Safety of HES 130/0.4 (Voluven(R)) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery: a prospective, randomized, controlled, parallel-group multicentre trial.

BACKGROUND AND OBJECTIVE: Patients with impaired renal function are at risk of developing renal dysfunction after abdominal aortic surgery. This study investigated the safety profile of a recent medium-molecular-weight hydroxyethyl starch (HES) preparation with a low molar substitution (HES 130/0.4) in this sensitive patient group. METHODS: Sixty-five patients were randomly allocated to receive either 6% hydroxyethyl starch (Voluven); n = 32) or 3% gelatin (Plasmion); n = 33) for perioperative volume substitution. At baseline, renal function was impaired in all study patients as indicated by a measured creatinine clearance < 80 mL min(-1). The main renal safety parameter was the peak increase in serum creatinine up to day 6 after surgery. RESULTS: Both treatment groups were compared for non-inferiority (pre-defined non-inferiority range hydroxyethyl starch < gelatin + 17.68 micromol L(-1) or 0.2 mg dL(-1). Other renal safety parameters included minimum postoperative creatinine clearance, incidence of oliguria and adverse events of the renal system. Baseline characteristics, surgical procedures and the mean total infusion volume were comparable. Non-inferiority of hydroxyethyl starch vs. gelatin could be shown by means of the appropriate non-parametric one-sided 95% CI for the difference hydroxyethyl starch-gelatin [-infinity, 11 micromol L(-1)]. Oliguria was encountered in three patients of the hydroxyethyl starch and four of the gelatin treatment group. One patient receiving gelatin required dialysis secondary to surgical complications. Two patients of each treatment group died. CONCLUSION: As we found no drug-related adverse effects of hydroxyethyl starch on renal function, we conclude that the choice of the colloid had no impact on renal safety parameters and outcome in patients with decreased renal function undergoing elective abdominal aortic surgery.

Heparin induced thrombocytopenia in patients with ventricular assistance device bridge-to-transplantation. A case series.

Heparin-induced thrombocytopenia (HIT), is a severe side effect of heparin. It occurs both in patients treated with unfractionated heparin (UFH) and in patients treated with low molecular weight heparin (LMWH). It is associated with anti-heparin/platelet factor (PF4) antibodies. HIT is a rare pathology, with rates going from 8% to 10% in patients in ventricular assist device support. The authors present three clinical cases which occurred in the Department of Anesthesiology of the Civil Hospital of Strasbourg (France) in patients receiving biventricular assistance bridge-to- cardiac transplantation. All the three patients were hospitalized for myocardial infarction. In case 1 HIT was diagnosed on VI day postoperative after a ventricular assistance device (VAD) implant. The patient was treated with lepirudin and transplanted after 73 days. In case 2 HIT diagnosis was made after 9 days receiving VAD. Also this patient was treated with lepirudin and transplanted after 48 days. Both case 1 and 2 received intra-aortic balloon pump (IABP) assistance before receiving VAD. Case 3 received VAD on XXII day of hospitalization; the patient developed HIT after 5 days, which was treated with lepirudin. He was transplanted after 66 days, but he died in course of intervention. HIT in patients undergoing VAD bridge-to-transplantation is a rare and often misdiagnosed cause of thrombocytopenia. Correct diagnosis, management and therapy are mandatory in this kind of patients, but they are not easy and standardized.

[Anaesthetic considerations for interventional radiology]. / Anesthésie pour imagerie interventionnelle.

OBJECTIVE: To describe the new procedures applied for interventional radiology leading to specific anaesthetic care and organization. DATA SOURCE: Record of references from national and international journals in Medline. STUDY SELECTION: All types of articles were selected including prospective studies, practice guidelines, reviews and case reports. DATA SYNTHESIS: During interventional radiology, anaesthesia should be adapted to the duration of the procedure, the pain induced by the radiologist, the position of the patient and its medical status. General anaesthesia would be preferred for long procedures, requiring total immobility. Locoregional anaesthesia can be proposed for some cases. Sedation associating hypnotics (propofol, midazolam, sevoflurane) and opioids (alfentanil, remifentanil) is commonly used according to different schemes, as discontinuous boluses, continuous infusion, target controlled intravenous sedation or patient controlled sedation. Monitoring of temperature and diuresis may be useful for long procedures. Haemodynamic monitoring (arterial catheter, central venous pressure) and haemostatic monitoring may be necessary for interventional neuroradiology and endovascular stenting. Radiofrequency and laser procedures are often painful, requiring the choice of adequate analgesic regimen. Hydratation associated with acetylcysteine seems to be able to prevent contrast induced nephropathy in patients with risk factors for chronic renal insufficiency. CONCLUSION: As advances in interventional radiology are obvious, general organisation as well as anaesthetic procedures should be adapted to these specific techniques.

