[Extensive mesenteric ischemia related to naratriptan overuse associated with grapefruit juice absorption]. / Ischémie mésentérique étendue associée à la prise excessive de naratriptan et de jus de pamplemousse.

We reported the case of a 61-year-old woman, who has been hospitalized in ICU because of an extensive mesenteric ischaemia, involving the small bowel, secondary to a naratriptan overuse. This mesenteric ischaemia was complicated by multiple organ failure and was responsible for extensive small bowel resection and left colectomy. A concomitant abundant absorption of grapefruit juice, a well-known P450 inhibitor, may have enhanced this naratriptan toxicity. This case underscore that an abdominal pain occurring in the context of headache treatment may be related to a mesenteric ischaemia.

Continuous care and empathic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction.

BACKGROUND: Continuous care (one anaesthesiologist per patient) and anaesthesiologist empathy at the preoperative visit could affect patient anxiety and satisfaction. We tested both unproven issues in a population at increased risk of anxiety and dissatisfaction. METHODS: In this single-blinded single-centre study, 136 women undergoing gynaecologic day-care surgery were sequentially randomized into four groups: (i) preoperative visit by an anaesthesiologist with either an empathic or a neutral attitude, and (ii) receiving either continuous or divided care (preoperative visit and anaesthesia performed by two different anaesthesiologists). Preoperative anxiety and wish for information were rated before and after the preoperative visit. Patient appraisal of the anaesthesiologist's attitude and the quality of care provided was obtained in the operating theatre. RESULTS: An empathic attitude at the preoperative visit significantly improved the perception of both the anaesthesiologist attitude (P<0.001) and the quality of information delivered (P<0.001), compared with a neutral anaesthesiologist attitude. Empathic attitude tended to decrease patient anxiety. In the operating theatre, patients who had the same anaesthesiologist (continuous care) exhibited greater satisfaction levels regarding anaesthesiologist behaviour and quality of care (P<0.001). Principal component analysis confirmed these findings, revealing that an empathic preoperative visit was linked to a reduction in preoperative patient anxiety. CONCLUSIONS: The 'one patient, one anaesthesiologist' model, in addition to ensuring sufficient time for open discussion and questions at the preoperative visit, improved patient satisfaction.

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study.

BACKGROUND: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia. METHODS: In this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded. RESULTS: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8+/-11.6, lidocaine 12.4+/-9.7; and saline 16.2+/-11.5, P=0.08). CONCLUSION: For the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.

[Night cardiac rhythm and conduction disturbances revealing obstructive sleep apnoea syndrome]. / Trouble de conduction atrioventriculaire paroxystique nocturne révélant un syndrome d'apnée du sommeil.

There is a strong prevalence of sleep apnoea syndrome in general population. Cardiac arrhythmia and conduction disturbances during sleep may complicate this syndrome. We report the case of a 73-year-old patient to whom the sleep apnoea syndrome was diagnosed after varied heart blocks during the sleep. A treatment by continuous positive airway pressure (CPAP) permitted to correct these conduction disturbances and to avoid pacemaker implantation.

[Arteriovenous difference in O2 content, pulmonary venous O2 saturation, cardiac index: are they equivalent in cardiac surgery?]. / Différence artérioveineuse du contenu en O2, saturation veineuse mêlée en O2 ou index cardiaque en postopératoire de chirurgie cardiaque : sont-ils équivalents ?

OBJECTIVE: To study the concordance of cardiac index (CI), mixed venous oxygen saturation (SvO(2)) and the arterial-mixed venous O(2) content difference, i.e.: C(a-v)O(2), postoperatively to cardiac surgery. We hypothesized that significant discrepancies would be measurable between C(a-v)O(2) and SvO(2), and CI, because the latter two indices encompass less metabolic components than the former. DESIGN: Analysis of variables collected as part of routine care. PATIENTS: Eighty anesthetized patients receiving mechanical ventilation after heart surgery. MEASUREMENTS AND RESULTS: Using linear regression of SvO(2) versus C(a-v)O(2) (Reg 1) and CI versus C(a-v)O(2) (Reg 2), respectively we found that CI=2.2 L min(-1)m(-2) and SvO(2)=70% were equivalent to C(a-v)O(2)=5 ml/100ml. The error reflected by the vertical scatter of points around the regression line, once normalized was 3.24 times greater in Reg 2 than in Reg 1. CONCLUSIONS: The correspondence of CI, SvO(2) and C(a-v)O(2) values observed in a population of patients studied immediately after scheduled heart surgery match those reported in critically ill patients. SvO(2) and furthermore CI induced a sizeable scatter of points around regression line. Accordingly, they appear as a lesser estimate of the flow/metabolism balance that may at best be inferred from C(a-v)O(2).

