Effects of trimebutine on sphincter of Oddi motility in patients with post-cholecystectomy pain.

BACKGROUND: Trimebutine is an opiate modulator of the gastrointestinal motility that interacts with enkephalinergic receptors. AIM: To evaluate the effects of trimebutine (50 mg intravenous injection) on the motility of the sphincter of Oddi (SO) as assessed by endoscopic manometry. METHODS: Endoscopic manometry was performed on 15 cholecystectomized patients who presented with symptoms suggestive of SO dysfunction. Prior to the endoscopic manometry, endoscopic ultrasonography was performed in order to rule out the possible presence of a bile duct stone. RESULTS: Injecting trimebutine resulted in a significant increase in the SO antegrade phasic contraction rate (P = 0.02). Trimebutine decreased the basal pressure of the SO (32.5 vs. 27.5 mmHg), but the difference is not statistically significant (P = 0.11). The effects of trimebutine differed depending on the basal SO motility anomalies involved, but the period of latency was similar (mean 89 s: range 30-240 s). The basal anomalies were an increased basal SO pressure of > 40 mmHg in three patients, a tachyoddia (frequency of phasic contractions (PC) > 10/min) in six patients, prolonged PC (> 10 s) in two patients and an absence of phasic contraction in one patient. The basal pressure of the SO decreased in the three patients presenting with SO hyperpressure, but returned to a normal value in one case. The frequency of the PC decreased to normal in three out of the six patients with tachyoddia. The duration of the PC returned to normal in the two patients with prolonged PC whereas their frequencies increased. Prolonged PC developed in the patient without any detectable phasic contraction. CONCLUSIONS: Trimebutine modulates SO motility in various ways depending on the basal SO motility anomaly observed after cholecystectomy. This regulatory effect suggests the existence of encephalinergic control of SO motility.

Comparing two heat and moisture exchangers, one hydrophobic and one hygroscopic, on humidifying efficacy and the rate of nosocomial pneumonia.

OBJECTIVE: Many heat and moisture exchangers with filter (HMEF) have been developed. In-house data from companies provide some information about their performances; unfortunately, to our knowledge, no comparative evaluation in clinical conditions has been undertaken of these newer products. The aim of this study was to compare the efficiency of two HMEFs, one hydrophobic and one hygroscopic, on humidifying capacity and the rate of bronchial colonization and ventilator-associated pneumonia in ICU patients. DESIGN: Prospective, randomized study. SETTING: ICU of a university hospital. PATIENTS: All patients who required mechanical ventilation for > or = 24 h during the study period. INTERVENTIONS: On admission to the ICU, patients were randomly assigned to one of two groups. In one group, the patients were ventilated with a hygroscopic device (Humid-Vent Filter Light HMEF; Gibeck; Upplands Vaesby, Sweden). The condensation surface was made of paper (Microwell) impregnated with CaCl2. The filter membrane was made of polypropylene. In the other group, the patients were ventilated with a hydrophobic device (Pall BB100 HMEF). The condensation surface was made of a hydrophobic resin with a hydrophylic layer. The filter membrane was made of ceramic fibers. In both groups, HMEFs were changed daily. MEASUREMENTS AND RESULTS: Both groups of patients were similar for the tested characteristics, including parameters of mechanical ventilation. Sixty-six patients were ventilated for 11.7+/-11 days with the Humid-Vent Filter Light HMEF and 70 patients for 12.2+/-12 days with the Pall BB 100. Patients ventilated with the Humid-Vent Filter Light underwent 6.0+/-3.0 tracheal aspirations and 1.7+/-2.0 instillations per day, and those with the Pall BB 100, 6.0+/-3.0 and 1.6+/-2.0 per day, respectively (not significant [NS]). Abundance of tracheal secretions, presence of blood, and viscosity, evaluated by semiquantitative scales, were similar in both groups. No difference in the rate of atelectasis was observed between the two groups (7.5% and 7.1%, NS). One episode of tracheal tube occlusion was observed with the Humid-Vent Filter Light HMEF, and one with the other HMEF (NS). One patient in each group (NS) was switched to an active heated humidifier because of very tenacious bronchial secretions despite repeated instillations. Tracheal colonization was observed at a rate of 67% with the Humid-Vent Filter Light and 58% with the Pall BB 100 (NS). A small, but NS difference was observed in the rate of ventilator-associated pneumonia: Humid-Vent Filter Light, 32% (27.1 per 1000 ventilator days); and Pall BB 100, 37% (30.4 per 1000 ventilator days). Bacteria responsible for tracheal colonization and pneumonia were similar in both groups. Three patients in each group died from their nosocomial pneumonia. CONCLUSION: Despite differences in their components, the two HMEFs tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected and very few patients (one in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the hygroscopic HME (Humid-Vent Filter Light) and the hydrophobic HME (Pall BB 100) are suited for use in ICU patients.