Intraoperative Pleth Variability Index Is Linked to Delayed Graft Function After Kidney Transplantation.

BACKGROUND: Delayed graft function (DGF) is an early postoperative complication of kidney transplantation (KT) predisposing to acute rejection and lower graft survival. Intraoperative arterial hypotension and hypovolemia are associated with DGF. Central venous pressure (CVP) is used to estimate volemia but its reliability has been criticized. Pleth variability index (PVI) is a hemodynamic parameter predicting fluid responsiveness. The aim of this study was to examine the relationship between intraoperative PVI and CVP values and the occurrence of DGF. METHODS: This was a prospective, noninterventional, observational, single-center study. All consecutive patients with KT from deceased donors were included. Recipients received standard, CVP, and PVI monitoring. Intraoperative hemodynamic parameters were recorded from recipients at 5 time points during KT. RESULTS: Forty patients were enrolled. There was a poor correlation between PVI and CVP values (r2 = 0.003; P = .44). Immediate graft function and DGF patients had similar hemodynamic values during KT, with the exception of PVI values, which were significantly higher in the DGF group. In particular, a PVI >9% before unclamping of the renal artery was the only predictive parameter of DGF in our multivariate analysis (P = .02). CONCLUSIONS: This study suggests that PVI values >9% during KT are associated with the occurrence of DGF.

[Digestive surgery and varicose vein surgery]. / Chirurgie digestive et varices.

The thromboembolic risk related to surgery may be considered as low for varicose vein surgery and non major digestive surgery. It could be defined as moderate in case of large dissection, long duration of procedures and emergency cases. The risk may be considered as high for major abdominal surgery involving cancer surgery or not and bariatric surgery. The absence of prophylaxis can be proposed for low risk surgery (grade B). However, elastic compression stocking are effective for all cases of digestive surgery and suggested to be used (grade A). There are no data concerning the moderate risk situation. Therefore, experts recommend the use of elastic compression stockings or low doses of LMWH (grade D). High-risk surgery requires the use of high doses of LMWH recommended for reasons of efficacy, tolerance, and easiness to use (grade A). Associated elastic stockings is efficious (grade B). The duration of prophylaxis lasts generally 7-10 days. Extension to 1 month is recommended for major abdominal cancer surgery (grade A).

[Interest of the Mini Mental State Examination to detect cognitive defects after cardiac surgery]. / Intérêt du Mini Mental Test dans le dépistage des troubles cognitifs après chirurgie cardiaque.

INTRODUCTION: Cognitive defects are frequently described after cardiac surgery. They occur in 30 to 79% cases. They might be related to the use of a cardiopulmonary bypass (CPB). They are poorly evaluated in clinical practice. OBJECTIVES: To evaluate the usefulness of the Mini Mental State Examination (MMSE) to screen patients scheduled for cardiac surgery. STUDY DESIGN: Prospective, open study. PATIENTS AND METHODS: 100 consecutive patients undergoing coronary artery bypass or valvular replacement under CPB were enrolled in the study. The MMSE was performed the day before surgery and five days later. Patients exhiting a postoperative defect> or =4 points were compared to those without changes or with improved results. RESULTS: 73 patients completed both tests. The mean score decreased postoperatively in 12 patients (15%). They were older (70+/-8 years), had longer CBP durations (128+/-50 min) and the lowest temperatures (30 degrees C+/-3) compared to the other patients. At the opposite, five patients (9%) improved their scores. CONCLUSION: These results entourage to carry out a more strict follow-up for the oldest patients in cardiac surgery. The MMSE could be systematically integrated to the pre and postoperative screening. The detection of cognitive dysfunction should lead to address the patient to a geriatrician for a prolonged follow-up.

Preferential glutamine uptake in rat brain synaptic mitochondria.

