[Blood requirements and transfusion practice evolution in surgery]. / Evolution des besoins transfusionnels en chirurgie.

During the years 1990, the focus was on transfusion hazards and blood savings strategies. This resulted in a decrease in labile blood products consumption. For a few years, there is a reverse tendency, with a reincrease in blood products consumption. In the same time, the limit of saving strategies has been attained, by identifying the risk of lack of transfusion (or too low transfusion threshold). A so-called multimodal blood savings strategy must be set. Vigilance is mandatory concerning the blood savings strategies that are detailed by scientific societies consensus conferences. Those strategies include a good anticipation of blood requirement, improvement of surgical techniques, pre- and intra-operative autologous transfusion, blood clotting pharmacological improvements, and anesthesia techniques. Transfusion today is relatively safe. Blood requirements must be precisely assessed to avoid going from Charybdis to Scylla i.e. from over- to under-transfusion.

[Validity of pretransfusion bedside agglutination tests for pretransfusional control]. / Etude régionale de validité, dans les services de soins, du test d'agglutination du contrôle ultime prétransfusionnel.

The incidence rate of ABO hazards of transfusion remains high in France. In this country, bedside pretransfusion controls include an agglutination test for red cells only, although its validity has scarcely been assessed in the practice. 847 nurses from 9 public hospitals and private clinics in a French region participated in a study aimed at measuring the sensitivity and specificity of pretransfusion bedside agglutination tests within hospital wards. Sensitivity was found to be 93.9% +/- 3%. Nondetection of mismatching was increased by two risk factors only: having worked more than 4 years in the same ward, and not having been trained to use this test. The sensitivity of this test might still be improved. This test is found sensitive enough to be kept. Nevertheless, if used alone, it is not a safe protection against recipient's mismatch. Authors recommend both to improve agglutination test sensitivity and to link it strongly to the bedside checking of both transfusion information and the recipient's identity.

[The use of opioids by the regional route in obstetrics]. / Utilisation des morphinomimétiques par voie régionale en obstétrique.

Epidural and spinal administration of opioids in obstetrics can be used during labour and for cesarean section. Although these routes of administration are of limited use when opiates are employed as sole agents, the association with local anesthetics may improve the characteristics of analgesia. The administration of a local anesthetic-opiate mixture allows a reduction of the total amount of local anesthetics, thus reducing the incidence of maternal hypotension and the percentage of instrumental extraction. In the particular setting of cesarean section, opioids could shorten the onset and improve the quality of the duration of analgesia. Opioids may also be used for postoperative analgesia after cesarean section. Since they could be responsible for an opioid-related respiratory depression in the mother and the neonate, a strict supervision is absolutely necessary following this particular mode of administration of opiates. If human and technical means of supervision failed to bring into operation, it would be better not to use opioids by the spinal route in such a context.

Rapid pre-operative immunotherapy in a patient allergic to muscle relaxants.

Allergic reactions to muscle relaxants are not uncommon. Although, in most instances, divalent quaternary ammonium salts are involved in these reactions, some monovalent quaternary ammonium compounds can trigger IgE-mediated reactions. A woman who suffered from several episodes of anaphylaxis with divalent (suxamethonium) and monovalent quaternary ammonium salts (tiemonium) needed surgery. Regional anaesthesia was contra-indicated owing to a possible intolerance to local anaesthetics. Investigation confirmed an allergy to monovalent quaternary ammonium salts. Rapid immunotherapy was started with a monovalent quaternary ammonium salt (tiemonium) and subsequently followed by a general anaesthesia using vecuronium. The patient did not develop anaphylactic symptoms.

Epidural analgesia with a bupivacaine-fentanyl mixture in obstetrics: comparison of repeated injections and continuous infusion.

We compared the efficacy and side-effects of continuous infusion versus repeated injections of epidural bupivacaine-fentanyl during labour. Forty-four parturients were randomly distributed into two groups balanced for population size, morphology and parity. Analgesia was begun at the same stage of labour with a mixture of 20 ml 0.25 per cent plain bupivacaine and 2 ml (100 micrograms) fentanyl. In Group I the initial dose ranged from 8-12 ml as a function of height; an injection of the same dose was repeated immediately upon recurrence of pain. In Group II, after an initial dose of 5-7 ml, a continuous infusion of 3 ml.h-1 was begun, and continued until full dilatation. Analgesia was rated using a pain scale; effects on maternal blood pressure, respiratory rate and neonatal status were noted. Bupivacaine and fentanyl assays were carried out on maternal venous blood in 30 parturients during the course of labour. There was a longer latency to onset of analgesia in Group II (approximately five minutes), followed by a more constant degree of analgesia. This better analgesia cannot be accounted for by a difference in dosage; doses were significantly lower in Group II, despite the fact that labour was of the same duration. The course of labour, and maternal and neonatal status were comparable in the two groups. Assays showed no difference in bupivacaine blood concentrations between the two groups nor signs of drug accumulation. The constant infusion technique is advantageous since it provides a more regular degree of analgesia with lower doses than those required for patients having repeated injections.