Comparing two heat and moisture exchangers with one vaporizing humidifier in patients with minute ventilation greater than 10 L/min.

STUDY OBJECTIVE: To evaluate in patients submitted to minute ventilation > 10 L/min the ability to preserve patients' heat and humidity of two heat and moisture exchangers (HMEs) and one vaporizing humidifier (VH). DESIGN: Prospective, randomized, comparative, non-blinded study. SETTING: Intensive care unit of a university hospital. PATIENTS: Nine tracheally intubated, mechanically ventilated patients, sedated and submitted to mechanical ventilation with minute ventilation > 10 L/min. INTERVENTIONS: Using the psychrometric method, relative humidity (RH) and absolute humidity (AH) of inspired gas were obtained as well as temperature of inspired gas and tracheal temperatures (maximal and minimal). Following a randomized order, each patient was ventilated for two 24-h periods with a vaporizing humidifier (Bennett Cascade 2, Bennett; France) and one of two HMEs: Pall Ultipor filter BB50 (Pall Biomedical; France) or DAR Hygroster filter (Peters; France). Both were first tested for a 45-min period and then the HME that achieved the best performance in terms of temperature and water preservation was tested for 24 h. MEASUREMENTS AND RESULTS: During the 45-min test period, the Pall Ultipor HME achieved a lower performance than the other two systems for any of the studied parameters (p < 0.05 to p < 0.0001). The DAR Hygroster HME achieved lower temperature of inspired gas (29.9 vs 32.0 degrees C, p < 0.005) and lower absolute humidity (29.3 vs 33.2 mg H2O/L, p < 0.005) than the Bennett Cascade 2. After 24 h of use, lower values of temperature of inspired gas (28.5 vs 32.0 degrees C, p < 0.002) and of AH (28.0 vs 33.6 mg H2O/L, p < 0.001) were obtained with the DAR Hygroster HME than with the Bennett Cascade 2. No differences were found between the two systems for the other tested parameters. At that time, no patients had RH lower than 97% and absolute humidity lower than 23 mg H2O/L with the use of the DAR Hygroster HME. CONCLUSIONS: In patients with minute ventilation > 10 L/min, the DAR Hygroster HME showed a thermic and humidification capability similar to the reference system, the Bennett Cascade 2 VH. In these patients, the Pall Ultipor HME had a significantly lower capability.

Selective decontamination of the digestive tract in multiple trauma patients. A prospective double-blind, randomized, placebo-controlled study.

STUDY OBJECTIVE: The aims of the study were to evaluate the technique of selective digestion decontamination (SDD) in preventing the development of nosocomial infections in a selected population and to assess the effects on colonization of the oropharynx, nares, and bronchi. A financial assessment was also performed. DESIGN: Prospective, double-blind, randomized placebo-controlled trial using amphotericin B, colistin sulfate (polymixin E), and gentamicin applied to the nares, the oropharynx, and enterally; no parenteral antibiotics were given during the study period. The SDD was applied every 6 h during the study period. SETTING: Multidisciplinary ICU in a university hospital. PATIENTS: A total of 148 trauma patients admitted emergently and intubated within less than 24 h were enrolled. Seventy-two patients who received placebo and 76 treated patients were analyzed on an "intention-to-treat" basis. INTERVENTIONS: Microbiologic surveillance samples of oropharyngeal and bronchial secretions, urine, and any other potentially infected sites were taken at the time of ICU admission and twice weekly thereafter until discharge from the unit. MEASUREMENTS AND RESULTS: With the use of SDD, colonization was significantly reduced in the oropharynx and nares (<0.05) but not in bronchi. However, episodes of bronchopneumonia were significantly reduced (19 in the active group vs 37 in the placebo group; p,0.01). Staphylococcus aureus remained the main potential pathogen causing bronchial colonization and subsequent bronchopneumonia. There was no reduction in the incidence of other infections. Days in the ICU, duration of mechanical ventilation, and mortality rate were unchanged. After the use of SDD, Gram-positive colonization tended to increase and this was mainly due to methicillin-resistant coagulase-negative staphylococci. The total cost of antibiotic therapy ($62,117 [US] in the placebo group and $36,008 in the SDD group) was decreased by 42% with the use of SDD. Clinically important complications of SDD were not encountered. CONCLUSIONS: The use of SDD in this population of trauma patients reduced the incidence of bronchopneumonia and the total charge for antibiotics. Stay in the ICU, mechanical ventilation, and mortality rate were unchanged. Methicillin-resistant coagulase-negative staphylococci were selected by SDD in some patients and the clinical relevance of this colonization needs further evaluation.

