[Esophageal bezoar resulting from nasogastric enteral feeding in an intensive care unit]. / Bézoard oesophagien survenu chez des patients recevant une alimentation entérale en réanimation.

We report two cases of oesophageal bezoar in patients given enteral nutrition by nasogastric tubing in an intensive care unit. These two complications occurred during the year following the replacement of our standard enteral feed by a new preparation enriched in proteins. In both patients, the bezoar could be endoscopically removed. The enteral feeding solution is likely to be responsible for the development of this complication because no other factor known to favour this complication such as concomitant administration of sulfacrate or anti-acid agents was given to the patients; and the bezoar developed shortly after the new enteral feeding solution was used, a hypothesis supported by several similar case reports in the medical literature.

Haemodynamic and ventilatory changes during laparoscopic cholecystectomy in elderly ASA III patients.

PURPOSE: To evaluate the haemodynamic and respiratory changes during laparoscopic cholecystectomy in elderly ASA III patients. METHODS: This clinical descriptive study included 16 patients aged > 75 yr. Anaesthesia was induced with fentanyl and etomidate and maintained with N2O in O2 (50%), fentanyl and isoflurane as needed. Inspired minute volume was kept constant during anaesthesia. Cardiovascular monitoring included a radial artery catheter and a pulmonary artery catheter for measurement of CO, RVEF and SvO2, and calculation of right ventricular end diastolic volume indexed (RVEDVI). Haemodynamic variables, arterial and venous blood gas analyses were collected before and 10 min after anaesthetic induction, 15, 30 and 60 min after insufflation (IAP = 12 mmHg) followed by a 10 degrees head-up tilt, and after exsufflation. RESULTS: The mean age was 81 +/- 4 yr. The main cardiovascular depression was recorded after anaesthetic induction. Peritoneal insufflation resulted in improvement of cardiovascular function with increases in cardiac index (+19%), heart rate (+21%), MAP (+ 19%) and SvO2 (+8%), (P < 0.05) which may be the result of a sympathetic stimulation. No change in preload (RVEDVI) and SVR was recorded. Cardiac index was unchanged during pneumoperitoneum. Laparoscopy was associated with an increase in PaCO2 15 min after CO2 insufflation (from 33.9 to 38.3 mmHg, P < 0.05) and a further elevation after 60 min (44.4 mmHg) without any sign of extra peritoneal diffusion. There was no change in the intra-pulmonary shunt and the Pa-ETCO2 gradient remained stable (mean 7.2 mmHg). CONCLUSION: We conclude that gradual abdominal insufflation to 12 mmHg followed by a limited 10 degrees head-up tilt is associated with cardiovascular stability in elderly ASA III patients.

Pharmacokinetics of lidocaine with epinephrine in piglets following epidural anaesthesia.

The time course of arterial plasma lidocaine concentration, following an epidural anaesthesia via the sacrococcygeal or the S4-S5 trans-sacral approach, was studied in nine healthy piglets (7.8 +/- 1.3 weeks). Plasma lidocaine concentrations were measured for up to six hours after administration (5 mg/kg). Peak plasma concentration was 1.83 +/- 0.17 mg/l. Pharmacokinetic parameters determined from an independent compartment model were not different from those observed after an epidural administration of lidocaine via the sacrococcygeal space in children, except for a wide variability in the time taken to reach the maximum concentration (27.3 +/- 7.4 min) and a shorter half-life of elimination (82.8 +/- 7.0 min). The total body clearance of lidocaine was similar in piglets (17.3 +/- 1.6 ml/min/kg) to that in children. The shorter half-life of elimination was therefore attributed to a smaller volume of distribution in piglets (2.0 +/- 0.2 l/kg).

Delayed forced air warming prevents hypothermia during abdominal aortic surgery.

We have evaluated the efficacy of the delayed forced air warming during abdominal aortic surgery in 18 patients. Patients were allocated randomly to one of two groups: the control group (n = 9) received no intraoperative warming device; the Bair-Hugger group (n = 9) had active skin surface warming with an upper body cover. The device was activated when core temperature decreased to less than 36 degrees C. The reduction in core temperature was 0.6 degrees C during the first hour after induction and 0.4 degrees C during the second hour in both groups. In the control group, core temperature continued to decrease until the end of surgery, whereas in the Bair-Hugger group, the reduction in core temperature stopped after 1 h of warming, and then rewarming began. At the end of surgery, core temperature in the Bair-Hugger group was similar to core temperature before induction, and was higher than core temperature in the control group (P < 0.003).

A comparison of direct, indirect, and fiberoptic laryngoscopy to evaluate vocal cord paralysis after thyroid surgery.

