Herpes simplex virus type 1 hepatitis due to primary infection in a pancreas-kidney transplant recipient.

Herpes simplex Virus (HSV) hepatitis is a rare complication of HSV-1 primary infection, with a delayed diagnosis, affecting mainly immunocompromised patients. We describe a case of HSV-1 hepatitis after primary infection occurring in the postoperative days after a pancreas-kidney transplantation. The patient presented with an unusual evolution of a persistent severe hepatitis associated with a persistent viremia (Quantitative Polymerase Chain Reaction) despite an adequate intravenous (iv) antiviral treatment. Abdominal computed tomography scan showed a miliary hepatitis. The diagnosis of HSV-1 hepatitis was confirmed by immuno-chemistry on liver biopsy. The donor was negative for anti-HSV antibodies, excluding contamination by the graft. This case report emphasizes a rather seldom risk of care-associated viral infections, predominantly in immunocompromised patients.

[Massive rhabdomyolysis: an uncommon complication of cholesterol embolization syndrome]. / Rhabdomyolyse massive: une complication rare de la maladie des emboles de cholestérol.

A 79-year-old man with atherosclerosis presented blue toes and livedo reticularis. The patient had eroded aortic atheromatous plaques, and cholesterol embolization syndrome was suspected. An endovascular technique to exclude sources of cholesterol emboli was however performed. The patient immediately presented with severe muscle pain and total functional disability of lower limbs, new ischemic lesions of toes, anal and genital necrosis, and a livedo extended up to the abdomen. A massive rhabdomyolysis occurred associated with acute kidney injury and hyperkaliemia treated by continuous renal replacement therapy with regional citrate anticoagulation. Steroids have been introduced and renal function improved. Cholesterol crystals were also found on a skin biopsy, performed before endovascular procedure.

[Value of skin tests for the choice of a neuromuscular blocking agent after an anaphylactic reaction]. / Intérêt des tests cutanés pour le choix d'un curare après une réaction anaphylactique.

We report a grade III allergic hypersensitivity reaction occurring in a 72-year-old patient immediately after anaesthesia induction. Anaphylaxis to cisatracurium was diagnosed on clinical symptoms, biological tests and positivity of the cutaneous tests to this neuromuscular blocking agent. Five days after this allergological assessment, rocuronium, a muscle relaxant for which skin tests appeared negative was used during surgery without adverse effects. The authors underline the value of a detailed allergological assessment to identify the pathophysiologic mechanism, the culprit drug and to propose a safer alternate drug that might be used.

[Metformin-associated lactic acidosis precipitated by acute renal failure]. / Acidose lactique toxique à la metformine provoquée par une insuffisance rénale aiguë.

In type II diabetes treated with metformin, lactic acidosis is a rare but severe complication. Commonly patients with lactic acidosis show signs of shock, tissue hypoxia, acute hepatic or renal failure and the link between metformin therapy and lactic acidosis may be coincidental, associated or causal. Excessive plasma metformin concentrations show that lactic acidosis is due to a toxicological mechanism. The case of a 65-year-old woman with type II diabetes, in whom severe type B2 lactic acidosis secondary to metformin was precipitated by acute renal failure, is presented. The association of diuretics with non-steroidal anti-inflammatory drugs and colchicine was responsible for a volume depletion and an acute renal failure. Initial serum creatinine was 643 micromol x l(-1) and arterial blood gas analysis revealed a pH of 7.01. Aggressive volume expansion and correction of the acidosis with intravenous bicarbonate therapy failed. At the intensive care unit, calculated anion gap was 35 mmol x l(-1) (normal range 10-18) and lactate concentration was 12.4 mmol x l(-1), liver profile was normal. Prolonged haemodialysis using bicarbonate dialysate resulted in a favourable outcome. Toxicology confirmed retrospectively the presence of a plasma concentration of metformine of 20 mg x l(-1) (normal <2). One month after this episode she has made a recovery of tubular necrosis, although no longer prescribed metformin. Metformin should be temporally stopped when acute renal failure occurs or is anticipated; patient with acute renal failure and high calculated anion gap should benefit from lactate measurements. Early bicarbonate haemodialysis is an adequate treatment of lactic acidosis caused by accumulation of metformin associated with acute renal failure

[Ischemia of a transplanted kidney and hyperlactatemia]. / Ischémie du greffon rénal et hyperlactatémie.

