[Use of a ternary mixture of local anaesthetics for peridural anaesthesia during urgent caesarean operation. Report on 125 cases]. / Intérêt d'un mélange ternaire d'anesthésiques locaux dans l'anesthésie péridurale pour opération césarienne urgente dans 125 observations.

125 caesarean operations are conducted under peridural anaesthesia with a mixture of local anaesthetics containing per milliliter: 2.5 mg of bupivacaine, 2.5 mg of etidocaine, 12.5 mg of lidocaine, and 5.10(-6) epinephrine. The dose injected is 23.37 +/- 1.98 ml, the volume necessary for blocking a metamer being 1.18 +/- 0.10 ml/segment. Satisfactory analgesia is obtained in 119 cases (95.2 p. cent), with adequate muscle relaxation in all cases. Block anaesthesia occurs after 5.81 +/- 0.67 min, last 197 +/- 62 min, and enable incision after 8.80 +/- 2.55 min with extraction of the infant after 13.72 +/- 2.85 min in 25 "extremely urgent" cases. Apgar is 8.98 +/- 1.62 after one minute and 9.68 +/- 1.31 after five minutes. These results prove that under perfect circumstances it is possible to get out the baby in about ten minutes.

[Maternal and fetal levels of local anaesthetics after epidural injection of a triple mixture]. / Taux maternels et foetaux d'anesthésiques locaux après injection péridurale d'un mélange ternaire.

Twenty-four parturients received an epidural injection of a 5.10(-6) adrenaline mixture containing: lidocaine 295 +/- 19 mg, bupivacaine 58 +/- 4 mg and etidocaine 58 +/- 4 mg. The mean serum levels measured in the mother (peripheral vein) and in the fetus (umbilical vein) and in the fetus (umbilical vein) and the fetus/mother ratios were, respectively:--1.05 +/- 0.47 micrograms . ml-1, 0.68 +/- 0.34 micrograms . ml-1 and 0.66 +/- 0.15 for lidocaine; --0.25 +/- 0.10 micrograms . ml-1, 0.14 +/- 0.06 micrograms . ml- and 0.51 +/- 0.16 for bupivacaine; ---0.27 +/- 0.10 micrograms . ml-1, 0.17 +/- 0.10 micrograms . ml-1 and 0.63 +/- 0.23 for etidocaine. From the sum of these concentrations the maternal and fetal serum levels and the fetus/mother ratio could be calculated in lidocaine equivalents. The values obtained were: 3.14 +/- 0.74 . ml-1, 1.90 +/- 0.68 micrograms . ml-1 and 0.60 +/- 0.13 respectively. A comparison of these data with those found in the literature led to the following conclusions: (1) The maternal serum levels of each anaesthetic drug in the mixture are the same as if it had been injected separately; (2) owing to tissue competition, the transplacental passage is increased by majoration of the free form, this being more pronounced with bupivacaine and etidocaine; (3) the circulating drug concentrations evaluated as lidocaine equivalent in the mother and fetus are comparable to those determined at the end of conventional local anaesthetic procedures.

[Rapid simultaneous assay of the principalamide-type local anesthetics by gas-liquid chromatography]. / Dosage rapide et simultané des principaux anesthésiques locaux de type amidé par chromatographie gaz-liquide.

