[Echo-Doppler for early diagnosis of deep venous thrombosis in orthopedic surgery and traumatology. A retrospective study of 1,647 patients]. / Echo-Doppler pour le diagnostic précoce des thromboses veineuses profondes en chirurgie orthopédique et traumatologique. A propos de 1,647 malades explorés.

UNLABELLED: The authors report the results of duplex ultrasound scanning investigation for the detection of deep venous thrombosis after orthopedic surgery and compare asymptomatic and symptomatic populations. PURPOSE OF THE STUDY: To estimate the rate of deep venous thrombosis diagnosed by duplex scanning in those 2 populations and precise their features. MATERIAL: A total of 1,647 in-patients all receiving low-molecular-weight heparin and investigated from 1989 to 1993. either for screening because of high risk of thrombosis (asymptomatic group: 930 patients, mean age +/- SD 63 +/- 17 years) or for clinical suspicion of deep vein thrombosis (symptomatic group; 717 patients, mean age +/- SD: 57 +/- 21 years). Difference between the two groups mean ages were significant (p < 10(-8). METHODS: An Hitachi EUB 450 duplex and an Acuson colour duplex 128 XP, with 3.5 MHz and 7.5 MHz linear probes were used. Veins were tested for compressibility in transverse view from caval site to both ankles. Retrospective analysis of patients database results has been achieved. RESULTS: There was no significant difference in deep vein thrombosis rate between screening asymptomatic group (356/930:38%) and symptomatic group (253/717: 35%). There was a linear relation, in the 2 groups, between age and deep vein thrombosis rate, from 10% before twenty to 45% after eighty years old. For a relative risk to have thrombosis detected before twenty definite at 1, it was 2.1 for 20-29, 4.9 for 40-49, 6.2 for 60-69 and 8.6 later than 80 years old. Proximal deep vein thrombosis was detected in only 5% (87/1,647) of patients. Distal muscular soleal veins were the most usual involved sites of thrombosis. Isolated soleal thrombosis were detected in 16% (270/1,647) of patients. There was non significant difference between the deep vein thrombosis rate after total knee or hip arthroplasty among selected patients for duplex scanning from 1989, and the true prevalence assessed among all the patients who have undergone total hip or knee arthroplaty during the last 6 months. DISCUSSION: Pessimistic results previously reported for duplex screening among asymptomatic patients are not confirmed. Calf vein thrombosis rate assessed by duplex scanning exceeds by 15 a 20% usual rates assessed by contrast venography, among patients receiving low-molecular-weight heparins. That difference could be assigned to the isolated muscular soleal thrombosis usually missed at contrast venography. CONCLUSION: Deep vein thrombosis rate among orthopedic surgical patients, is much higher when detected with Duplex ultrasound scanning than detected with contrast venography, and is related to patient age. Screening for deep venous thrombosis by duplex scanning in orthopedic surgery is as efficient among asymptomatic as among symptomatic patients and could become soon a systematic screening. Soleal vein thrombosis are the most usual. Mechanical calf venous pump stimulation in association with low molecular weight heparin, has to be evaluated in attempting to reduce those muscular soleal veins thrombosis.

[Efficacy and tolerance of Elohes 6% during peroperative normovolemic dilution]. / Efficacité et tolérance de l'Elohes 6% au cours de l'hémodilution normovolémique peropératoire.

This study assessed the cardiovascular stability of intraoperative normovolaemic haemodilution carried out with 6% Elohes during the exchange, the intraoperative, recovery and postoperative periods, as well as its effects on coagulation and renal function. Ten patients, ranked ASA 1, were included. Patients were premedicated with 100 mg of hydroxyzine, and anaesthesia was induced with 2 mg.kg-1 propofol, 3 micrograms.kg-1 fentanyl, and 0.5 mg.kg-1 atracurium. Maintenance was obtained with propofol, fentanyl and 50% nitrous oxide in oxygen. Haemodilution, carried out with a peripheral venous catheter, size 14 G, consisted in the removal of 15 ml.kg-1 of blood and its simultaneous replacement with Elohes 6%. Heart rate, systolic, diastolic and mean blood pressures were recorded before anaesthetic induction, every 5 min during the haemodilution, and thereafter during surgery, recovery and postoperative periods, up to the third postoperative day. Blood haemoglobin, fibrinogen, prothrombin, sodium, potassium, urea and creatinine concentrations, haematocrit, platelet count, and bleeding and activated cephalin times were assessed before and immediately after haemodilution, and on postoperative days 1 and 3. A mean of 1,295 +/- 68 ml of blood were removed during a 32 +/- 2 min period, and replaced by 1,315 +/- 64 ml of Elohes. Haematocrit decreased from 44 +/- 1.1% to 29.7 +/- 0.8%. There were no significant alterations in other parameters, except for an increase in heart rate at the time of extubation. Cardiovascular parameters, as well as the haemodilution, were stable up to the end of the study period. It is concluded that replacing blood with Elohes for intentional haemodilution affords convenient cardiovascular stability.(ABSTRACT TRUNCATED AT 250 WORDS)

[Contribution of autologous blood transfusion in cardiac surgery in the adult]. / Apport de l'autotransfusion sanguine en chirurgie cardiaque de l'adulte.