Local antibiotic prophylaxis in surgery.

The perioperative use of antibiotics is an established and accepted technique for the prevention of postoperative infection. Intravenous administration often is preferred, and intramuscular administration is possible, although it has certain drawbacks. This article examines a variety of other routes of administration for delivering antibiotics locally to the surgical site. These techniques merit further study in prospectively randomized trials.

Simplification of the SAPS by selecting independent variables.

A series of 950 consecutive admissions to a multidisciplinary ICU were divided into 2 groups (group I = 450 and group II = 500). In the first group, 351 admissions were used to retrospectively create two scores: SAPS.R derived from the 14 original SAPS variables and SAPS.E derived from 22 variables (14 of SAPS plus 8 additional biological variables). Using a multiple logistic regression analysis only 5 variables were retained for SAPS.R and 7 for SAPS.E. In the second group, 446 patients were used to assess prospectively the discriminating power of SAPS, SAPS.R, SAPS.E by comparing the areas under the receiver operating characteristic (ROC) curves. There were no significant differences between the overall accuracies of these 3 scores. Adding biological variables did not improve the accuracy but the number of variables in the original SAPS could be greatly reduced.

The combination of a heat and moisture exchanger and a Booster: a clinical and bacteriological evaluation over 96 h.

OBJECTIVE: To determine whether the combination with a new device (Booster ) for active humidification improves the efficacy of a hydrophobic heat and moisture exchanger (HME). DESIGN AND SETTING: Prospective, interventional study in the ICU of a university hospital. PATIENTS: Consecutive patients requiring controlled mechanical ventilation INTERVENTIONS: Patients were ventilated with a HME, and a Booster was added for 96 h to the ventilatory circuit. MEASUREMENTS AND RESULTS: During the inspiration phase the following factors were measured: peak and mean airway pressures, maximal (beginning of inspiration), minimal (end of inspiration), and mean values of temperature of inspired gases, and relative and absolute humidity of inspired gases. Microbiological samples were obtained from the Booster, the ventilator side of the HME, and the tracheal secretions on days 1 and 4. Minimal and mean temperatures were increased as soon as the Booster was used and this increase was maintained for 96 h until the Booster was withdrawn. Then the temperature returned to baseline values. Absolute humidity values followed the same course. There was also some indirect evidence of very little, if any, changes in the HME resistance. The ventilatory side of the HMEs remained sterile in each patient, and the Booster was colonized by the same bacteria as those in the tracheal secretions. CONCLUSIONS: Adding the Booster to a hydrophobic HME improved the heat and water preservation of ventilatory gas.

Changing a hydrophobic heat and moisture exchanger after 48 hours rather than 24 hours: a clinical and microbiological evaluation.