This method can assay simultaneously, using 300 microliters of plasma, of the three principle local anesthetic agents used by peridural injection for post-operative anesthesia and analgesia: xylocaïne, etidocaïne, bupivacaïne. The assay method consists of three steps: (a) the addition of an internal calibrating agent (mepivacaïne). (b) defecation using trichlorocetic acid. (c) alcalinization of the supernatent (pH 11), extraction with dichloromethane and concentration at room temperature of the organic phase. (d) chromotography using an SE 30 or OV 17 impregnated column. The method is sensitive between 0.37 mumoles per l-1 (0.1 microgram . ml-1) and the coefficient for the mean deviation is 10.9% for concentration between 0.37 mumoles 1-1 and 75 mumole1-1 (0.1 microgram . ml-1 and 20 micrograms . ml-1). The correspondence of the figures recorded in this large concentration range without any change in the technique means that the kinetics of the plasma concentrations before and after peridural injection can be followed. The results obtained by gas liquid chromatography for the assay of lidocaïne were compared in 115 different plasma samples with concentrations obtained by an immuno enzymatic method ("EMIT") fitted to a centrifuge analyser. The correlation coefficient between the two methods was: (r = 0.95 with y = 0.09 x +0.25 microgram . ml-1 implying the absence of any interference and the specificity of the two methods. The columns also separate in 20 minutes the two main metabolites of lidocaïne: monoethylglycinexylidide (M.E.G.X.) and glycinexylidide (G.X.). These results demonstrate that continuous peridural injection of lidocaïne produces a high plasma concentration without any clinical toxic phenomena.

[Comparison of postoperative blood levels of prolactin and somatotropin after two methods of anesthesia]. / Comparaison des taux sanguins de prolactin et de somatotrophine en post-opératoire après deux modes d'anesthésie.

Prolactin and somatotrophin were measured during the postoperative period in two series of 15 patients after gynaecological surgery. Samples were collected for four days at the same times during the 24 hours period. The anesthetic given in the first group was a neuroleptanalgesia of dextromoramide-droperidol type followed by postoperative analagesia using a noramidopyrine compound. In the second group, epidural anaesthesia was given, followed postoperatively by the injection of lidocain at constant rate interrupted between the final two samples. In the neuroleptanalgesia group, from a basal levels of 11 micrograms.l-1, prolactin rose to 22 micrograms.l-1 on the evening after surgery (p less than 0.001) to subsequently stay on a plateau between 6 and 8 micrograms.l-1 (p less than 0.025 to p less than 0.005). From a basal level of 2.8 micrograms.l-1, somatotrophin rose to 9 micrograms.l-1 (p less than 0.05) then fell progressively from 7.5 to 2 micrograms.l-1 (NS on D1, D2, D3). In the epidural group, from a basal level of 13.5 micrograms.l-1, prolactin rose to 23 micrograms.l-1 on the evening after surgery (NS) to fall sharply on D1 to 5.6 micrograms.l-1 (p less than 0.01) and then follow a plateau on D2 and D3 of the order of 11 to 12 micrograms.l-1 (NS). From a basal level of 1.9 micrograms.l-1, somatotrophin rose to 10 micrograms.l-1 (p less than 0.001) to fall again to 4.5 micrograms.l-1 on D1 (p less than 0.01) and to 2 micrograms.l-1 on D2 and D3 (NS). Comparison of these two groups showed a difference only on D2 with regard to somatotrophin (p less than 0.05) and on D2 and D3 with regard to prolactin (p less than 0.025 and p less than 0.05). These results are discussed. They do not indicate any fundamental difference in the endocrine response to aggression in relation to the two types of anaesthetic studies.

[Decrease in BSP clearance during epidural anesthesia at a constant flow rate. Clinical implications]. / Diminution des clairances de la B.S.P. sous analgésie péridurale a débit constant. Ses implications cliniques.

The fractional clearance K1 of bromsulphthalein was measured in twelve surgical patients at an interval of a least 48 hours. The first measurement was performed pre-operatively and the second postoperatively 24 hours after the operation, whilst the patients were receiving analgesia by the epidural injection of lignocaine at a constant flow rate. Between the two determinations there was a fall in BSP clearance of 25 +/- 11 p. 100 (range: -8 and -40 p. 100) P less than or equal to 0.0001. The clinical implications are discussed on the basis of concrete examples.

[Comparison of postoperative blood cortisol levels after neuroleptanalgesia and extradural anesthesia]. / Comparaison de la cortisolémie post-opératoire après neuroleptanalgésie et anesthésie extra-durale.

