[Risks acceptability related to obstetrical epidural analgesia]. / Acceptabilité des risques associés à la mise en place d'une analgésie péridurale obstétricale.

OBJECTIVES: Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists. STUDY DESIGN: Prospective, transversal, single center study. MATERIALS AND METHODS: Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability. RESULTS: One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations. CONCLUSION: In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

Inter-patient variability upon induction with sevoflurane estimated by the time to reach predefined end-points of depth of anaesthesia.

BACKGROUND AND OBJECTIVES: A difficult issue in anaesthesia is its titration for an individual patient to avoid over- and underdosage. Common practice is to use an initial dose and increase it subsequently if the defined end-point is not reached. This assumes that the end-point is reached after a similar interval of time in all patients given a similar dose. In order to test this hypothesis we measured the time to reach end-points such as loss of consciousness (LOC), a bispectral index (BIS) value of 60, the minimal BIS and the minimal mean arterial pressure (MAP) values. METHODS: Thirty patients aged 18-60 yr scheduled for general surgery were included in this observational study. After preoxygenation, induction was performed with 6% inspired concentration of sevoflurane in 6 Lmin-1 oxygen using the SiBI connector and the tidal volume technique. Remifentanil was administered when the BIS value was 60 and tracheal intubation was performed 4 min later. RESULTS: Time (median, minimum-maximum) to LOC, a BIS value of 60, the minimal BIS and MAP values were, respectively, 75 (45-135), 120 (75-270), 300 (120-720) and 450 (120-1200) seconds. The time to the minimal BIS value was significantly (P < 0.05) shorter than the time to reach the minimal MAP value. CONCLUSIONS: These results demonstrate large inter-patient variability for the time necessary to reach defined end-points of depth of anaesthesia when a similar dose of anaesthetic is given. Measuring the time to reach a predefined BIS value would allow application of nociceptive stimuli only at adequate levels of hypnosis and would facilitate titration.

[Peri-operative anticoagulation with danaparoid for a patient with Budd-Chiari syndrome and heparin-induced thrombocytopenia]. / Anticoagulation péri-opératoire par danaparoïde (Orgaran) chez un patient ayant un syndrome de Budd-Chiari et une thrombopénie induite par l'héparine.

We report a case of Budd-Chiari syndrome revealing a polycythemia vera and complicated by heparin-induced thrombocytopenia. A surgical porto-caval shunt was inserted with danaparoid as anticoagulant during the peri-operative period. The doses of danaparoid were as follows: a continuous intravenous infusion of 200 U/h with a target between 0.5 et 0.8 U/ml antifactor Xa activity during the preoperative period, followed by 100 U/h with a target of 0.3 U/ml during the peroperative period; an increase in doses of danaparoid to 150 and 200 U/h with a target above 0.5 U/ml was used during the postoperative period. This case report is a rare situation of hypercoagulable state, in a surgical context, treated with danaparoid.

Desflurane-remifentanil-nitrous oxide anaesthesia for abdominal surgery: optimal concentrations and recovery features.

BACKGROUND: Intraoperative combinations of volatile and opioid agents are used to achieve unconsciousness, hypnotic sparing, haemodynamic stability and uneventful recovery. This study describes the influence of different remifentanil concentrations on these variables when combined with desflurane during abdominal surgery. METHODS: Sixty-one healthy adult patients were randomly allocated to one of five predefined remifentanil target concentrations (3, 5, 7, 10 or 15 ng ml(-1)). Anaesthesia was titrated to maintain mean blood pressure (MBP), heart rate (HR) and BIS trade mark within predetermined values by adjusting desflurane delivery. Postoperative analgesia using propacetamol and morphine was initiated 30-45 min before skin closure, and continued using morphine PCA. RESULTS: Desflurane requirements adjusted to both BIS and haemodynamics were not significantly modified by the remifentanil concentration (median Fet(DES) 2.7% before incision, 2.5% intraoperatively, and 2.2% during closure), resulting in a calculated drug consumption of 0.22-0.25 ml min(-1) (with 1.5 l min(-1) fresh gas flow). High remifentanil concentration decreased MBP and HR, and reduced the duration of tachycardia, but increased the duration of hypotension. The optimal balance was obtained with a remifentanil concentration of 5-7 ng ml(-1) for intubation, 3 ng ml(-1) until incision, 10 ng ml(-1) during intra-abdominal surgery and 5-7 ng ml(-1) during closure. Post-operative morphine requirements were not significantly modified by intraoperative remifentanil concentrations (median 30 mg/24 h, range [2-88]). CONCLUSION: Remifentanil target concentrations from 3 to 15 ng ml(-1) had little influence on desflurane requirements or postoperative morphine consumption, but markedly modified intraoperative haemodynamic stability, suggesting that the target concentration should closely follow the successive noxious stimulations.