OBJECTIVE: Complications following ventilation with dry and cold gases may be prevented by the use of artificial noses or heat and moisture exchangers, which are a solution to both the problems of humidification and heat preservation. The aim of the present study was to determine whether changing hydrophobic heat and moisture exchangers (HMEs) every 48 h rather than 24 h would affect their efficacy to preserve the heat and moisture of inspiratory gases. The impact of a prolonged use of the HME on its microbial colonization was also assessed. DESIGN: Prospective observational study. SETTING: ICU of a university hospital. PATIENTS: Twelve patients requiring controlled mechanical ventilation for more than 2 days were evaluated. INTERVENTIONS: The patients were ventilated with a heat and moisture exchanger (HME) (Maxipleat Filter, Europe Medical, France). The hydrophobic HME was placed between the Y-piece and the connecting tube and changed after 48 h of continuous use. Temperature (degree C), relative humidity (%) and absolute humidity (mgH2O/l) were obtained using the capacitive sensor principle. Bacterial colonization (tracheal secretions and ventilator side of the HME) were obtained on days 1 and 2. MEASUREMENTS AND RESULTS: After 48 h of ventilation with the same HME, tracheal tube occlusion was never observed. Using the same hydrophobic HME for 48 h rather than 24 h did not affect its technical performance: temperature at 24 h: 32.5 +/- 1.3 degrees C, at 48 h: 32.7 +/- 1.8 degrees C; relative humidity (RH) at 24 h: 99.0 +/- 1.4%, at 48 h: 99.0 +/- 1.4%; absolute humidity (AH) at 24 h: 34.0 +/- 2.4 mgH2O/l, at 48 h: 34.4 +/- 3.5 mgH2O/l. Peak and mean airway pressures did not change over the 48-h study period, with identical tidal and minute volumes in the study patients. Total respiratory heat losses were not modified during the 48-h study period (at 24 h: 152 +/- 47 cal/min, at 48 h: 149 +/- 65 cal/min). Evaporative and convective heat losses were not modified either. On day 1, eight patients had positive cultures of their tracheal secretions at a colony count of 10(3) or higher cfu/ml. After 48 h of use of the same HME, only six patients had a positive culture of their tracheal secretions. Cultures from the ventilator sides of the HMEs were all sterile (12/12) after 48 h of use. CONCLUSIONS: Changing the hydrophobic HME after 48 h rather than 24 h did not affect its technical performance in terms of heat and water preservation of ventilatory gases. There is also some indirect evidence of very little, if any, change in HME resistance. No bacterial colonization of the ventilator sides of the HMEs was observed after 48 h of use. However, other large clinical trials should be undertaken to confirm the safety of extending the time between HME changes.

Study of some phagocyte membrane receptors in patients receiving intravenous polyvalent immunoglobulins as adjunct treatment for nosocomial pneumonia.

PURPOSE: Phagocytosis is a major mechanism of defense against bacterial infections. The ingestion of bacteria by phagocytes involves a variety of cell membrane recognition structures and, among them, immunoglobulin receptors. The aim of this study was to test the phagocytic activity of granulocytes and monocytes of intensive care unit (ICU) patients, and to evaluate the effects of intravenous polyvalent immunoglobulins (IVIG) used as adjunct treatment of nosocomial pneumonia on some phagocyte membrane receptors of these patients. MATERIALS AND METHODS: The phagocytic activity of granulocytes and monocytes of 41 mechanically ventilated patients with nosocomial bacterial pneumonia was studied during the acute phase of infection. These ICU patients were compared with 21 hospitalized, noninfected volunteer patients hospitalized in a medical ward. Peripheral blood granulocytes and monocytes were studied. Of the 41 ICU patients, after randomization, 21 received IVIG at a dose of 1 g/kg for 3 days. The 41 ICU patients were compared with the 21 non-ICU, noninfected hospitalized controls. The 21 ICU patients who received 3 days of IVIG were also compared with the 20 ICU patients not receiving IVIG. Cells were tested in standard immunoglobulin-free medium (fetal calf serum) and in the presence of patients' serum. Blood granulocytes and monocytes were purified and separately exposed to three types of particles: antibody-coated erythrocytes (to test immunoglobulin receptors), opsonized zymosan (to test C3 receptors), and glutaraldehyde-treated erythrocytes (to test lectinlike or other nonspecific binding sites). Phagocytosis and superoxide anion production (oxidative burst) were measured. RESULTS: Granulocytes of ICU patients compared with those of non-ICU, noninfected patients exhibited a substantial decrease of zymosan ingestion (P < .05), whereas phagocytosis of other particles was normal. Monocytes from the ICU patients, compared with those of the non-ICU, noninfected patients, displayed an unselective overall decrease of phagocytic ability for the three particle types (P < .05). The phagocytosis activity of the three membrane receptor species of blood monocytes and granulocytes of ICU patients was not significantly modified by the IVIG infusion. For both monocytes and granulocytes, no significant improvement was observed in the fraction of cells that ingested at least one foreign particle and the mean number of particles per cell having phagocytized at least one foreign particle. Granulocyte and monocyte functions were also tested by the production of reduced ferricytochrome and no significant improvement in the oxidative burst was observed after infusion of IVIG. CONCLUSION: Infected ICU patients display a deficiency of phagocytosis membrane receptors of blood granulocytes and monocytes. The addition of IVIG to standard therapy does not improve the phagocytic activity of ICU patients with nosocomial pneumonia.

