[Metabolic risks in surgical hysteroscopy]. / Le risque métabolique de la chirurgie hystéroscopique.

Operative hysteroscopy is often carried out using glycine as an irrigant. This solution has interesting properties but also metabolic effects that are very well known by urologists. This study is concerned with the biological changes that have occurred after one hundred surgical hysteroscopies of which twenty nine were carried out using glycine. In hysteroscopy the significant variations are concerned with blood levels of protein, the haematocrit, changes in sodium levels and glycaemia. 44.9% of patients had changes greater than 5% as compared with the pre-operative levels. These changes concerned the haematocrit readings and in 57.1% the changes in protein in the blood and in sodium in 12%. The haematocrit changes, the protein changes and to a lesser degree the sodium changes could be correlated with one another but not with changes in glycine levels in the blood. Whatever the pathology inside the uterus, glycine went through in equal quantities. It was particularly significant when there was perforation of the uterus. It is linked to the glycine balance and to the length of time the operation had taken. When a mean quantity of fluid of 2.6 litres was used to irrigate, levels after the operation as compared with before the operation had multiplied 4.5 times. This corresponds to the dosage of glycine used. In five patients out of twenty nine post-operative quantities were 10 times those before operation. The consequences of these changes in glycine levels are variable and seem to be more significant in women who have never been pregnant or who are very heavy. Using vasoconstrictor agents does not alter these metabolic changes.

Intraoperative evolution of coagulation parameters and t-PA/PAI balance in orthotopic liver transplantation.

The changes in coagulation and fibrinolysis were investigated in 10 patients undergoing orthotopic liver transplantation (OLT) which is known to be frequently associated with perturbations of haemostasis. The coagulation profile, already deteriorated before surgery in most patients, showed no appreciable further alteration. On the other hand, important modifications of fibrinolytic parameters occurred, essentially concerning tissue-type plasminogen activator (t-PA) and its specific inhibitor (PAI). t-PA activity constantly increased in the course of transplantation, reaching a maximum at the end of anhepaty. Large interindividual variations were noted in the level of t-PA activity (7.5 to 135 IU/ml). Free PAI activity followed a reverse kinetics, remaining low during the anhepatic stage, and dramatically increasing after allograft reperfusion. Despite the fibrinolytic potential related to high circulating t-PA levels, no biologic nor clinical evidence of systemic fibrinolysis was observed peroperatively. These findings suggest that PAI release could represent an early process making the use of antifibrinolytic drugs during OLT unnecessary.

[Fibrinolytic activity in patients undergoing hepatic transplantation]. / Activité fibrinolytique chez les patients opérés pour transplantation hépatique.

Bleeding complications during liver transplantation have been attributed to accelerated fibrinolysis. In order to determine its cause, 11 adults (mean age: 38.9 +/- 13.2 yr) undergoing liver transplantation were studied. There were three groups of patients: cirrhosis (n = 4), fulminating hepatitis (n = 4) and one group including a primary biliary cirrhosis, a hepatic metastasis and a hepatoma. The following factors were studied in the immediate preoperative period, at different surgical times throughout the procedure and 2-3 h after the end of the abdominal sutures: platelet count, prothrombin concentration, fibrinogen, activated kephalin time, factors II, V, VII + X and VIIIc, antithrombin III, protein C, D-dimers, fibrinogen and fibrin degradation products (PDF), plasma plasminogen, tissue plasminogen activator (tPA) and the fast tPA inhibitor (PAi). Preoperatively, only the two patients with hepatic cancer had a normal haemostatic profile. Throughout the procedure, all patients had only moderate changes in platelets, coagulation factors and their inhibitors, and plasminogen, because platelet concentrates and fresh frozen plasma were transfused. Levels of tPA rose, becoming very high during the anhepatic period and just after graft reperfusion. An abrupt fall occurred at the end of surgery. There were important individual differences in tPA activity. PAi activity was low during the preanhepatic and anhepatic stages, rising rapidly after revascularization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Autologous transfusion by peroperative salvage in orthotopic transplantation of the liver]. / Transfusion autologue par recueil peropératoire pendant les transplantations orthotopiques du foie.

As large quantities of blood are required during orthotopic liver transplantation, intraoperative autotransfusion is therefore often carried out in adult patients. This study aimed to assess the ease of use of this technique, its efficiency and possible side-effects. Intraoperative blood salvage was carried out using a Cell Saver 4R (Haemonetics) in 14 patients. The chest blood was collected, anticoagulated with heparin and sodium citrate, centrifuged and washed with Ringer lactate. During surgery, and the subsequent 5 days, the following data were recorded: red cell and platelet count, haemoglobin concentration, parameters of renal function, potassium, citrate and fibrinogen levels, parameters of renal function, blood cultures and the extubation delay. Autotransfusion was simple to use, with no side-effects during the procedure. An average of 20.5 red cell packs were required, of which 59.2 +/- 2.3% were supplied by autotransfusion. The volume of transfused blood was similar, or inferior, to other studies. The different haematological parameters, blood gases and serum potassium levels remained stable. Only 4 +/- 2.8 red cell packs were required postoperatively to maintain a stable haematocrit value. There was no increase in thrombin time, and therefore no effect due to the used heparin. Citrate levels were correlated with the amount of autotransfused blood. They were lower than in other studies because autotransfusion limited the citrate load. There was no haemolysis. Postoperative renal function remained normal. There was no change in the blood coagulation profile, except when large volumes were transfused, resulting in a dilutional coagulopathy. Extubation was always carried out during the first two postoperative days. Bacteriological studies remained negative, no bacteraemia being noted. During orthotopic liver transplantation autotransfusion is a simple, reliable technique, with few side-effects.

