[Postoperative respiratory complications of myotonia dystrophica (Steinert's disease)]. / Complications respiratories postopératoires de la myotonie dystrophique (maladie de Steinert).

Respiratory difficulties have long been recognized to be a major risk in patients with myotonia dystrophica, but postoperative pulmonary complications have only rarely been considered. Two cases of postoperative pulmonary complications which led to the patients's death stressed the severity and difficulty of treatment of these complications. A third case of postoperative respiratory failure revealed the underlying disease. These cases showed all the more the importance of preventing pulmonary complications. Pre-, per- and postoperative measures, chosen with respect to the severity of the myotonia and the seat of the surgical procedure, are suggested.

[Prolonged apnea after suxamethonium administration during staphylococcal toxic shock]. / Apnée prolongée après administration suxaméthonium au cours d'un choc toxique staphylococcique.

A toxic shock syndrome occurred after a femoral nail removal requiring revision surgery. After administration of suxamethonium (1 mg.kg-1), an apnoea prolonged over 45 minutes was observed. The trachea was extubated 105 minutes after suxamethonium administration. For the nail removal, two days before, the anaesthetic had been given by the same anaesthesiologist, with a similar protocol. Apnoea extended over 20 minutes. The day of the revision surgery, plasma cholinesterase activity was 410 UI.L-1 and reached 910 UI.L-1, 9 months later. Dibucaine number was 20 and fluorure number 17. The apnoea was in relation with a genetic plasma cholinesterase deficiency increased by the toxic shock syndrome. Shock and hepatic insufficiency were suspected to contribute to the decrease in plasma cholinesterase. Suxamethonium should be avoided in case of toxic shock syndrome.

[Postoperative thyrotoxic crisis during beta blockade: an atypical picture of generalized muscle deficiency]. / Crise thyrotoxique postopératoire sous bêta-bloquants: tableau atypique de déficit musculaire généralisé.

The case is reported of a 42 year old female patient with Graves disease who presented with an atypical thyroid storm after subtotal thyroidectomy. Surgery was indicated because of poor patient compliance with the medical treatment, and its partial failure. High doses of propranolol (240 mg a day) were given for 5 days preoperatively. Anaesthesia and surgery were uneventful however, towards the end of the first postoperative day, a severe myopathic syndrome started, with neither fever nor tachycardia. Respiratory failure and pneumonia occurred 24 h later. This was deemed to be due to an atypical thyroid storm. The patient was intubated and ventilated, and treated with high doses of propranolol (320 mg a day). Muscle strength began returning to normal on the 4th postoperative day, being completely normal 2 months later. Even though a particularly severe form of thyrotoxic myopathy appeared to be the most likely cause of this temporary muscle disorder, beta-blockers may have been involved. Their potential role is discussed.

[Viral hepatitis B. Risk for the anesthetist]. / Hépatite virale B. Risque pour l'anesthésiste.

The risk of hepatitis B, previously reported in other countries, has never been investigated in French anaesthetic medical staff. The prevalence of hepatitis B viral markers has been calculated among the medical staff of the Department of Anaesthesiology, the hospital health care personnel, patients before surgical procedure and renal transplantation patients. The frequency in anaesthesiologists (18.75%; 12 out of 64) was significantly greater (p less than 0.05) than in health care personnel (10.5%; 91 out of 863). Prevalence increased with the length of practice in anaesthesiology. Prevalence of markers is 8.7% (27 out of 196) in patients undergoing surgery and 82% (27 out of 33) in patients operated on for renal transplantation in 1981. Frequency of carriers of the hepatitis B surface antigen is 0% in medical staff, 0.2% in health care personnel and 0.5% in patients before surgery. Among the health care staff, anaesthesiologists belong to a high risk population for hepatitis B. Prevention by administration of hepatitis B vaccine is recommended to protect the anaesthesiologist, his relatives and his patients.

[Invasive aspergillosis in surgical intensive care patients]. / Aspergillose invasive en réanimation chirurgicale.

Aspergillosis is a rare event in intensive care patients. Three cases of invasive aspergillosis due to Aspergillus fumigatus were diagnosed in a surgical critical care unit. Risk factors for aspergillosis were found in two liver transplanted patients. One of them had a primitive cutaneous aspergillosis, and the other, treatment difficulties due to the unavailability of an injectable preparation of itraconazole, a new triazole antifungal agent efficient against Aspergillus species. The third case occurred in a patient who had had surgery for gastric carcinoma with liver metastasis. The mycological examination of the air and workbench in the patients' rooms disclosed between 2 and 13 CFU.mm-3 of different Aspergillus species. Plasma itraconazole concentrations were measured in one patient only. They were below the therapeutic range, probably because of intestinal disturbances. The oral administration of itraconazole capsules through gastro-intestinal feeding tubes results in a poor availability of the drug. Such a technique of administration should therefore be undertaken with larger doses than those commonly recommended. Moreover, itraconazole plasma concentrations should be monitored. The association with amphotericin B is recommended until normal intestinal absorption has been obtained.

[Acute renal failure after extracorporeal circulation with aortic counterpulsation in surgically treated patients]. / Insuffisance rénale aiguë après circulation extracorporelle chez des opérés avec contrepulsion aortique.

