Changes in metabolism of cerebral glucose after stereotactic leukotomy for refractory obsessive-compulsive disorder: a case report.

Brain glucose metabolism was investigated with PET and [18F]fluorodeoxyglucose, before and after a bifrontal stereotactic leukotomy in a 37 year old woman with refractory obsessive-compulsive disorder. A bilateral decrease in glucose metabolism was found in the orbital frontal cortex after psychosurgery. Glucose metabolism was decreased to a lesser degree in Brodmann's area 25, in the thalamus, and in the caudate nucleus. Clinical improvement in obsessive-compulsive disorder after stereotactic tractotomy seems to be associated with metabolic changes in the brain, in particular, in the orbital part of the frontal lobe.

The effect of oral ondansetron in the prevention of postoperative nausea and vomiting after major gynaecological surgery performed under general anaesthesia.

The efficacy and safety of ondansetron in preventing postoperative nausea and vomiting following major gynaecological surgery was evaluated in this multicentre, double-blind study. A total of 243 patients were randomised to receive three doses of oral ondansetron 8 mg or matching placebo at 8-hourly intervals, with the first dose being given an hour before surgery. A standard general anaesthetic technique was employed throughout. Nausea, vomiting and safety assessments were performed continuously during the 24 h postrecovery period. Of the 237 patients evaluated for efficacy, significantly fewer ondansetron 8 mg treated patients (65/117; 56%) experienced postoperative nausea and/or vomiting compared with placebo-treated patients (94/120; 78%) during the study period (p < 0.001). In addition, ondansetron 8 mg reduced the severity of nausea (p < 0.001) and the total number of vomiting episodes experienced (p < 0.001). Overall, ondansetron 8 mg was well tolerated and effective in preventing postoperative nausea and vomiting in this surgical setting.

Morbidity risk for alcoholism and drug abuse in relatives of cocaine addicts.

The morbidity risks for alcoholism in the first-degree relatives of a cohort of male cocaine addicts with or without alcoholism comorbidity were studied. Of the 71 patients who participated in our study, 40 (56.3%) had a history of alcoholism and 37 (59.1%) a history of opioid abuse. Twenty-two patients (30.1%) also met criteria for a lifetime diagnosis of a major psychiatric disorder. Significant increases in morbidity risks for alcoholism were found among male relatives of cocaine addicts with comorbid alcohol dependence when compared with relatives of cocaine addicts with no alcohol comorbidity. Among fathers, risks were .69 vs .32 (z = 2.98, p < .003). Among brothers, risks were .38 vs .15 (z = 2.35, p < .03). Significantly increased risks were also observed in male relatives when probands with a psychiatric diagnosis were excluded from the analyses. Among female relatives, increases in morbidity risks were found but they failed to reach statistical significance. Two interpretations are consistent with these findings. One of these interpretations is that alcoholism is a disorder distinct from other addictions and has its own mode of transmission. The second interpretation is that the transmission of substance use disorders lacks specificity and that the substances selected are influenced by sociocultural or biological factors.

Popliteal sciatic nerve block aided by a nerve stimulator: a reliable technique for foot and ankle surgery.

The reliability of popliteal sciatic nerve blocks was prospectively assessed in 625 blocks performed in 507 patients. The sciatic nerve was approached at the apex of the popliteal fossa, in the midline, with an insulated needle connected to a peripheral nerve stimulator partially designed by one of the authors. When needed, an inguinal paravascular femoral nerve block was also performed. The drugs used were 1% mepivacaine or 0.5% bupivacaine with or without 1:200,000 epinephrine. The sciatic and femoral nerves were blocked with 30 ml and 10 ml of local anesthetic, respectively. The block was sufficient to provide surgical anesthesia in 92%; supplemental analgesia was necessary in 5% and general anesthesia was required in 3% of the cases. Discomfort associated with the block procedure was found to be minimal by 89% of the patients, moderate by 9% and severe by 2%. Overall satisfaction with perioperative analgesia was evaluated by 466 patients: 444 (95%) were completely satisfied, 20 (4%) expressed moderate reservations and two (1%) expressed major reservations. The authors conclude that the technique is a safe and reliable alternative to more common forms of anesthesia for surgery below the knee. They attribute the great success rate to a high popliteal approach, the use of insulated needles, a discriminating mode of nerve stimulation and the systematic search for optimal response to needle stimulation.

Mortality and morbidity conferences in a teaching anesthesia department.

In our anesthesia department, Morbidity and Mortality conferences (M & M's) evolved from a well established system of voluntary reporting of anesthesia related incidents. They were however not restricted to accidents solely attributable to anesthesia. Between May 1983 and December 1989, 160 cases were presented, usually by the resident or consultant in charge of the patient at the time of event. The format of conferences is described in detail in this paper. Despite an active selection process, the case mix of presentations closely reflected that of major epidemiological surveys of complications in anesthesia. Residents attending regularly M & M's during the five years of their specialty training got an accurate picture of anesthesia-related mishaps, their mechanisms of onset and their outcome. In particular, the important role played by human intervention was clearly underlined. Due to the selection process, interaction with other physicians or health professionals were described with great frequency in the genesis of accidents anesthetists had to deal with. M & M's proved a valuable teaching tool, but also contributed to improve patient care by revealing faulty routines.

