Successful term pregnancy after Mustard operation for transposition of the great arteries.

Transposition of the great arteries is a complex cardiac malformation with poor prognosis without surgical correction. Since the introduction of surgical procedures such as the intra-auricular reorientation of the venous return (Mustard procedure), an increasing number of patients may reach adulthood and experience pregnancy. Because long-term complications after the Mustard operation include systemic heart failure, arrhythmias, venous return stenosis and pulmonary edema, hemodynamic changes during pregnancy and delivery may potentially engender life-threatening complications in these patients. We report the case of a 24-year-old primigravida who underwent a Mustard procedure at the age of 2 years for transposition of the great vessels, and who carried out a full-term pregnancy. The pregnancy was uneventful until the 34th week, when the woman developed signs of moderate right ventricular failure and frequent episodes of accelerated junctional rhythm. Digitalisation improved symptoms and elicited return to normal sinus rhythm. The patient delivered at term by elective cesarean section, under close hemodynamic monitoring.

[Per- and postoperative buprenorphine analgesia: cardiocirculatory and respiratory effects]. / L'analgésie per et postopératoire à la buprénorphine: effets cardio-circulatoires et respiratoires.

In 25 non-premedicated patients, buprénorphine (5 micrograms/kg - 1) has been injected i.v. 30 mn before coelioscopic sterilization under general anaesthesia. Following the i.v. injection there no significant modification of the arterial systolic and diastolic blood pressure was observed but post-operative bradycardia. Tidal volume and minute/ventilation decreased whereas the respiratory rate remained stable. Arterial blood gaz analysis showed slightly hypoxaemia and a significant rise of PaCO2 with post-operative acidosis similar to that in the control group. Good postoperative analgesia was achieved but with profound sedation and a high incidence of nausea and vomiting.

[Cardiovascular effects of Rohypnol used as an agent to induce anesthesia]. / Les effets cardiovasculaires du Rohypnol utilisé comme agent d'induction anesthésique

The study involved 34 surgical patients in whom anaesthesia was induced by the intravenous injection of an average dose of 2.5 mg of flunitrazepam (Rohypnol or Ro-5-4200). The induction of anaesthetic sleep was obtained in 50 to 60 seconds and the duration of the anaesthetic effect 15 to 20 minutes. The patients continued to show hypnosedative effects for several hours postoperatively. The cardiovascular parameters studied - radial BP, ECG and pulmonary arterial pressure - were recorded directly whilst cardiac output was measured by thermodilution using a Swan-Ganz catheter. The decrease in systolic and diastolic pressures in relation to pre-anaesthetic values was 21 p. 100 and 16 p. 100 respectively, whilst pulmonary artery pressure fell by 13 p. 100. Cardiac output fell in a non-significant fashion and the same applied to systolic ejection volume for a given constant heart rate. There was a significant (18 p. 100) decrease in total peripheral resistance but alterations in central venous pressure were negligeable. The decrease in peripheral vascular and pulmonary artery resistances suggest that the product has a peripheral circulatory action and it is possible to correct the alterations seen.

[Hemodynamic effect of enflurane in man]. / Action hémodynamique de l'enflurane chez l'homme

The following hemodynamic parameters: cardiac frequency, peripheral arterial pressure, pulmonary pressure and cardiac output were measured by direct catheterisation, as the total peripheral vascular resistance and the systolic ejection volume were calculated from the registered results. The cardiac frequency and the pulmonary arterial pressure were practically not modified in our patients, though we have observed a statistically significant decrease of systolic (-30p. 100) and diastolic (-27p. 100) arterial pressure. The total peripheral vascular resistance shows a marked diminution (-20p. 100) after giving Ethrane? for ten minutes. If it is possible that one part, surely important, of the cardiac output, is preserved under Ethrane anesthesia by a significant decrease of the total peripheral vascular resistance, a myocardial depression might be questionned, the decrease of cardiac output at 30 minutes being more important than the decrease of the total peripheral vascular resistance.

