Wound infiltration with magnesium sulphate and ropivacaine mixture reduces postoperative tramadol requirements after radical prostatectomy.

PURPOSE: This prospective, randomized, double-dummy study was undertaken to compare the effects of magnesium sulphate (MgSO(4)) administered by the intravenous vs. the infiltration route on postoperative pain and analgesic requirements. METHODS: Forty ASA I or II men scheduled for radical retropubic prostatectomy under general anaesthesia were randomized into two groups (n=20 each). Two medication sets A and B were prepared at the pharmacy. Each set contained a minibag of 50 ml solution for IV infusion and a syringe of 45 ml for wound infiltration. Group MgSO(4).IV patients received set A with 50 mg/kg MgSO(4) in the minibag and 190 mg of ropivacaine in the syringe. Group MgSO(4)/L received set B with isotonic saline in the minibag and 190 mg of ropivacaine +750 mg of MgSO(4) in the syringe. The IV infusion was performed over 30 min at induction of anaesthesia and the surgical wound infiltration was performed during closure. Pain was assessed every 4 h, using a 100-point visual analogue scale (VAS). Postoperative analgesia was standardized using IV paracetamol (1 g/6 h) and tramadol was administered via a patient-controlled analgesia system. The follow-up period was 24 h. RESULTS: The total cumulative tramadol consumption was 221 +/- 64.1 mg in group MgSO4.IV and 134 +/- 74.9 mg in group MgSO(4).L (P<0.01). VAS pain scores were equivalent in the two groups throughout the study. No side-effects, due to systemic or local MgSO(4) administration, were observed. CONCLUSION: Co-administration of MgSO(4) with ropivacaine for postoperative infiltration analgesia after radical retropubic prostatectomy produces a significant reduction in tramadol requirements.

Pharmacological control of head motion during cerebral blood flow imaging with CT or MRI.

Uncontrolled head motion during CT/MRI cerebral blood flow (CBF) imaging has been estimated between 3 and 15% of the cases. We present a pharmacological approach which permitted us to maintain the incident at 0.06% with few side effects. The protocol involves the systematic use of general anesthesia (sevoflurane) in children below five years and those with mental retardation. In anxious, claustrophobic or agitated adults, mild sedation with propofol, midazolam or hydroxyzine was used with mild effects on CBF. We strongly recommend the availability of basic cardiorespiratory resuscitation equipment and a recovery room before any sedation or general anesthesia is undertaken.

Optimal management of an aneurysmal subarachnoid hemorrhage in a patient with known factor XI deficiency: a case report.

The authors report a rare case of an acute cerebral aneurysm rupture in a patient with a known factor XI deficiency. Aneurysmal subarachnoid hemorrhage (SAH) accounts for a high mortality and morbidity rate. When SAH is associated with an inherited coagulation disorder such as hemophilia C, an unexpected and possible increase in hemorrhagic stroke and increase in bleeding during surgery and in the postoperative period could lead to an extremely bad outcome. Clinical management consists of rapid correction of the coagulation disorder before undergoing any invasive intracranial procedure. Such an optimal therapeutic strategy must be under the care of a multidisciplinary medical and surgical team. Human factor XI concentrate (Hemoleven, Laboratoire Français du Fractionnement et des Biotechnologies [LFB], Les Ulis, France) was used successfully in this case report. New treatment using recombinant factor VIIa is discussed.

A retrospective study of the potential complications during alveolar distraction osteogenesis in 55 patients.

The aim of this retrospective study was to analyse the outcome of alveolar distraction osteogenesis for the correction of vertical defects in a large series of 55 cases. The existing bone deficiencies were secondary to atrophy after periodontal disease or tooth extraction. The overall success rate of this technique was 89.1%. The complications presented during treatment were divided into minor (no effect on final result, but immediate intervention required) 14/55 patients (25.4%), and major (lead to technique failure) 6/55 patients (10.9%). The frequency of minor complications was 8/27 in the anterior maxillary region, 1/27 in the anterior mandibular region and 15/27 in the posterior mandibular region. The frequency of major complications was 5/6 in the posterior mandibular region and 1/6 in the anterior maxillary region. The mean alveolar height achieved was 6mm. The overall rate was 36.3%. On the basis of these results it was concluded that alveolar distraction osteogenesis is an effective technique to treat vertical alveolar ridge deficiencies.

