Evaluation of infectious episodes in neonates using a new procedure for the nitroblue tetrazolium test.

A new procedure for the NBT slide test for peripheral blood neutrophils has been tested. 255 neonates were studied of which 63 served as control cases. Among the 114 term infants, 37 were patently infected, 30 suspicious and 47 non-infected. The latter did not significantly differ from control cases, whereas suspicious and infected infants were credited with significantly higher NBT scores. 78 infants were preterm, 31 of which were patently infected, 22 suspicious and 25 non-infected. NBT scores of infected and suspicious infants were significantly higher than those of non-infected infants, but, as previously reported, scores of preterm infants were systematically and significantly lower than those of full-term infants of the same bacteriological class. Threshold values are suggested; they could represent an accurate diagnostic aid in the early differentiation of healthy infants from high-risk infants regarding bacterial infections.

Influence of acute renal failure on FPIA rapid serum assay of midazolam and its main metabolite.

We recently developed a simple and fast assay technique, providing the possibility of monitoring of midazolam (M) during sedation. We compared HPLC vs FPIA for the measurement of the sum M plus alpha 1-hydroxymidazolam (OM), its main and pharmacologically active metabolite, in the serum of sedated ICU patients; this activity referred to as M-like. We identified certain patients in whom M-like activity appeared abnormally high in comparison with HPLC assays. Their common denominators were: long-term sedation with M, and seriously impaired renal function. Further, the conjugates of OM (OMG) accumulated in patients with acute renal failure could contribute to the sedation. We compared the metabolic and analytic behavior of M, OM, and OMG in 2 groups of sedated patients either presenting with normal renal functions (group 1) or with a picture of acute renal failure (group 2). Blood samples were assayed by HPLC and by FPIA and analysis was performed before and after hydrolysis of OMG. Before hydrolysis there was a dramatic accumulation of OMG in the patients of group 2, HPLC vs FPIA results were not different within group 1, while in group 2 the FPIA response exceeded that of HPLC. After hydrolysis, measurement by HPLC was greatly increased in group 2, in each group (vs HPLC) and from one group to another, the FPIA signal (the M-like activity) showed a significant increase. It would be important to take OMG into account as a coprotagonist in sedation whenever circumstances predispose to its accumulation.

Spontaneous perforation of Meckel's diverticulum in a neonate.

A case of a male newborn infant with spontaneous perforation of Meckel's diverticulum is reported. The clinical course consisted of delayed occlusive disorders and bloody stools following 36 h of normal gastrointestinal transit, without pneumoperitoneum and infection. Pathogenesis of the perforation is discussed and the importance of early diagnosis, especially in maternity hospitals, is emphasized.

Comparison of continuous, constant rate enteral tube feeding in supine patients to bolus food intake in ambulatory, healthy subjects regarding bioavailability of perorally administered cefroxadine.

Stabilized, bedridden, inactive trauma patients on enteral nutrition via continuous, constant rate tube feeding (2 different formulas) were given a single dose of cefroxadine p.o. There were no differences in the pharmacokinetic parameters between the groups on different enteral nutrition. These patients were compared to cefroxadine absorption in ambulatory healthy subjects after a standardized meal (bolus-fed). The mean residence time was significantly longer in the patients, and the extent of absorption was slightly reduced with one enteral nutrition formulation and significantly reduced with the other. The other pharmacokinetic parameters were not significantly different. The difference is believed to be caused by reduction in splanchnic blood flow in the immobilized patients, weakening of migrating motor complex due to tube feeding and the lower temperature (4 degrees C) of enteral nutrition.

Peroral absorption of cefroxadine in patients within the first day after severe trauma: comparison to cefroxadine pharmacokinetics in fasted, healthy volunteers.

Peroral absorption of cefroxadine given to 7 24-h fasted trauma patients by nasogastric tube within the first day of admission was compared to that obtained in fasted healthy volunteers. The trauma patients exhibited significantly lower Cmax and reduced AUC. Even though rate and extent of bioavailability cannot be determined from these two different population groups since the total clearance must be assumed to be different in patients and healthy subjects, a reduced bioavailability is assumed based on pathophysiologic reflections.

[Premedication and sedation complications during ophthalmic anesthesia]. / Les complications de la sédation et de la prémédication en anesthésie ophtalmologique.