Target-controlled sedation-analgesia using propofol and remifentanil in women undergoing late termination of pregnancy.

Twenty-one women undergoing termination of pregnancy for severe fetal abnormality received remifentanil and propofol using a target-controlled infusion system and were studied prospectively. Target concentrations were initially set at 1 ng.mL(-1) for remifentanil and 0.8 microg.mL(-1) for propofol. Remifentanil concentration was adjusted to obtain visual analog scores <50 mm with preservation of ventilation. Visual analog scores assessed by the patients and physiologic data were recorded every 15 min until delivery. The median duration of administration was 150 min [10th-90th centiles: 42-282 min). Visual analog scores decreased within the first 5 min (P < 0.05) and remained under 50 mm for 91.7% of time. The median rate of infusion of remifentanil was 0.056 microg.kg(-1) min(-1) [10th-90th centiles: 0.037-0.15 ng.mL(-1)]. At delivery, the median target concentration was 2.2 ng.mL(-1) [10th-90th centiles: 1.25-4 ng.mL(-1)] for remifentanil and 0.8 microg.mL(-1) [10th-90th centiles: 0.32-1.12 microg.mL(-1)] for propofol. Remifentanil requirements were statistically correlated to gestational age, parity and duration of labor. No episodes of ventilatory depression, nausea, vomiting or pruritus were noted. Patients scored analgesia as excellent in 12 cases, good in 7 cases and moderate in 2 cases. Further studies are required to determine the place and the best regimen of remifentanil infusion for pain management in labor in those cases when epidural analgesia is contraindicated.

[Modes of administration of Diprivan]. / Modes d'administration du Diprivan.

Administration of propofol using standard syringe pumps has become routine in anaesthesia. The marketing of syringe pumps adapter for anaesthesia (high flow rate enabling a bolus injection and a slower rate for maintenance), allows an easier setting up of total intravenous anaesthesia. Computer-aided infusion of propofol will undoubtedly expand in the near future, as a result of the forthcoming marketing of computer-controlled infusion pumps and of improvement in the recognition of accurate individual pharmacokinetic parameters. This computer-aided infusion will be based on a blood concentration criterion, and no longer on a dosage regimen given to the patient. A closed loop regulatory system remains in the domain of research.

[Opioid anesthetics (sufentanil and remifentanil) in neuro-anaesthesia]. / Les morphiniques (sufentanil et rémifentanil) en neuro-anesthésie.

Remifentanil is the latest available compound of the 4-anilidopiperidine derivatives. It is characterized by an ultrashort duration of action and a metabolism independent of both hepatic and renal functions. Its main drawback is a lack of residual analgesia and the risk of postoperative hyperalgesia. Since its introduction in clinical practice, this drug has been compared to other congeners in a few studies in the setting of neurosurgery. Cerebral hemodynamics, intracranial pressure and CO(2) reactivity are similar to the effects of fentanyl and sufentanil provided that systemic arterial pressure is maintained. Haemodynamics does not greatly vary according to the type of the opioid. Fentanyl and sufentanil require higher hypnotic dosage (halogenated agents, propofol) and remifentanil is accompanied by greater volumes of fluid infusion. A marked reduction in extubation times and superior level of consciousness are reported with remifentanil. Rescue analgesic has to be given faster but pain scores remain low. Morphine 0.08 mg/kg IV administered at bone replacement results in good postoperative analgesia without delayed recovery. In summary, remifentanil is appropriate when rapid recovery and neurological evaluation are desired. Conversely, sufentanil is more suitable and easier to administer when postoperative mechanical ventilation and postponed awakening are scheduled.

