[Eisenmenger syndrome and pregnancy. Apropos of a case]. / Syndrome d'Eisenmenger et grossesse. A propos d'un cas.

A case of Eisenmenger syndrome associated with an ongoing pregnancy and maternal death one month after cesarean section is reported. The review of the world literature shows the very high maternal risk of this condition, which should be prevented by tubal sterilization or therapeutic abortion in the very early pregnancy.

[Morphine analgesia by the intrathecal route]. / Analgésie morphinique par voie intrathécale au cours de l'accouchement.

30 patients for whom an epidural injection using local anaesthesia was hazardous (deformed spine) or contra-indicated (allergic to local anaesthetic agents) received an injection of 0.008 mg cm-1 of morphine chlorhydrate intrathecally. Residual pain scored from 0 to 5 was 2.5 after 10 minutes and 1.5 after 25 minutes. Thereafter there was only a simple ache which was well tolerated right up to the time of delivery. Uterine action was not changed, which allowed 27 labours to be completed vaginally, of which 23 were without forceps. There was no haemodynamic change or respiratory depression, either immediately of later, in the mother nor in the infant (there were 26 Apgar scores of 9 or more). The ratio of plasma concentrations of morphine between the mother and the fetus using radio-immunological assays was inverted as time passed. These were at 6 mg ml-1 or less, which explains the medullary characteristic of the analgesia and the absence of general repercussions. The safety that is offered by the poor diffusion of substance between the fetus and the mother and the ability to prevent secondary effects (pruritus and headache) are features that make intrathecal analgesia and interesting alternative to a conduction block in labour.

[Severe preeclampsia: management. Is conservative treatment justified?]. / La Prééclampsie sévère: prise en charge. Un traitement conservateur est-il justifié?

Severe preeclampsia is a major contributor to maternal and perinatal morbidity and mortality. This review was performed to assess the fetal and maternal benefits of allowing women presenting with severe preeclampsia between 24 and 32-34 weeks of amenorrhea to continue their pregnancy following antihypertensive treatment. After ultrasound scanning to assess growth and biophysical state of the fetus, patients without deteriorating maternal conditions, were managed with volume expansion, antihypertensive drugs (as hydralazine, labetalol, nifedipine), anticonvulsants and prophylactic steroids to promote fetal pulmonary maturity. Previous studies have indicated that this conservative management is also possible with the HELLP syndrome, without an increase in maternal morbidity.

[Ambulatory anesthesia and induced abortion. Comparative study of propofol-alfentanyl and ketamine-midazolam combinations]. / Anesthésie ambulatoire et interruption volontaire de grossesse. Etude comparative des associations propofol-alfentanil et kétamine-midazolam.

The use of propofol alone or with alfentanil in the day-case anaesthesia for abortion was compared with that of ketamine with midazolam. Two hundred young women were assigned to two successive series of two groups each. The four groups were: group 1 (2 mg . kg-1 propofol only); group II (0.5 mg . kg-1 ketamine with 0.25 mg . kg-1 midazolam); group III (2 mg . kg-1 propofol with 4 micrograms . kg-1 alfentanil); group IV (1 mg . kg-1 ketamine with 0.1 mg . kg-1 midazolam). All the patients were premedicated one hour before anaesthesia with 0.25 mg . kg-1 midazolam orally. All the patients were asleep at the end of the propofol injection (60 s), and 10 to 15 s later for the ketamine-midazolam groups. The haemodynamic parameters did not vary much during induction with ketamine-midazolam. In the propofol groups, the heart rate remained steady, with an 8 to 12% fall in blood pressure. A fall of the mandible was seen in 40 and 84% of the patients in the propofol groups, with a short apnoea in 32 and 48% of these same patients. Clinical recovery was very quick, less than 12 min for all groups. The four psychomotor and sensory tests were carried out at the 30th min by 95% of the patients in the propofol groups, whereas only 50% of those in the ketamine-midazolam groups did so. Speed and quality were significantly better in the propofol groups. The most frequent adverse effect of propofol was pain during injection in 32 and 14% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pharmacokinetics of continuous infusion of etomidate in cirrhotic patients]. / Pharmacocinétique de l'étomidate en perfusion continue chez le patient cirrhotique.