Sedation allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command. For ophthalmic surgery patient's anxiety and discomfort can be relieved during placement of a peribulbar block and during surgery by intravenous sedation. Intravenous sedation should only be administered by an anesthetist. Three different classes of drugs are used for intravenous sedation: analgesics (fentanyl and alfentanil), benzodiazepines (midazolam) and profofol, an intravenous anesthetic. Sedation may result in ventilatory, cardiovascular and neurologic complications. Excessive sedation can induce hypoventilation from central ventilatory depression or airway obstruction. Uncontrolled and unexpected movements of the head could result in major surgical complications. For the prevention of the complications related to sedation the same monitoring as for general anesthesia is essential.

[Nitroblue tetrazolium test. Neonatal infections and antibiotic therapy]. / Test au nitrobleu de tétrazolium. Infections néonatales et antibiothérapie.

The authors report the results of a prospective test of NBT carried out by an original method already described, and now used for seventy newborn babies. Eleven of them (group I) were tested by simultaneously taken samples from the cord and the heel in the labour ward. The levels obtained according to the position from which the samples were taken showen no significant difference. In 59 other infants (group 2) three successive tests were carried out in the first two weeks of life. These results were classified according to whether the children were: infected, perhaps infected and non-infected. The results confirm correlations between raised levels and infections. Giving antibiotic therapy does not alter significantly the levels in non-infected babies, nor the high positive scores in infected babies that were revealed in the four days after the start of treatment. Following this delay, levels of infected babies' blood did drop significantly, which was a probable indication of the efficacy of the antibiotic therapy.

[Does the lipid emulsion of Diprivan explain some pharmacological effects?]. / L'émulsion lipidique du Diprivan explique-t-elle certains effets pharmacologiques?

In currently available experimental or clinical studies, there is no report of any adverse effect related to the lipid emulsion of propofol, for procedures not exceeding on average four hours of duration. General anaesthesia produced by propofol alone is associated with only moderate alterations of blood lipid concentrations. Therefore there is no restriction to the use of propofol. In the absence of precise data, it is recommended not to use propofol infusion in congenital hyperlipaemias (e.g., hyperchylomicronaemia). The lipid emulsion of propofol may alter the rheological properties of circulating blood, platelet aggregation, chemotactic activity of neutrophils and lymphocytes functions. These alterations are always limited. Furthermore, most studies which have recorded these effects are not directly applicable to clinical practice and additional studies are necessary. There are no data demonstrating that propofol would increase surgical bleeding or the incidence of postoperative infections. Since there is a low probability of these adverse effects, they should not limit the use of propofol.

[Postanoxia encephalopathies]. / Encéphalopathies postanoxiques.

Ischaemic brain damage can follow global cerebral hypoxia, localized cerebral hypoxia and global cerebral anoxia as it occurs after circulatory arrest. The calcium-ion-mediated mechanism is one of the main routes to cerebral deterioration. Barbiturates are restricted for treatment of increased intracranial pressure and seizures. Calcium channel blockers cannot yet be recommended. Therapy remains mainly symptomatic. Hyperglycaemia should be avoided.

[Effects of anesthesia on postoperative micturition and urinary retention]. / Effets de l'anesthésie sur la miction et rétention aiguë d'urine postopératoire.

Postoperative micturition difficulties, considered as minor complications, have a high incidence. Acute urinary retention can follow all types of anaesthetics or operations. Surgical trauma to the pelvic nerves or to the bladder, postoperative oedema around the bladder neck, and pain-induced reflex spasm of the external and internal urethral sphincters may play a role in the development of urinary retention. Acute urinary retention is the most common complication of surgery for benign anorectal disease. The incidence of urinary retention is more likely to occur in old male patients. Preoperative urinary symptoms are not a prerequisite for developing postoperative urinary retention, although they are considered to be a risk factor. The type of anaesthetic, postoperative pain and its management may have little effect on the occurrence of postoperative urinary dysfunction. Studies on the urodynamic effects of various anaesthetic agents are rare. The parasympatholytic drugs increase bladder capacity, decrease the rate of bladder contractions and cause downward trends in urethral resistance. The barbiturates and halothane produce similar effects on urethral resistance. The anaesthetic agents decrease the intrabladder pressure and inhibit the micturition reflex. Halothane decreases bladder contractions and increases its capacity measured by the cystometrogram. Urinary retention is a side effect of opioids, particularly after intrathecal or epidural administration. Epidural morphine relaxes the detrusor muscle with a corresponding increase in the maximal bladder capacity. Spinal opioids influence the function of the lower urinary tract, by direct spinal action on the sacral nociceptive neurons and autonomic fibres, as well as by an effect on supraspinal centres. Naloxone increases detrusor pressure, decreases bladder capacity, and causes a need to void. Urinary retention is less common after a short-acting (lidocaine 5%) than after a long-acting agent (bupivacaine 0.5%). After spinal anaesthesia, detrusor strength and the ability to void restarts with the return of sacral sensation to pinprick. A single episode of bladder overdistention can result in significant morbidity. Overfilling of the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so that recovery of micturition may not occur when the bladder is emptied. On the other hand, the excessive use of an indwelling catheter can lead to urinary tract infection, urethral stricture and prolonged hospital stay. Short-term prophylactic catheterisation is recommended in patients with obstructive symptoms. Patients at risk for urinary retention should be stimulated to void and provided a quiet environment in which to do so. They should be encouraged to seat, stand or ambulate as early as possible. The alpha 1 adrenergic receptor blocking agents have been used for treatment of organic or functional urinary retention. It is essential to make sure the bladder empties regularly in the postoperative period, especially in day-case surgery or in patients receiving opioid analgesia or after epidural anaesthesia.