[Oral dantrolene in a parturient with myotonic dystrophy and susceptibility to malignant hyperthermia]. / Dantrolène oral chez une parturiente atteinte de myotonie de Steinert et sensible à l'hyperthermie maligne.

A 33 year old woman, with myotonia atrophica and a known susceptibility to malignant hyperthermia, presented during her second pregnancy with multiple episodes of hyperthermia. They were associated with a rapid rise in the serum creatine phosphokinase (CPK) level, and not with infection or a myotonic crisis. Because of the obstetric conditions, caesarean section was planned. Preoperative oral dantrolene was used as prophylaxis. Six days after the start of this treatment, CPK and serum myoglobin levels were back within the normal range. There were no side-effects for the mother nor for the foetus. There were no further increases in either CPK or serum myoglobin levels during surgery or afterwards, but the rectal temperature remained markedly raised for 48 h after the delivery. Oral dantrolene was given during the first nine postoperative days. The occurrence of episodes of high fever during pregnancy linked to MHS and myotonia atrophica is discussed, as well as the anaesthetic management of such a patient. Side-effects of dantrolene for the mother or the foetus are also considered, especially as foetal levels of this drug would seem not to reach therapeutic levels. It would appear interesting to measure maternal dantrolene blood levels, especially if high doses are administered, to avoid reaching therapeutic levels in the foetus.

[Bacteroides fragilis meningitis. 2 cases]. / Méningites à Bacteroides fragilis. Deux observations.

In this study based on 2 personal cases and 23 cases from the literature the main clinical and therapeutic features of meningitis caused by Bacteroides fragilis are reviewed. The disease occurs in either very young or elderly people, with contributing factors in 54% of the cases. Clinically, the infectious syndrome is associated with meningoencephalitis and sometimes motor disorders. Although septicaemia is present in 80% of the cases, the patient's general condition is moderately affected. Blood leucocyte counts are definitely increased and CSF disturbances are those common to all types of bacterial meningitis. The initial focus of infection can be determined in 60% of the cases. The mortality rate is higher in adults than in children. Neurological complications are frequent. Nitro-imidazole derivatives, which are active against Bacteroides fragilis and reach high CSF concentrations, constitute the treatment of choice.

[A severe form of Mediterranean boutonneuse fever]. / Une forme grave de fièvre boutonneuse méditerranéenne.

A severe case of boutonneuse fever was reported which was only diagnosed after death. The infectious syndrome and cutaneous eruption were associated with meningitis, encephalitis, hypoxaemia and thrombocytopaenia. The absence of an initial lesion ("tache noire") and the notion of recent German measles contamination explained the late diagnosis. Serious cases of boutonneuse fever were usually rare; they were better known as Rocky Mountain spotted fever, a rickettsial infection of the same group, the clinical symptoms of which were very similar and which gave the same proteus agglutination reactions as with boutonneuse fever. An earlier diagnosis, now possible thanks to immunofluorescent techniques using skin biopsies, should enable earlier treatment.

[Effects on muscular and general proteolysis in burn patients of a solution enriched with branched amino acids]. / Effets sur la protéolyse musculaire et générale du brûlé d'une solution enrichie en acides aminés ramifiés.

In order to assess the effects of a branched chain amino acid (BCAA) enriched solution on urinary nitrogen loss and muscle protein breakdown, 22 burnt patients were randomly divided into two groups immediately after hospital admission: 11 patients received a 22% BCAA amino acid solution, 11 patients received a 41% BCAA amino acid solution. Nitrogen intake was 0.2 g per day during the first 4 days in each group. Urinary total nitrogen, urinary creatinine and urinary 3,methylhistidine (3,MeHis) were measured for 4 days. Nitrogen balance, 3,MeHis/nitrogen ratio and 3,MeHis/creatinine ratio were calculated in each group. The two groups were compared using Student's test. Nitrogen, creatinine and 3,MeHis urinary excretion, and nitrogen balance were not significantly different in the two groups, except for urinary nitrogen on day 3 which was slightly higher in the 41% BCAA group. The 3,MeHis/nitrogen ratio on day 1, day 2 and during the whole study period, as well as the 3,MeHis/creatinine ratio on day 2, were significantly lower in the 41% BCAA group. These results were in agreement with a decrease in muscle/whole body urinary nitrogen excretion. However, no beneficial effect upon nitrogen loss or nitrogen balance was shown by using the 41% BCAA rich amino acid solution.

[Occult intrapulmonary hemorrhage caused by anticoagulants]. / Hémorragies occultes intrapulmonaires par accidents des anticoagulants.

Intrapulmonary occult bleeding is a serious complication of anticoagulants. Diagnostic difficulties are such that this complication is rarely described: 8 cases in the literature. The authors report two new cases. In both of these patients oral anticoagulant therapy resulted in a severe haemorrhagic syndrome on a clinical (melaena and/or epistaxis) and laboratory (haemoglobin less than 9 g/100 ml and prothrombin time less than 10 p. 100) basis. After a period of 24 to 48 hours, an acute respiratory distress syndrome developed. There was dyspnoea without major haemoptysis, a hypoxia/hypercapnia syndrome and, by X-ray, the rapid development of a diffuse micronodular miliary picture. The diagnosis of intrapulmonary occult bleeding was based upon fibroscopy with bronchoalveolar lavage (BAL) showing the pathological presence of large numbers of alveolar siderophages. However, the worsening of hypoxia brought about by bronchoalveolar lavage is such that careful consideration must be taken before the technique is used. Intrapulmonary occult bleeding must therefore be borne in mind in the presence of an imbalance in anticoagulant treatment complicated by respiratory distress and a reticulonodular radiological appearance.