the blood levels of propofol administered by continuous perfusion during extracorporeal circulation]. / Evolution des niveaux sanguins de propofol administré en perfusion continue au cours de la circulation extracorporelle.

The pharmacokinetics of propofol administered in continuous infusion was studied in 10 patients without left ventricular insufficiency during extracorporeal circulation (ECC) with hemodilution, for aortocoronary bypass. After a dosage of 1.5 mg.kg-1 during anaesthetic induction, the blood level was 4,800 micrograms.l-1. Under continuous infusion levels remained very high: they decreased by 40% during EEC induction and rose more than 10% when artificial ventilation started again. These modifications can be explained by physiological variations induced by EEC (non pulsated flow, redistribution, vasoconstriction, hemodilution, hypothermia) and they lead to adapt dosages in this type of anaesthesia.

[Evaluation of epidural analgesia. Analysis of a prospective questionnaire answered by 100 women who delivered with epidural analgesia]. / Evaluation de l'analgésie péridurale. Analyse d'un questionnaire prospectif chez 100 femmes ayant accouché sous analgésie péridurale.

An enquiry was carried out by sending 368 women a double questionnaire at the eighth month of pregnancy and after delivery, in order to assess their opinions and motivations as far as epidural anaesthetic was concerned, and how far their expectations had been fulfilled. One hundred forms were returned. The sample was: 64% primipara and 36% multipara, of whom 64 women were married, 27 living in a stable relationship and 9 living on their own. 85% had a profession and 52% were in a higher social category. Eighty two of the women asked for an epidural in order to: in 58% of cases participate in their delivery, and in 31% of cases bond with the child. 57% hoped for less pain rather than for complete absence of pain which was asked for in 43%. Of the 36 multipara, 34 asked for epidural analgesia. Those who refused to have an epidural thought that they would be able to live through the delivery in a more natural way (44%) and 52% thought the process had become too medicalized and that complications of a medical nature might supervene. 33% gave no reason for refusing. This group contained more primipara (16) than multipara (2). These primipara thought that epidural analgesia would stop them taking part in the delivery and 10 of these knew that they would have pain in the delivery. Post partum replies showed that 58% had a higher opinion of epidural after than before the delivery and 93% were highly satisfied with the analgesia that they received. This despite the fact that the techniques were not perfect. Seven women thought the procedure unsatisfactory although there were no technical faults but the enquiry showed that they expected more from epidural analgesia. Whether they were satisfied or not, 98% of the women said that they would ask for epidurals in subsequent deliveries.

[Diaphragmatic paralysis after puncture of the internal jugular vein]. / Paralysies diaphragmatiques après ponction jugulaire interne.

Two cases of paralysis of the diaphragm occurring after puncture of the internal jugular vein are reported. Both were old cancer patients, requiring an internal jugular venous catheter for intravenous feeding. Although the catheter was easily placed in both cases, the diagnosis of diaphragmatic paralysis was made postoperatively. The first patient remained asymptomatic, despite paradoxical breathing when lying supine; there was no change in her condition up to her death 4 months later. The second patient became increasingly breathless, with hypoxia and hypercapnia, during recovery from a gastrostomy under general anaesthesia. She required artificial ventilation, from which she could not be weaned and died 25 days later. A lesion of the phrenic nerve is possible when placing an internal jugular venous catheter, because they are closely related behind the sternocleidomastoid muscle. In the opposite to compression by a haematoma, or transient blockade following local anaesthetic infiltration, such a direct injury may be irreversible.

[Anesthesia in a medical unit for treatment of trophic disorders of vascular origin]. / Anesthésie en milieu médical pour soins des troubles trophiques d'origine vasculaire.

The authors report here a first experiment of anaesthesia in a medicine unit. 29 anaesthesias were performed for 22 patients classed ASA II and III. The indications were nurses dressing for trophic troubles related to extremely painful vascular diseases. The whole treatment was realised in the medicine ward. Anaesthesia consists first in morphine injection as a premedication then several injections of propofol and alfentanil combined. The heart beat frequency was still and the blood pressure never lowered more than 10% of the preoperative level. No incident occurred. The awaking was of good value and without discomfort. The usual autonomy is regain in 2 hours after anaesthesia. This type of anaesthesia offers a new approach of painful cares and through a better dressing should lower the hospital stay.