[Value of the monitoring of curarisation during prolonged mivacurium induced neuromuscular block]. / Intérêt du monitorage de la curarisation lors d'un bloc neuromusculaire prolongé par mivacurium.

A case of neuromuscular blockade of about 200 min of duration, in a 9-year-old boy from mivacurium 0.15 mg.kg-1 is reported. The diagnosis was delayed, after onset of the first signs of recovery, due to the lack of monitoring of neuromuscular transmission. The neuromuscular blockade was reversed with neostigmine 0.04 mg.kg-1. Complete reversal required fifty minutes. The presence of an abnormal genetic variant of pseudocholinesterases was demonstrated by the measurements of pseudocholinesterase activity and dibucaine number. The importance of monitoring of neuromuscular transmission for diagnosis and treatment of mivacurium-induced neuromuscular blockade is underlined.

Long-term results of tissue development and cell differentiation on Dacron prostheses seeded with microvascular cells in dogs.

PURPOSE: The purpose of this study was to investigate in vivo the long-term development, differentiation, and proliferation of the subendothelial tissue on Dacron prostheses seeded with microvascular cells (MVC). METHODS: Autologous MVC from omental adipose tissue were seeded on 4 mm Dacron prostheses and the prostheses interposed in the carotid arteries of mongrel dogs for 5, 13, and 26 weeks. RESULTS: Light and electron microscopic evaluation of patent seeded prostheses demonstrated an almost complete monolayer of endothelial cells and well-organized subendothelial tissue, whereas patent control prostheses were mainly covered by red and white thrombi, which were partially replaced by organized tissue with increased implantation time. The measurements of the thickness of the luminal cell layer in seeded and control grafts showed no statistically significant increase between 5 and 26 weeks of implantation. The subendothelial tissue of seeded prostheses demonstrated a time-dependent maturation of highly synthesizing myofibroblasts embedded in a collagen matrix to cells with features of smooth muscle cells located in a collagen-elastin matrix. In control grafts examined after 26 weeks the spontaneous endothelialization was accompanied by a delayed or incomplete maturation of subendothelial tissue. CONCLUSIONS: Our study indicates that MVC seeded onto Dacron prostheses are able to generate a vascular wall that does not continue to proliferate after prolonged implantation and that increasingly resembles the wall of a normal artery in cell differentiation and intercellular matrix.

[Use of homologous erythrocyte concentrates. Analysis of economical factors]. / Consommation de concentrés érythrocytaires homologues--Analyse des facteurs d'économie.

The factors involved in reducing consumption of bank packed red cells (PRC) were studied over three one year periods (1983, 1987 and 1989) in a Department of Vascular and General Surgery. The effects of autologous blood salvage (started in 1987), associated with the management of homologous blood by a branch of the blood bank inside the operating theater suite were assessed. In 1989, intentional normovolaemic haemodilution became virtually systematic, on top of the intraoperative blood salvage, for all patients due to undergo surgery with a risk of severe blood loss. The number of surgical procedures carried out during those three years did not vary. However, in the same time, the annual consumption of homologous PRC decreased by an overall 56% (36.7% between 1983 and 1987, and 29.8% between 1987 and 1989). This decrease was mostly due to a fall in prescription in the operating theaters, and not in the wards. In the same time, albumin consumption increased sixfold. Such transfusional policies can only be carried out if there is good cooperation between the blood bank and the prescribers of blood products.

[Endothelialization of 6 mm vascular prostheses with microvascular endothelial cells from fatty tissue of the omentum]. / Endothelialisierung von 6-mm-Gefässprothesen mit mikrovaskulären Endothelzellen aus dem Fettgewebe des Omentums.

The seeding of 6 mm Dacron prostheses with microvascular endothelial cells from omental adipose tissue leads to endothelialized prostheses, 5 weeks later with a complete coverage of functional and thrombus free endothelium. The method is ready for clinical trials.

[Hemodynamic and gasometric modifications during the anesthesia recovery period in patients undergoing ventilation after surgery of the abdominal aorta]. / Modifications hémodynamiques et gazométriques á la phase de réveil chez le sujet ventilé après chirurgie de l'aorte abdominale.

This study was carried out on 12 patients (mean age 61) in order to assess the oxygen consumption (VO2) in the post-operative stage of an elective surgical procedure (replacement of the abdominal aorta). Anesthesia was a combination of thiopentone, pancuronium bromide and high doses of droperidol and fentanyl. Patients were kept intubated and ventilated in the post-operative period. VO2 and other related metabolic parameters as well as hemodynamic parameters were measured every 45 minutes over a period of 5 hours. A VO2 increase (127%) related to the increase in body temperature was noted. Mean VO2 for all patients during the whole period was 170 +/- 13 ml.min-1.m-2 (range: 51-411 ml.min-1.m-2). Mean value of maximal VO2 was 240 +/- 21 ml.min-1.m-2 (range: 1471-411 ml.min-1.m-2). Large dose of droperidol are shown to limit VO2 increase. In patients with shivering, the maximal value of VO2 was found during shivering. The amount of droperidol administered during anesthesia was greater in patients without shivering. VO2 increase was due to a rise in tissular O2 extraction. Cardiac index was insufficiently increased (+ 9.4%) and a certain extent of myocardial inadaptability was suspected in relation with: high blood pressure, hypovolaemia and/or myocardial effect of anesthesia agents.

