[Haemodialysis, L-carnitine therapy and valproic acid overdose]. / Epuration extrarénale, supplémentation en L-carnitine et intoxication à l'acide valproïque.

We report the case of a severe valproic acid poisoning in a 36-year-old man. In front of a high serum concentration of valproic acid at the admission, haemodialysis was initiated to decrease serum valproic acid concentration. A L-carnitine therapy (50 mg/kg per day) was also started. A cerebral oedema appeared at the third day, but the patient recovered without any sequela.

[Coagulation abnormalities after total hip prosthesis (THP), a rare cause: antibiotic prophylaxis]. / Anomalies de la coagulation après prothèse totale de hanche (PTH), une cause rare: l'antibioprophylaxie.

A 87-year-old patient developed coagulation abnormality following hip surgery related to the prophylactic use of cefamandole. Cefamandole as others cephalosporins with a methyl-tetrazol-thiol lateral chain interferes with the vitamin K regeneration cycle as do oral anticoagulants. Therefore, the use of others antibiotics or systematic vitamin K1 supplementation or single dose of cefamandole is recommended for patients with renal failure or with malnutrition. Vitamin K1 supplementation is a simple method resulting in complete resolution of the coagulation disorder.

Treatment of experimental pneumonia in rats caused by a PER-1 extended-spectrum beta-lactamase-producing strain of Pseudomonas aeruginosa.

The antibacterial activity of imipenem, cefepime and piperacillin-tazobactam alone or in combination with amikacin against a Pseudomonas aeruginosa strain producing an extended-spectrum beta-lactamase (PER-1) were compared using an experimental model of pneumonia in non-leucopenic rats. Animals were infected intratracheally with 8.0 +/- 0.4 log10 cfu of P. aeruginosa, and therapy was initiated 3 h later, by which time animal lungs showed bilateral pneumonia containing >7 log10 P. aeruginosa cfu/g of tissue. Since rats eliminate antibiotics much more rapidly than humans, renal impairment was induced in all animals to simulate the pharmacokinetic parameters of humans. MICs determined using an inoculum of 4 log10 cfu/mL were as follows: imipenem, 1 mg/L; cefepime, 8 mg/L; piperacillin-tazobactam, 32 mg/L; and amikacin, 16 mg/L. A noticeable inoculum effect was observed with the four antimicrobial agents tested, which was greatest for cefepime and piperacillin-tazobactam. In-vitro studies indicated that imipenem was the beta-lactam with the greatest bactericidal effect and that amikacin was synergic only in combination with cefepime and imipenem. Cefepime and piperacillin-tazobactam alone failed to decrease bacterial counts in the rats' lungs 60 h after therapy onset, whereas imipenem and, to a lesser extent, amikacin significantly reduced the number of viable microorganisms. Combination of amikacin with any of the three beta-lactams tested was synergic, despite a high amikacin MIC for the infecting strain. These results paralleled our in-vitro data showing a marked inoculum effect for cefepime and piperacillin-tazobactam. Based on the results of this study, the best treatment for infections caused by this type of extended-spectrum beta-lactamase-possessing strain would be imipenem plus amikacin.

[General or locoregional anesthesia: which to choose for a patient at risk?]. / Anesthésie générale ou anesthésie locorégionale: que choisir chez le sujet à risque?

HIGH RISK SITUATIONS: The risk of surgery is higher in certain situations (subjects over 70 years of age, underlying disease states). Procedures lasting more than 3 hours or performed in emergency situations also increase the risk. The question is often raised as to which type of anesthesia, general or locoregional, is the most appropriate to lower the risk of complications in such situations. ANESTHESIA-DEPENDENT EFFECTS: Respiratory complications during or after surgery are more frequent if general anesthesia is used. Cardiovascular complications are not influenced by the type of anesthesia. Local-regional anesthesia can lower the risk of post-operative venous thrombosis and the development of thrombus formation secondary to vascular surgery. It also eliminates the neuroendocrine response to surgical stress. MODEST EFFECT: Only a few precise parameters can differentiate risk between general and locoregional anesthesia. However, the type of anesthesia has little effect on overall morbidity or mortality, which depend more on the general status of the patient and the surgical procedure performed.

Is lidocaine-prilocaine cream (EMLA) always useful for venous puncture in preoperative autologous blood donation?

PURPOSE: The goal of the present study was to evaluate in adults the benefit of the Eutectic Mixture of Local Anesthetics (EMLA) for preoperative autologous blood donation. METHODS: Twenty-six adult patients requiring three blood samples were studied. The pain of venipuncture was assessed by the patient using a 100 mm Visual Analogue Scale (VAS) and a four-category Verbal Rating Scale (VRS). The first puncture was performed without anaesthesia, as a "reference puncture". The second and third punctures were performed with EMLA and placebo in a double-blind cross-over randomization. For statistical analysis, the patients were allocated to two groups according to the VAS scores of the reference puncture: (Group 1) VASref < 20 mm; (Group 2) VASref > or = 20 mm. RESULTS: For the whole 26 patients, the VAS and the VRS pain scores were lower for EMLA puncture than for both the placebo and reference punctures (P < 0.05). Twenty patients had a VASref < 20 mm and six patients a VASref > or = 20 mm. In Group 1, there was no difference between EMLA and placebo for both the VAS and VRS scores. In contrast, in Group 2, the VAS score was lower for EMLA than for both the placebo and the reference punctures (respectively 11 +/- 7.1, 28.9 +/- 7.9, 29.1 +/- 6.4; P < 0.01); the VRS score was also lower for EMLA puncture than for placebo puncture (P < 0.05). CONCLUSION: In adults requiring repeated venous punctures, pain from cannulation may be evaluated at the first puncture with a Visual Analogue Scale, thus indicating or not the need for EMLA.

[The real risks of locoregional anesthesia]. / Les vrais risques de l'anesthésie loco-régionale.

Regional anaesthesia involves its own risks of which five main categories appear to stand out: 1. Excessive indications, especially of epidural anaesthesia instead of nerve blocks or general anaesthesia. 2. Delayed use of vasopressive amines after excessive fluid infusion. 3. Toxicity of local drugs which can be largely avoided by slow injection. 4. Neurological complications of traumatic punctures, such as nerve root or dura mater injury. 5. Excessive complementary sedation.

Ventilatory response to CO2 following axillary blockade with bupivacaine.

The systemic effect of bupivacaine on the control of ventilation was studied in eight ASA I (six male, two female) unpremedicated healthy subjects aged 30-55 yr (mean 43.5 yr) and weighing 59-82 kg (mean 69 kg) after axillary blockade with bupivacaine 0.5% without epinephrine, 3 mg/kg. The slope of the ventilatory response to CO2 was significantly increased (P less than 0.05) from its control value (1.77 +/- 1.03 l X min-1 X mmHg-1 [mean +/- SD]) 30 min (+19 +/- 32%) and 60 min (+32 +/- 37%) after axillary blockade, while plasma bupivacaine levels were 1.65 +/- 0.82 and 1.40 +/- 0.60 micrograms/ml, respectively. The correlation between individual plasma bupivacaine levels and the changes in the slope of the ventilatory response to CO2 was significant (r = 0.57, n = 16, P less than 0.05). Resting minute ventilation and end-tidal CO2 values did not change significantly. These results suggest that bupivacaine has a systemic stimulating effect on the ventilatory control mechanisms.