[Fulminant coma: think hyperammonemia and urea cycle disorders]. / Coma d'évolution foudroyante: penser à l'hyperammoniémie quel que soit l'âge.

The authors report the case of 14-year-old boy admitted for acute coma without neurological focal symptom. The only relevant finding was the death of one uncle after a coma in the year 1992. This coma was associated with an ammonia blood level of 344 mumol l-1 and it rapidly lead to cerebral death despite a symptomatic treatment. The diagnosis of hereditary ornithine transcarbamylase deficiency was confirmed by liver biopsy in the immediate post-mortem period. The authors recommend the measurement of blood ammonia in every coma without diagnosis, whatever patient's age.

[Continuous administration of drugs by infusion pumps. Presentation of an infusion rate mathematical computing software]. / Administration continue de médicaments au pousse-seringue. Présentation d'un logiciel de calcul posologique.

Intensive therapy includes continuous delivery of drugs with infusion pump. This article describes an infusion rate computing programme using a Macintosh micro-computer and the HyperCard 2 software. The latter permits the classification of data onto cards collected in stacks. The card that is displayed when the programme is launched shows fifteen buttons assigned to various drugs. Click upon a button opens the corresponding card which displays the presentation of the drug and suggests a dilution. The next step associates input of patient's weight into the appropriate field and a click on the main button. A display then indicates for various standard dosages, the corresponding rate of infusion in mL.h-1 and the daily consumption of the drug. In order to avoid casual or voluntary changes of the setting, soft securities have been inserted in the programme.

[Persistent leakage of cerebrospinal fluid after removal of a device implanted for subarachnoid analgesia]. / Fuite persistante de liquide céphalorachidien après retrait d'un site d'analgésie sous-arachnoïdienne.

A case is reported of a persisting leakage of cerebrospinal fluid (CSF) occurring after removal of a subarachnoid analgesia kit. The kit had been inserted in a 79-year-old man who had severe perineal cancer pain. Fifteen months later, after a second episode of meningitis, the kit was removed. The leakage was noticed a few hours after removal of the kit. Biological parameters confirmed the fluid was most certainly CSF. Despite making the patient lie prone, water restriction and a compressive dressing, the leakage was still present three days later. A blood patch, and the epidural injection of biological glue, were of no avail. The leakage was only stopped by tying off the fistula with a ligature. The actiology and treatment of skin CSF fistulae after puncture of the dura mater are discussed.

[Controlled trial of a non-invasive continuous blood pressure monitor: Cortronic AMP 770]. / Essai contrôlé d'un moniteur continu non invasif de pression artérielle, l'APM 770 Cortronic.

The performances of a Cortronic AMP 770 monitor, a new apparatus for non invasive continuous blood pressure monitoring was assessed. Its working principle is derived from oscillometry. The blood pressure cuff is kept at a low pressure (about 20 mmHg), and the oscillations induced by the arterial pulse are converted into blood pressure. Systolic, mean and diastolic blood pressure was measured in 9 healthy volunteers, under physiological conditions, using both the AMP 770 and a traditional oscillometer (Physiogard SM 785 NI, Odam). A group of 124 paired measurements was obtained, with values ranging from 87 to 150 mmHg for systolic pressure, from 48 to 97 mmHg for diastolic pressure, and from 63 to 114 mmHg for mean pressure. The mean differences (APM 770-Physiogard) were -1.2 +/- 10 mmHg for systolic pressure, 3.2 +/- 8 mmHg for diastolic pressure, and -3.8 +/- 8 mmHg for mean pressure. There was no correlation between blood pressure levels and discrepancy in the measurements obtained with the two methods. The Cortronic AMP 770 was reliable under normal circumstances, when compared with a traditional oscillometer. However further studies are required to assess its reliability under pathological circumstances (severe hypotension or hypertension, arrhythmias and sudden changes in blood pressure).

[Postoperative pulmonary leukostasis responsible for fatal respiratory distress]. / Poumon hyperleucocytaire postopératoire responsable d'une détresse respiratoire fatale.

A case is reported of a 78-year-old woman with a history of chronic leukemia and who developed after emergency appendicectomy a fatal respiratory distress syndrome related to pulmonary leukostasis. Clinically, the patient had fever, dyspnea and severe hypoxaemia. Chest x-ray showed diffuse pulmonary infiltrates. The patient died from progressive respiratory failure despite ventilatory support. Post mortem lung biopsies were taken for pathologic examination. They showed thrombi composed of leukaemic blast cells which obstructed and distended the lumens of pulmonary arterioles and capillaries. The respiratory distress is attributed to pulmonary leukostasis. Toxic substances released from the leukostatic leukaemic cell or local hypoxia due to vascular occlusion produce this endothelial cell and basement membrane damage. An infectious origin or endogenous pyrogen substances released from leukaemic monocytes may explain the fever. The frequent occurrence of pulmonary leukostasis in patients with leukocyte count greater than 100,000/mm3 point out the need for prevention or therapy of pulmonary leukostasis in these high-risk patients. They need chemotherapy and, if rapid reduction is not observed, leukopheresis which may favourably influence the outcome of patients.

