Antimicrobial prophylaxis for major head and neck cancer surgery with piperacillin and ornidazole.

A prospective study in 53 eligible patients, undergoing major head and neck cancer surgery was carried out to assess the combination of an ureido penicillin, piperacillin with a nitro imidazole agent, ornidazole, in order to prevent post-operative general and wound infections. Both antibiotics were administered for five days. Each patient had piperacillin 4 gm every eight hours and ornidazole 1 gm every 24 hours. The overall rate of infections was 13.2 per cent (n = 7), with 3.8 per cent (n = 2) wound infections and 11.3 per cent (n = 6) general infections (one patient presented both complications). There was no wound infection in the total surgery group (n = 12). General infections who only consisted of pneumonias were respectively 12.2 per cent (n = 5) in the group with partial procedures (n = 41) and 8.3 per cent (n = 1) in the total surgery group. This antibioprophylaxis can be recommended in major oncological neck surgery, specially in the case of partial procedures.

[Effects of flunitrazepam on intraocular pressure (author's transl)]. / Effets du flunitrazépam sur la pression intra-oculaire.

Though ophthalmologists operate upon patients that are in a debilitated state, a general anesthesia has to be employed with increasing frequency. Flunitrazepam, known to possess good cardiovascular tolerance, was studied to evaluate its effects on intraocular pressure in 34 unselected patients undergoing 41 operations under general anesthesia, usually 41 operations under general anesthesia, usually for retinal detachment or cataract. Ocular pressure was normal in all cases before surgery, but a history of chronic respiratory insufficiency was obtained in 8 cases and of cardiovascular disease in 18. After premedication with 0.02 mg . kg-1 of flunitrazepam and 0.01 mg . kg-1 of atropine, anesthesia was induced by 0.04 mg . kg-1 i.v. of flunitrazepam alone. No marked alterations in cardiac of respiratory functions were observed. Intraocular pressure was measured with a Schiötz tonometer, just before and 5 minutes after the i.v. injection of flunitrazepam. Results showed -- before: 1.61 +/- 0.51 kPa (12.1 +/- 3.8 mmHg); after: 1.09 +/- 0.36 kPa (8.2 +/- 2.7 mmHg) -- a statistically reduction of 32 p.cent. The precise mechanism of action of flunitrazepam on intraocular pressure is not known, but cannot be related to the reduction in aqueous humor secretory flow or the marked diminution in arterial or venous pressure. A probable explanation is the lowering of resistance to aqueous humor flow exterior to the ocular globe as a result of the muscle relaxant properties of the product. Flunitrazepam appears to be a narcohypnotic of choice in ophthalmological surgery on these inherently debilitated patients.

[Anesthesia in high class athletes]. / Anesthésie chez le sportif de haut niveau.

A case of general anaesthesia in a 49 year old male, high level specialist in triathlon, is reported. At the preoperative assessment, the patient had a sinus bradycardia of 45 b.min-1. The electrocardiogram (ECG) exhibited 2 mm ST segment elevation in leads V3-V5, an inverted T wave in leads V1 and V4, and a prolonged QT interval. The QRS axis was 60 degrees, the Sokolow index 44 mm; there was a partial right bundle branch block. These ECG anomalies disappeared during exercise. Heart sounds and blood pressure were normal. On chest X-ray the heart was enlarged. Five mg of midazolam were given orally 30 min before induction, and 1 mg atropine intravenously to increase the heart rate (40 b.min-1). Anaesthesia was induced with 2.5 mg.kg-1 propofol and alfentanil 15 micrograms.kg-1. Vecuronium 0.05 mg.kg-1, alfentanil 0.5 mg, 0.5% isoflurane in a mixture of 40% oxygen and 60% nitrous oxide were used to maintain anaesthesia. A further bolus of 0.5 mg atropine was necessary because of persisting sinus bradycardia. Surgery lasted 70 min. Heart rate and blood pressure returned to their initial values when the patient recovered from anaesthesia. Cardiac abnormalities are common in athletes; they must be distinguished from pathological conditions. When carrying out anaesthesia in these patients, it would seem highly recommendable to give 1-2 mg atropine, and to avoid associating negative chronotropic drugs.

[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)

[Intubation in otorhinolaryngologic surgery: propofol versus propofol-suxamethonium]. / Intubation en chirurgie ORL: propofol vs propofol-suxaméthonium.

