[Complete heart block and myocardial ischaemia during a severe anaphylactic reaction]. / Bloc auriculoventriculaire complet peranesthésique et ischémie myocardique contemporains d'un choc anaphylactique grave.

An 83-year-old man had to be operated under general anaesthesia for a head skin tumor. The preanaesthetic exam of the cardiovascular function was reassuring but a cardiac arrest with a complete heart block occurred a few minutes after induction of anaesthesia. Resuscitation managing was successful but a myocardial ischaemia appeared. Biological tests confirmed severe anaphylactic reaction. The electrocardiographic expression, pathophysiology and management of cardiac anaphylaxis are discussed.

[Antibiotic prophylaxis in surgery of the esophagus]. / Antibioprophylaxie en chirurgie de l'oesophage.

Surgery of oesophagus carcinoma is a long and major procedure. Perioperative radiochemotherapy is often required. Therefore many factors favour the occurrence of local and general postoperative infection, justifying an antibiotic prophylaxis directed against oesophageal and gastric flora. In case of oesophageal stenosis, the oesophageal floral often switches to the fecal type. Antimicrobial agents diffuse to the surgical site and reach there high concentrations for the time of surgery. We recommend, just prior the induction of anaesthesia the intravenous administration of a single dose of a third generation cephalosporin (ceftriaxone 2 g) and nitroimidazole (ornidazole 1 g). The long half-life of these agents allows sufficient concentrations at surgical site to be obtained and the efficacy of this regimen has been demonstrated. Selective decontamination of the digestive tract with systemic antibiotherapy is another approach for the prevention of postoperative complications of surgery of oesophagus carcinoma.

[Mesentric venous thrombosis. Risk factors, treatment and outcome. An analysis of 18 cases]. / Thromboses veineuses mésentériques. Facteurs de risque, traitement et évolution. Analyse de 18 observations.

Eighteen patients with an acute thrombosis of the splanchnic veins were reviewed. Most of apparently idiopathic cases of splanchnic vein thrombosis are related to an increased coagulation related to a congenital or acquired defect of haemostasis. The aim of this study was to assess the effects of a new and effective treatment. Nine male and 9 female patients (range of age: 19 to 81 years) experienced a mesenteric venous thrombosis. There were 14 mesenteric vein thromboses with infarction, two transient mesenteric venous ischaemias without bowel infarction and two acute thromboses of the splanchnic veins without bowel ischaemia. A coagulopathy was detected in seven patients: oral contraception, protein C (PC) or antithrombin III (AT III) congenital deficiencies, acquired deficiency of AT III, PC and protein S (PS), polycythaemia in the post-partum period and primary myeloproliferative disorder. No coagulopathy was associated with thrombosis in eight cases: mesenteric haematoma, splenomegaly, cirrhosis, appendicectomy, cholescytectomy, chronic heart failure, treatment with beta-adrenergic receptor antagonist and digitalis, stenosis of the portal anastomosis after liver transplantation. Twelve patients required surgery: eight intestinal bowel resections with immediate anastomosis, four resections without immediate anastomosis. Only one patient underwent a second look for a repeat bowel resection. No death occurred in the early postoperative period and 17 out of 18 patients were alive after 12 years. An oral anticoagulant therapy was undertaken from two months to seven years. However, three patients suffered a recurrent thrombosis. Two of them required a long-term anticoagulation. Six patients experienced a portal hypertension and oral anticoagulants were discontinued in three of them because of bleeding oesophageal varices. Six patients were treated only by unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by oral anticoagulants. After laparotomy, two were only treated with UFH without any bowel resection, as mesenteric venous ischaemia was too extensive. These observations suggest that the choice between an appropriate medical or surgical treatment is important and must be discussed. Since 1989, the therapeutic choice has been modified by ultrasonography and contrast enhanced computed tomographic scan which confirms diagnosis, allows to follow up and check the effects of anticoagulation and to choose the time for surgery. When the diagnosis is established and the patient's risk is low, the IU . kg(-1) . d(-1) to obtain an antifactor Xa activity between 0.3 and 0.6 antiXa IU mL(-1). When the diagnosis is uncertain and the patient's risk if high a laparotomy is required.(ABSTRACT TRUNCATED AT 400 WORDS)

[Early biological markers of anaphylactoid reactions occurring during anesthesia]. / Marqueurs biologiques précoces des réactions anaphylactoïdes peranesthésiques.

Three markers of in vivo histamine release, i.e. plasma histamine and tryptase, and urinary methylhistamine, were assessed using sensitive radioimmunoassays in 18 patients who had experienced an adverse reaction to an anaesthetic agent. Controls were obtained from 35 patients following a general anaesthetic, which included a muscle relaxant, and who remained free from any adverse reaction. A first blood sample was obtained from all 18 patients a mean 25 +/- 26 min after the reaction, and a second one in thirteen a mean 120 +/- 65 min after the reaction. Ten patients had had a life-threatening reaction. Plasma histamine levels were increased in all these cases, and tryptase concentrations in 9 out of 10. Urinary methylhistamine rarely reached pathological levels (4 out of 10). Skin tests were positive in the four tested patients. Plasma histamine concentration was still high in 8 cases thirty minutes after the reaction, and remained increased for more than 2 h in two patients. Among the other eight patients with a moderate reaction, 3 had high histamine levels, with normal or weakly increased tryptase concentrations, and normal urinary methylhistamine. Two of these patients had positive skin tests. There were no abnormal findings in any of the investigations carried out in the other five patients, except for a slightly positive skin test to atracurium in one patient. Plasma histamine had a higher sensitivity than tryptase levels. Methylhistamine concentrations were only rarely of interest. There were no false positives with the three investigated markers.(ABSTRACT TRUNCATED AT 250 WORDS)

Biochemical markers of anaphylactoid reactions to drugs. Comparison of plasma histamine and tryptase.

