[Acute pulmonary edema occurred during tocolytic treatment using nicardipine in a twin pregnancy. Report of three cases]. / OEdème aigu du poumon lors d'une tocolyse par nicardipine chez une grossesse gémellaire. A propos de trois observations.

We report three cases of acute pulmonary edema that occurred during treatment by intravenous tocolysis using nicardipine in twin pregnancy patients with no previous heart problems. The three patients were admitted into our unit on account of the risk of premature birth after 29 to 32 weeks of amenorrhea. The treatment by intravenous tocolysis using nicardipine combined with glucocorticoids therapy had been undertaken in the previous maternity ward. The three patients presented symptoms of acute dyspnea 48 hours after the beginning of the treatment. Paraclinical examinations eliminated the diagnosis of pulmonary embolism. The patients'condition improved rapidly with appropriate diuretic treatment and by modifying the tocolysis. There are currently few studies proving the benefits of nicardipine in tocolysis treatment. Few similar cases of acute pulmonary edema have been noted in twin pregnancy patients treated with nicardipine. Haemodynamic modifications specific to twin pregnancy, intravenous hydratation and glucocorticoid maturation may explain a part of this complication. Therefore, it is appropriated to limit the use of intravenous nicardipine in the sole indication of tocolysis in twin pregnancy, and to prefer the use of nifedipine and atosiban, that have proven their effectiveness in this indication.

Adult overwhelming meningococcal purpura. A study of 35 cases, 1977-1989.

The study objective was to describe the clinical, biologic, and hemodynamic features of adult overwhelming meningococcal purpura and to examine the prognostic factors by multivariate analysis at the time of admission to the intensive care unit. Thirty-five patients (greater than or equal to 13 years of age) with meningococcal infection, circulatory shock, and generalized purpuric lesions of abrupt onset were recorded in eight intensive care units from 1977 to 1989. The patients were young (mean age, 26.6 years; range, 13 to 68 years) and had been previously healthy. The female-to-male ratio was 3:1. Mortality was 54.3%, with most deaths occurring within the first 48 hours, usually secondary to irreversible shock with multiple organ failure. Ischemic complications (eight cases), prolonged heart failure (seven cases), and secondary septicemia (five cases) were the chief complications among survivors. Initial hemodynamic study after volume loading showed low stroke volume index (mean +/- SD, 29.4 +/- 13 mL/m2) and tachycardia (mean +/- SD, 138 +/- 16 beats per minute), a profile suggesting a greater myocardial depression than usually observed in gram-negative bacillary septic shock. Univariate prognostic analysis showed that four variables at the time of admission were associated with fatal outcome: a plasma fibrinogen level of 1.5 g/L or less, a factor V concentration of 0.20 or less, a platelet count lower than 80 x 10(9)/L, and a cerebrospinal fluid leukocyte count of 20 x 10(6)/L or less. Stepwise regression analysis showed that low fibrinogen level (less than or equal to 1.5 g/L) was the sole adverse prognostic variable (odds ratio = 2, 95% confidence interval, 1.5 to 2.7). Adult overwhelming meningococcal purpura is still associated with high mortality and morbidity. Low fibrinogen level at time of admission may permit early recognition of the most severely ill patients.

Dobutamine in the treatment of depressed cardiac function: a study in patients with ischaemic heart disease during the early post-operative period.

Dobutamine was administered by intravenous infusion to 10 patients with ischaemic heart disease who had a low cardiac output syndrome following abdominal surgery. The dosage of dobutamine started from 2.5 mcg kg-1 min-1 and was increased stepwise to 5, 7.5, 10, 12.5 and 15 mcg kg-1 min-1. Cardiac index increased significantly from 2.05 +/- 0.32 to 3.03 +/- 0.61. min-1 min-2 with 15 mcg kg-1 min-1. Heart rate was unchanged with 7.5 mcg kg-1 min-1 but increased significantly from 97.7 +/- 18.5 to 126.1 +/- 21.5 beats. min-1 with 15 mcg kg-1. min-1. Stroke index increased significantly from 21 +/- 4.4 to 25.4 +/- 5.1 ml m-2. beat-1 with 7.5 mcg kg-1 min-1. Pulmonary wedge pressure fell significantly from 14 +/- 2.9 to 9.1 +/- 2.4 mmHg with 2.5 mcg kg-1 min-1. Mean arterial pressure showed no significant change. No side effects were observed in these patients. We conclude that in patients with depressed cardiac function dobutamine at low doses of 2.5 mcg kg-1 min-1 decreases afterload and filling pressures. At the average doses of 5 - 7.5 mcg kg-1 min-1 stroke index and cardiac index are increased. At higher doses of 10 - 15 mcg kg-1 min-1 heart rate and cardiac index increase while stroke index fails to increase further.

