[Meningitis after spinal anesthesia]. / Méningite après rachianesthésie.

The occurrence of meningitis after spinal anaesthesia is a very rare event. We report a case of Streptococcus sanguis meningitis following spinal anaesthesia for orthopaedic material removal. The presence of Gram positive cocci (Streptococcus sanguis) in the cerebrospinal fluid was in favour of an exogenous contamination, originating either from the patient's skin or the anaesthesiologist's oropharynx. The outcome was uneventful. The responsibility of the latter can result in legal consequences. The scrupulous compliance with guidelines prevents this risk.

[Meningitis after locoregional spinal anesthesia]. / Méningites après anesthésie locorégionale rachidienne.

OBJECTIVE: Meningitis is a severe and an uncommon complication of both spinal and epidural anaesthesia. This review summarizes the knowledge on epidemiology, clinical and microbiological diagnosis and the ways to prevent them. DATA SOURCES: Articles published in English and French language since 1989 has been collected on Medline database, using "meningitis", "spinal anaesthesia" and "epidural anaesthesia" as keywords. DATA SYNTHESIS: Bacterial meningitis are usually in relation with Gram positive bacterias which is a clue for an exogenous contamination. Another unusual ways of contamination are blood circulating bacterias and spreading of local infection. Aseptic meningitis has been described, in relation to introduction of irritant agents in subarachnoid space. Lumbar puncture must be done each time meningitis suspected so that it can assert the diagnosis and guide antibiotherapy. Easy hygienic guidelines has been widely published to prevent meningitis. Usually, antibiotherapy alone is sufficient to treat meningitis but with an unjustified cost and sometimes severe persistent neurologic sequelae. CONCLUSION: The unexpected appearance of meningitis during the wearing-off of a spinal anesthesia is exceptional; the possibility of death or serious sequela must be taken into account. The sources of contamination are quite frequently exogenous, the germs coming most often from the patient's cutaneous flora or the anesthetist's ENT flora. Prevention of this risk involves a rigorous respect for cutaneous disinfection and hygiene procedures. The anesthetist's medico-legal responsibilities will be called upon in case of exogenous contamination.

Fatal sepsis due to Escherichia coli after second-trimester amniocentesis.

The case of a pregnant woman (16th week) needing an amniocentesis is reported. She rapidly developed a septic shock. Despite vaginal delivery, curettage and antibiotherapy, the patient deteriorated with the onset of an acute respiratory distress syndrome and a typical disseminated intravascular coagulation. Bacteriological data showed positive blood cultures to Escherichia coli. Amniotic liquid was positive to the same E. coli. Cultures obtained from instruments, disinfectant solutions and gel used during the procedure were negative. On the contrary, amniotic and fetal cultures were positive to E. coli and Clostridium perfringens. She died 2 days later. The incidence of septic shock following amniocentesis is very low but we report the first case of fatal sepsis and multiorgan failure, due to E. coli and C. perfringens. The mechanisms of infection are discussed: contamination from the instruments, systemic dissemination of bacteria coming from an asymptomatic intra-amniotic infection, and inoculation of the placenta with a needle passing through the bowel.

Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. PCA morphine.

We have compared the quality of three regimens of postoperative analgesia (continuous epidural administration of ropivacaine (Ropi. group), epidural ropivacaine and patient-controlled analgesia (PCA) with i.v. morphine (Ropi. + PCA group) and PCA morphine alone (PCA group)) during the first postoperative 24 h in a multicentre, randomized, prospective study. Postoperative analgesia was studied in 130 patients after major abdominal surgery performed under general anaesthesia. The ropivacaine groups received 20 ml of epidural bolus ropivacaine 2 mg ml-1 via the epidural route at the end of surgery, followed by continuous infusion of 10 ml h-1 for 24 h. The Ropi. + PCA group also had access to i.v. PCA morphine 1 mg, with a 5-min lockout. The PCA group received morphine as the sole postoperative pain treatment. The two ropivacaine groups had lower pain scores (P < 0.01) than the PCA group. Morphine consumption was higher in the PCA group (P < 0.05) than in the two ropivacaine groups. The quality of pain relief was rated as good or excellent in 79-85% of patients in the three groups. The percentage of patients without motor block increased between 4 and 24 h from 61% to 89% in the Ropi. group, and from 51% to 71% in the Ropi. + PCA group.