Adverse reactions to drugs require that their mechanisms be elucidated, particularly when anaphylaxis is suspected. Early diagnosis can be achieved by plasma histamine measurements. Unfortunately, the short plasma half-life of histamine and the difficulties in handling the sample usually preclude this measurement, although a sensitive radioimmunologic kit is routinely available. It has been recently suggested that mast cell tryptase, a component of the mast cell granules, could provide an alternative to histamine determination. We have measured plasma histamine and tryptase in 19 patients who developed possible anaphylactoid reactions to anesthetic or other drugs. Eight patients had increased values for both histamine and tryptase. In 4 a muscle relaxant drug was proved responsible for the reaction. Six patients had normal levels for both substances. In each case, the clinical signs of anaphylaxis were moderate. Two patients had normal histamine and high tryptase concentrations, due to late sampling (greater than 5 h). In 2 other patients, histamine was high, with normal tryptase: in 1, muscle relaxant allergy was further demonstrated. Tryptase half-life was equal to 90 min in 3 patients. At least 15 min was necessary to reach the peak level when the responsible drug was administered intravenously. The best time for measuring tryptase was 1-2 h after the reaction (not greater than 6 h), whereas for histamine it was 10 min to 1 h. We conclude that measurement of plasma tryptase along with measurement of plasma histamine may aid in diagnosis of anaphylaxis.

[Hereditary deficiency of antithrombin III, protein C and protein S. A study of 31 patients from 8 unrelated families]. / Les déficits constitutionnels en antithrombine III, protéine C et protéine S. Etude de 31 sujets appartenant à huit familles non apparentées.

The families of eight unrelated patients were studied with regard to a hereditary deficiency in antithrombin III (ATIII), protein C, or protein S. These deficiencies were recognized in the course of investigations for deep-vein thrombosis (DVT) in the eight patients. A group of 31 individuals (patients and family members), mostly less than 40-year-old was explored. Two cases of AT III deficiency were discovered, as well as 21 of protein C deficiency, and seven of protein S. Ten of the 30 have had recurrent venous thrombosis at the time of bedrest, trauma, surgery, pregnancy, postpartum or during oral contraceptive treatment. Spontaneous DVT occurred in three cases. Seventeen patients had remained asymptomatic till then. Such patients need antithrombotic treatment during surgery or pregnancy. Prophylactic treatment with enoxaparin in one patient (deficiency in protein C) during her second pregnancy is discussed. It seems that low molecular weight heparin may be a safe alternative to unfractionated heparin. Oral anticoagulants are efficient in preventing reoccurring venous thromboembolism in patients with AT III deficiency. The questions of whether oral anticoagulants should be continued in the long-term in patients with protein C or protein S deficiency who have had a DVT, and whether asymptomatic deficient patients should be given any antithrombotic treatment outside circumstances likely to induce a DVT, remain as yet unanswered.

[Biological criteria for the evaluation of prophylactic treatment with a low molecular weight heparin (Kabi 2165)]. / Critères biologiques d'évaluation d'un traitement prophylactique par une héparine de bas poiids moléculaire (Kabi 2,165).

Efficacy of a low molecular weight heparin (Kabi 2165) was compared with that of non-fractionated heparin in the prevention of abdominal surgery postoperative venous thrombosis by means of a double-blind randomized trial in 79 patients. Determination of D. dimers in these patients allowed assessment of specificity of this assay for detection of postoperative venous thrombosis.

[Evaluation of the activity and quality of care in a digestive surgery department]. / Evaluation de l'activité et de la qualité des soins dans un service de chirurgie digestive.

Since 1980, details of all patients operated upon in a digestive surgery unit have been entered on record-cards with the view of obtaining information on the activity of the unit and improving post-operative care. Over a 3-year period, 2005 patients underwent surgery, 25% of them for cancerous lesions. Biliary tract operations (385 patients), fundoplication by the abdominal route for gastro-oesophageal reflux (58 patients) and curative resection of the colon for carcinoma (100 patients) were set apart for evaluation. For each of the above pathologies, morbidity, mortality and duration of stay in hospital in cases with uneventful or complicated post-operative course were analyzed. Annual audits of this kind result in accurate evaluation and periodical reappraisal of the therapeutic habits of the medico-surgical team.

[Lethal complication related to the per-operative insertion of a naso-gastric tube. A case (author's transl)]. / Adénome de l'hypophyse méconnu. Perforation accidentelle mortelle lors de la pose d'une sonde gastrique.

The patient who was operated on for the recurrence of a colic cancer had an unknown pituitary adenoma. The adenoma was destructing partly the anterior basis of the skull and was protruding in the nasal fossae. The naso-gastric tube entered without any difficulty the right cerebral hemisphere creating lethal cerebral lesions. Some reflexions determined by this very rare condition are discussed.