The pharmacokinetics of etomidate were studied in 9 control subjects (with normal liver function) and in 5 patients with cirrhosis scheduled for gastro-intestinal surgery. Anaesthetic induction included an initial bolus of etomidate 0.3 mg.kg-1, together with fentanyl 2 micrograms.kg-1, and pancuronium 60 micrograms.kg-1. An etomidate infusion was then started according to one of two following schemes: a (0.03 mg.kg-1.min-1 for 10 min, and then 0.01 mg.kg-1.min-1), or B (0.1 mg.kg-1.min-1 for 10 min, followed by 0.02 mg.kg-1.min-1 for a further 110 min, and 0.01 mg.kg-1.min-1 thereafter). Plasma concentrations of etomidate were determined at regular intervals throughout anaesthesia, and up to four hours afterwards, using inverse phase high pressure liquid chromatography. The infusion was given for 273 +/- 87 min in controls, and for 259 +/- 56 min in the cirrhotic group. Scheme A, only used in 3 controls and 1 cirrhotic in a preliminary study, resulted in very low plasma concentrations: 0.2 to 0.4 micrograms.ml-1. Those measured during the apparent plateau phase (steady state) of infusion protocol B were close to predicted values (0.5 to 0.6 micrograms.ml-1) in controls, whereas higher concentrations (approximately 1.5 micrograms.ml-1) were reached in cirrhotic patients. For all the patients the time interval to spontaneous recovery was 41 +/- 27 min; plasma levels were then 0.199 +/- 0.092 micrograms.ml-1. There were significant alterations in pharmacokinetic parameters in the cirrhotic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rupture of the stomach after insertion of a Linton-Nachlas sound (author's transl)]. / Rupture de l'estomac. A propos d'un cas après mise en place d'une sonde de Linton-Nachlas.

Rupture of the stomach occurred after insertion of a Linton-Nachlas sound in a 91-year-old patient. Possible mechanisms for the lesion were increased pressure from accumulation of blood in the stomach or the herniation of the balloon of the sound. Recovery was uneventful after intensive care therapy and suture of the wound. The possibility of such an accident should not discredit the use of hemostatic sounds.

[Septicemia due to polyresistant Staphylococcus aureus (author's transl)]. / Septicémie à Staphylocoque aureus polyrésistant.

The efficiency of vancomycin hydrochloride in the treatment of septicemia due to polyresistant aureus staphylococcus is illustrated by the observation of a patient affected with a necrotic and hemorrhagic acute pancreatitis and post-operative septicemic syndrome, which has been cured after a one-month treatment with a daily dose of two grammes. The vancomycin hydrochloride, because of its potential toxicity on the kidneys and cochlea should be reserved to the treatment of major staphylococcic infections. It could be prescribed either alone or in association, with a mean daily dose of 30 milligrammes a kilo, slowly administered by intravenous way. The side effects are prevented by adjusting the doses in case of renal insufficiency and by controlling the serous concentrations in case of a long continued treatment.

[Attempt at a mathematical definition of pachycurare dosage. Application for pancuronium and AH 8165]. / Essai de définition mathématique de la posologie d'un pachycarare. Application pour le pancuronium et l'AH 8165

Correlations among the elements indispensable to the choice of an average dose of pachycurare are established for surgical needs. Weight and duration of the surgery jointly allow to foresee with approximately 80 p. 100 accuracy the effective dose required for a surgical curarization controlled according to clinical and electromyographical criteria. After calculation of the average consumption of pachycurare per unit of time, a group of curves is established by successive integrations of additional doses representing a family of parabolae corresponding to a second-degree equation: P = alpha + beta t + gamma t2 where P: the cumulative dose for a determined period of time, per kg of body weight and thus total dose if t: the duration of the surgery, t: the time variable, alpha, beta and gamma: significant calculated coefficients. This analytical function established for the use of Pancuronium - bromide in surgery, is also being tried for the curarizing substance: AH.8165.

Maternal and fetal concentration of morphine after intrathecal administration during labour.

Twenty-five healthy women in labour received morphine 1-1.75 mg in normal saline intrathecally. The residual pain was evaluated on a scale from 0 to 5 at 10 min (score 2.5) and at 25 min (score 1.5). After delivery the maternal and fetal plasma morphine concentrations were measured by radioimmunoassay in 14 parturients. Twenty-three women of 25 had vaginal deliveries, 20 of them without forceps. The maternal and fetal plasma concentrations of morphine were 6 ng ml-1 or less. The intrathecal (but not extradural) administration of morphine is effective and could provide an interesting alternative for pain relief in labour.