Left ventricular function in tetanus: influence of therapy.

Nine patients hospitalized for tetanus were studied under the same protocol which included two haemodynamic studies with a preload trial (PLT). The first being made during therapy (diazepam barbiturate association), on the sixth day of hospitalisation, and the second one after recovery. The comparison of the results shows that before PLT the mean arterial pressuure (MAP) is significantly increased (p less than 0.05) in patients after recovery in comparison to the same patients undergoing therapy. After PLT there is no significant difference between the two groups. Lastly, the variation of the left ventricular function points under PLT shows no significant difference between patients during therapy and after recovery. These results suggest that the diazepamphenobarbital combination does not alter the left ventricular function of the patients undergoing this therapy during tetanus.

[Myxedema coma. Apropos of 8 cases]. / Le coma myxoedémateux. A propos de 8 observations.

Eight cases of hypothyroid coma observed between 1971 and 1981 are reported, and their main clinical, biological and therapeutic features described. Three out of the 8 patients died. Physiopathological and therapeutic comments are made with reference to these cases and previous reports, concerning the hypothermia, cardiac and respiratory function, hyponatraemia and the endocrine disturbances observed in hypothyroid coma.

[A rare cause of postoperative acute respiratory insufficiency: diaphragmatic hernia]. / Une cause rare d'insuffisance respiratoire aiguë postopératoire: la hernie diaphragmatique.

A case of postoperative failure after total hip replacement is described. A gastric tube was passed and the stomach was seen to be within the right hemithorax on the chest X-ray. Aspiration of gastric gas and juice relieved the respiratory symptoms.

[Fluid loading in the surgical care of pheochromocytoma. Hemodynamic study]. / Le remplissage vasculaire dans la chirurgie du phéochromocytome. Etude hémodynamique.

Collapse following removal of pheochromocytoma can be usually prevented by fluid loading. Fluid infusion is administered at the early beginning of the surgical procedure and is accelerated just after removal. Some authors prefer to start the fluid infusion in the preoperative period. In every cases preload measurements are of primary importance for a safely fluid administration. Problems of fluid loading in course of pheochromocytoma surgery are studied in six patients. Hemodynamic data are collected during pre, per and postoperative periods. Pre and post operative rapid fluid loading was performed in three patients in order to obtain a left ventricular function curve. Before any fluid treatment, two groups of patients are distinguished: 1) five hypovolemic patients who are about to receive 1 000 +/- 300 ml to normalize pulmonary wedge pressure, 2) one patient with high pulmonary wedge pressure and with alterated myocardial performance observed during rapid fluid loading. Combined use of sodium nitroprusside and fluid loading allowed to control hypertensive accesses and preload elevations and to prevent collapse following tumor removal. Hypovolemia and myocardial lesions are not necessarily present in all cases of pheochromocytoma. The routine use of a pulmonary artery catheter is warranted to improve cardiac pump function by combined fluid and vasodilator management.

[Hemodynamic effects of dobutamine in hyperkinetic septic shock treated with norepinephrine]. / Effets hémodynamiques de la dobutamine dans le choc septique hyperkinétique traité par noradrénaline.

A prospective study of the haemodynamic effects of dobutamine was carried out in six men and four women suffering from hyperkinetic septic shock, already treated with noradrenaline and dopamine. All ten patients had septic shock, defined as a mean arterial blood pressure of less than 70 mmHg and an urine output under 15 ml.h-1, persisting despite fluid loading, associated with positive blood cultures, increased white blood cell counts, and a septic area. Initial treatment consisted in fluid loading, so as to increase cardiac output whilst keeping pulmonary wedge pressure (Ppw) between 8 and 10 mmHg. Dopamine was then added, up to a dose of 15-20 micrograms.kg-1.min-1, in an attempt to improve coronary and renal blood flows. In patients in whom this failed, the amounts of dopamine were then decreased, down to 3 micrograms.kg-1.min-1, and replaced by noradrenaline. When patients had as steady cardiac index (CI) greater than 3 l.min-1.m-2 and a systemic arterial resistance index (RsaI) of less than 1,800 dyn.s.cm-5.m-2 for more than 60 min, they were included in the protocol. Dopamine was then replaced by increasing doses of dobutamine (0, 5, 7.5, 10, 15 and again 0 micrograms.kg-1.min-1). The usual haemodynamic parameters were measured and calculated once a steady state had been obtained at each dose (within 20 to 30 min). Ppw was kept between 8 and 10 mmHg by fluid loading with a 4% albumin solution. At the beginning of the study, patients had a mean blood pressure of 78 +/- 6 mmHg, a CI of 4.8 +/- 1.5 l.min-1.m-2 and a RsaI of 1,285 +/- 341 dyn.s.cm-5.m-2 RsaI.(ABSTRACT TRUNCATED AT 250 WORDS)

[The effects of dobutamine in postoperative disorders of left ventricular function in coronary patients undergoing abdominal surgery. Apropos of 18 cases]. / Effets de la dobutamine sur les troubles post-opératoires de la performance ventriculaire gauche chez le coronarien opéré en chirurgie abdominale. A propos de 18 cas.