This study was carried out to assess the conditions of intubation in head and neck surgery when using propofol alone or associated with suxamethonium. Sixty patients were randomly allocated in two groups of 30. Group I was given 3 mg.kg-1 propofol and Group II 3 mg.kg-1 propofol immediately followed by 1.5 mg.kg-1 suxamethonium. All patients were premedicated orally with midazolam 0.1 mg.kg-1, 0.5 to 1 mg atropine and 7 to 10 micrograms.kg-1 alfentanil, while a colloidal solute (Plasmion) up to 250-500 ml was infused. One minute after injection of propofol, lidocaine 5% was pulverized on the glottis and intubation performed. The mean time required for intubation was similar in both groups: 128 +/- 10 sec in group I vs 132 +/- 9.7 sec in group II. Thirty-five % of patients had to be considered as difficult to intube but the mean times in these cases were not statistically different: 169 +/- 14 sec in group I vs 175 +/- 13 sec in group II. Opening of the glottis was found to be better in group II than in group I (p less than 0.01) and bucking was more frequent in group I (p less than 0.01). Successful intubation was obtained after one attempt at a similar rate in the two groups. The haemodynamic variations consisted in a significant decrease of systolic blood pressure compared to the initial value but these variations were similar in the two groups at each time (2.3 and 5 min) from induction.(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)

[Definition of the antineurotic, antipsychotic, neuroplegic and neuroleptic properties of psychotropic substances used in anesthesia and resuscitation]. / Essai de définition des propriétés antinévrotiques, antipsychotiques, neuroplégiques et neuroleptiques des substances psychotropes utilisées en anesthésie-réanimation

There is a great deal of evidences (pharmacological, experimental and clinical, therapeutic, biological, biochemical, metabolic, toxicological and neurophysiological) which permits one to characterise among the psychotropic substances, the antineurotic or antipsychotic properties of certain psycholeptic drugs. They authorize also the differentiation in the sub-group of "antipsychotics" of substances with a dominant neuroplegic or neuroleptic activity and others, such as lithium, which do not have this activity. This revision of the terminology avoids the confusion maintained by the use of terms "tranquillisers" and "neuroleptics" in the classification of psychotropic drugs.

[Pharmacoclinical competition between the benzodiazepines. Demonstration with diazepam and flunitrazepam in man]. / Compétition pharmacoclinique entre les benzodiazépines. Mise en évidence chez l'homme avec le diazépam et le flunitrazépam.

While using a new benzodiazepines flunitrazepam by the intravenous route in ordinary anethesia a competitive action with another benzodiazepine which is being used for the last 15 years, namely diazepam, was demonstrated for the first time in man. This study on 170 patients operated for ear, nose and throat conditions demonstrated this phenomenon, confirmed it and it was possible to reproduce the effect. The interaction is mainly characterized by: - A reduction of the effects of flunitrazepam (less profound sleep, even wakefulness with a waking patient who could talk and could react to pain). This effect was obtained with injection of a normal clinical dose of diazepam. - There was a blocking action or a reduction in the pharmacological action normally expected of flunitrazepam by the previous administration of a clinical dose of diazepam, when given by the intravenous, intramuscular or oral routes. This suggests that there are common receptor sites for these two benzodiazepines at the cerebral level and this would explain this apparently paradoxical action. Even though flunitrazepam has a greater affinity for these receptor sites this molecule seems to be displaced, according to the law of mass action, by diazepam when used at a high dose. This interaction shown for these two benzodiazepines is also seen in other derivatives of the same chemicals series. This is important in therapeutics with the increasing use of these products in general medicine, and anesthetics and neuropsychiatry where they are quite often used in association.

[Apneic anesthesia in unventilated patients for various operations and explorations in laryngotracheal surgery]. / Anesthésie en apnée sur malade non ventilé pour certaines interventions et explorations en chirurgie larygno-trachéale

A technique of anesthesia is considered for laryngoscopy in suspension, and certain acts of surgery of the vocal cords, e.g. myxoma, and of the trachea, e.g. destruction of papillomatosis. The patient is in apnea, unventilated, a catheter brings down to the level of the carena a current of oxygen of 15 liters per minute, the gaseous acidosis is buffered by injections of a solution of molar sodium bicarbonate. After briefly recalling the notions which justify this technique, its repercussion on homeostasis is studied by arterial gasometry. General anaesthesia with apneic oxygenation may offer the ENT surgeon increased possibilities of exploration and operation at the level of the larynx and trachea, but owing to its biological consequences, it should be used only with circumspection and its indications should be totally justified, for acts of limited duration. The technique seems, at present, difficult to adapt to surgery with laser.

[Trials of controlled hypotension with sodium nitroprusside in ORL surgery. Resistance and tachyphylaxis]. / Essais d'hypotension controlée par nitroprussiate de sodium en chirurgie O.R.L. Résistance et tachyphylaxie

Sodium nitropusside has been used to lower blood pressure during surgical operations on the ear, nose and throat when an operative field without bleeding was desired, e.g. surgery of the inner ear under microscope in particular. In our experience, with the preparation used, sodium nitropusside proved to be a powerful hypotensive agent, the effect of which comes on early but it is difficult to use owing to frequent tachyphylaxis, the possible causes of which are considered. No undesirable side-effects were noted on the main functions. From this limited personal experience, the efficacy of this technique of per-operative hypotension did not appear greater in the surgical field under consideration to those of the anaesthetic techniques used commonly, e.g. neuroleptanalgesia under artificial ventilation, which proved sufficient for reduction in operative bleeding and which had already caused the authors to abandon, some time ago, the use of hypotensive ganglioplegic drugs.

[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.

[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.