[Low doses ketamine: antihyperalgesic drug, non-analgesic]. / Kétamine à faibles doses: antihyperalgésique, non analgésique.

Recent data in animal experiments as in clinical trials have clearly reported that pain modulation is related to an equilibrium between antinociceptive and pronociceptive systems. Therefore, the apparent pain level could not only be a consequence of a nociceptive input increase but could also result from a pain sensitization process. Glutamate, via NMDA receptors, plays a major role in the development of such a neuronal plasticity in the central nervous system, leading to a pain hypersensitivity that could facilitate chronic pain development. By an action on NMDA receptors opioids also induce, in a dose dependent manner, an enhancement of this postoperative hypersensitivity. "Antihyperalgesic" doses of ketamine, an NMDA receptor antagonist, were able to decrease this central sensitization not only in painful animal but also in human volunteers exposed to different pain models, or in the postoperative period. Many studies have reported that ketamine effects are elicited when this drug is administered the following manner: peroperative bolus (0.1 to 0.5 mg/kg), followed by a constant infusion rate (1 to 2 microg/kg per min) during the peroperative period and for 48 to 72 hours after anaesthesia. Those ketamine doses improved postoperative pain management by reducing hyperalgesia due to both surgical trauma and high peroperative opioid doses. This antihyperalgesic action of ketamine also limited the postoperative morphine tolerance leading to a decrease in analgesic consumption and an increase in the analgesia quality.

[Clinical evaluation of the single use Laryngeal Tube in adults: the LTD]. / Evaluation clinique chez l'adulte du tube laryngé à usage unique: le LTD.

OBJECTIVES: The Laryngeal Tube (LT) is a supra-laryngeal device indicated to manage upper airway during anaesthesia. Leak pressures were lately reported higher for the LT as compared to the LMA. A recent study found a small amount of proteinaceous material on LMA after classical sterilization suggesting a risk of contamination by unconventional transmissible agents (prions). The aim of this study was to evaluate the effectiveness of the single use Laryngeal Tube: the LTD. STUDY DESIGN: Prospective study realized after ethical committee agreement and patient consent for participation. PATIENTS AND METHODS: Adults, ASA score< or =3, 18 to 75-year-old, without upper airway abnormality or difficult intubation criteria, anaesthesia< or =2 h, free access to patient's head and LTD. The following criteria were evaluated: easiness of insertion, assisted (AV), controlled (CV) and spontaneous ventilation (SV); leak pressure (LP) 5 and 15 min after insertion; complications during anaesthesia conducted with propofol and remifentanil under bispectral index monitoring. RESULTS: 55 patients were included; only one failure was reported at insertion. AV and CV were easy, SV difficult in 4 patients with chin lift necessary for adequate ventilation. LP was 28.92+/-8.4 and 30.87+/-8.68 cmH2O 5 and 15 min after insertion respectively. No major incident was noticed throughout the study. CONCLUSION: the use of the LTD was easy and successful. Moreover the LTD totally excluded the risk of contamination by unconventional transmissible agents.

Regional cerebral blood flow measurements with Xenon-CT in the prediction of delayed encephalopathy after carbon monoxide intoxication.

Reported evaluations of CBF with Xe/CT were performed in 11 patients during the lucid interval following CO intoxication. Results were compared with clinical and SPECT data. Two patients developed neuropsychiatric behavior (delayed encephalopathy) one month following the initial recovery. The symptoms persisted in one of them 15 months later. Their CBF values as well as those in most of the other patients, monitored at the basal ganglia and white matter areas, were in relation with the clinical outcome, However, further studies with a larger number of patients, are needed to confirm the predictive significance of Xe/CT measurements for the long term sequelae of CO poisoning.

Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain.