Low molecular weight heparin compared with unfractionated heparin in prevention of postoperative thrombosis.

Three consecutive randomized open studies have been carried out to determine the optimal dosage of low molecular weight heparin (LMWH) in the prevention of postoperative thrombosis in general surgery (892 patients). All patients undergoing abdominal, gynaecological, thoracic or urological surgery were over 40 years old and presented at least one of the following risk factors for thrombosis: previous thromboembolism, obesity, varicose veins, malignancy (30 per cent), pre-operative hospitalization over 5 days, oestrogen therapy, chronic cardiac disease or bronchitis. Isotopic venous thrombosis and bleeding complications were assessed after subcutaneous administration of a LMWH fragment (LMWH, Enoxaparine) or unfractionated heparin (UH). The three studies compared 3 X 5000 units UH daily with 1 X 60 mg, 1 X 40 mg, 1 X 20 mg LMWH daily. Thromboembolic events rates were not significantly different from group to group (UH: 3.8 per cent, 2.7 per cent, 7.6 per cent respectively compared with LMWH: 2.9 per cent, 2.8 per cent, 3.8 per cent). Bleeding episodes including wound haematoma formation, perioperative blood losses and systemic haemorrhage were not significantly different in patients receiving LMWH or UH. Significant decreases in haematocrit and haemoglobin were only observed in patients receiving 60 mg Enoxaparine (as compared to UH). An analysis using the 'intention to treat' approach gave results consistent with those of an analysis of good compliers. An overview of isotopic thromboses in the three studies gave no evidence of differences amongst the effects of the three doses of LMWH (P = 0.20), and pooling the results of the three studies using the Mantel-Haenszel procedure gave no evidence of a global difference between Enoxaparine and UH (P = 0.54). These results suggest that an optimal dosage of 20 mg/day of Enoxaparine is safe and effective in the prevention of postoperative thrombosis in this population.

[The second electromyographic study of surgical curarization with AH.8165, a new pachycurare derivative of azobis-arylimidazo(1-2a) pyridinium]. / Seconde étude électromyographique de la curarisation chirurgicale par ah.8165, nouveau pachycurare dérivé de l'azobis-arylimidazo-(1-2a) pyridinium

This second electromyographic study of AH-8165, a product derived from azobis-arymilidazo-(1-2a) pyridinium, carried out with a special apparatus which both stimulates and records, specifies the characteristics of the neuro-muscular block induced by this new non-depolarizing type curarizing substance while taking into account the usual factors of the curarimimetic variability of action. After an initial dose of 1 mg per kg of bodyweight, we notice particularly: -the lapse of time required for a complete block (90 s), its intensity and duration (normally total during at least one hour) -the morphology of the electromyogram during the curarization and the decurarization either spontaneous or induced by Neostigmin with in particular -the muscular fatigability after repeated stimulation following curarization and chiefly during decurarization, chronological data und electro-myographic aspects which are found as well after a reinjection of AH-8165 equivalent to the half of the previous one.

[The effect of surgical incisions on ventilatory function]. / Retentissement des incisions chirurgicales sur la fonction ventilatoire.

Normal surveillance was extended to include respiratory function tests (Vital capacity, FEV1, Maximum Breathing Capacity) on 40 post-operative patients. The reduction relative to pre-operative values on the 1st day after operation was of the order of 60 p. 100 for high abdominal incisions, 35 p. 100 for low abdominal incisions and 15 p. 100 for non abdominal incisions. A return to preoperative values was obtained on the 15th, the 6th and the 4th post-operative days respectively. These changes are found to be well correlated to the limitation of diaphragmatic movement in high incisions. As a result, there is a hypoventilation of the lower lobes of the lungs and a shunt effect which lead to hypoxaemia. The reduction in respiratory function in those subjects without an abdominal incision demonstrated that other factors, particularly the influence of a general anaesthesia, need to be taken into account. Numerous clinical observations show that a reduction in respiratory volumes and capacities do not spare the young subjects and may be dramatic in certain cases. These indicate that a daily assessment of respiratory function at the bedside may provide a simple means for early recognition of intercurrent complications.