[Etomidate: cardiovascular effects of a new intravenous anesthetic agent]. / Etomidate: effets cardio-vasculaires du nouvel agent anesthésique intraveineux

The cardiovascular effects of intravenous Etomidate (0.2 mg/kg) were studied in 14 surgical patients with ages varying from 49 to 90. The anaesthetic induction occurs within 10 seconds and the mean duration of anaesthesia is from 6 to 8 minutes. I.V. Etomidate causes a slight lowering of the mean arterial pressure (8.5 per cent), a negligible increase of the heart rate (2.8 per cent) and an insignificant lowering of the mean pulmonary artery pressure (7 per cent). Cardiac output and stroke volume are respectively lowered by 7.6 per cent and 10 per cent. The peripheral vascular resistance is discreetly reduced by 3.8 per cent. From these results, we believe that Etomidate seems to induce sleep with the lightest hemodynamic disturbances in comparison with other agents commonly used. However, some undesirable side effects appeared in some of our patients which can become somewhat annoying, for example myoclonic movements and pain at the point of injection.

[Visual identification of Doppler sounds in gas embolisms]. / Identification visuelle des sons "doppler" lors d'embolies gazeuses.

The method of choice for the early detection of air metabolism during neurosurgical operations in a sitting position is that of continuous cardiac auscultation using Doppler effect ultrasound apparatus. In the present study, involving 15 patients, an air embolism was produced by the injection of 2 ml of CO2 into the right heart and acoustic changes were recorded on paper using a photographic process. These optical changes, although variable, were invariably present and characteristic of aire emboli and represent an additional element in early diagnosis.

[Effects of Etomidate on ventilation and blood gases]. / Effects de l'étomidate sur la ventilation et les gaz du sang

17 surgical patients, agent 49 to 87, are studied. Their anaesthetic induction was performed by an intravenous injection of Etomidate on a 0,23 mg/kg body weight basiis. Respiratory frequency and minute ventilation were put on continuous recording, PO2, PCO2 and arterial blood pH were measured 1,3 and 5 minutes after injection of the drug. Anaesthetic induction, occuring 10 seconds after injection of the drug, was followed by an increase in respiratory frequency (32 p 100) and a rather modest increase of minute ventilation (9,2 p. 100). Among blood gases measurements, only PaO2 showed a decrease of 6,7 p. 100, when PO2 and pH remained practically unchanged. The small increase in minute ventilation, compared with a relatively important increase in respiratory frequency, suggests some decrease in efficient alveolar ventilation without however affecting blood gases in an important fashion.

[Accumulation of carbon dioxide in the operative field in ophthalmic interventions under local anesthesia]. / L'accumulation de CO2 sous le champ opératoire des interventions ophtalmologiques en anesthésie locale.

In eye surgery under local anaesthesia, a micro-climate develops under the operative field. Respiratory CO2 concentration, measured by an infrared capnograph, increases rapidly and becomes stable at a certain level. A three-dimensional relation has been established (CO2 concentration X weight of the patient X free space under the field). The effects of the accumulated CO2 are complex and partially depending on premedication. The air inhaled by the patient should be renewed by elimination of the excess CO2.

Comparison of extradural administration of sufentanil, morphine and sufentanil-morphine combination after caesarean section.

We have studied postoperative analgesia and unwanted side effects of a single dose of a mixture of morphine and sufentanil administered extradurally with the effects produced by extradural injection of each opioid alone in 64 patients after Caesarean delivery. The patients were allocated randomly to receive morphine 4 mg (n = 21), sufentanil 50 micrograms (n = 22) or morphine 2 mg with sufentanil 25 micrograms (n = 21) via an extradural catheter in a double-blind design. Intensity of pain was measured using a linear visual analogue scale. Compared with the effect produced by morphine alone, the morphine-sufentanil combination produced more rapid onset of pain relief (19 (SD 5) min vs 79 (23) min for a 75% reduction of pain; P less than 0.01), whereas the duration and quality of analgesia assessed during 12 h was similar for these two groups. In contrast, patients receiving sufentanil alone required significantly more supplementary analgesia 4 h after administration than with morphine alone or morphine combined with sufentanil. There were no significant changes in cardiorespiratory variables in any group. Side effects consisted mainly of pruritus and nausea and did not differ between groups, with the exception of early and transient dizziness which was observed only in patients given sufentanil either alone or in combination with morphine. We conclude that a single extradural injection of morphine and sufentanil combines the short onset time produced by sufentanil and the long duration of analgesia attributable to morphine, thus providing excellent and prolonged analgesia after Caesarean delivery.