The use of autologous blood transfusion in cardiac surgery is still controversial. This study was prospectively designed to evaluate the haemodynamic and haematological benefits of this method, with special attention to its impact on reducing bank blood requirements. Between November 1983 and October 1984, 160 patients underwent cardiac surgery with extracorporeal circulation and were randomly assigned to two groups: group I (81 patients) was the control group and group II (79 patients) received autologous transfusion following extracorporeal circulation. Blood was withdrawn immediately after the induction of anaesthesia via a jugular catheter and stored in CPD solution at room temperature. The volume of blood removed was replaced with gelatin solutions; after bypass, blood was returned to the patient. There was no difference in systolic, diastolic or mean blood pressures between the two groups. Right atrial pressure and heart rate were not statistically different in both groups. Myocardial perfusion and myocardial oxygen consumption remained unchanged in group II compared with group I. Complete haematological evaluation was carried out before and during bypass, and thereafter daily for the first twelve days of the postoperative period. There was no significative difference between the two groups in platelet counts, fibrinogen levels, prothrombin and partial thromboplastin times. During extracorporeal circulation, mean haematocrit was 22.9 +/- 0.4% in group II and 25.3 +/- 0.5% in group I (p less than 10(-3)). The mean haematocrit time course was similar in both groups during the postoperative period and returned to preoperative value at discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

[Preventive antibiotics in cardiac surgery: cefazolin versus cefamandole]. / Antibioprophylaxie en chirurgie cardiaque: céfazoline versus céfamandole.

A prospective, randomized study was carried out to evaluate two antibiotic prophylactic regimens for patients undergoing cardiac surgery with cardiopulmonary bypass. Each patient of the first group (cefazolin) received four intravenous injections of 1 g cefazolin during 12 hours, patients of second (cefamandole), four doses of 750 mg. 155 patients scheduled for cardiac operation were included in the study. (May 1983 to April 1984). Patients were not admitted to the study in case of emergency, if their weight was less than 20 kg, if they had received antibiotics during the week before surgery or if they had a history of anaphylactic reactions to cephalosporins. There were no differences between the two groups on age, weight, height, sex, previous history of infectious disease, surgery and intensive care. There were no significant differences between the two groups in minor infections. The rate of urinary tract infection by streptococci was significatively higher (p less than 0.02) in the cefamandole group (38.3%) than in the cefazolin group (17.6%). There were no major infections (septicemia, mediastinitis, endocarditis). Patients temperature was the same during the first four postoperative days. Hospital stay was the similar in the two groups. The two antibiotics are similarly effective to prevent major infections in cardiac surgery. However cefazolin was preferred for antibiotic prophylaxis in cardiac surgery because of the higher rate of streptococcal urinary infections in patients given cefamandole.

[Contribution of hemoconcentration in the recovery of residual blood from extracorporeal circulation circuits]. / Apport de l'hémoconcentration dans la récupération du sang résiduel des circuits de CEC.

The effects of recuperation from the remaining pump circuit blood with restitution to the patient after hemoconcentration are studied in 80 patients undergoing cardiopulmonary by-pass. This population is randomized into two groups: group 1 of 41 patients represents the control group and is compared with the group 2 of 39 patients who undergo the post-by-pass hemoconcentration. The volume of restored blood is 669 +/- 14 ml with an hematocrit of 38 +/- 6,6% and the total protein concentration is 81,2 +/- 2 g.l-1. The heparin level is high (4,24 units.ml-i) and the perfusion of the hemoconcentrated blood must be preceded by a slow injection of 0,8 mg.kg-1 of protamine sulfate. The advantages of this method represent a saving of two homologous blood units (p less than or equal to 10(-4] and the post operative urine output is increased by 32% (p less than or equal to 0,05). No complication, particularly infectious, was observed in this study.

[Complications of surgical treatment of interventricular communications in the infant]. / Complications du traitement chirurgical des communications interventriculaires du nourrisson.

Interventricular communication in the infant is presently treated by complete surgery under extracorporeal circulation and hypothermia. Improved techniques in surgery, anesthetics and resuscitation explain a low, acceptable, level of postoperative morbidity; it is estimated by most authors at 3-4% during the first six months of life. Postoperatively, acute pulmonary arterial hypertension is to be feared, resulting in low cardiocirculatory flow from right ventricle failure. In a group of 20 infants who underwent IVC surgery, the authors have observed two cases of this complication, one being lethal. Its treatment is based on the administration of alpha-blocking vasodilating agents, which can be associated or not with exogenous bêta I-adrenergic catecholamines. Results could probably be improved by preventing such acute postoperative pulmonary arterial hypertension.

