Comparative effects on hemodynamics of enoximone (MDL 17,043), dobutamine and nitroprusside in severe congestive heart failure.

To assess their comparative effects on hemodynamics, nitroprusside, dobutamine and enoximone were sequentially administered to 10 patients with severe congestive heart failure. Nitroprusside, dobutamine (at 10 micrograms/kg/min) and enoximone (at 2 mg/kg) increased stroke volume index to a similar extent (31%, 34% and 36%, respectively). Enoximone produced less tachycardia than dobutamine and, consequently, a smaller improvement in cardiac index. Mean arterial pressure was not altered by dobutamine but was reduced 9% by enoximone, 2 mg/kg. This finding accounts for the larger (although not significant) increase in left ventricular stroke work index observed with dobutamine compared with enoximone. Ventricular filling pressures and vascular resistances were significantly decreased by all 3 drugs (p = 0.001). All 3 drugs improved cardiac pump function when assessed by the increase in stroke index to a similar extent; however, enoximone (2 mg/kg) resulted in less hypotension than nitroprusside (mean arterial pressure -9% vs -22%, p = 0.0001) and in less tachycardia than dobutamine 10 micrograms/kg/min. Those differences in mode of action account for the variations observed in the heart rate-blood pressure product (dobutamine 10 micrograms/kg/min, +18%, enoximone 2 mg/kg, -5%, p = 0.003). Enoximone thus appears to be of great value in the management of severe congestive heart failure by its combination of vasodilatory and inotropic properties. Enoximone (2 mg/kg) provides a clinically significant increase in cardiac index, a clear reduction of ventricular filling pressures, a moderate reduction of mean arterial pressure and only minor changes of heart rate and of rate pressure product.

Intensive care course after orthotopic liver transplantation in children.

Eight children 1 to 13 years old, were submitted to OLT. Six patients had normal liver function and complete rehabilitation 4 to 17 months after OLT. Two patients died during their ICU course respectively on day 15 and 34 after operation. The ICU management of the surviving patients is compared to the two fatal cases. At the time of admission in the ICU, there was no difference between the two groups, except for age. All patients were physiologically stable and needed essentially continuous monitoring and nursing care. All were rapidly weaned off artificial ventilation. During the first week after operation, surviving patients demonstrate improvement of liver function test, absence of infection, normal renal function and short ICU stay. They all suffered from systemic hypertension easily controlled by drugs. The two fatal cases were less than 15 months old and did not show improvement of their liver function. They suffered from severe infection, renal failure and protracted systemic hypertension and needed prolonged invasive monitoring and therapy.

Percutaneous peritoneal dialysis as an early treatment of acute necrotic hemorrhagic pancreatitis.

In this study, 8 years experience of early percutaneous peritoneal dialysis (PPD) in the treatment of acute necrotic hemorrhagic pancreatitis (ANHP) are presented. The introduction of methemalbuminemia and the presence of specific ascites rich in amylase, lipase and methemalbumin as early indicators of the presence of ANHP enabled us to confirm the diagnosis in 53 patients, after which early institution of PPD was possible. Thirty patients survived by PPD alone and 9 patients survived by the combination of PPD and surgery, giving an overall mortality rate of 26.4%. A better survival rate of patients having a high Ranson prognostic score was obtained. The introduction of computerized axial tomography (CAT), in 1980 into our hospital allowed us to use this technique for followup. This change and the fact that we were more experienced with PPD, divided our study into two periods: 1976 to 1979, 22 patients; 1980 to 1983, 31 patients. A more aggressive medical approach to treating ANHP was observed during the second period. Surgery was delayed compared to the first period and confined to treating late complications, such as infections, by drainage procedures. Despite the fact that the results were not statistically different, a trend towards a lower mortality rate (19.3%) in the second period compared to the first period (36%) was obtained.

Early diagnosis of peritoneal infection by simultaneous measurement of lactate concentration in peritoneal fluid and blood.

The level of lactate in peritoneal fluid has been suggested to be of great value in the early diagnosis of peritoneal infection [5]. However, this value is affected by multiple systemic factors producing lactic acidosis; these contributed to the high rate of false positive results, obtained in that study. In our study, a better correlation has been found between the peritoneal fluid to blood lactate gradient levels and the presence or absence of peritoneal infection. A threshold gradient level of 2.2 mmol/l in a total of 37 infected and 48 non-infected samples gave the best prediction with a sensitivity of 95% and a specificity of 96%.

[Effects of three types of respiratory assistance (continuous positive pressure, intermittent positive pressure, classical respiratory physiotherapy) on PaO2 and PaCO2 in patients undergoing digestive tract surgery]. / Effets de trois méthodes d'assistance respiratoire sur la PaO2 et la PaCO2 chez l'opéré digestif (pression positive continue, pression positive intermittente, kinésithérapie respiratoire classique)

Two hundred and seventeen patients undergoing digestive tract surgery, either randomly or non-randomly allocated in two separate groups, and presenting postoperative hypoxemia, were studied during intensive care : 77 were ventilated by continuous positive pressure (CPP), 70 by intermittent positive pressure (IPP), and 70 were treated by classical respiratory physiotherapy. Results showed that CPP was the method of choice for ventilatory assistance following digestive tract surgery: hematosis was improved in a prolonged manner without modification of CO2 levels. The other procedures had a beneficial effect on PaO2 but at the price of a hyperventilation. Patients receiving IPP developed hypocapnea and hypoxemia five minutes after the end of the treatment. Physiopathological bases for these differences in gasometric behaviour in patients undergoing digestive tract surgery are analyzed as a function of the characteristics of CPP on the one hand, and IPP and respiratory physiotherapy on the other.