[Effects of propofol on blood concentration of cyclosporine]. / Effets du propofol sur les concentrations sanguines de ciclosporine.

OBJECTIVE: This study was designed to assess whether propofol modifies the blood concentrations of cyclosporine and lipoproteins, which bind cyclosporine. STUDY DESIGN: Prospective open study. PATIENTS: Fifteen consecutive grafted patients, scheduled for surgery allowing them to resume their oral treatment postoperatively. Their immunosuppressive treatment, included cyclosporine (Cy A), at a steady-state dosage. METHODS: Blood samples were drawn and residual Cy A blood concentrations were measured the days before and after anaesthesia and before and immediately after discontinuing the propofol infusion. Serum triglycerides, cholesterol, high-density lipoprotein (HDL) concentrations were measured before and immediately after discontinuing the propofol infusion. RESULTS: The 15 patients were given propofol by infusion for 30-210 min (mean 85 +/- 59 min). They received a total dose of propofol of 696 +/- 497 mg, a total fentanyl dose of 175 +/- 82 micrograms, and a total midazolam dose of 2.8 +/- 0.8 mg. The residual cyclosporine blood concentrations were similar the day before (142 +/- 47 ng.mL-1) and following anaesthesia (128 +/- 46 ng.mL-1) (P = 0.08). Serum cholesterol concentrations were not significantly influenced by propofol infusion, but serum triglycerides levels increased (1.46 +/- 0.66 vs 1.97 +/- 0.81 g.L-1), and HDL and LDL levels decreased (0.54 +/- 0.20 vs 0.47 +/- 0.18 g.L-1; 1.44 +/- 0.42 vs 1.28 +/- 0.37 g.L-1). CONCLUSION: Propofol by infusion does not modify the cyclosporine concentration. It is concluded that propofol may be a suitable agent for intravenous anaesthesia in cyclosporine treated patients, provided a close postoperative monitoring of cyclosporine blood concentrations is maintained.

Role of the kidney in the production of a low molecular weight growth factor (MW < 1000 Da): experimental study in the pig.

Small peptide molecules known as low molecular weight growth factor (LMW-GF) have been identified in human serum. They enhance the effect of IGF-1 (insulin-like growth factor) on proteoglycan synthesis. In the present work we investigated the role played by the kidney in the production of LMW-GF, using the pig as an experimental model. Six pigs underwent bilateral nephrectomy followed 24 h later by orthotopic autotransplantation of the kidney. Renal and liver functions were evaluated by measurement of serum creatinine, urea, electrolytes, amino transferases (ASAT, ALAT), proteins, and bilirubin. LMW-GF was measured by bioassay using 11-day-old pelvic chick embryo cartilages. We observed that LMW-GF quickly disappeared from pig serum after nephrectomy and only reappeared when transplantation was successful. Reappearance of LMW-GF can precede improvement of renal function evaluated by plasma creatinine levels. These data appear to demonstrate that the kidney is involved in LMW-GF production.

[Penile block in adults]. / Bloc pénien chez l'adulte.

A block of the penile nerves provides a sensory blockade of the penis. In adults, surgery can thus be carried out on the foreskin, glans, corpus cavernosum, corpus spongiosum or penile urethra. The two dorsal nerves of the penis can be blocked by two different routes. In the median technique, only one injection is performed in the subpubic space, near the posterior inferior aspect of the symphysis. In the bilateral technique, each penile nerve is blocked separately at the level of the penile root. Whichever technique is used, additional subcutaneous infiltration of the penile root improves the quality of analgesia. Bupivacaine without adrenaline is used at a concentration of 0.25% or 0.5%. In the median technique, bilateral diffusion of the anaesthetic solution has been demonstrated in ten patients by adding contrast medium to the anaesthetic solution. On the other hand, contralateral diffusion was only found in six of ten patients after an unilateral injection. These results substantiate the value of the bilateral technique in the adult. Both techniques were used in a group of 80 patients, aged 17 to 87 years. In 47 patients no other agent was administered, while the remaining 33 had either additional sedation or a general anaesthetic. Among the latter, three had a partial failure of the block. Postoperative analgesia, which was of excellent quality, covered an average of 10 hours. Neither local nor general incident occurred. Penile block is a reliable technique for regional anaesthesia. Because it is easy to carry out, and comfortable for the patient, this technique may be suggested to adults requiring penile surgery.

[Zona after spinal anesthesia: coincidence or consequence?]. / Zona après rachianesthésie: coïncidence ou conséquence?

A case is reported of a herpes zoster infection occurring a few days after spinal anaesthesia in a man with severe cardiac disease who had undergone transurethral endoscopic resection of a prostatic epithelioma. The question as to whether there was a relationship between the two events had to be asked, all the more so as the rash seemed to be centered on the puncture wound. Others factors involved may have been the effect of anaesthesia on the body's defence mechanisms, the use of prophylactic antibiotics and the neoplasm.