After thyroidectomy, the anesthesiologist usually performs a laryngoscopy to detect laryngeal edema and nerve palsies. The goal of this study was to compare three different methods of laryngeal examination after tracheal extubation of the patients. For that purpose, between 1990 and 1995, a prospective series of 1608 patients operated for thyroidectomy has been studied. The series was divided into 4 groups. In group I (n = 200), four anesthesiologists have evaluated the efficiency of the immediate postextubation direct laryngoscopy. In group II (n = 100), one anesthesiologist has compared the direct, indirect, and flexible laryngoscopies in every patient in a fixed and timed fashion. In group III (n = 100), the four examiners have evaluated the flexible laryngoscopy at a different timing so as to eliminate the possible temporal relationship of the ease of visualization in group II. In group IV (n = 1208), the four examiners have evaluated flexible laryngoscopy, on a large scale, at any time during the 1-h stay in the recovery room. Special attention was directed to the patients with known cardiovascular diseases. Direct and indirect laryngoscopies were only effective in 76 and 73%, respectively, of the patients, whereas flexible laryngoscopy was effective in 99.6% of them. Flexible laryngoscopy was easy to perform in 96.5% of the patients versus 65 and 55% with direct and indirect laryngoscopies. Finally, variations in monitored cardiovascular parameters were significantly lower with flexible and indirect laryngoscopies than with direct laryngoscopy. These mild variations induced by flexible laryngoscopy were well tolerated by patients with known cardiovascular diseases. Flexible laryngoscopy is the best method for an immediate laryngoscopic examination after thyroidectomy.

Airway complications in thyroid surgery.

Perioperative and postoperative morbidity and mortality were studied in a series of 3,008 thyroidectomies. Compressive symptoms, frequent in substernal and cancerous goiters, were present in 11.0% of the patients, although a low rate of dyspnea (2.7%) was observed. In large goiters, some orotracheal intubations were difficult. In such cases, the transtracheal approach can also be difficult, so failure should be anticipated. Postoperative causes of respiratory obstruction included local hemorrhages, bilateral recurrent nerve palsies, and laryngeal edema. A tracheal collapse was not observed. These respiratory obstructions led to repeat surgery in 11 patients, tracheostomy in 3, and temporary reintubation with steroid therapy in 1. The recurrent laryngeal nerve, which may have been affected preoperatively, was found to be damaged postoperatively in 0.5% of the patients with benign goiters, compared to 10.6% of the patients with thyroid cancer. In this last group a bilateral palsy was observed in 3 cases with prolonged or extensive surgery. After these short-term orotracheal intubations (114 minutes on average), injuries of the airway caused by the endotracheal tube were found in 4.6% of the patients.

[Allergy to ketamine]. / Allergie à la kétamine.

A case is reported of allergy to ketamine substantiated 2 years after the accident. The female patient had ketamine for the removal of a mole. During this procedure, she developed a generalized rash and laryngospasm; the use of adrenaline was required. Since that time, although no confirmatory investigations had been carried out, she had been given a paper identifying Ketalar as being the involved drug. Investigations were carried out after she had been given a further anaesthetic (without using ketamine) 2 years after the accident. These confirmed an allergic reaction to ketamine, and not to the solvent, chlorobutanol.

[Recovery following anesthesia with diazepam-ketamine and fentanyl-methohexital]. / Réveil après anesthésie par diazépam-kétamine et fentanyl-méthohexital.

The quality of recovery from general anaesthesia for day-case surgery is assessed by the Trailmaking test in a randomized study of 100 women scheduled for termination of pregnancy on an outpatients basis. All patients are in ASA group I or II. Recovery following diazepam-ketamine based anaesthesia is compared to that following fentanyl-methohexital based anaesthesia. In group A, 5 min after intravenous injection of diazepam (0,2 mg.kg-1), anaesthesia is induced with ketamine (1 mg.kg-1). If necessary, in response to spontaneous movement, for maintenance of anaesthesia, 1 or 2 supplementary doses of ketamine (0,5 mg.kg-1) are administered. In group B, 5 min after intravenous injection of fentanyl (1 microgram.kg-1), anaesthesia is induced with methohexital (2 mg.kg-1). If necessary, in response to spontaneous movement, for maintenance of anaesthesia, 1 or 2 supplementary doses of methohexital (0,7 mg.kg-1) are administered. The quality of recovery is assessed by Trailmaking test 1/2 h and 1 h after surgery and compared with pre-anaesthetic score. The two groups are comparable with regard to age, weight, educational level and average duration of anaesthesia. In group A, the mean score for the two parts of the test is not significantly different 1 h after surgery from the pre-anaesthetic score. In group B, the mean score for the two parts of the test is not significantly different 1/2 h after surgery than the pre-anaesthetic score. This better post-anesthetic score is explained by a learning effect of the test when used several times.(ABSTRACT TRUNCATED AT 250 WORDS)