Percutaneous intraaortic balloon pumping: initial experience.

The necessity of surgical procedures for insertion as well as for removal of the balloon catheter remains a serious disadvantage of IABP. The percutaneous technique of insertion and removal of a specially designed balloon catheter is therefore of a great interest. Our initial clinical experience shows that this is simple, rapid and safe and can be performed at the bedside in a few minutes by any physician experienced with arterial catheterization. Its hemodynamic efficiency is identical. No specific complications were encountered although two cases of pulmonary embolism were recorded. A causal relationship between pulmonary embolism and the percutaneous removal of a balloon catheter must therefore be considered.

[Peritoneal dialysis treatment for acute necrotic hemorrhagic pancreatitis (author's transl)]. / Traitement de 30 cas de pancréatite aiguë nécrotico-hémorragique par une dialyse péritonéale médicale.

Thirty patient suffering from acute necrotic hemorrhagic pancreatitis and treated from admission by peritoneal dialysis were studied. According to developments, 4 groups are defined. The first group consisted fo 14 patients treated only by peritoneal dialysis, 3 died. The second group consisted of 7 patients whose peritoneal dialysis was interrupted during hospitalization and who underwent differed surgery. The third group consisted of 5 patients who were operated during the period of peritoneal dialysis, all died. Finally, the fourth group consisted of 4 patients who were dialysed for a short period before emergency surgery, there were no deaths. Peritoneal dialysis, associated with other therapeutic measurements resulted in early improvement of abdominal and toxaemic signs such as shock and functional renal insufficiency. Acute tubular necrosis, observed in 5 patients was reversible in two. Six out of eleven were weaned from assisted ventilation. This allowed the spontaneous resorption of peripancreatic necrotic masses in four cases. Nevertheless it did not prevent the development of new necrotic masses in 5 other cases nor peritoneal infection, seen in 4 cases. It is ineffective in the development of shock lung which followed in 2 cases, during the course of treatment. In all, 11 patients survived by medical peritoneal dialysis only. Of the 30 patients, 19 survived or 63.4%. If the period between the first digestive signs and the installation of the peritoneal dialysis is less than or equal to 7 days, as seen in 21 cases, 15 patients survived or 71.5%.

[Acute necrotic hemorrhagic pancreatitis. Major complications (author's transl)]. / Pancréatite aiguë nécrotico-hémorragique. Complications graves.

Forty-four cases of acute necrotic haemorrhagic pancreatitis are studied. Fourteen cases were treated medically by peritoneal dialysis, 20 were treated surgically of which 16 had been medically treated by peritoneal dialysis. Fifteen died or 34%. Forty-one patients, 93.1% presented 8 major complications on admission and 2 complications were observed during the course of medical treatment (pulmonary shock and high digestive haemorrhage). The post surgical complications are excluded from this study. We report in order of frequency; effusion of the large peritoneal cavity (37 cases : 84%), hypocalcaemia less than or equal to 8 mg% (21 cases : 47.7%), renal insufficiency defined by a creatinaemia greater than or equal 2 mg% (17 cases : 38.6%), state of shock (13 cases : 29.5%), severe neurological disorders (11 cases : 25%), peritoneal haemorrhage (3 cases : 4.5%), disseminated intravascular coagulation (1 case : 2.2%), acute rabdomyolysis (1 case : 2.2%). Certain cases are particularly derogatory : pulmonary shock : 2 cases -- 2 deaths (100%); hypocalcaemia less than or equal to 7 mg/ : 6 cases -- 5 deaths (83.3%); acute tubular necrosis : 8 cases -- 6 deaths (75%); hypocalcaemia less than or equal 8 mg% : 21 cases -- 12 deaths (57.1%); high digestive haemorrhage : 3 cases -- 1 death (33.3%); amber known brown peritoneal effusion : 27 cases -- 12 deaths (44.4%); shock : 13 cases -- 5 deaths (38.5%). When in the same patients, less than 3 complications were present, the mortality rate was 20.8%. If more than 3 signs were observed the mortality rate rose to 53.3%. Except for pulmonary shock, six major complications were needed to give 100% mortality rate.

Prevention by ticlopidine of platelet consumption during extracorporeal circulation for heart surgery and lack of effect on operative and postoperative bleeding.