[Perforation of a solitary diverticulum of the transverse colon. Contribution of preoperative x-ray computed tomography and echography]. / Perforation d'un diverticule solitaire du côlon transverse. Apport de la tomodensitométrie et de l'échographie en pré-opératoire.

Diagnosis of perforation of a solitary diverticulum of transverse colon followed the discovery at operation of an abdominal mass, ultrasound and CT scan imaging demonstrating a heterogeneous mass of enhanced density provoking apparent extrinsic compression of colon. A literature review showed the rarity of this complication, only 22 cases being reported but associated almost constantly with a pseudo-tumoral abscess centered on the diverticulum. This was the case in the patient reported but current imaging methods (ultrasound and particularly CT scanning) allowed correct evaluation of the nature and relations of the mass preoperatively, eliminating, its neoplastic nature by precise morphologic criteria. Despite its rarity, the diagnosis of perforation of an isolated transverse colon diverticulum should be evoked systematically by an extrinsic mass developed in contact with its wall, the nature of which is now simple to define preoperatively by CT scan imaging.

[Anesthesia and cardiac pacing]. / Anesthésie et stimulation cardiaque.

Nowadays, anaesthetists often have to deal with pacemaker patients. All the problems encountered in the anaesthetic management of such patients are discussed in this paper: the pacemaker, specific risks linked to the pacemaker, monitoring of such patients, and temporary pacing. The preoperative assessment of pacemaker function is an absolute necessity. The technical characteristics of the pacemaker can be found in the patient's booklet. The clinical history should reveal a possible malfunction (syncopes). The underlying cardiac disease should be known, as it will have repercussions on the anaesthetic and surgical risks. An electrocardiogram and measurement of blood electrolytes must be carried out. There are three major risks linked to the pacemaker during surgery: 1) the loss of pacing by threshold (drugs, dyskaliemia); threshold (drugs, dyskalemia); 2) ventricular fibrillation (the intracardiac electrode conducting the electrocautery currents); 3) reprogramming or damaging of the pacemaker by electrocautery, cardioversion or nuclear magnetic resonance. The only mandatory monitoring of these patients is the electrocardioscope. Other monitoring techniques will be dictated by the underlying cardiac disease or the surgery planned. Temporary pacing is indicated in the same conditions as permanent pacing. However the intracardiac electrode can be displaced by moving the patient; the efficacy of pacing must therefore be continuously checked. During cardiac surgery, with cardiopulmonary bypass, conduction disturbances can occur. Temporary pacing electrodes should therefore be sewn onto the ventricular epicardium for the duration of the surgery; atrial electrodes should be added if sinus troubles can be expected. Oesophageal pacing is possible in the operating theatre because it is easily and rapidly set up: a bipolar oesophageal electrode linked to an external pacer can speed up the heart (atrial dysfunction) or slow down a tachycardia. An oesophageal electrocardiogram can also be carried out with this electrode. Swan-Ganz catheters can be also used for temporary pacing: either with two pairs of electrodes, atrial and ventricular respectively--this system being useful in a patient who does not move--or with a newer system where a single small electrode is introduced into the right ventricle by a special lumen in the Swan-Ganz catheter. Although external pacing was historically the first technique to be developed, it was abandoned because of the muscle pains it gave. Recently, a new technique of external pacing, with large electrodes and longer stimuli, has been developed for use in emergency situations.(ABSTRACT TRUNCATED AT 400 WORDS)

[Prevention of per- and postoperative myocardial ischemia in non-cardiac surgery by intravenous diltiazem]. / Prévention de l'ischémie myocardique per- et postopératoire en chirurgie non cardiaque par le diltiazem intraveineux.

A controlled double-blind trial was carried out to assess the efficacy and safety of a continuous intravenous infusion of diltiazem in preventing perioperative myocardial ischaemia in patients with coronary artery disease. Sixty-six patients undergoing non cardiac surgical procedures (vascular surgery, n = 37; other, n = 29) were randomly chosen to receive either diltiazem (group D, n = 32); or placebo (group P, n = 34); there was no difference between these groups in the number of patients in each NYHA class (I: 13/16; II: 14/14; III: 5/4) or having had a previous myocardial infarct (20/22). ECG leads CM5 and CL5 were recorded continuously with an ICR 7200 Holter monitor. After starting recording, either placebo or a loading dose (0.5 mg.kg-1) of diltiazem was given, followed by an infusion of 5 micrograms.kg-1.min-1. Anaesthesia was induced by thiopentone and suxamethonium, and maintained with nitrous oxide (50%), fentanyl and either halothane or droperidol. The number of myocardial ischaemic episodes was significantly (p less than 0.05) lower in group D (2 ST depressions in two patients) than in group P (8 ST depressions in six patients, 2 myocardial infarcts and 1 pulmonary oedema). No conduction disturbance was observed; the lowest cardiac frequency was found in group P (32 b.min-1). Systolic and diastolic arterial blood pressures were lower in group D than in group P, but no difference was found in heart rate and rate-pressure product.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reprogramming of a pacemaker induced by electrocautery]. / Reprogrammation d'un stimulateur cardiaque induite par le bistouri électrique.