To evaluate the long-term effectiveness of a single cervical epidural steroid injection (CESI) performed with or without morphine, 24 patients, without need of surgery, but suffering for more than 12 months from cervical radicular pain, were included in a prospective and randomised study. The cervical epidural space was injected (C7-D1; 18-ga needle) with an increasing volume (10 ml maximum) of isotonic saline solution to exacerbate the patient's radicular pain. The patients were then randomly allocated to 2 groups: the steroid group (group S, n = 14) received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg/ml) and the steroid plus morphine group (group S + M, n = 10) received the same combination plus 2.5 mg of morphine sulphate. Pain relief was assessed as the percentage of pain decrease on a visual analogue scale on day 1 and at months 1, 3, 6, 8 and 12 after CESI, up to 48 months. Anthropometric data between the 2 groups were similar. The mean volume injected in the epidural space was: 6.6 +/- 2.1 and 6.3 +/- 1.9 ml in groups S and S + M, respectively, and this volume exacerbated pain in 21 of 24 patients. Despite observing a better transient improvement the day after CESI in the S + M group, long-term results did not differ. The success rate was 78.5% in group S and 80% in group S + M providing pain relief of 86.8 +/- 14.7% and 86.9 +/- 17.9%, respectively. Pain relief remained stable with time (mean follow-up: 43 +/- 18.1 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of premedication with oral hydroxyzine on patient motion during inhalation of 32% xenon for regional cerebral blood flow mapping.

Because of its anesthetic properties, inhalation of 30-35% Xenon is associated with uncontrolled patient motion in 3-15% of the cases. This constitutes a major setback to regional cerebral blood flow studies with Xenon-enhanced computed tomography (Xe-CT CBF). The present study attempted to determine the effects of oral premedication with hydroxyzine (H) in the control of motion. Patients scheduled for Xe-CT CBF, aged 20-55 years, were randomly allocated to 3 groups: H 50 mg (n = 41), H 100 mg (n = 36) or Placebo (n = 43). The drugs were administered orally 90 minutes before Xenon inhalation. This consisted a gas mixture of 32% Xe and 25% oxygen. Motion was classified as controlled or uncontrolled depending on whether CBF data acquisition was possible or not. Anxiolysis and sedation were evaluated by a visual analogue scale. Motion was significantly reduced in the H 50 mg (0.8% vs 2.5% in the H 100 mg and 6.7% in the Placebo group). An anxiolytic effect of hydroxyzine was suggested.

Disability and handicap 5 years after a head injury: a population-based study.

A population-based cohort of 407 head trauma patients has been studied since 1986 to estimate the prevalence of long-term disabilities and handicaps by means of a structured questionnaire. Five years later, 6-1 patients were deceased and 36 were lost to follow-up. Prevalence of subjective and behavioral complaints was high whatever the initial head trauma severity. Lethality in severe head injuries was 56%, and half of the survivors remained disabled. In minor and moderate head injured patients, most disabilities were related to extracranial injuries. Taking all disabilities into consideration, each year 24 per 100,000 patients of such a population are likely to suffer from at least one long-lasting disability, including 10 per 100,000 whose disabilities are due to extracranial injuries. Head injuries induce long-lasting handicap in 9 per 100,000 habitants which is severe in 2 per 100,000. These figures point to the need of reinforcing preventive actions and long-term care of these patients.

The epidemiology of head trauma in Aquitaine (France), 1986: a community-based study of hospital admissions and deaths.

This paper reports the findings of a study of head trauma conducted over a one-year period within a defined region with a population of 2.7 million (Aquitaine, France). It includes cases resulting in death prior to hospitalization or requiring hospitalization. During the one-year period, 391 deaths and 8549 hospital admissions due to head trauma occurred, yielding an annual estimate of 8940 head-injured people. The immediate case-fatality rate was 4.4%. Among non-fatal cases, 80% were mild, 11% moderate and 9% severe. The overall annual incidence was 281/100,000 in both sexes (384 and 185/100,000 in males and females respectively). The annual death rate was 22/100,000 (33 and 12, respectively). Patterns of incidence by age and sex were in general agreement with earlier studies. The main causes of head trauma were traffic accidents (60%) and falls (33%). One-third of hospitalized patients had no injury other than the head trauma. The most frequently associated injuries were those involving extremities, whereas the most severe were those involving the abdomen. The Injury Severity Score (ISS) ranged from 4 to 66, with a mean of 9 and a median of 5. At the eighth day following injury, 25% of hospital-treated patients were still hospitalized and 2% had died. The outcome correlated well with the ISS.

Cognitive sequelae of propofol anaesthesia.