Latex allergy in a child: report of a case.

A case of life-threatening anaphylactic shock in a boy undergoing complex urologic surgery under combined general and epidural anesthesia is described. Latex allergy was suspected and later confirmed by a positive RAST for latex. A short review about latex allergy, its diagnosis and prevention is presented.

Intraoperative hemodynamic modifications during pediatric orthotopic liver transplantation.

OLT is generally associated with important cardiovascular changes occurring during the vascular clamping and at the time of revascularization of the newly transplanted liver. In our series of 60 OLT performed in 52 children, the IVC clamping is generally followed by a fall in the PAP and the PWP, the SBP remaining fairly stable in half of the cases. This good tolerance is confirmed by the fact that a veno-venous bypass was used only in 3 instances and vasopressive drugs were needed in only 6 cases. At unclamping, a severe decrease in SBP is associated with a sharp rise in PAP and PWP in most of the cases, whereas some hypovolemic patients decrease their SBP, PAP and PWP. Therefore, we believe that adequate fluid replacement under careful monitoring of the filling pressures provides a good hemodynamic stability in most of the children during the different stages of OLT.

Sudden complications in regional anesthesia.

In regional anesthesia sudden and severe complications occur from time to time and may rapidly turn into life threatening situations. Their rarity might well be their most vicious characteristic. Therefore, awareness of the possible complications, careful preparation to cope with them, vigilance enabling prompt recognition of their occurrence and quick administration of the appropriate treatment are all essential for a safe practice of regional anesthesia. The routine use of pulse oximetry is now strongly recommended.

A new lormetazepam galenical formulation for sublingual premedication.

This study reports a double-blind evaluation of a new formulation of lormetazepam for sublingual administration, given as a premedicant in 48 female patients undergoing minor gynecological procedures. Both patient's and nurse's assessments for anxiety and sedation were recorded at different times. Anxiolysis and sedation were present 30 minutes after administration of the drug as reported by the patient with a peak effect at 45 minutes. Nurses reported significant differences in sedation only, but already present at 30 minutes after premedication. The memory test showed no persistent effect of the benzodiazepine one day after surgery.

The peroperative management in multiple organ donors: a crucial phase in organ transplantation.

Recent developments in organ transplantation led to the fact that any potential cadaver donor might be considered as a multiple organ donor (MOD). The anesthesiologist's role is to maintain good hemodynamic conditions during the long and complex harvesting procedure, taking into account that in renal cadaver transplantation, donor's stable hemodynamic conditions play a crucial role in the immediate function of the graft. Taking the opportunity of a case of simultaneous liver, pancreas and kidneys procurement in the same cadaver donor performed for the first time in our country, we are reviewing the different phases of the donor peroperative management. This implies a strict control of the systolic blood pressure (SBP) and central venous pressure (CVP). The first step was to maintain the blood volume: during the 3 hours procedure, 5.5 liters of crystalloid, 1.2 liters of colloid and 1 liter of blood were perfused to maintain a CVP higher than 8 mm Hg and a SBP above 110 mm Hg. To obtain the best possible renal and hepatic perfusion, 4 micrograms/kg/min. dopamine is injected continuously, along with 100 mg phenoxybenzamine since the beginning of the operation in order to avoid any local arterial spasm. After heparinization (3 mg/kg 10 minutes prior to clamping), all organs are simultaneously perfused in situ with 3 liters of Euro-Collins solution at 4 degrees C, for cold storage in optimal conditions. The pancreas along with one kidney was transplanted in a diabetic women in preterminal end-stage renal disease: current creatinine (2 months post-transplant) is 1.3 mg/dl and C-peptide is 0.8 pmol/ml. The other kidney was successfully transplanted in another center. The liver graft was implanted in a cirrhotic patient: current bilirubin is 6 mg/dl, S.G.O.T. and S.G.P.T. respectively 50 and 149 U.I.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthetic experience in adult and pediatric orthotopic liver transplantation.

The authors report their experience with orthotopic liver transplantation in 8 adults and 6 children operated during a 14 months period. The anesthetic technique is described and three points of it are underlined: Renal failure is prevented by a systematic low-dose dopamine infusion added to optimal preloading and mannitol given during the anhepatic phase. Donor liver flush via the portal vein with lactated Ringer's solution is checked by serial measurements of K+ concentration in the fluid draining from the infrahepatic vena cava: the flush is assumed adequate if that K+ level is less than 10 mmoles/l. The risk of air embolism at the time of unclamping is minimized by discontinuing N2O, adding a mild PEEP and placing the patient in Trendelenburg position. The values of hemodynamic and metabolic measurements are given and discussed. There was no peroperative mortality.

Anesthetic protocol in human renal transplantation: twenty-two years of experience.

This paper reviews the experience of 22 years of transplantation. From June 1963 to December 1984, 1362 human renal grafts were performed in our center. Throughout this period, advances in surgical techniques, kidney preservation methods and immunosuppressive regimen have improved patient and graft survival. Simultaneously, progress in anesthetic monitoring and techniques (particularly the use of new muscle relaxants and isoflurane) led to better and safer surgical conditions. A protocol of maximal intraoperative hydration using pulmonary arterial pressure monitoring was progressively developed. This protocol has allowed to reduce significantly the incidence of delayed graft function.