[Premedication with intranasal midazolam in pediatric anesthesia]. / Prémédication par midazolam intranasal en anesthésie pédiatrique.

To evaluate nasally administered midazolam 0.2 mg.kg-1 for preinduction of anaesthesia in paediatric patients the authors studied ASA 1 patients scheduled for elective surgery. Forty-five children, ages 3 to 126 months, were randomized in three groups: group D (n = 16) received diazepam 0.33 mg.kg-1 orally, group P (placebo) (n = 13) 0.04 ml.kg-1 normal saline via the nasal route; in group MDZ (n = 16) the children were given intranasal midazolam 0.3 mg.kg-1. The premedication was assessed on a 5-point sedation scale, modified to include the response to mask placement and the quality of the induction of general anaesthesia. The degree of sedation, heart rate, blood pressure, respiratory rate and oxygen saturation levels were recorded on the arrival in the operating room (0 min) and 3, 6, 9, 12 and 15 min (mask placement) after drug administration. With intranasal midazolam sedation was demonstrable at 6 min and was significant at 9 and 12 min. In this group all the children were calm or drowsy. The induction of anaesthesia was equivalent in group D and MDZ but easier than in those patients receiving normal saline. Vital signs did not change during the study period in any of the three groups. Intranasal midazolam was slightly more effective than oral diazepam. In children, it produces anxiolysis and sedation with rapid onset and is an attractive alternative to other routes for preanaesthetic medication.

[French and foreign recommendations for the practice of anesthesia-intensive care]. / Recommandations françaises et étrangères sur la pratique de l'anesthésie-réanimation.

UNLABELLED: This article reviews the development of STANDARDS, Recommendations and Guidelines for practice in anaesthesiology in France and other countries. The French society for anaesthesia and intensive care (Sfar) has published, since 1989, 11 basic STANDARDS: 1) Recommendations for the monitoring of patients during anaesthesia (June 1989, amended on January 1994) [APSF Newsletter, Summer 1990, page 22]; 2) Recommendations for postanaesthesia monitoring and care (September 1990); 3) Recommendations for preanaesthesia care (September 1991); 4) Recommendations for anaesthetic apparatus and checking before use (January 1994); 5) Recommendations for the equipment of anaesthesia working places (January 1995); 6) Recommendations for the tasks of the nurse anaesthetist (January 1995); 7) Recommendations for hygiene standards in anaesthesia practice (December 1997); 8) Recommendations for outpatient anaesthesia (September 1990); 9) Recommendations for the practice of obstetrical analgesia (September 1992); 10) Recommendations for interhospital physician-accompanied transfers (December 1992); 11) Recommendations for intrahospital physician-accompanied transfers (February 1994). Additionally the Sfar produced or coproduced 9 Experts' conferences, 15 Consensus conferences and 5 Guidelines for clinical practice.

[Prospective preoperative survey of 300 patients using prick tests with muscle relaxants]. / Enquête prospective préopératoire chez 300 patients par prick-tests aux myorelaxants.