Glutamine uptake has been studied in purified rat brain mitochondria of synaptic or non-synaptic origin. It was taken up by an active saturable transport mechanism, with an affinity two-times higher in synaptic than in non-synaptic mitochondria (Km = 0.45 and 0.94 mM, respectively). Vmax of uptake was 7-times higher in synaptic mitochondria (Vmax = 9.2 and 1.3 nmol/min per mg protein, respectively). Glutamine transport was found to be inhibited by L-glutamate (IC50 = 0.64 mM) as well as thiol reagents (mersalyl, N-ethylmaleimide). It is suggested that differential uptake of glutamine in mitochondria of synaptic or non-synaptic origin may be a major mechanism in the regulation of the synthesis of the neurotransmitter glutamate.

Auxiliary liver transplantation for fulminant and subfulminant hepatic failure.

We report the first series of 9 auxiliary liver transplantations performed as a bridge to recovery in 8 patients with fulminant and subfulminant hepatic failure. Hepatic failure was due to hepatitis A virus (n = 3), hepatitis B virus (n = 1), hepatotoxic drugs (n = 2), autoimmune disease (n = 1), or it was of unknown origin (n = 1). The donor liver was reduced to a left lobe (n = 2), a left liver (n = 4), or a right liver (n = 3), and was implanted in an orthotopic position beside the native liver after it was resected by a left or a right hepatectomy. Conventional immunosuppression was used to prevent rejection. Six patients regained normal consciousness within 2 weeks, without any sequelae. Two patients had persisting encephalopathy due to graft initial dysfunction, one of whom showed portal vein thrombosis, which was successfully cleared. The other one showed hepatic vein stenosis and was retransplanted at day 15. Five of eight patients had to be reoperated because of a surgical complication. Five patients showed rapid regeneration of their native liver, but one died at day 45 from severe herpes virus broncholitis. The auxiliary grafts were removed (n = 3) or left to atrophy by tapering immunosuppression (n = 1). One patient developed cirrhosis of the native liver and died of infectious complications at day 42. The native livers of the two remaining patients are still atrophic, one at 4 months and one at 1 month posttransplant. Finally, 6 of 8 patients are alive with a follow-up of 1 to 17 months. Four of them have permanently stopped their immunosuppressive therapy. Our experience demonstrates that auxiliary orthotopic liver transplantation (1) is feasible in children and adults, using either a left or a right liver graft, (2) is efficient in providing adequate liver function, and (3) gives a real chance to the native liver to regenerate, offering these patients a future free of immunosuppression.

[Diprivan: drug interactions]. / Diprivan: interactions médicamenteuses.

Concerning the pharmacokinetic or pharmacodynamic interactions, the following is recommended: Use smaller doses of alfentanil when the latter is combined with propofol, because of a higher risk of ventilatory depression. Decrease doses of each agent whenever propofol is combined with thiopentone or midazolam to induce anaesthesia. The prophylactic or therapeutic use of atropine is indicated when propofol is associated with agents reducing heart rate. Prefer propofol to induce anaesthesia for eye surgery, if suxamethonium is required. In the absence of sufficient data, propofol should be administered with care in patients taking cardiovascular medication (risk of hypotension) or cyclosporine (enhanced toxicity).

[Anesthesia in the HIV positive or AIDS patient]. / Anesthésie du patient VIH positif ou atteint du SIDA.

OBJECTIVE: To analyze the current anaesthetic management of HIV/AIDS patients. DATA SOURCES: References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service, personal files. STUDY SELECTION: Original articles, reviews, cases reports, letters to the editor in French and English were analyzed and selected. DATA EXTRACTION: Current data on HIV infection, perioperative clinical and biological symptoms, arguments for choice of the type of anaesthesia, risks of transmitting HIV to health care workers and protective measures were extracted. DATA SYNTHESIS: Twenty per cent of HIV-positive patients require surgery during their illness. Anaesthesia and surgery decrease cell mediated immunity and modify the activity of immune mediators. These changes are more pronounced under general anaesthesia compared to regional anaesthesia. They are transient and not clinically significant. Poor information is available concerning the perioperative management of HIV-positive patients and the effects of anesthesia on their immune status. Preoperative evaluation focuses on the following three important data: patient's status, surgery, and anaesthesia. In patients in good clinical conditions who comply with treatment, the anesthetist assesses the effects of the antiretroviral treatment and the risk of interactions between anaesthetic and antiretroviral agents. Etomidate, atracurium, cisatracurium, remifentanil and desflurane are not dependent on hepatic metabolism by the cytochrome P450 system. In patients in bad clinical conditions or in patients who do not comply with treatment, attention focuses on cardiovascular, pulmonary, neurologic and nutritional status. The specific antiretroviral treatment is not discontinued in the perioperative period, as far as compatible with the type of surgery and associated dysfunction of the digestive tract. Regional anaesthesia offers the benefits of not interfering with the immune system and antiretroviral agents. However, the viral infection can be enhanced by regional anaesthesia due to the cofactors' effect of local anaesthetic agents in cerebrospinal fluid. Homologous blood transfusion is not recommended as it increases postoperative infection and viral activation. Erythropoietin can be of benefit in selected cases. In the future, supportive immunotherapy will probably be the main tool for perioperative management of HIV and AIDS patients.