As with any substance that interferes with nervous system functioning, anaesthetics are likely to have neural effects the duration of which extend beyond the acute loss of consciousness. Studies of recovery after anaesthesia have shown that physiological effects and psychomotor functions return to pre-anaesthesia levels within at most 90 min of the cessation of propofol administration. To date no report has been published concerning the possible longer term effects of propofol anaesthesia on higher cognitive functions such as learning, language, reasoning and planning. We evaluated a range of cognitive tasks (short and long-term memory, attention, language comprehension and planning) up to 6 h after cessation of Propofol administration, and found that this set of cognitive functions was still depressed after 3 h, but had recovered by 6 h. The results suggest that, for their security, patients should be remain in a supervised environment for at least 3 h after propofol anaesthesia, and that oral information to patients within those 3 h should be avoided.

Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital.

OBJECTIVE: To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics. DESIGN: Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis. SETTING: Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams. MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF. CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change.

[Characteristics of head trauma in children: epidemiology and a 5-year follow-up]. / Particularités des traumatismes crâniens chez les enfants: épidémiologie et suivi à 5 ans.

BACKGROUND: Accidents are the major cause of morbidity and mortality in children. The aim of this population-based study was to describe characteristics of head injuries leading to hospitalization in children less than 15 years old, in a defined geographic population (Aquitaine: 2.7 millions inhabitants) and the longterm outcome (5-year follow up) of a sample of these patients. PATIENTS AND METHODS: Hospitalized patients, residents of the region, were included in a prospective study during 13 weeks spread over the whole year in 1986 in all emergency services of the region. The follow-up study concerned patients hospitalized in 3 hospitals (a trauma I level center, a pediatric hospital and a general hospital), with a sampling frame taking into account the overall injury severity. Impairments, disabilities and handicaps were assessed with a structured questionnaire five years later and results in children compared with those of adults. RESULT: Annual incidence of hospitalized head injuries in children was 294/100,000 inhabitants. The lethality was 0.3% in hospitalized patients. Ninety-two percent of head injuries were minor. In the youngest patients, the most frequent circumstances were a fall at home. The traffic accidents rate increased with age from 14% to 53% in the 10-14 years old children. Five years later, 104 children were reviewed (83 minor and 21 moderate or severe head injuries). Children complained less often of somatic symptoms than adults. Two children had disabilities in daily life activities, including one whose minor head injury eventually worsened and one after a very severe brain injury. According to the Glasgow Outcome Scale three patients had a poor recovery (2 severe and 1 moderate disability). CONCLUSIONS: Origin and mechanisms of head injuries in childhood were similar than in previous studies. Incidence was higher because of a higher proportion of minor head injuries. Disabilities and poor recovery happened in children with brain lesions or in one children with a minor head injury complicated by a severe anoxia. Anxiety and depression should be better studied in these children.

[Resuscitation in the elderly: prognostic factors]. / Réanimation du sujet âgé: facteurs de pronostic.

High medical environment in our society is linked up with an increase of intensive care in geriatric patients. Such a situation can seem to be inappropriate, especially when it results in a trial to obtain the survival of patients who are finishing their life. Therefore an appropriate medical evaluation and management are required in order to quantify as fairly as possible both prognosis and specific risks. Mortality factors in elderly patients are multiple and additive. Two groups of risks can be distinguished: intrinsic risk factors depending on the patient (age, neurologic impairment, severity of acute illness, previous health status), and extrinsic risk factors, related to medical environment (i.e. length of stay in intensive care unit, care quality...). These latter are improvable. In the elderly, the mortality rate is twofold higher (about 35%) than in young patients. Evaluation of intensive care unit outcome on 6 month survival makes this rate worse, as 10% to 20% more patients die secondarily. However, most of the studies demonstrate that duration of stay in intensive care units is similar, whatever the age and outcome. It must also be underlined that quality of life after intensive care is similar in young and old patients. It is concluded that individual's and society's views concerning cost and effectiveness of intensive care in elderly patients do not always coincide with objective results. If medical motivation has to be preserved, specific care strategy remains to be established.

[Comparative repercussions of general and spinal anesthesia on the psychological functions of the aged subject]. / Répercussions comparées de l'anesthésie générale et de la rachianesthésie sur les fonctions psychiques du sujet âgé.

