[Acute colectasia in patients on artificial respiration. 10 cases]. / Colectasie aiguë chez les malades sous ventilation artificielle. Dix observations.

Acute colectasia may occur in patients under mechanical ventilation. Causative factors include haemodynamic changes, potassium loss, underlying pathology (chronic respiratory failure, cirrhosis) and especially morphine-like compounds used for sedation. Analysis of the results obtained with various treatments suggests that surgery is not justified: caecal perforation is extremely rare in a previous healthy colon; any surgical procedure is hazardous in this type of patient, and colectasia frequently regresses under appropriate medical treatment, even though mechanical ventilation is pursued.

Effects of captopril on pulmonary haemodynamics.

The effects of oral captopril on pulmonary haemodynamics were studied in two groups of 6 patients, one of subjects with chronic respiratory failure (PaO2 52 +/- 5.1 mmHg, PaCO2 54 +/- 2.1 mmHg), and the others with chronic heart failure and high plasma renin activity. Two potential mechanisms of its actions were assessed, namely inhibition of hypoxic vasoconstriction and inhibition of the possible effects of angiotensin II on the pulmonary circulation. There were significant (p less than 0.05) decreases in mean arterial pressure, pulmonary wedge pressure and in systemic arterial resistance associated with improvement in cardiac index in both groups. In the chronic respiratory failure group there was no change in blood gases, mean pulmonary arterial pressure or pulmonary vascular resistance. An increase in driving pressure (p less than 0.05) indicated that captopril had had no effect on pulmonary haemodynamics. In chronic heart failure, mean pulmonary arterial pressure and pulmonary capillary wedge pressure were decreased by a similar extent, so that driving pressure and pulmonary vascular resistance were not changed. It is concluded that oral captopril did not inhibit hypoxic vasoconstriction, and that it modified pulmonary haemodynamics in chronic heart failure patients with high renin activity only as a consequence of reduction in systemic afterload.

[Value of captopril in the treatment of systemic arterial and pulmonary hypertension with increased plasma renin in scleroderma]. / Intérêt du captopril dans le traitement d'une hypertension artérielle systémique et pulmonaire avec activité rénine plasmatique augmentée au cours d'une sclérodermie.

The effects of the converting enzyme inhibitor captopril (Lopril) were studied in a 53 year old woman with acute exacerbation of scleroderma. In addition to her chronic symptoms of Raynaud's syndrome, the patient presented with severe hypertension, cardiac failure and oligoanuria. Right heart catheterisation with a Swan-Ganz catheter confirmed the systemic hypertension with cardiac failure, and also demonstrated precapillary pulmonary hypertension with raised pulmonary arterial resistance. The organic renal failure was an indication for renal biopsy which showed segmental and focal fibrinoid necrosis with microthrombosis and chronic ischemic changes. Due to raised plasma renin activity, treatment with captopril was instituted, leading to a rapid normalisation of systemic and pulmonary hypertension, the regression of cardiac failure and a transient improvement in the Raynaud's syndrome. The renal failure did not improve and the patient had to undergo chronic hemodialysis. These spectacular initial results should be interpreted in the context of the poor prognosis of acute exacerbations of scleroderma despite the encouraging data published recently after well-controlled antihypertensive therapy.

Combined hemodynamic effects of dopamine and dobutamine in cardiogenic shock.

In eight mechanically ventilated patients in cardiogenic shock, we assessed the hemodynamic effects of an infusion of dopamine and dobutamine and evaluated its role in preventing the deleterious effects of administering each amine alone. Each patient received three infusions in a randomly assigned order: dopamine, 15 micrograms/kg/min; dobutamine, 15 micrograms/kg/min; and a combination of dopamine, 7.5 micrograms/kg/min, and dobutamine, 7.5 micrograms/kg/min. Stroke volume index increased similarly with the three infusions, but dopamine alone increased oxygen consumption (p less than 0.05 vs dobutamine alone and dopamine-dobutamine combined). The dopamine-dobutamine combination increased mean arterial pressure (p less than 0.05 vs dobutamine), maintained pulmonary capillary wedge pressure within normal limits (p less than vs dopamine), and prevented the worsening of hypoxemia induced by dopamine (p less than 0.05). The dopamine-dobutamine combination appears to be useful in the management of mechanically ventilated patients in cardiogenic shock.

[Fatal pulmonary embolism with a normal PaO2]. / Embolie pulmonaire mortelle avec PaO2 normale.

A case of massive pulmonary embolism confirmed by angiography and necropsy, without arterial hypoxemia (PaO2 = 109 torr while the patient breathing room air) was reported. The onset of hypoxemia and increase in venous admixture secondary to cardiac output improvement with dobutamine was discussed.

[Non-surgical pneumoperitoneum complicating status epilepticus. Two cases (author's transl)]. / Pneumopéritoine non chirurgical compliquant un état de mal épileptique. Deux observations.

Two cases of pneumoperitoneum following status epilepticus are reported. In both patients perforation of a hollow viscus was excluded by laparotomy and status epilepticus had been accompanied by haematemesis. An increase in upper digestive tract pressure resulting from high abdominal pressure during seizures might have caused leakage of air into the peritoneum through lacerations in the lower oesophageal mucosa. Awareness of this mechanism of non-surgical peritoneum would avoid unnecessary exploratory laparotomy in these seriously ill patients.

Plasma amino acid patterns in respiratory encephalopathy.

Serum amino acid determinations were made in 23 patients with chronic bronchitis presenting with acute respiratory insufficiency both during and after regression of signs of encephalopathy. The ratio of branched chain amino acids to aromatic amino acids was initially significantly lower than normal but returned to normal range when the signs of encephalopathy had disappeared. The modifications observed in amino acid concentrations were similar to those seen in hepatic encephalopathy. The role of the liver in the observed modifications of amino acid levels in respiratory failure is discussed.