[Perforation of the pulmonary artery following Swan-Ganz catheterization]. / Perforations de l'artère pulmonaire consécutives à l'utilisation du cathéter de Swan-Ganz.

Pulmonary arterial rupture due to the use of a Swan-Ganz catheter is a rare accident, with an estimated 2% incidence rate. It is fatal in almost 50% of cases. Predisposing factors are age greater than 60 years, pulmonary arterial hypertension and anticoagulant treatment. In patients older than 60 years, changes in the arterial wall increase the risk of rupture; pulmonary hypertension leads to too distal a movement of the catheter, and a concomitant treatment with anticoagulant drugs increases the amount of blood lost. Handling errors when setting up the catheter are often the cause of these accidents, especially a balloon too blown up and a catheter pushed too far. A subsequent movement of the catheter can be a cause of rupture during cardiac surgery. Haemoptysis is the major symptom of this accident, being found in 90% of cases. It can however be of minor importance; if it is ignored, this can lead to a secondary overwhelming haemorrhage. The haemorrhage can be life-threatening because of the cardiovascular collapse and acute respiratory failure by asphyxia. The treatment can only be carried out in intensive care. It will depend on the severity of the accident. It can go from an expectant wait after partial or total removal of the catheter, to an emergency thoracotomy for vascular suture, segmentectomy or even lobectomy. Intermediate measures include turning the patient onto the healthy side, injecting adrenaline or a clot of the patient's blood by the distal end of the catheter, placing a Fogarty catheter in the affected bronchus, or tracheal intubation with a double-lumen catheter and using mechanical ventilation with PEEP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Accidental ingestion of a battery]. / Ingestion accidentelle d'une pile électrique.

A case of accidental battery ingestion by a three-year old boy is reported. The possible complications are local (i.e. necrosis of tissues by leakage of the alkaline electrolyte, by electrical injury or by impaction of the battery) and general (mercury poisoning). Large diameter batteries impacted in the oesophagus need prompt removal. When the battery is located in the stomach, two attitudes are discussed: some authors allow it to progress through the gastrointestinal tract spontaneously under radiological control, others recommend rapid removal by endoscopy or surgery in order to avoid the complications above described.

[Cardiac arrest during anesthesia and recovery period]. / Arrêt cardiaque pendant l'anesthésie et en phase de réveil.

Cardiac arrests (CA) occurring during anaesthesia and recovery can be classified into three groups: CA not related to anaesthesia (NACA), CA related to anaesthesia (ACA), whether partially (PACA) or totally (TACA). In the French survey, NACAs were three times more frequent than ACAs. Nearly 25% of ACAs occurred at induction and consisted mainly in TACAs. Another quarter of ACAs occurred during maintenance and consisted mainly in PACAs. About 50% of ACAs occurred after the end of anaesthesia and had the highest mortality rate. Cardiac arrest corresponds to the status of a heart unable to generate the minimum aortic blood flow required for functioning of vital organs. For the brain, a zero-blood flow of more than 4 seconds results in coma. Consequently CA exists when the time interval between two subsequent efficient systoles is greater than 4 seconds. Anaesthetic agents can result in CA by 1) overdose (absolute, relative), 2) anaphylactoid/anaphylactic reactions, 3) specific effects (acetylcholine-like effect, hyperkalaemia and malignant hyperthermia for succinylcholine; vagal effect of vecuronium and atracurium; cardiotoxicity of bupivacaine) and 4) drug interaction. In hypoxic CA, severe neurologic impairment often still exists at the time of onset of CA. The anaesthesia machine and controlled ventilation can induce CA by hypoxic ventilation, overdose of anaesthetic vapour, excessive CO2 reinhalation, hypoventilation, disconnection, excessive pressure in airways. Cardiac hypothermia can be a cause of CA as well as a cause of unsuccessful CPR. Massive infusion of unwarmed fluids and IPPV with unheated gases generate a temperature gradient within the heart which may result in severe arrhythmias and CA.(ABSTRACT TRUNCATED AT 250 WORDS)

[General anesthesia in the elderly]. / Anesthésie générale du sujet âgé.