Although worsening cerebral function in the elderly is often said to be due to anaesthesia, it still remains to be proved that anesthesia acts on an elderly patient's psychological make-up. This study aimed to compare the psychological effects of general or spinal anaesthesia on 35 patients more than 70-yr old under repair of a subcapital femoral fracture, after having excluded 63 patients. They were randomly divided into two groups, the first receiving a spinal anaesthetic with 1.5 mg.kg-1 prilocaine (RA; n = 19), and the others a general anaesthetic with 5 mg.kg-1 thiopentone, dextromoramide, nitrous oxide and enflurane (GA; n = 16). None of the patients wer given a premedication. They underwent a battery of six psychological tests before and 36 h after surgery, all carried out by the same physician. Six patients in GA group and three in RA group developed a transient fall in mean blood pressure just after anaesthetic induction (not significant). There were no significant differences between the two groups in age, sex distribution, ASA class and performance in the tests, both before and after surgery. Individual psychological scores did not differ either. In the RA group, the postoperative tests were even better carried out than before surgery (p less than 0.05). It could therefore be concluded that anaesthesia alone has little impact on the psychological status of elderly patients.

[Untreatable ventricular hemorrhage revealing cerebral metastasis of malignant melanoma]. / Hémorragie intraventriculaire incoercible révélatrice d'une métastase cérébrale d'un mélanome malin.

High levels of tissue-like plasminogen activator in cerebrospinal fluid reported in a patient with an intracerebral haemorrhage associated to cerebral metastasis of malignant melanoma could support the hypothesis of cerebral haemorrhage induced by tPA tumoral synthesis.

[Transfusion-related acute lung injury. A case report]. / Etiologie des oedèmes pulmonaires lésionnels transfusionnels. A propos d'un cas.

Acute lung injury is a common adverse effect of massive blood transfusion, responsible for 17% of the deaths due to transfusion in France. A cardiac origin is often suspected. We report a case of post-transfusional pulmonary oedema in a cirrhotic patient, which could be related to a non-cardiac and underdiagnosed aetiology: the so-called transfusion related acute lung injury (TRALI).

[Procedures use by French anesthetists in cases of difficult intubation and the impact of a conference of experts]. / Procédures utilisées par les anesthésistes-réanimateurs français en cas d'intubation difficile et impact de la conférence d'experts.

OBJECTIVE: To analyse the management of difficult intubation (DI) by French anaesthetists and the impact of the French experts' conference (EC) on this topic. STUDY DESIGN: Prospective, comparative, before/after study by questionnaire carried out in Aquitaine, Provence-Alpes-Côte d'Azur and Alsace-Lorraine. MATERIAL AND METHODS: A questionnaire on demographical data, detection of DI, management techniques and desiderata for continuing education on DI, was sent three months before the publication of the EC to 100 randomly selected anaesthetists, in each region (group PRE). Three months after the diffusion of the EC, the questionnaire completed by a survey on the impact of the EC was sent to 100 other randomly selected anaesthetists in each region (group POST). In the latter group, anaesthetists who considered the EC were compared to those who did not. RESULTS: The participation rate was 91% for the group PRE and 79% for the group POST respectively. Both groups were not significantly different for age, gender, position and seniority. Most used techniques that included blind nasal intubation (84%), intubation through laryngeal mask (82%), and intubation with fibrescope (53%). Demands for additional training were for translaryngeal ventilation (68%), intubation with fibrescope (64%), retrograde intubation (52%), and intubation through a laryngeal mask (46%). The EC was known by 71% of anaesthetists. In this group, the EC improved the assessment rate of the three recommended predictive criteria for DI from 12 to 28% (P < 0.02), but neither the management policy, nor the desiderata for additional training. CONCLUSION: Currently, the search of predictive indicators for DI is not systematically applied. The EC has only slightly modified the practice patterns. The need for additional training is important.

[Post-traumatic cerebral fat embolism]. / Embolie graisseuse cérébrale post-traumatique.

A seventeen year old boy sustained pelvic, femoral shaft and malleolar fractures in a road traffic accident. Six hours after admission, the patient became comatose (Glasgow coma score = 7); the coma worsened such that, 24 h later, the coma score was 4. Petechiae were present on the conjunctiva and anterior chest wall. Computed tomography revealed diffuse brain swelling. The diagnosis of cerebral fat embolism was made. There were multiple episodes of severe intracranial hypertension. After 23 days of traction, the femoral fracture was internally fixed. The patient returned home after five months of hospital, with just a few memory and writing problems. Ten months after the accident, magnetic resonance imaging showed a small ventricular dilatation due to subcortical atrophy. Residual ischaemic lesions and demyelination could be seen in the right centrum ovale and temporal lobe. The cerebral lesions contrast with the reversibility of the clinical state.