Alkalinization of lidocaine 2% does not influence the quality of epidural anaesthesia for elective caesarean section.

This double-blind randomized study compared the effects of an epidural injection of lidocaine hydrochloride 2% (HCl) (Group 1), alkalinized lidocaine 2% (1 ml NaHCO3 per 10 ml of solution) injected either immediately (Group 2) or one hour after preparation (Group 3) in 45 parturients (n = 15 per group) scheduled for elective Caesarean section. Each patient received 16 ml of one of the three solutions. The mean pH values measured just before administration with a pH-meter PHM 64 Metrohm AG were 6.77 for the HCl lidocaine 2% solution, 7.34 for the freshly alkalinized solution and 7.35 for the solution prepared one hour before injection. The median maximal sensory level (range) observed was T3 (T8-C7), T4 (T5-C8) and T4 (T6-C6), obtained after 19 +/- 6 min, 18 +/- 8 min and 16 +/- 6 min respectively for each group. A motor block of grade 2 or 3 on the Bromage scale was obtained in 11, 10 and 14 patients respectively. No failure was observed although 3, 5, and 2 patients in Groups 1, 2, and 3 respectively required a supplementary bolus 20 min after the initial injection because of inadequate sensory level or pain at the operative site. In conclusion, this study shows that neither fresh alkalinization of 2% lidocaine nor the delay of one hour between preparation and injection of the alkalinized solution influences the onset or quality of epidural anaesthesia for elective Caesarean section.

[Comparative study of sequential analgesic anesthesia (SAA) with continuous-infusion analgesia by fentanyl]. / Etude comparative de l'anesthésie analgésique séquentielle (AAS) avec l'analgésie en perfusion continue au fentanyl.

A group of elderly (mean age: 75 years) patients undergoing a prothetic on the hip under analgesic anaesthesia using fentanyl by continuous infusion (7 micrograms.kg.h(-1)) was compared with a similar group receiving sequential analgesic anaesthesia using fentanyl (25 micrograms.kg as a bolus then 7 micrograms.kg(-1).2030mins(-1)). Comparison of the results obtained revealed a variation in mean cardiocirculatory parameters which was less marked in the group receiving fentanyl by infusion than in the group receiving it sequentially. The higher doses used in the sequential analgesia group led in the majority of cases to severe respiratory depression requiring its reversal by an antagonist or postoperative ventilatory assistance, whilst the use of fentanyl by infusion made it possible to reduce total doses of the drug and ensure adequate spontaneous respiration at the end of the operation.

Epidural-morphine-induced pruritus: propofol versus naloxone.

In a prospective, randomized, double-blind clinical trial, we compared the efficacy of propofol and naloxone for the treatment of spinal-morphine-induced pruritus. Forty patients presenting with severe pruritus within 24 h of epidural morphine administration were allocated to receive either propofol 10 mg intravenously (i.v.) or naloxone 2 micrograms/kg. In the absence of a positive response, a second dose of the same treatment was given 5 min later. Pruritus and the level of post-operative pain were assessed every 5 min up to the end of the study period (45 min) using a verbal rating scale. The overall success rate in treating pruritus was similar in the two groups (80%). The rate of success after the first injection of the treatment drug was also similar (55%). The level of postoperative pain decreased after drug treatment in six patients (30%) in the propofol group versus none in the naloxone group (P < 0.05). Forty-five percent of the patients in the naloxone group had an increase in the level of postoperative pain versus none in the propofol group (P < 0.05). In conclusion, these results suggest that propofol and naloxone are equally effective in treating spinal-morphine-induced pruritus. However, the level of postoperative pain is significantly less in the propofol group.

Subhypnotic doses of propofol possess direct antiemetic properties.