Physiologic and pathologic changes due to ageing should be taken in account for the preoperative evaluation and peroperative management of geriatric patients. Pharmacokinetic changes ed to reduce the doses of intravenous agents by 50%. MAC of inhalational agents is decreased by 25 to 75%. Pharmacodynamic deleterious effects are limitative in the choice of some drugs. Cardiocirculatory and pulmonary functions need specific, if possible non invasive monitoring, during surgery, recovery and the early postoperative days.

[Immediate evaluation of continuous medical education]. / Evaluation pédagogique immédiate d'une action de formation médicale continue.

OBJECTIVES: To analyse the results of the immediate evaluation of an European teaching session using a questionnaire provided by the French College of anaesthesiologists. STUDY DESIGN: Open evaluation. MATERIAL: Questionnaires completed after each topic by 50 participants of an European course including 15 lectures were collected. METHODS: The types of professional exercise and the medical practise reliable to the different topics were pointed out. The evaluation included 4 items noted from 1 to 10: new information for medical practise, definition of pedagogic objectives, quality of means used for teaching, interest for the treated subject. The global mean score for each item and for each speaker was calculated. Results were compared according to the professional mode of exercise, the own medical practise and the project to modify it in the future. RESULTS: Scores affected to items were significantly lower for participants exercising in PSPH compared to general and university hospitals and private clinics (p < 0.001). New information was better found in case of poor or absence of practise, but interest was improved when medical practise was frequent. 2/3 of the participants projected to modify their practise after the session. CONCLUSION: The analysis of medical evaluation should allow to determine an acceptable zone of quality which may be useful for accreditation. However, distorting results according to the professional mode of exercise and the own medical practise should encourage the development of adapted continuous medical education. Delayed evaluation may be necessary to objective the putative benefits of CME on medical practise.

[Anesthesia for non-specific surgery in a post-transplantation patient]. / Anesthésie pour chirurgie non spécifique chez le patient transplanté.

The increase of non specific surgeries in transplanted patients may be related to the better survival achieved by the efficacy of immunosuppressive therapy and improved surgical and intensive care conditions. Therefore, the anaesthetist may be mandated to give anaesthesia in such patients, treated in hospitals which are not involved in transplantation procedures. The ignorance of the main physiologic and pharmacological changes in the new grafted organ as well as the knowledge of high risks of rejection or infection contribute to the anxiety often encountered in front of these patients. The denervated heart is unable to respond to stimulations requiring the integrity of autonomic neural mechanisms. Modulation of cardiac output depends on intrinsic activity (Frank-Starling mechanism) and therefore of end diastolic volume (preload). The denervated transplanted lung shows inability to elicit cough reflex; the latter is totally abolished in case of tracheal anastomosis. These physiologic changes have no deleterious effects on early cardiac and pulmonary functions following transplantation. In the same way, renal, liver or pancreatic functions are restored after respective replacement. However chronic rejection occurs frequently in 50% of patients in a mean time of 5 years following surgery except for liver transplanted patients which seem to be better protected. It results in a progressive decrease in organ function tests. The preoperative assessment requires primary contact with the transplant center. This communication should give precious information about the last biological and functional results as well as about the immunosuppressive therapy. Standard preoperative investigations include measurements of haemoglobin, urea, electrolyte and creatinine concentrations, liver tests, ECG, chest X-ray and coagulation pattern. Previsible difficult intubation should be detected in case of previous pancreas transplantation. Immunosuppressive therapy and other treatments should not be disrupted until surgery. Usual premedication may be used. Previsional peroperative transfusion requires specific packed red blood cells, fresh frozen plasma and platelets in order to reduce CMV contamination and GVH reactions. Locoregional or general anaesthesia may be used with respect to usual contraindications. Special attention should be given in cardiac transplanted patients in order to maintain adequate preload. As atropine is ineffective, bradycardia may be treated by isoprenaline. Patients with lung transplants require a reduction of vascular loading and of hydratation and early postoperative pulmonary physiotherapy. Pancreas transplanted patients often suffer from severe cardiac diseases (coronaropathy). The immunosuppressive therapy modifies the pharmacological behavior of many anaesthetic agents. Ciclosporine enhances mainly the effects of muscle relaxants. Peroperative invasive monitoring requires full aseptic techniques. Invasive monitoring should be discussed in terms of benefit-risk ratio.(ABSTRACT TRUNCATED AT 400 WORDS)

[Perforation of the pulmonary artery during the insertion of a Swan-Ganz catheter]. / Perforation de l'artère pulmonaire lors de la mise en place d'un cathéter de Swan-Ganz.