Information booklets to patients' family and relatives. Survey of practice in a sample of 59 intensive care units, in France.

OBJECTIVE(S): To assess the content of the intensive care unit (ICU) information booklet delivered to patient families, and that of the general information booklet of the hospital in a sample of intensive care, in France. STUDY DESIGN: Survey. METHODS: A sample of 105 ICU was obtained at random from a national database. A survey form was sent to each ICU medical director. The ICU information booklet, that one from the hospital and the corresponding questionnaire of each participating ICU have been studied to assess the percentage of information items present which matched the recommendations of at least one of three different professional guidelines. RESULTS: Fifty-nine ICU answered. We observed a significant (P<0.01) heterogeneity by the kind ICU considered (general, medical, or surgical). The percentage of information items matching guidelines remained low (median: 41%) even if higher (P<10(-3)) than the percentage of items not matching guidelines (median: 6%). Among a panel of items we considered as important, we observed a significant discrepancy (P<10(-3)) between a low citation rate in ICU booklets (median: 14%) and the opinion of doctors who judged it should included in booklets (median: 68%). CONCLUSION: Guidelines in terms of patient and family information in ICU seem to have a mild impact on the information booklets which are also very different among the types of ICU. There is a gap between what doctors judge to be included in booklets and what they effectively write in these documents.

Supratentorial primitive neuroectodermal tumours of the brain: multidirectional differentiation does not influence prognosis. A clinicopathological report of 18 patients.

AIMS: To examine the clinical and pathological characteristics of supratentorial primitive neuroectodermal tumours (PNETs) in a retrospective series of 18 patients, according to the strict definition of the World Health Organization classification of tumours that excludes other types of malignant embryonal tumours of the brain. METHODS AND RESULTS: Eleven children and seven adults with supratentorial PNETs were diagnosed between 1993 and 2002 and their medical records were reviewed. An immunohistochemical study was performed on formalin-fixed paraffin-embedded tissue of 18 primary tumours and five recurrences with antibodies for neuronal (neuron specific enolase, synaptophysin, neurofilament, chromogranin A), epithelial [epithelial membrane antigen (EMA), cytokeratin], glial [glial fibrillary acidic protein (GFAP)], muscle (desmin, h-caldesmon, alpha-smooth muscle actin, myogenin) differentiation and with two anti-CD99 antibodies. All tumours showed at least one neuronal marker except chromogranin A; a variable number of cells were GFAP+ or EMA+ in 18/23 tumours. Six primary tumours and one recurrence were positive for cytokeratin and/or one muscle antigen except myogenin. CD99 was observed in 33% of the cases. The mean duration of overall survival was 20 months. The estimated overall survival rates were 61% at 1 year, 29% at 2 years, and 18% at 3 years. Two factors of poor prognosis were identified by univariate analysis: a positive cerebrospinal fluid cytology at diagnosis and the absence of complete resection. No distinct immunophenotype was statistically related to survival. CONCLUSIONS: A multidirectional differentiation is a frequent event in supratentorial PNETs but has no apparent influence on the outcome of this aggressive neoplasm.

Gas embolism: an exceptional complication of radial arterial catheterization.