Increasing doses of dobutamine were administered to the first group of 10 coronarians having undergone and abdominal surgical procedure, and presenting, one hour after awakening from the anesthesia, hemodynamic modifications with a diminution of cardiac index (CI), systolic index (SI), systolic work index of the left ventricle (SWILV) increase in the pulmonary capillary pressure (PCP), and in the total peripheral resistance (TPR), as well as an acceleration of the cardiac rate (CR). Doses of dobutamine of 5 or 7.5 microgram.kg-1.min-1 corrected the IC, PCP and TPR. Dobutamine ameliorated the SI and SWILV in an increasing fashion up to a dose of 10 microgram.kg-1.min-1 only and without restoring them to the control values of the pre-operative period. CR progressively increased with the increasing of the doses reaching 126 +/- 21.5 beats min-1 for 15 microgram.kg-1.min-1. Extrasystoles appeared at dose levels of 12.5 and 15 microgram.kg-1.min-1 in two patients. Tests of vascular filling (pre-charge tests) carried out in the second group of patients under 10 microgram,kg-1.min-1 of dobutamine and in a third group under 15 microgram.kg-1.min-1 showed a good cardiac adaptation to filling, equal or superior to that of the pre-operative period. It also appeared that the amelioration of CF obtained with a moderate vascular filling (300 ml of low molecular weight dextran) under 10 microgram.kg-1.min-1 of dobutamine is greatly superior to the amelioration obtained by 10 to 15 microgram.kg-1.min-1 of dobutamine.

[Hemodynamic effects of equipotent doses of phenoperidine and fentanyl in man]. / Effets hémodynamiques de doses équipotentielles de phénopéridine et de fentanyl chez l'homme.

The haemodynamic effects of phenoperidine and fentanyl were studied in ten patients with craniocerebral trauma who presented no surgical indications. They were all mechanically ventilated with a constant tidal volume and rate and their cardiovascular state was stable. The patients were given 5 gamma/kg of fentanyl intravenously; the haemodynamic measurements were performed at two mn interval for 20 mn. Three hours later, the patients were given 30 gamma/kg of phenoperidine intravenously and the haemodynamic measurements were performed similarly. Phenoperidine and fentanyl had the same effects: a significant fall in heart rate, mean arterial pressure and cardiac index without any change in pulmonary wedge pressure. These changes do not dangerously alter the haemodynamic condition of the patients and thus are not a contra-indication to the general use of phenoperidine and fentanyl in anaesthetic practice and in intensive care.

Preoperative acute volume loading in patients with pheochromocytoma.

Ten patients with pheochromocytoma underwent preoperative acute volume loading to determine whether fluid infusion severely increased pulmonary capillary wedge pressure without improving forward flow, and to provide a guide for intraoperative volume replacement. In one patient, volume loading confirmed baseline pressure data suggesting a discrepancy between right and left ventricular filling pressures. In a second patient with normal baseline wedge pressure, volume loading revealed an unsuspected ventricular dysfunction. During subsequent surgery, both volume and speed of fluid infusion were adapted to the preoperative ventricular response.

Norepinephrine therapy has no deleterious renal effects in human septic shock.

We investigated 25 patients (aged 20 to 70 yr) in septic shock with low systemic vascular resistance in order to assess the effects on renal function of prolonged (24 to 240 h) norepinephrine (NE) infusion (range 0.5 to 1.5 micrograms/kg.min). Two sets of renal function tests were made: a) control study before NE therapy after the initial intravascular loading and on dopamine infusion (mean dosage 14 +/- 2 micrograms/kg.min); b) in the last 24 h of NE infusion associated with dopamine (2 to 3 micrograms/kg.min). The following renal function tests were measured: urine flow rate, creatinine, osmolar and free water clearances, and fractional excretion of sodium (FENa). Data were collected only in 22 nonanuric patients: urine flow rate, creatinine, and osmolar clearance increased (p less than .001), and free water clearance (p less than .001) and FENa (p less than .02) decreased. These results suggest that NE (0.5 to 1.5 micrograms/kg.min) may be used in the treatment of human septic shock without deleterious renal effects.

[A prognostic study of 238 cases of chest trauma. Influence of the delay in admission in an intensive care unit (author's transl)]. / Etude pronostique de 238 traumatisés thoraciques. Influence du retard à l'admission dans un service de réanimation.