An accidental rupture of the pulmonary artery in a 77 year old female patient is reported. She was admitted for total mastectomy, but her past medical history revealed an old myocardial infarct, treated arterial hypertension and asthma. She was under heparin as well for her varicose veins. Her clinical examination revealed a patient in mild chronic heart failure. It was therefore decided to carry out invasive monitoring during surgery and the recovery period. A Swan-Ganz catheter was put up. Its progression was controlled by looking at the pressure curves. Several attempts were made to obtain a wedge pressure, with no success. During these attempts, the patient developed a cough followed by massive haemoptysis. Despite adequate resuscitative measures, the patient died before a surgical procedure could be attempted. Postmortem examination showed the rupture to be 9 cm away from the origin of the pulmonary artery. This unfortunate accident confirmed that the following three factors, all present in this patient, should call for extreme care in the setting-up of Swan-Ganz catheters: age greater than 60 years, pulmonary arterial hypertension and anticoagulant therapy.

[Anesthesia and implantable automatic defibrillator]. / Anesthésie et défibrillateur automatique implantable.

Since the introduction of first generation automatic implantable cardioverter defibrillators (AICD) in 1980, an increasing number of such devices have been inserted in patients at high risk for sudden death by ventricular tachycardia or fibrillation (VT/VF). With the improvement of technology and implanting techniques, devices may be inserted at present subcutaneously into the abdominal or the thoracic wall, rather than by thoracotomy. The anaesthesist is involved in the primary implantation of the AICD and the secondary testing of efficiency. Implantation generally requires general anaesthesia and the extension of monitoring is guided by the patient's underlying disease(s). The efficiency of the implanted system is tested one to two months later in inducing VT/VF under general anaesthesia and in determining the defibrillation threshold. The anaesthetist may also have to take care of patients with a AICD. For such cases the following recommendations can be made: a) gloves should be worn by doctors and nurses coming into contact with these patients, in order to limit the risk of electrification; b) a ring magnet must be available to inactivate the unit; c) in case of external defibrillation, the external paddles should be oriented perpendicularly to the line joining the two implanted electrodes; d) AICD should be disabled during electrocautery and prior to electroconvulsive therapy; e) the assistance of a electrophysiologist may be helpful for the management of these patients.

[Peroperative massive pulmonary embolism of tumoral origin. Value of extensive monitoring]. / Embolie pulmonaire massive peropératoire d'origine tumorale. Intérêt d'un monitorage extensif.

A case is reported of a 47-year-old female patient who suffered from massive tumour embolism during a nephrectomy for a renal carcinoma invading the inferior vena cava. Intraoperative monitoring consisted in direct blood pressure measurement (radial artery cannula), central haemodynamic monitoring (Swan-Ganz catheter), pulse oximetry and capnography. During the surgical manipulation of the suprahepatic vena cava, Petco2 suddenly decreased (from 25 mmHg to 14 mmHg), together with Spo2 (from 99% to 89%), and the mean pulmonary arterial pressure increased from 18 mmHg to 40 mmHg. The drop in arterial blood pressure to 50/30 mmHg, initiated an immediate sternotomy. After clamping the superior and inferior venae cavae, numerous tumour fragments were removed from the pulmonary artery. Cardiac activity restarted after internal cardiac massage, 1 mg adrenaline, 1 g calcium chloride and 150 mmol of molar sodium bicarbonate. The whole procedure lasted 30 min. Arterial blood pressure became stable at 110/50 mmHg, pulmonary arterial and wedge pressures at 20 and 5 mmHg. The Spo2 increased to 98%, and Petco2 to 25 mmHg. The nephrectomy was then carried out, the patient being given 5 micrograms.kg-1.min-1 dobutamine and 3 micrograms.kg-1.min-1 dopamine. At the end of surgery, systolic blood pressure was 120 mmHg, mean pulmonary arterial pressure 25 mmHg, and PaCO2 34 mmHg. The patient left the intensive care unit after twelve days. After one year of follow-up, no complication had occurred. The value of cardiopulmonary bypass in nephrectomy for renal carcinoma invading the vena cava, or the renal vein, is discussed.(ABSTRACT TRUNCATED AT 250 WORDS)