It is now well established that the retrospective diagnosis of anaphylaxis to muscle relaxants may be based on skin prick testing. These tests, which use undiluted solutions of muscle relaxants, are as sensitive, specific and reproducible as intradermal tests for the diagnosis of IgE related adverse reactions to muscle relaxants. The rate of muscle relaxant anaphylaxis (1/1 500 to 1/5 000) justifies its prevention based on a possible latent sensitization. A prospective investigation was carried out in 300 surgical patients scheduled for general anaesthesia. Prick tests were carried out using the 6 available muscle relaxants: suxamethonium, gallamine, alcuronium, pancuronium, vecuronium and atracurium. The wheal the drug might produce was compared with that obtained with codeine phosphate (a histamine releasing drug). Thirty-seven patients (13%) were considered to be atopic; 262 (87%) had undergone a previous anaesthesia. Three percent (n = 11) of tests were positive for atracurium. The wheal produced by atracurium was in favour of non-specific histamine release. One test was found positive for suxamethonium. Confirmation of this probable latent sensitization was unfortunately not possible. There were no other positive skin tests. Muscle relaxants were subsequently used in 58 patients (80% vecuronium) without any problem. Skin prick testing should be used on a larger scale to detect latent sensitization. However, predictive skin tests with atracurium should be avoided, as wheal reactions with this drug are probably due to non-specific histamine release.

[Comparative hemodynamic effects of midazolam and flunitrazepam in head injury patients under controlled ventilation]. / Effets hémodynamiques comparés du midazolam et du flunitrazépam chez les traumatisés crâniens en ventilation contrôlée.

The haemodynamic effects of midazolam were compared with those of flunitrazepam in 10 patients with severe head injury under controlled ventilation. Right atrial pressure, pulmonary pressure, pulmonary capillary wedge pressure and cardiac output were measured using a Swan-Ganz thermodilution catheter. Arterial pressure (Pa) was recorded by radial arterial canulation. All patients in this cross-over study received midazolam (0.15 mg X kg-1) and flunitrazepam (0.02 mg X kg-1) intravenously randomly, with 24 h between the two injections. The measurements were first carried out before and then 5, 10, 20, 30 and 60 min after injection. The only significant variations after midazolam and flunitrazepam were a fall in Pa (from 93 +/- 12 to 81 +/- 11 mmHg for midazolam and from 89 +/- 14 to 78 +/- 20 mmHg for flunitrazepam) and in cardiac index (from 4.80 +/- 1.03 to 4.17 +/- 1.14 l X min-1 X m-2 for midazolam and from 5.18 +/- 1.32 to 4.54 +/- 1.03 l X min-1 X m-2 for flunitrazepam). The small decrease in heart rate was not significant. The cardiovascular changes after midazolam and flunitrazepam were small and similar for both drugs. It seemed that midazolam and flunitrazepam were safe for sedating head injured patients under controlled ventilation.

[Hemodynamic effects of fentanyl during anesthesia with 2 concentrations of enflurane]. / Effets hémodynamiques du fentanyl lors d'anesthésies à deux concentrations d'enflurane.

The cardiovascular effects of intravenous fentanyl were determined in eleven patients undergoing intra-abdominal surgical procedures under enflurane anaesthesia. The patients were curarized with pancuronium and ventilated with nitrous oxide (50%) in oxygen. The systemic arterial pressure (Pa) was measured by means of a left radial arterial catheter. The pulmonary artery pressure (Ppa), the pulmonary wedge pressure (Ppw), the cardiac output, the pH and blood gases of mixed venous blood were measured by means of a thermodilution Swan-Ganz catheter. Before the surgical procedure, the measurements were carried out 10 and 20 min after the administration of 0.8% enflurane, and 5 and 15 min after 5 micrograms X kg-1 intravenous fentanyl. During surgery, the measurements were repeated under 0.8% enflurane, and then after 10 and 20 min of receiving 1.6% enflurane, and 5 and 15 min after a second intravenous injection of fentanyl (5 micrograms X kg-1).(ABSTRACT TRUNCATED AT 250 WORDS)

[Penile block in adults]. / Bloc pénien chez l'adulte.

A block of the penile nerves provides a sensory blockade of the penis. In adults, surgery can thus be carried out on the foreskin, glans, corpus cavernosum, corpus spongiosum or penile urethra. The two dorsal nerves of the penis can be blocked by two different routes. In the median technique, only one injection is performed in the subpubic space, near the posterior inferior aspect of the symphysis. In the bilateral technique, each penile nerve is blocked separately at the level of the penile root. Whichever technique is used, additional subcutaneous infiltration of the penile root improves the quality of analgesia. Bupivacaine without adrenaline is used at a concentration of 0.25% or 0.5%. In the median technique, bilateral diffusion of the anaesthetic solution has been demonstrated in ten patients by adding contrast medium to the anaesthetic solution. On the other hand, contralateral diffusion was only found in six of ten patients after an unilateral injection. These results substantiate the value of the bilateral technique in the adult. Both techniques were used in a group of 80 patients, aged 17 to 87 years. In 47 patients no other agent was administered, while the remaining 33 had either additional sedation or a general anaesthetic. Among the latter, three had a partial failure of the block. Postoperative analgesia, which was of excellent quality, covered an average of 10 hours. Neither local nor general incident occurred. Penile block is a reliable technique for regional anaesthesia. Because it is easy to carry out, and comfortable for the patient, this technique may be suggested to adults requiring penile surgery.