238 cases of chest trauma were studied according to the same protocol. With this protocol we can perform on the one hand a comprehensive study of the prognosis according to the thoracic lesions and associated lesions and on the other hand a prognostic study according to the delay of admission in a intensive care unit. All our data show that the most serious lesion is the pulmonary contusion and that mortality increases if an associated lesion is present, according to its nature. On the other hand a comparison was performed between the patients directly admitted in the intensive care unit (GI) and the patients hospitalized after a delay (GII) this comparison shows that in G II patients the rate of complications was higher, the mortality more important and respiratory sequelae more frequent than for patients of GI with thoracic lesions of the same importance or less important. These data show that an early admission of chest trauma patients in an intensive care unit is desirable and that the duration of this hospitalization must be at least 3 or 6 days.

[Collective acute poisoning by nitrous gases]. / Intoxication aiguë collective par les vapeurs nitreuses.

A collective nitrous fumes poisoning (five cases) is reported. Two patients (case 3 and case 4) were comatose, in severe respiratory distress. Shock and slate blue cyanosis were noted. Physical examination and chest X ray revealed acute pulmonary edema-Methemoglobin levels were 71,3% (case 3) and 58% (case 4). Despite treatment both of them died from severe hypoxia resulting in cardiorespiratory arrest. Post-mortem examination was performed upon these four men. On admission the last one (case 5) was conscious, and in good hemodynamic condition. Acute pulmonary edema and cyanosis were present. Methemoglobin level was 37,3%. This patient recovered appropriate therapy. For case 1 and 2 acute anoxia due to methemoglobinemia seems to be cause of death. For cases 3 and 4 death is due to hypoxemia associated with pulmonary edema.

[Measurement by mass spectrometry of oxygen consumption and carbon dioxide production in mechanically ventilated patients]. / Mesure par spectrométrie de masse de la consommation d'oxygène et de la production de gaz carbonique chez les patients ventilés artificiellement.

The authors present a technique of VO2 and VCO2 measurements by a non invasive method in mechanically ventilated patients. Inspirated and expirated gas are sampled respectively in the inspiratory limb of the patient's breathing circuit and in a mixing chamber. Gas samples are analysed by mass spectrometry in the laboratory. Expiratory flow rate is determined by the ventilator flowmeter. To evaluate this procedure the authors have studied the stability of the inspirated and expirated gas samples and the reproductibility of measurements. In a patient with respiratory and haemodynamic stable status this method measures VO2 within 8,2% and VCO2 within 7%.

A reappraisal of norepinephrine therapy in human septic shock.

The effectiveness and safety of iv infused norepinephrine (0.5 to 1 microgram/kg X min) were evaluated in 12 hyperdynamic vasodilated septic patients, who remained hypotensive despite iv volume expansion and antimicrobial and dopamine therapy. During norepinephrine infusion, mean arterial pressure and systemic vascular resistance index increased (p less than .001) and heart rate decreased (p less than .02). Cardiac index either increased or was unchanged in ten patients and decreased slightly in the remaining two patients. Urine flow increased (p less than .01) and was more than 0.5 ml/min when a critical renal perfusion pressure was reached if renal damage was not overwhelming. We conclude that norepinephrine may improve arterial BP and urine flow when volume replacement and dopamine therapy have failed to reverse the hypotension of septic shock.

[Circulatory and metabolic disturbances in accidental hypothermia (author's transl)]. / Perturbations circulatoires et métaboliques dans l'hypothermie accidentelle

This work sums up several studies: clinical observation (electrocardiogram, cardiac rhythm, circulatory state), and biology (glycemia, blood oxygenation, acid-base balance) in 24 cases of accidental hypothermia, not related to poisoning by central nervous system depressive agents; haemodynamics in 18 of these cases; pathology of the myocardium in 11 cases; haemodynamics and microscopy of the myocardium in dogs with slowly induced or prolonged hypothermia; finally an electron microscope study in hypothermic rats. Electrocardiographic study and continuous monitoring of cardiac rhythm and tracing show, in addition to well known manifestations (bradycardia, lenghtening of QT, J wave), acute dysrhythmias, particularly circulatory arrests by asystole during or even 72 hours after rewarming. The clinical haemodynamic changes, measurable (cardiac output, mean arterial pressure, central venous pressure), or computable (stroke volume, peripheral resistances) are observed during rewarming. Several haemodynamic developments can be distinguished: --favourable evolution when the initial disturbances (decrease in cardiac output and in stroke volume, increase in peripheral resistances) disappear without any therapeutic support: --haemodynamic developments showing at a certain time evidence of hypovolemia requiring only moderate vascular replacement; --haemodynamic developments showing myocardial damage. In some cases, only hypothermia accounts for these. In circulatory arrests during or after rewarming, these haemodynamic disturbances raise the hypothesis of severe cardiac changes due to hypothermia itself.