Postoperative plasma cortisol levels were measured in two series of surgical patients who had undergone a gynaecological operation, with respectively 17 and 16 subjects. Samples were drawn on D0 6pm, D1 8am, D2 8am and D3 8 am. A reference sample had been taken before the premedication on D0 at 8 am. The first series had been anaesthetised using a dextromoramidedroperidol type neuroleptanalgesia followed by postoperative analgesia by a noramidopyrine compound. The second series required epidural anaesthesia followed by postoperative analgesia by the injection of lidocaine at constant rate, interrupted between the last two samples. In the neuroleptanalgesia group: from a basal level of 470 nmol.l-1, plasma cortisol rose to 800 nmol.l-1 (p less than 0.01) on D0 at 6 pm to subsequently remain on a plateau between 500 and 550 nmol.l-1 (NS) within the normal physiological limits for the laboratory. In the epidural group, from a basal level of 420 nmol.l-1, plasma cortisol rose to 1000 nmol.l-1 (p less than 0.01) to return to basal levels only on D3: 450 nmol.l-1 (NS) with intermediate values of 700 and 630 nmol.l-1 (respectively: p less than 0.001 and p less than 0.05). Statistical comparison between the two groups showed that the increase in cortisol in the epidural group in relation to the other was significant throughout the period of administration of lidocaine at constant flow rate: p less than 0.05 on D0 at 6pm, D1 and D2. The results are discussed.

[Peridural anesthesia and cesarean section. Apropos of 117 cases]. / Anesthésie péridurale et césarienne. A propos de 117 observations.

One hundred and seventeen caesarean sections performed under epidural anesthesia are reported. Following localization by air myelography, catheterization of the epidural space was performed in all cases. The estimated level of injection was L 1.76 +/- 0.82. The local anesthetic used was: lignocaine 2 p. 100 with adrenalin 1/160,000 (N = 13) in a dose of 388 mg +/- 81.4; bupivacaine 0.5 p. 100 with adrenalin 1/2000,000 (N = 77) in a dose of 106.6 mg +/- 20; or a mixture of bupivacaine 0.5 p. 100 with adrenalin 1/200,000 and lignocaine 2 p. 100 without adrenalin (N = 27) at doses of 91.0 mg +/- 23.9 and 238 mg +/- 53.4 respectively. The failure rate was 5.97 p. 100 and the operative conditions were satisfactory in 91.5 p. 100 of cases. Apgar scores were greater than 7 in 87 p. 100 of cases at one minute and 99 p. 100 of cases at 5 minutes. The proportion of minor incidents was 30 p. 100, and of complications 3.5 p. 100. Their prevention and treatment and the anesthetic protocol are discussed.

[Postoperative analgesia by constant flow injection of lignocaine in obstetrical and gynecologic surgery]. / Analgésie post-opératoire par injection péridurale à débit constant en chirurgie obstétricale et gynécologique utilisant la lignocaïne.

154 surgical patients were given post-operative analgesia by peridural injection at a constant flow in the post-operative period after obstetric or gynecological surgery. These patients received 536.2 +/- 105.3 mu mol.h-1 (145.2 +/- 28.5 mg.h-1) of lignocaine for 46.97 +/- 15.56 h through a catheter omserted between L1-L2. The drug was given in concentrations which varied between: 27.7 to 18.5 m mol.l-1 (0.75 to 0.50 p. 100) depending on the age; and the volume varied between 17.5 to 30 ml.h-1 depending on the height. Satisfactory analgesia in 87 p. 100 of cases allowed all supplementary analgesia to be stopped. The only significant hemodynamic effect was a slight tachycardia (+ 15 p. 100). Two undesirable side effects were noted: a transitory but well-defined (type 2 or 3) motor paralysis, and an accumulation of plasma lignocaine (40 mu mol.l-1 (1.1 microgram.ml-1) at 48 h).