BACKGROUND: We report a rare complication of radial arterial catheterization in a 74-year-old man who had undergone retroperitoneal surgery for an infra-renal aortic aneurysm. A right subclavian venous catheter and a right radial artery catheter were inserted for hemodynamic monitoring. RESULTS: The patient suddenly went into a coma, with dyspnea and bradycardia, 1 day postsurgery, as a result of a cerebral gas embolism produced by the accidental entry of pressurized air into the artery via the arterial catheter. Cerebral Magnetic Resonance Imaging revealed multiple, diffuse brain lesions. Six months later the patient still had a left hemiparesis and a cognitive deficit. He walks with assistance. CONCLUSION: Misuse of an arterial catheter can lead to a severe gas embolism. The infusion system used to flush arterial catheters should be checked regularly to ensure it contains no gas.

[French residents in anaesthesia and critical care - a nationwide survey]. / Les internes en anesthésie-réanimation - une enquête nationale.

OBJECTIVE: We surveyed the residents in their first (R1) and fourth (R4, last) years of residency in anaesthesia and intensive care in France. METHODS: The questionnaires mailed to each resident were designed to obtain personal data, motivation for specializing in anaesthesia and their opinion of their training. RESULTS: The response rates were 48% for the R1 residents and 77% for the R4 residents. There were 40% females in this population and the R1 residents were 25 +/- 1 year old, 29 +/- 2 year-old for the R4 residents. Almost half (46%) of the R1 responders were married as were 74% of the R4 residents. They spent an average of 726 each year on books, computers and other educational items. Most (71%) had opted for anaesthesia after considering other medical specialties, but only 12% had considered surgery. Half (51%) were on a training program that was far away from their home. They thought highly of their training, with the clinical training being rated above the non-clinical component. About half of them had obtained specialized certificates (mainly additional certification in intensive care and antibiotic therapy) during their residency. Two thirds of those in R4 expected to work in a public hospital and about one third expected to work in intensive care. Money was an important factor in their choice of profession. A majority planned to remain in the area where they had graduated in anaesthesia after their residency. Finally, 96% declared that they would choose anaesthesia again if they had to do so. CONCLUSION: French residents in anaesthesia are satisfied of their initial choice for anaesthesia and don't regret it at the end of their residency training.

[Voice recognition applied to ICU medical reports]. / Logiciel de reconnaissance vocale pour les comptes rendus d'hospitalisation de réanimation.

OBJECTIVE: Medical reports in ICU are usually tape recorded and then typed by transcriptionist. Digital voice recognition (DVR) has considerably improved and may be a time saving method. The purpose of this study was to test IBM Viavoice (Pro Edition, Release 8, French version) for the generation of medical reports in a surgical intensive care unit. METHODS: A senior resident (Int) in anaesthesia, a senior academic (AS) anaesthesiologist and a confirmed medical secretary (Sec) all working in the same surgical ICU participated to the study. First, Int and AS trained Viavoice according to the software requirements. Then 60 medical records (text files) served to automatically train the software. For the study, we prospectively used 20 consecutive medical records, which had been dictated on tape by either Int or AS. The transcription time by Sec, the number of typing errors and time needed for corrections were recorded. Int and AS with Viavoice processed the same records. Turnaround time and errors were assessed for comparison to Sec work. RESULTS: Accuracy was 97, 92 and 95% for Sec, Int and AS, respectively. Transcription by Viavoice was always significantly faster whatever the speaker than conventional transcription by a secretary. However, Int required significantly longer time to correct recorded text than did Sec and AS. The total turnaround time was significantly faster for AS than Sec (p < 0.01) but Int did not differ from Sec. The performance of Viavoice did not rise with the number of records. CONCLUSION: Viavoice is as efficient as a confirmed transcriptionist.

[Severe metabolic alkalosis following hypokalemia from a paraneoplastic Cushing syndrome]. / Alcalose métabolique sévère avec hypokaliémie révélant un syndrome de Cushing paranéoplasique.

Metabolic alkalosis is frequently observed in critically ill patients. Etiologies are numerous but endocrinal causes are rare. We report a case of a patient with severe respiratory insufficiency, metabolic alkalosis and hypokalemia. The evolution was fatal. Further explorations revealed an ectopic Adrenocorticotropine Hormone syndrome. The initial tumor was probably a small cell lung carcinoma.