[A new toy: upswing in curare use in Spanish anesthesia]. / A new toy: la irrupción del curare en la anestesia española (1946).

The introduction of curare for general anesthesia by Harold Griffith in 1942 was one of the most important moments in the development of anesthesiology. However, several years passed before curare came to be used in Spain. We review the early application of curare and the role played by Robert Macintosh, Professor of Anaesthesia at Oxford, in introducing the drug to Spain.

[The use of curare-like agents in resuscitation]. / Utilisation des curares en réanimation.

OBJECTIVE: To analyse current data on use of neuromuscular blocking agents (NBA) in the intensive therapy unit (ITU) patients and to propose practice guidelines. DATA SOURCES: We did a Medline search of French and English language articles on NBA administration in ITU patients from 1960 to 1998. Data were also selected from our own collection of articles and books. STUDY SELECTION: Original articles, clinical cases, letters to the editor and review articles were considered. DATA EXTRACTION: Data on pharmacology of NBA in the ITU patient were extracted, as well as data on administration patterns and cost. DATA SYNTHESIS: The indications for myorelaxation in ITU patients include either short term use, as in anaesthesia, or long term administration for facilitation of mechanical ventilation, control of increased intracranial pressure, status epilepticus, tetanus and oxygen demand in case of muscular hyperactivity, diagnostic and therapeutic procedures facilitation. A beneficial effect of NBA on the prognosis of the disease for which these agents have been used is not yet proven. Suxamethonium, because for its short onset time and duration of action, is the agent of choice for endotracheal intubation if myorelaxation is required. Among the benzylisoquinolines, atracurium and besilate of cisatracurium are convenient agents in ITU patients, whereas mivacurium is of no special interest. Among the aminosteroids, pancuronium and vecuronium are the most often used agents in the ITU. Rocuronium has not yet been extensively assessed. Myorelaxants carry risks for morbidity and mortality. The difficulty to assess the neurological status and the level of sedation is a recognised adverse effect. An accidental disconnection from the circuit and the resulting asphyxia is nowadays recognised without delay by the ventilator. NBAs increase the rate of bronchopulmonary infections. Cardiovascular complications include extreme bradycardia or sinus arrest following vecuronium administration, and cardiac arrest after suxamethonium injection mainly in burned or traumatised patients. Conversely to anaesthesia, NBAs do not carry a significant risk for anaphylactic or anaphylactoid complications in the ITU. Tachyphylaxis occurs mainly in burns and other pathologies modifying acetylcholine receptors. Neuromuscular complications include myopathy from steroids, postparalytic syndrome, deconditioning syndrome and intensive care polyneuropathy. Prolonged curarisation after discontinuation of NBA administration has a multifactorial origin and must be differentiated from neuromuscular complications. For prolonged neuromuscular blockade, pancuronium, vecuronium and atracurium are the agents of choice. The association with an adequate sedation is essential. Assessment of depth of neuromuscular blockade is not based on clinical symptoms but on train-of-four (TOF) twitch monitoring. A convenient basic relaxation is usually obtained with the suppression of the two last responses to TOF. CONCLUSION: The use of NBA in ITU patient should result from a rational decision making procedure, the blockade titrated with a TOF monitor and maintained as superficially and shortly as possible.

[Skin tests for general anesthetics]. / Tests cutanés aux anesthésiques généraux.

During a meeting between anaesthetists and allergists, skin tests were presented to show their value and the difficulties to which they give rise when they are weak. General principles, techniques and readings are described first. As usual, it is sensitivity, specificity and negative predictive value that are at the centre of attention. Selected clinical cases are given as examples. The high prevalence of cases who show a latent sensitisation to curare indicates an increase in allergological tests to patients who present risk factors.

[Polyneuropathy and neuromyopathy in intensive care. 4 new cases]. / Polyneuropathie et neuromyopathie de réanimation. Quatre nouveaux cas.

Neuromuscular complications acquired in the intensive care unit form a new clinical entity. Three neuromuscular deficits are described: so-called critical illness polyneuropathy where neuromyopathic changes are associated with corticosteroid and/or neuromuscular blocking agents, and catabolic myopathy. We report four new cases: three of them concerning polyneuropathy and one neuromyopathic change.

Generalized periarticular myositis ossificans as a complication of pharmacologically induced paralysis.

To our knowledge, no previous direct associations have been made between generalized myositis ossificans and pharmacological therapy. We report a case of generalized periarticular myositis ossificans associated with the use of curare and diazepam. The previously reported associations of myositis ossificans with tetanus and burns may be misleading. It is possible that it is not the disease process itself (e.g., tetanus, severe burn) that precipitates heterotopic ossification, but the treatment of these ailments. These observations suggest the importance of early mobilization and restrained use of immobilizing drugs. Further investigation is warranted with regard to the predisposing factors of generalized myositis ossificans and to its prevention.

Myasthenia gravis presenting during general anaesthesia for oesophagoscopy--a cautionary tale.

We report myasthenia gravis presenting as dysphagia of acute onset in a 56-year-old female who had no other stigmata of the disease and who was generally well despite rheumatoid arthritis and hypothyroidism. She recovered respiratory function following a general anaesthetic for oesophagoscopy only when antimyasthenic treatment was instituted. She remains well to date. In patients who are known to have autoimmune diseases and who present with dysphagia, features of myasthenia gravis should be specifically sought.

Ocular muscular dystrophy. A cause of curare sensitivity.

A case is described of a child with ocular muscular dystrophy, who demonstrated the extreme sensitivity to non-depolarising muscle relaxants, with lack of reversal by anticholinesterases, characteristic of this condition.

Self-regulation of response patterning: implications for psychophysiological research and therapy.

This paper develops the basic premise that learning to self-regulate a pattern of responses can have different consequences from those observed when controlling individual functions alone. It is suggested that the self-regulation of patterns of responses can be a particularly sensitive and effective procedure for (a) uncovering biological linkages and constraints between responses in the intact human, (b) investigating how multiphysiological systems combine to produce unique subjective experiences and effects on performance, and (c) enhancing the clinical effectiveness of biofeedback procedures by training patients to integrate and coordinate voluntarily specific patterns of cognitive, autonomic, and motor responses. These hypotheses are illustrated by basic research involving biofeedback training for patterns of blood pressure, heart rate and EEG activity, related experiments on the cognitive self-regulation of patterns of physiological responses using affective imagery and meditation procedures, and case studies of patients treated with biofeedback. The concept of electronic biofeedback as an "unnatural act" is presented with the goal of placing self-regulation within a more biobehavioral perspective emphasizing the natural patterning of physiological processes.