[How to assess the psychomotor test "Track Tracer"?]. / Comment interpréter le test psychomoteur "Track Tracer"?

The psychomotor test "Track Tracer" is usually assessed by measuring the number of errors and the time needed for its completion. The link existing between the number of errors and the time of completion permitted the authors to propose a scoring system representing a reliable evaluation of psychomotor function recovery.

[Effects of an additional dose of propofol on intraocular pressure in patients over 60 years of age]. / Effets d'une dose additionnelle de propofol sur la pression intraoculaire chez les sujets de plus de 60 ans.

Changes in intraocular pressure (IOP) and mean arterial pressure (MAP) were studied in fifty patients, ASA 1 or 2, aged more than 60 years and scheduled for surgery of the anterior chamber of the eye. The exclusion criteria were: arterial hypertension, raised IOP, obesity, renal or hepatic disease, treatment likely to alter IOP, and a possibly difficult intubation. The patients were randomly assigned to groups P1 (n = 25) and P2 (n = 25). All were given lorazepam 1 mg orally 90 min before induction, which was carried out with propofol 1.5 mg.kg-1 and vecuronium 0.1 mg.kg-1. Patients in group P1 were intubated as soon as the train-of-four response (TOF) had been abolished. Those in group P2 were given an additional 0.7 mg.kg-1 dose of propofol before intubation. MAP, heart rate and IOP were measured before and after induction, and 1, 2 and 3 min after intubation. IOP decreased after induction, and remained below the baseline values at all times in both groups. MAP had a similar course in both groups up to 1 min after intubation: a decrease after induction followed by an increase after intubation. In group P1, MAP remained above control values 2 and 3 min after intubation, whereas in P2 it remained below. From this study, it can be concluded that using an additional dose of propofol in elderly patients was not useful for avoiding the rise in IOP due to endotracheal intubation. This was all the more so as the haemodynamic effects of such a dose of propofol could have deleterious effects in these patients.

[Do we have to monitor foetal heart rate during general anesthesia?]. / Faut-il monitorer le rythme cardiaque foetal au cours d'une anesthésie générale?

We present a case of an emergency Caesarean section due to misinterpretation of the cardiotocography (CTG) trace during general anaesthesia for treatment of dental abscess. Following failure of the dental abscess treatment under local anaesthesia, a 29-year-old female in the 36th week of a twin pregnancy was to undergo general anaesthesia. Foetal well-being was monitored with ultrasonographic evaluations of foetal heart rate. During surgery, senior obstetrician recorded a lack of beat-to-beat variability of the cardiotocography trace. The CTG pattern was interpreted as foetal distress and an emergency Caesarean section was performed under general anaesthesia. That was probably due to general anaesthesia. Then, two infants were extracted without neonatal distress necessitating intubation. This case report underlines the risk to misread an intraoperative CTG monitoring and if the CTG monitoring is normal before anaesthesia, reduced foetal beat-to-beat variability with a normal baseline heart rate during general anaesthesia is probably normal.

[Target-controlled intravenous anesthesia]. / Anesthésie intraveineuse à objectif de concentration.

Target-controlled infusion (TCI) is a new delivery system for i.v. anaesthetic agents with which the anaesthetist targets a plasma drug concentration to achieve a predetermined effect. With this system, the tedious task of calculating the amount of administered drug required to achieve the target concentration is left in charge of a microprocessor which commands the infusion device. TCI has long been used only by a few research teams, but this year a much wider field opens to this delivery system through marketing of Diprifusor, a TCI system specifically designed for administration of propofol in everyday practice. This article describes the rationale for administering i.v. agents through TCI delivery systems, the pharmacokinetic basis of TCI, the regulations and a broad overview of clinical applications, both recent and yet to come.

[Survey of 39 South East Group hospital centers on the practice of antibiotic prophylaxis in surgery]. / Audit sur 39 centres hospitaliers des pratiques d'antibioprophylaxie en chirurgie et le groupe du sud-est pour l'étude de l'antibioprophylaxie.