The authors report four cases of patients presenting with hyperlactatemia following renal transplantation. The post-transplantation course of three patients who underwent renal transplantation was complicated by occult haemorrhage. Excessive blood loss was not evident, the patients were haemodynamically stable and their blood pressure, pulse rare and filling pressure (central venous pressure) were unremarkable. Late examinations revealed an early increase in arterial lactate concentrations a non-aniograp acidosis or lactic acidaemia occurred. Surgical decompression was carried on in all patients. An increase in the intraabdominal pressure might have caused renal impairment in the absence of haemodynamic disturbance, and retroperitoneal haematoma a change in the distribution of intrarenal blood flow. Another patient developed a partial renal venous thrombosis associated with hyperlactatemia. During this re-operation, a renal lactate production was measured. The renal cortex is a site of lactate clearance. Impaired renal perfusion should result in decreased lactate clearance and when the kidney is hypoperfused a lactate production was occur. In the absence of any signs of clinical shock, patient at risk of retroperitoneal haematoma or presenting with oliguria should benefit from lactate measurements, which could help diagnosing severe hypoperfusion of the graft.

[Failure to recover after anesthesia attributed to a transient dissociative state]. / Retard de réveil anesthésique attribué à un état dissociatif transitoire.

Failure of a patient to recover rapidly after anaesthesia is a rare event, due to various causes, including medication related effects, metabolic disturbances or neurologic insults. We report a case in a middle aged physically healthy woman who failed to recover promptly after intravenous anaesthesia. Propofol was administered for 20 minutes. Results of neurologic assessment were normal, as were laboratory tests and CT-scan. Four hours after completion of the anaesthesia, return to consciousness occurred spontaneously. The patient had a history of depressive symptoms. However the psychiatric assessment was unremarkable. We hypothesise that she developed a transient dissociative disorder.

[Renal harvesting from donors in cardiac arrest: report of 3 cases and surgical technique]. / Prélèvement rénal chez le donneur à coeur arrêté: à propos de trois cas et technique chirurgicale.

During periods of transplant organ shortage, techniques designed to "salvage" transplants must be developed. The authors report three cases of renal harvesting from donors in cardiac arrest, in which the use of in situ perfusion-cooling with transfemoral introduction of Gillot's catheter resulted in six good quality transplants. The indications, surgical technique, alternatives and results are discussed.

Assessment of deep vein thrombosis prophylaxis in surgical patients: a study conducted at Nancy University Hospital, France.

OBJECTIVE: This retrospective evaluation aimed to assess the adequacy of prophylaxis against thromboembolism prescribed to surgical patients at the authors' institution, and to compare it with generally accepted published guidelines. Aspects considered were indications for prophylaxis, regimens used and monitoring. METHODS: Eleven units (nine surgical and two surgical intensive care) took part in the survey on a voluntary basis. The clinical audit system used involved developing a set of criteria based on existing guidelines, comparing observed practice with those recommendations, analysing the factors underlying any deviation and developing corrective measures. RESULTS: When the medical records of 117 patients hospitalized in October 1995 were examined, prophylaxis against deep vein thrombosis was documented in 86 (low molecular weight heparin in 85, dextran in one). No associated physical preventative measures were recorded. Indications and dosage were appropriately handled in 90.7% and 75.2% of patients, respectively. Ninety-five cases were outside the reference criteria: 74 for excluded surgical indications, 13 which involved laparoscopy, and eight in which spinal or epidural anaesthesia was administered. Platelet count was performed in 73.8% of cases before prophylactic treatment, and in 23.10% during its course. Anti-Xa activity was measured in 0.4% of cases. Analysis of causes showed that guidelines were not complied with either because of lack of organization, or because of disagreement with them. DISCUSSION: In this study, indications for prophylaxis were well established and heparin dosages used were not fundamentally flawed. The weak point in practice was a failure to carry out platelet counts, particularly during the course of treatment. Appropriate corrective action consists of disseminating guidelines and relevant information, and using a preoperative checklist to assess thromboembolic risk. CONCLUSION: Physicians agree that opportunities to improve preventative practices exist, and that the quality improvement programme should be pursued.

Relationship between blood pressure and renin, angiotensin II and atrial natriuretic factor after renal transplantation.