[Twin pregnancy with acute hepatic steatosis followed by antehypophyseal insufficiency and diabetes insipidus]. / Grossesse gémellaire avec stéatose hépatique aiguë, puis insuffisance antéhypophysaire et diabète insipide.

A 22-year old woman in the 37th week of her third pregnancy (twins) developed acute fatty liver complicated with a haemorrhagic syndrome from disseminated intravascular coagulation. Two normal girls were delivered by caesarean section. Persistent surgical bleeding required hysterectomy and a short stay in an intensive care unit. The disseminated intravascular coagulation subsided within 8 days. Three weeks after delivery a pituitary insufficiency (Sheehan's syndrome) was diagnosed. A second liver biopsy showed that the lesions had regressed. One week after delivery, the patient developed polyuria and polydipsia. The diagnosis of diabetes insipidus was confirmed by the lack of increase of plasma antidiuretic hormone level during an 8-hour water deprivation test. The pathophysiology of these different syndromes is discussed. Disseminated intravascular coagulation might be the link between hypopituitarism and diabetes insipidus.

[Congenital anomaly of serum pseudocholinesterase originating in neonatal respiratory distress]. / Anomalie congénitale des pseudocholinestérases sériques à l'origine d'une détresse respiratoire néonatale.

Prolonged suxamethonium-induced apnoea was observed after obstetrical anaesthesia in a 30 year old woman with abnormal plasma cholinesterases (homozygous Ea1-Ea1). Flaccidity and apnoea in the child required controlled ventilation for 30 min. Possible mechanisms underlying prolonged apnoea after the use of suxamethonium for obstetrical anaesthesia are discussed. Atypical pseudocholinesterases were identified using quantitative dosage of enzymatic activity and inhibition of atypical pseudocholinesterases by dibucaine, fluoride, chloride, scoline and urea. This was carried out in the patient, her baby and family, thus identifying the genotype of the different family members.

[Explosion of intestinal gas during surgery]. / Explosion des gaz intestinaux en cours d'opération.

Two cases of colonic gas explosion during surgery are reported. The treatment of the lesions required a partial colectomy in one case and a total colectomy in the other case. The different factors involved in such accidents are discussed. Three factors are necessary to trigger off an explosion of intestinal gases: the presence of combustible gases (hydrogen, methane), the presence of combustive gases (oxygen, nitrous oxide) and an initiating heat source (endoscopic or surgical electrocautery). The mannitol used for bowel cleansing undergoes partial colonic bacterial fermentation increasing the intraluminal concentration of hydrogen. During anaesthesia the oxygen-nitrous oxide mixture increases the intestinal concentration of these two major combustive gases. Electrocautery provides the spark triggering the explosion. The use of mannitol for colonic preparation should be questioned; the use of electrocautery to open the colon is advised against.

[Circulatory and respiratory effects of celioscopy in the obese]. / Répercussions circulatoires et ventilatoires de la coelioscopie chez l'obése.

Hemodynamic and respiratory variations were measured in ten obese women scheduled for laparoscopy. Peritoneal insufflation was associated with a decreased cardiac index (from 2.80 to 2.26 1 X min-1 X m-2; p less than 0.01) and increased systemic vascular resistances (from 1,230 to 1,940 dyn X s X cm-5). Heart rate remained stable (from 85 to 86 c X min-1). Mean arterial pressure was increased (from 86 to 104 mmHg; p less than 0.01). Placing the patients in Trendelenburg's position was associated with a small increase in cardiac index (from 2.26 to 2.49 l X min-1 X m-2; p less than 0.05). Under controlled ventilation, Paco2 was slightly increased (from 26 to 30 mmHg; p less than 0.01). A decrease in venous return due to intraperitoneal vascular compression explained the decrease in cardiac output. The rise in PaCO2 could be explained by CO2 reabsorption from the peritoneal cavity, and also by a change in the ventilation/perfusion ratio due to the curarization, mechanical ventilation and increased abdominal pressure. These results did not differ from the data available in non obese patients.