Propofol is associated with a low incidence of postoperative nausea and vomiting. In a prospective, randomized, double-blind, placebo-controlled study, we investigated the possible direct antiemetic properties of a subhypnotic dose of propofol. Fifty-two ASA physical status I or II patients, aged 15-60 yr with nausea and vomiting after minor gynecologic, orthopedic, or digestive tract surgery, were included in the study and received either propofol (10 mg = 1 mL) or placebo (1 mL Intralipid) intravenously in the postanesthesia care unit. Patients treated with propofol experienced a larger reduction in nausea and vomiting than patients treated with placebo (81% vs 35% success rate; P less than 0.05). Patients successfully treated had a similar incidence of relapse (propofol 28%; placebo 22%) within the first 30 min after therapy. Thirty-three percent of the propofol-treated patients and 44% of the placebo-treated patients showed a minor increase in sedation. The level of postoperative pain did not change in either group. Hemodynamic values remained unchanged in both groups. Pain on injection (7.6%) or dizziness (3.6%) only occurred in the propofol group. We conclude that propofol has significant direct antiemetic properties.

Subhypnotic doses of propofol relieve pruritus induced by epidural and intrathecal morphine.

We investigated the efficacy of subhypnotic doses of propofol for spinal morphine-induced pruritus in a prospective, randomized, double-blind, placebo-controlled study. Fifty patients, ASA physical status 1-3, with spinal morphine-induced pruritus were allocated to receive either 1 ml propofol (10 mg) or 1 ml placebo (Intralipid) intravenously after gynecologic, orthopedic, thoracic, or gastrointestinal surgery. In the absence of a positive response, a second drug treatment was given 5 min later. The persistence of pruritus 5 min after the second treatment dose was considered a treatment failure. All failures then received, in an open fashion, a supplementary dose of propofol (10 mg) and were reevaluated 5 min later. Both groups were well matched. The success rate was significantly greater in the propofol group (84%) than in the placebo (16%) group (P less than 0.05). Ninety percent of the treatment failures in the placebo group were successfully treated by a supplementary dose of 10 mg propofol. Eight percent of the patients (4% in each group) were resistant to all treatments, including naloxone 0.08 mg intravenously. Three patients had a slight increase in sedation in the propofol group versus none in control (not significant). The beneficial effect of treatment was longer than 60 min in 85% of patients in the propofol group and in 100% of the controls (not significant). These results suggest that propofol in a subhypnotic dose is an efficient drug treatment for spinal morphine-induced pruritus. At the dose administered (10 mg), side effects were rare and minor.

Peripartum cardiomyopathy: a case report.

Peripartum cardiomyopathy is characterized by congestive left ventricular failure appearing during the last trimester of pregnancy or during the 6 months following delivery, without any specific etiology or pre-existing cardiac disease. The present report describes the case history of a woman presenting with severe cardiac failure immediately after the delivery of twins.

Low incidence of the oculocardiac reflex and postoperative nausea and vomiting in adults undergoing strabismus surgery.

PURPOSE: To investigate the incidence of the oculocardiac reflex (OCR), and of postoperative nausea and vomiting (PONV) in adults undergoing strabismus surgery. METHODS: Adults (18-86 yr) undergoing inpatient strabismus surgery received 10 micrograms.kg-1 atropine and 10 micrograms.kg-1 altentanil iv and were randomly allocated to: (A) 5 mg.kg-1 thiopentone iv, isoflurane/N2O maintenance; (B) 3 mg.kg-1 propofol iv, propofol/N2O maintenance (10-14 mg.kg-1.hr-1); 3 mg.kg-1 propofol iv, propofol/air/O2 maintenance (10-14 mg.kg-1.hr-1). Analyses were with the number-needed-to-treat/harm. RESULTS: In 97 adults the absolute risk of OCR (13-20%) and PONV (21-31% after 24 hr) was low, with no differences between groups. Number-needed-to-treat to prevent PONV with propofol with or without N2O compared with thiopentone-isoflurane was 7 to 11. Number-needed-to-harm for one OCR with propofol compared with thiopentone-isoflurane was 17. CONCLUSION: Adults undergoing strabismus surgery with prophylactic atropine had a low risk of OCR and PONV, independent of the anaesthetic technique used.