A survey was carried out in 39 hospitals regarding the prescribing of perioperative antibiotics. The day of the survey, hospital pharmacists collected information on prescription patterns of antibiotics and, for 3 days, the duration of their administration. A total of 1,131 cases were surveyed, originating from digestive surgery (20%), orthopaedics (31%), gynaecology (15%), ophthalmic surgery (15%), and others (19%). Duration of surgery was 72 +/- 68 min. For all types of surgeries, antibiotics not recommended by the French consensus conference were prescribed. Third generation cephalosporins were used in 17% of patients in gynaecological surgery. In 20% of cases, antibiotics were administered at an inappropriate time: 9.5% after the beginning of surgery, 8% at the time of pre-medication, and 2.5% the day before surgery. Administration exceeded 48 hours in 10% of the cases. In conclusion, special attention should be paid to limit the prescription of third generation cephalosporins, to inject antibiotic at the induction of anaesthesia and to reduce the duration of their administration.

[Computer-assisted intravenous anesthesia: value, method and use]. / Anesthésie intraveineuse assistée par ordinateur: intérêt, méthode et application.

Total intravenous anaesthesia (TIVA) is becoming increasingly popular among anaesthetists. It has several advantages, namely each component of the anaesthetic protocol can be independently controlled, and the operating room remains unpolluted with nitrous oxide or volatile anaesthetic agents. TIVA aims to maintain a constant blood concentration of each anaesthetic agent. This means that infusion rates need to be repeatedly altered. A computer calculates theoretical blood concentrations of agent according to a pharmacokinetic model, and drives an infusion device. Only a few programmes have been developed by research teams. No commercial device is available as yet. However, there are several syringe pumps and volumetric pumps which are accurate enough for use in TIVA and which may be controlled by computer. Clinical studies have shown the benefits of TIVA: greater haemodynamic stability, decreased drug consumption, more rapid recovery, and a lesser need for postoperative ventilatory support. The most appropriate agents are propofol and etomidate as hypnotics, alfentanil and sufentanil for opioids, vecuronium and atracurium as muscle relaxants. Etomidate is not recommended for prolonged infusions, because of the risk of adrenocortical suppression. TIVA seems to be attractive for neurosurgery, thoracic surgery, day case surgery, endoscopic procedures, and anaesthesia in remote locations. Unfortunately, it is an expensive technique. Moreover, there is considerable interpatient variability of the drug concentration required for a same clinical effect. Two methods are proposed to decrease this variability: population pharmacokinetic models and Bayesian forecasting. Closed loop systems are still research tools. It is concluded that computer-driven anaesthesia is the equivalent to the vaporizer for volatile agents. However, further clinical studies are needed to determine whether the advantages of this technique outweigh its disadvantages.

[Target controlled infusion (TCI) anesthesia using propofol. Assessment of training and practice in the operating room]. / Anesthésie intraveineuse à objectif de concentration (Aivoc) avec le propofol. Evaluation des formations et pratiques au bloc opératoire.

OBJECTIVE: To evaluate overall awareness of TCI and the need for training in the TCI technique. To assess, among trained anaesthetists, the value of the session and the impact of TCI technique on their working practice. STUDY DESIGN: Two prospective domestic surveys during the first quarter of 1999. METHODS: Three hundred anaesthetists representative of French anaesthetists as a whole, and 336 anaesthetists who had taken part in a training course. RESULTS: The notoriety of TCI was high and greater in the public sector compared with the private sector. Almost 3/4 of anaesthetists believed that training was necessary but only four anaesthetists out of ten TCI users said they had taken part in training sessions. After the training session nine anaesthetists out of ten became TCI users and would have recommended the training course despite the low number and variety of anaesthetic procedures observed during the practical part of training. The main difficulties reported during initial use were the choice of target concentrations and the management of drug interactions. Familiarisation to the technique was rapid (less than 20 procedures). Despite the lack of long experience (< 6 months for more than 2/3 of them), TCI appeared to be more likely used for anaesthesia of average duration. CONCLUSIONS: TCI was perceived to be an innovative concept with a requirement of a specific training. This preliminary appraisal of training sessions was generally satisfactory but underline a need for future training sessions focused on practical aspects.