We studied the effects of ticlopidine, a platelet antiaggregant drug, on platelet consumption during and after extracorporeal circulation (ECC) and on the operative and postoperative blood loss in a double-blind, placebo-controlled trial on 20 patients who underwent open-heart surgery for implantation of a valvular prosthesis. We monitored the changes in platelet count during and after ECC, the need for platelet transfusions to compensate for excessive consumption, and the operative and postoperative blood loss. We also followed the cephalin-kaolin time, the prothrombin time, the fibrinogen level, the fibrin/fibrinogen degradation products, and the euglobulin lysis time. Ticlopidine effectively reduced operative and post-ECC thrombopenia and prolonged the bleeding time. Apart from these changes, no differences in coagulation tests were observed between the ticlopidine-treated group and the placebo group. No side effects were observed. There was no significant difference between the groups concerning operative and postoperative blood loss, indicating that ticlopidine does not induce a hemorrhagic diathesis. Ticlopidine therapy may be of value during the first postoperative days because it prevents clotting on valvular prosthesis and complications such as systemic embolization. However, more trials and controlled studies are needed before such therapy can be recommended for routine use.

[Therapeutic aspects of laparotomy after digestive fistula or after surgical intervention for acute pancreatitis (author's transl)]. / Aspects thérapeutiques de la déhiscence d'une plaie de laparotomie après fistule digestive ou après intervention pour pancréatite aiguë.

Fourteen cases of digestive fistulas, complicated by a dehiscence of the laparotomy wound, are described. Ten patients have a single fistula and 4 have multiple digestive fistulas. There were eleven survivors. This represents a mortality of 21.4%. In 9 cases, the spontaneous recovery of the fistulated zone is followed by a losing of the laparotomy wound. In 2 cases, surgical intervention was necessary to permit the recovery of the fistula and of the dehiscence of the laparotomy. The treatment of such patients requires a mean hospitalization in an intensive care ward of about 48 days +/- 25.8 (SD). The authors report the different therapeutic aspects: the nutritional support, the control of the infection and of the locoregional and systemic complications.

Intravenous amiodarone in the treatment of various arrhythmias following cardiac operations.

In a group of 95 patients having cardiac operations with extracorporeal circulation, intravenous (IV) amiodarone, administered in doses of 2.5 to 5 mg/kg, was used in the treatment of various perioperative arrhythmias. Conversion to sinus rhythm was achieved in 55 (61%) of 90 patients with supraventricular arrhythmias, the other patients showing a satisfactory slowing of their heart rate. Total suppression and control was obtained in 18 patients with persistent ventricular extrasystoles associated with various supraventricular arrhythmias. Amiodarone was administered in five patients with life-threatening ventricular arrhythmias resistant to other antiarrhythmic agents: Suppression was obtained in one of two patients with recurrent ventricular tachycardias and control was achieved in three patients with repetitive ventricular tachycardia and ventricular fibrillation, allowing the effective use of intra-aortic balloon counterpulsation (IABP) needed for hemodynamic support. Seven patients experienced minor side effects such as nausea or flushing. No complete atrioventricular (AV) block was noted. Significant hypotension occurred at the end of the IV injection in 17 (18%) patients. In all but five patients, hypotenion was transient, without clinical complications. In the five others, adrenergic drugs in four cases and IABP in one case were necessary. Those five patients had marked cardiomegaly with poor myocardial contractility. IV bolus injection of amiodarone seems prohibited in such patients; constant infusion would be preferable.

[Therapeutic aspects of dehiscence of a laparotomy wound after a digestive fistula or following intervention for acute pancreatitis]. / Aspects thérapeutiques de la déhiscence d'une plaie de laparotomie après fistule digestive ou après intervention pour pancréatite aiguë.

Fourteen cases of digestive fistulas, complicated by a dehiscence of the laparotomy wound, are described. Ten patients have a single fistula and 4 have multiple digestive fistulas. There were eleven survivors. This represents a mortality of 21.4%. In 9 cases, the spontaneous recovery of the fistulated zone is followed by a losing of the laparotomy wound. In 2 cases, surgical intervention was necessary to permit the recovery of the fistula and of the dehiscence of the laparotomy. The treatment of such patients requires a mean hospitalization in an intensive care ward of about 48 days +/- 25.8 (SD). The authors report the different therapeutic aspects : the nutritional support, the control of the infection and of the locoregional and systemic complications.

Hyaline membrane disease: prognostic factors and medium-term follow-up.

One hundred and twenty two cases of severe hyaline membrane disease are reported. 68 of them survived (57%). Adverse clinical, radiological and laboratory factors, and their effects on the early mortality rate, are analysed with particular reference to the referring centers, delay in admission, transport and the critical state of most infants on admission. The follow-up of 29 survivors treated before 1974 has been examined with reference to birthweight and assisted respiration. Four (30%) of the twelve infants with birthweights below 2000 g had major neurological sequelae. Only two out of the 17 babies with a birthweight over 2000 g had minor mental disturbances.

A case of candida albicans endocarditis 3 years after an aortic valve replacement. Successful combined medical and surgical therapy.

The authors report a case of candida albicans endocarditis occurring 3 years after aortic valve replacement and bacterial endocarditis. They may attempt to the difficulty of the diagnosis, the successful combined surgical and medical treatment, the duration and the follow-up of the therapy and finally the aspect of the side effects of the used antifungal drugs.