In a series of 604 adults operated on for cardiac surgery with cardiopulmonary bypass (CPB), 21 (3.5%) underwent circulatory assistance by intra-aortic balloon pump (IABP); in 5 of them (24%), acute renal failure (ARF) was observed. ARF occurred in only 26 (4.4%) of the other patients who did not require IABP. Evolution of ARF and its factors were therefore investigated in those patients having received IABP. ARF was defined as serum blood urea nitrogen (BUN) greater than or equal to 16 mmol X 1(-1), urinary urea/BUN less than 10, creatinine clearance less than 40 ml X min-1 X 1.73 m-2. Some perioperative features were compared between patients with postoperative ARF and those without ARF. ARF occurred in the 5 patients with IABP during, or immediately after, weaning from IABP. ARF was more frequent in patients operated on for mechanical complications of myocardial infarction with a significant more severe haemodynamic status. They had significantly longer CPB and aortic clamping times. The prognosis depended on the cardiac failure and not on the ARF. In patients with mechanical complications of infarction, early IABP seemed to be the predominant preventive measure. Other therapeutic implications are suggested, particularly the use of dopamine (1 to 3 micrograms X kg-1 X min-1) because of its renal vasodilating action which can contribute to the maintenance of urinary flow.

[Value of Tissucol in cervical anastomosis of esophagoplasty]. / Intérêt de l'utilisation du Tissucol dans les anastomoses cervicales des oesophagoplasties.

There is an important fistula rate associated with the cervical anastomosis of oesophagoplasties. The authors report their experience with reinforcement of these anastomoses by adhesion using a fibrinogen based biological tissue glue. They propose that this technique be used in all high risk anastomoses, in particular, for those affecting a non peritonealized section of the digestive tract.

[Hemodynamic study during the postoperative period in coronary patients undergoing non-cardiac surgery. The role of mechanical ventilation and sedation]. / Etude hémodynamique au cours de la période postopératoire chez le coronarien en chirurgie non-cardiaque. Intérêt de la ventilation mécanique et de la sédation.

The initial period of postoperative rewarming is frequently marked by rapid increases in metabolic rate and myocardial work leading to haemodynamic instability. In order to test the beneficial effect of mechanical respiratory support with sedation in the postoperative period, 18 patients with coronary artery disease operated upon for abdominal or orthopedic surgery were submitted to a hemodynamic study. The patients were divided in two groups. In group II intravenous nitrates were administered perioperatively. Postoperative hemodynamic profiles were similar in both group. No perioperative signs of myocardial ischemia were detected. Prolonged ventilation with sedation can prevent the hemodynamic stress of recovery.

[Incidence and prognosis of acute renal failure after cardiac surgery with extracorporeal circulation]. / Fréquence et pronostic des insuffisances rénales aiguës après chirurgie cardiaque avec circulation extra-corporelle.

Acute renal failure occurred in 21 patients after 311 cardiac operations with cardiopulmonary bypass in adults (6,75%). It was non oliguric in 20 cases. It is related to per and postoperative hemodynamic depression. Patients operated for valvular replacement seemed most at risk if severe cardiac failure existed with or without preoperative renal dysfunction. Similarly those operated upon for mechanical complications of myocardial infarction were often affected. The prognosis depends on the degree of cardiac failure. Strict patient selection, myocardial protection during bypass and measures to increase low cardiac output are recommended. Intra-aortic balloon pump for patients with myocardial infarction and dopamine in the early postoperative period seem helpful.

[Heart surgery with extracorporeal circulation in hemodialyzed patients with renal insufficiency]. / Chirurgie cardiaque sous circulation extra-corporelle chez des insuffisants rénaux hémodialysés.

The authors report 4 valvular replacements under cardiopulmonary bypass in chronic hemodialysis-dependent patients. The peri-operative management was the same in every case. The recent improvements of intensive care medicine amend this protocol. Considering the analysis of data from the literature and the results of our 4 valvular replacements these operations and coronary artery-bypass graft, can be scheduled with an acceptable risk in these patients. Because of the hemodynamic improvement secondary to the cardiac operation, which allows a better tolerance of hemodialysis, this surgery must not be delayed.

[Lung infection and acute adult respiratory distress syndrome during surgical resuscitation]. / Infections pulmonaires et syndrome de détresse respiratoire aiguë de l'adulte en réanimation chirurgicale.

Non cardiogenic pulmonary edema (PE) is frequently observed during the postoperative period. 56 patients with postoperative PE were divided into two groups: ARDS, acute respiratory distress syndrom and NHPE, non hemodynamic PE. The incidence of primary pulmonary infection and pulmonary superinfection were investigated. Both groups were not different except for the level of PaO2 lower in ARDS. Mortality was higher in ARDS (80%) than in NHPE (42%). Pulmonary primary infection and superinfection were respectively observed in 33 and 10%, and 23 and 15% of ARDS and NHPE. Blood cultures were more frequently positive during abdominal sepsis than during pneumonia. Viral etiology was thrice noted in 13 pneumonitis. Value of diagnostic methods for respiratory infections is discussed.

[Infections in surgery under extracorporeal circulation. Results of 3 years of antibioprophylaxis]. / Infections en chirurgie sous circulation extra-corporelle. Bilan de 3 ans d'antibioprophylaxie.

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.