[Associated septal and intrapericardial rupture of the heart in the acute phase of myocardial infarction. Apropos of a case surgically treated with success]. / Rupture septale et intrapéricardique associées du coeur à la phase aiguë de l'infarctus du myocarde. A propos d'un cas opéré avec succès.

The authors report the case of a double rupture of the heart (septal and parietal intrapericardial) on the 5th day of primary transmural anterior myocardial infarction in a 73 year old women. The diagnosis of septal rupture was made after cardiac arrest and the findings of a systolic murmur, and by echocardiography. Intrapericardial free wall rupture was diagnosed at surgery. The incidence, predisposing factors, gravity, prognostic factors and different medico-surgical therapeutic approaches to septoparietal complications of acute myocardial infarction are reviewed.

[Pulmonary atresia with major hypoplasia of the pulmonary branches. A radical 2-stage correction]. / Atrésie pulmonaire avec hypoplasie majeure des branches pulmonaires. Cure radicale en deux temps.

Pulmonary atresia with ventricular septal defect (VSD) and severe hypoplasia of the pulmonary branches is a serious malformation and reputedly inoperable. The surgical restoration of a pulmonary outflow tract may nevertheless dilate the pulmonary arterial branches in the long term. The probable mechanism of this effect is related to high right ventricular and pulmonary pulse pressures due to the absence of the pulmonary valve. The right to left shunt, initially, reverses after a few weeks so authorizing closure of the VSD. Two patients, an adult and a child, were successfully treated by this technique.

[Advantage of nicergoline after cardiac surgery in an adult (author's transl)]. / Chirurgie cardiaque chez l'adulte. Intérêt de la nicergoline intraveineuse dans ses suites (43 cas).

Hemodynamic effects of nicergoline injected by intravenous route were studied in 43 patients early after open-heart operations. A serial witnesses has been compared with 5 other groups for which the posologies were increased. Catheterisms of radial artery and pulmonary artery allows the measuring of systolic arterial pressure (SP), right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP) and cardiac index (CI). The heart rate (HR) was noticed. The systemic vascular resistance (SVR), the stroke index (SI) and the left ventricular stroke work index (SWI) were calculated. The results were statistically analysed by the Student test. After injection of a bolus of 0,3 mg kg-1 by intravenous route, stable effects are obtained with a maintenance posology of 0,8 mg.kg-1.h-1. The SP diminishes by 20 p. cent (123 to 104 mm Hg; p less than 0,01). There is a loose of 16 p. cent from the RAP (9,5 to 8 mm Hg; p less than 0,05) and of 18 p. cent from the PCWP (16,5 to 13,5 mm Hg; NS). The HR decreases by 13 p. cent (97 to 81 syst. min.-1; p less than 0,05). The CI increases by 25 p. cent (2,2 to 2,75 1.min.-1m-2; p less than 0,01); the SI by 40 p. cent (35 to 35 ml beat-1m-2; p less than 0,01) and the SWI by 32 p. cent (27,5 to 36 g.m.m-2; p less than 0,05). We conclude from this investigation that nicergoline injected through intravenous route with an output of 0,8 mg.kg-1.h-1 mainly leads to afterload reduction. Thanks to its effect on the CI and on the HR as well as to its mild to moderate action, it is a clinical useful agent for primary or adjunctive therapy of postoperative low cardiac output.

[Pulmonary artery catheterization. Advantages of internal jugular route. 75 cases (author's transl)]. / Le cathétérisme de l'artère pulmonaire. Intérêt de la voie jugulaire interne. 75 cas.

The authors relate, after 75 cases, their experience of pulmonary artery catheterism carried out in case of cardiac surgery intervention. The Swan-Ganz catheter is exclusively introduced by the percutaneous internal jugular route and generally right (82 p. cent). During the progression of the catheter the radiologic control is not necessary. The complete failures are rare (2,5 p. cent) and the right pulmonary artery is mostly catheterised in every case. Complications are exceptional and often correspond to benign incidents like premature ventricular contractions which always disappear spontaneously, balloon ruptures (three cases) and the isolation of a non-pathogenic organism during the systemic bacteriologic examination without infections reactions. A serious infection complication has been found in one case and a pulmonary infarction is observed in another case. Compared with other venous route the advantages of this method lie in its very easy, simple, fast and trusty execution.

[The management of mediastinal infection following cardiac surgery. Role of the reanimation and of hyperalimentation (author's transl)]. / Traitement des médiastinites suppurées aiguës dans les suites de la chirurgie cardiaque. Rôle de la réanimation et de l'hyperalimentation.

Apprehended complication of the cardiac surgery by median sternotomy, the mediastinitis leads very often to a high death rate, a long hospital-treatment, frequent and sometimes serious sequelae. Considering eleven cases, we are trying to show the interest brought by the choice of the immediate thorax-closing method, in so far as this technic is associated with a correct disinfection of the mediastin a good irrigation-drainage properly well-maintained and overseen, a reanimation technic the main purpose of which is to assure a sufficient caloric and nitrogenous supply.