Treatment of deep venous thrombosis with a very low molecular weight heparin fragment (CY 222).

Thirty patients presenting with phlebographically confirmed deep venous thrombosis were treated with a very low molecular weight heparin fragment (CY 222) in an open and prospective phase-2 trial. A uniform dosage of 750 IC anti-factor Xa units/kg/day was administered subcutaneously for 10 days or more to patients whose thromboses were categorized as postsurgical (17 cases) or medical (13 cases). The clinical symptoms of venous thrombosis diminished in 93% of the patients overall. The extent of vascular clearing was assessed by an original scoring system which compared the pre- and posttreatment phlebographies. The effect of treatment was globally rated 'very good' (more than 75% lysis) in 37% of the patients, 'good' (about 50% lysis) in 40% and 'poor' (0-25% lysis) in 17%; the phlebographic thrombosis worsened in 6.6%. Little change occurred in laboratory tests exploring thrombolysis, but a strong anti-factor Xa activity was detected.

[Hemodynamic changes caused by laparotomy during aorto-iliac surgery]. / Variations hémodynamiques induites par la laparotomie en chirurgie aorto-iliaque.

A haemodynamic study was carried out on 53 patients undergoing elective surgery of the abdominal aorta in order to assess the haemodynamic changes consequent to abdominal manipulations prior to aortic clamping. Surgery was carried out under general anaesthesia and ventilation was controlled. The following parameters were monitored: mean arterial pressure (Pa), cardiac index (CI), systolic index (SI), systemic vascular resistances (Rsa), pulmonary vascular resistances (Rpa), heart rate (fC). Cutaneous circulation was monitored using a photoplethysmographic transducer. The following haemodynamic pattern was seen as the peritoneal cavity was opened and traction on the mesentery was applied: CI +40.7%; fC +28.61%; SI +9.85%; Rsa -39.16%; Rpa -28.43%; Pa -15.7%. The recording of the facial cutaneous photoplethysmographic wave showed an increase of 50%. In some extreme cases, a state of cardiovascular collapse with marked cutaneous erythema strongly resembling anaphylactic shock ensued. The physiopathology of these cardiovascular reactions is unclear, but the haemodynamic pattern as well as the cutaneous vasodilation suggest a stimulation of both vagal and sympathetic nervous systems and the release of vasoactive substances into the general circulation.

[Peroperative autotransfusion]. / La transfusion autologue peropératoire.

Between April 1976 and December 1984, 297 patients underwent major elective and emergency surgery using intraoperative autotransfusion (Bentley ATS unit). An amount of 732 l of blood was reinfused, representing 61% of the total intraoperative blood transfusion. Thanks to this method, an average 2.46 l of blood per patient was spared, with a range of 0.9 to 6 l according to the type of surgery (elective or emergency). Twelve accidents are reported, including four bradycardias (less than 45 b X min-1), two air emboli and six haemorrhages due to an excess of anticoagulation. These complications were related either to poor technique (too great a transfusion output) or insufficient blood anticoagulation control. Simplicity of use and high transfusion output of the device adapted to the blood loss are the advantages of intraoperative autotransfusion.

[Pleural clot ablation and fibrinolytic agents]. / Décaillotage pleural et fibrinolytiques.

Two patients presenting with an important intrapleural clot with cardiorespiratory repercussions were given in situ thrombolytic treatment after drainage with a suction tube had failed. The first patient was treated immediately after thoracophrenolaparotomy for hepatic surgery. Dissolution of the clot was obtained with two local injections of urokinase (450,000 IU). The second patient was treated on the tenth day of a recurring post-traumatic clot, with urokinase (75,000 IU, then 225,000 IU) each day. In addition, this patient received lys-plasminogen locally (15 mukat, then 30 mukat). Dissolution of the clot was complete within five days. Clinical tolerance was excellent and there was no effect on the usual clotting studies. This study confirms previous findings, and underlines the usefulness of this method and its lack of adverse effects, even immediately postoperatively.

[Measuring bronchial obstruction in intensive care]. / Mesure de l'obstruction bronchique en soins intensifs.

The nature and degree of bronchial obstruction is not easy to assess in the intensive care unit. The classic airway resistance measurement technique cannot be performed without heavy equipment and the patient's cooperation. On the basis of the forced oscillations technique, measurement of acoustical respiratory impedance is an extension, in a higher frequency range, of earlier dynamic compliance measurements, which are known to be sensitive to peripheral airway obstruction but unsuitable for critically ill patients. The main advantage of respiratory impedance measurement is simplicity, since the patient simply breathes freely for a minute in the apparatus. This method contributes an effective means of quantifying evolution and treatment during an asthmatic attack. It can also be used to monitor left heart failure.