[Acute hemorrhagic pancreatitis]. / Pancréatite aiguë hémorragique.

Necrotizing acute pancreatitis is defined as necrosis of the adipose tissue, interstitial tissue and glandular tissue associated with areas of hemorrhage. Several causes are known predominantly biliary lithiasis and alcoholism. Severe consequences due to the release of pancreatic enzymes include activation of inflammation mediators which can lead to multiple organ failure. Although no therapy has been proven to be effective, progress in intensive care has helped reduce mortality. Rapid diagnosis and evaluation of the severity of illness with specific or general scores (Apache II score) are the keys to rapid management using therapies adapted to the degree of organ failure. Indication for surgery must be established in coordination with surgeons and depends both on the clinical course and computed tomography score.

Effects of volatile anesthetics, thiopental, and ketamine on spontaneous and depolarization-evoked dopamine release from striatal synaptosomes in the rat.

BACKGROUND: Recent experimental data indicate that anesthesia is often associated with significant changes in brain concentrations of dopamine (DA), an inhibitory neurotransmitter located in restricted, but functionally important, areas such as the striatum. Whether the presynaptic DA nerve endings represent potential targets for anesthetics remains unknown. Therefore, the current study was designed to investigate the effects of volatile anesthetics, thiopental, and ketamine on both spontaneous and depolarization-evoked DA release from striatal synaptosomes in the rat. METHODS: Purified striatal synaptosomes preloaded with 3H-DA were superfused with artificial cerebrospinal fluid (1 ml/min). Radioactivity obtained from 1-ml fractions was measured over 15 min; first, in the absence of any treatment (spontaneous release), then in either the absence (time-dependent control) or presence (evoked-release) of anesthetic and pharmacologic agents, and finally, again, without any pharmacologic stimulation. The compounds tested were: potassium chloride (15 and 50 mM), glutamate, N-methyl-D-aspartate (NMDA) and kainate (10(-4) M and 10(-3) M), MK-801 (10(-4) M, an antagonist of NMDA receptors) and 6-cyano-7-nitro-quinoxaline-2,3-dione (10(-4) M, an antagonist of D,L-alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate [AMPA] receptors), halothane, enflurane, isoflurane (1, 1.5, and 2 minimum alveolar concentrations), ketamine (10(-5) and 10(-4) M), and thiopental (10(-5) and 10(-4) M). RESULTS: Volatile anesthetics induced a significant, concentration-related increase in spontaneous 3H-DA release, but thiopental and ketamine were ineffective. The effect of 2 minimum alveolar concentration enflurane (but not halothane or isoflurane) was significantly enhanced when a Mg(2+)-free cerebrospinal fluid was used, and was reduced by MK-801 application. Nomifensine (10(-5) M, a blocker of monoamine transporter) did not affect the 3H-DA release evoked by volatile anesthetics. Glutamate, kainate, NMDA, and potassium chloride induced a significant, dose-related, Ca(2+)-dependent 3H-DA release. Halothane and isoflurane produced a significant and concentration-related decrease in the 3H-DA peaks evoked by glutamate, kainate, and NMDA; however, enflurane significantly attenuated the glutamate- and kainate-mediated release, but enhanced that evoked by NMDA. Thiopental and ketamine (10(-4), but not 10(-5) M) significantly reduced the glutamate- and NMDA-stimulated release, but only thiopental decreased the kainate-induced effect. Furthermore, the effect of potassium chloride (15 mM) was significantly reduced by all anesthetics examined, whereas that of potassium chloride (50 mM) was unaffected. CONCLUSION: The authors conclude that: (1) volatile anesthetics, thiopental, and ketamine exert significant changes in both spontaneous and depolarization-evoked 3H-DA release in the rat striatum; (2) enflurane uniquely enhances NMDA-receptor mediated dopamine release; and (3) the results obtained from these receptor-mediated effects (AMPA and NMDA) may apply to postsynaptic, as well as presynaptic, glutamate receptors.