A case is reported of reprogramming of a ventricular unipolar permanent pacemaker induced by electrocautery during biliary surgery. After skin incision and use of the unipolar electrosurgery unit, the CPI model 505 multiprogrammable pulse generator previously set at 70 b X min-1 abruptly fired at 120 b X min-1. Application of a magnet over the pacemaker reduced the heart rate to 100 b X min-1. After surgery, the pulse generator was successfully reprogrammed to a rate of 65 b X min-1. Based on the analysis of this case and of previous reports, it is suggested, so as to avoid such complications, that the unipolar electrocautery be avoided when the surgical field is near the pulse generator or lead: that the bipolar electrocautery be preferred; that a magnet and non-invasive programmer be available during and after surgery; and that a postoperative assessment of the pulse generator be carried out.

[Reliability of automatic oscillometric monitoring of arterial pressure. Effect of hypotension and arrhythmias]. / Fiabilité du monitorage oscillométrique automatique de la pression artérielle. Influence de l'hypotension et des troubles du rythme.

The object of this study was to assess the reliability of automatic oscillometric monitoring of the systemic blood pressure. The trial was carried out in 4 patients in situations including hypotension and attacks of arrhythmia. The oscillometric pressure measured in the arm was compared with the pressure recorded by an intra-radial arterial catheter in the opposite arm. All patients were in the dorsal decubitus position. One hundred and ten comparative measurements were performed with values ranging from 48 to 200 mmHg for the systolic pressure, 36 to 112 mmHg for the diastolic pressure and 40 to 136 mmHg for mean arterial pressure. A satisfactory correlation was found between the two methods in 91 measurements in sinus rhythm with respect to systolic (r = 0.95, p less than 0.001), diastolic (r = 0.93, p less than 0.001) and mean arterial pressures (r = 0.95 p less than 0.001). The average duration of the measurements was 32 +/- 5 seconds. During the study, one patient developed paroxysmal atrial fibrillation during which 19 comparative measurements of the mean pressure were performed. The correlation between the two methods was not as good as that observed during sinus rhythm (r = 0.73, p less than 0.01) and the average duration of measurement increased significantly (44 +/- 14 seconds). A correlative study was also performed during hypotension. This was defined as directly recorded systolic blood pressures of less than 90 mmHg, diastolic pressures less than 60 mmHg and mean pressures of less than 70 mmHg (n = 40).(ABSTRACT TRUNCATED AT 250 WORDS)

[Is automatic oscillometric measurement of blood pressure reliable in hypotension?]. / La mesure oscillométrique automatique de la pression artérielle reste-t-elle fiable en cas d'hypotension?

The reliability of an automatic oscillometric device for measurement of blood pressure (BP) was assessed in a large range of BP values during intraoperative normotension and induced hypotension. Direct BP measurements were carried out with a radial catheter. Data were compared with those obtained with the oscillometric device placed on the opposite arm. Nine patients were studied, undergoing 234 measurements of BP ranging from 55 to 208 mmHg (7.3 to 27.7 kPa) for systolic blood pressure (Pasys), from 32 to 130 mmHg (4.3 to 17.3 kPa) for diastolic blood pressure (Padia) and from 36 to 154 mmHg (4.8 to 20.5 kPa) for mean blood pressure (Pa). Good correlation between the two techniques was found for Pasys measurements recorded during both normotension and hypotension (r = 0.93; p less than 0.01). 92% of the values recorded with the oscillometric device were lower than those measured invasively. In the other cases (8% of the data), the mean difference between the two techniques was 5.5 mmHg (0.7 kPa). When BP values lower than 90 mmHg (12 kPa) for Pasys, 60 mmHg (8 kPa) for Padia and 70 mmHg (9,3 kPa) for Pa were considered individually, the correlation coefficients were 0.83, 0.73 and 0.77 respectively. These findings suggested that the oscillometric method can be considered as relatively suitable for monitoring moderate hypotension induced by vasodilators. The invasive technique must however remain the method of choice during profound hypotension.

[Anesthesia in patient with the ventricular pre-excitation syndrome]. / L'anesthésie chez les sujets atteints de syndrome de pré-excitation ventriculaire.

The Wolff-Parkinson-White syndrome or its variant, the pre-excitation syndrome, are described in about 1.2 per 1000 of the population, so the anaesthetic management of patients with this syndrome is important. Our experience is reported in 15 elective operations on seven patients with pre-excitation syndrome. The most significant feature is the occurrence of variation of the morphology of QRS complexes. Rhythm disturbance most commonly encountered is supraventricular tachycardia, but different cardiac arrhythmias may occur and sometimes these are fatal. In our study, major complications or cardiac arrhythmias did not occur. With regard to the anaesthetic technique, care should be taken not to produce tachycardia. Atropine is not absolutely contraindicated for premedication. Preoperative use of propranolol or of quinidine is questionable.