The objective of the study was to assess the evolution of renin, angiotensin II, atrial natriuretic factor (ANF) and blood pressure (BP) in the first trimester following renal transplantation in man Thirty-two recipients were investigated for 3 months post-transplantation. Twenty had a history of hypertension with moderate cardiac hypertrophy. Thirty-one retained their native kidneys. Five kidney donors had a history of mild hypertension. The recipients were perioperatively volume-expanded with 0.9% saline and diuresis was maintained for 48 h with furosemide and dopamine. The sodium intake was 25 mEq/24 hours. Prophylactic immunosuppressive therapy was antilymphocyteglobulins (25 cases), or anti-LFA1 (7 cases) and maintenance therapy was cyclosporine-prednisone (8 cases), or cyclosporine-prednisone-azathioprine (24 cases). Mean BP, serum creatinine, urinary sodium excretion (UNA) and hormonal (renin, angiotensin II and ANF) parameters were collected every other day for the first week after transplantation and then twice monthly. Twenty (62.5%) patients developed hypertension and hypertension was more frequent in patients with a delayed graft function, than in patients with immediate good graft function (10/20 vs. 4/12, p < 0.05%). Both hypertensive (group HBP) and normotensive (group NBP) patients had similar very low renin and angiotensin II plasma levels, after an initial early peak. Analysis of covariance with multiple regression analysis showed that in the HBP patients, BP was negatively correlated with UNA (p = 0.02) and positively with plasma ANF (p < 0.01). The normal BP patients also showed a correlation between BP and UNA, although it was limit of statistical significance (p = 0.05); there was no correlation between ANF and BP. We conclude that the RAS is rapidly depressed after renal transplantation and does not interfere with BP regulation. The hypertension in the early stage of post-transplantation varies inversely with the urinary sodium excretion. The defective sodium excretion, which dominates the effect of the low sodium diet, results in volume overload, increased ANF and volume-dependent hypertension.

Extracorporeal shock wave lithotripsy in a patient with complete atrioventricular heart block.

Extracorporeal shock wave lithotripsy using a spark gap generator is contraindicated in patients with complete atrioventricular heart block. A case of a patient with such a heart block, who successfully underwent renal lithotripsy, without cardiac pacemaker, is reported.

Computer-controlled monitoring of bladder pressure in the prevention of 'TUR syndrome': a randomized study of 53 cases.

OBJECTIVE: To evaluate the performance of a computer-controlled monitor of bladder pressure in the prevention of transurethral resection (TUR) syndrome. PATIENTS AND METHODS: The in vitro pressure loss in catheters and endoscopes of different size was measured for irrigant flow rates of 0-500 mL/min to calibrate them before surgery. The calibrations were used in a computerized monitoring system designed to control bladder pressure during TUR of the prostate (TURP). The performance of the system was assessed in a randomized study of 53 patients with a prostate adenoma or carcinoma (Group A, 27 unmonitored patients; Group B, 26 monitored patients). The primary criterion for evaluating the absorption of irrigating fluid was the level of glycine in the blood. RESULTS: When patients with capsule perforation were included in the analysis, there was no statistically significant difference in mean glycine absorption between the groups, although glycine levels were highest in Group A, particularly in those cases with perforation (four in Group A; two in Group B). When the results for patients with capsule perforation were excluded from the analysis, there was a significant difference in the incidence of irrigant absorption between the groups. The extent of absorption was not related to the duration of operation (which was shorter in Group B) nor to the weight of resection chippings. CONCLUSION: The continuous computerized monitoring of bladder pressure during TURP effectively reduced the absorption of irrigant fluid, making the procedure safer for the patient and easier for the surgeon.

[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.

[Effects of anesthesia on postoperative micturition and urinary retention]. / Effets de l'anesthésie sur la miction et rétention aiguë d'urine postopératoire.

Postoperative micturition difficulties, considered as minor complications, have a high incidence. Acute urinary retention can follow all types of anaesthetics or operations. Surgical trauma to the pelvic nerves or to the bladder, postoperative oedema around the bladder neck, and pain-induced reflex spasm of the external and internal urethral sphincters may play a role in the development of urinary retention. Acute urinary retention is the most common complication of surgery for benign anorectal disease. The incidence of urinary retention is more likely to occur in old male patients. Preoperative urinary symptoms are not a prerequisite for developing postoperative urinary retention, although they are considered to be a risk factor. The type of anaesthetic, postoperative pain and its management may have little effect on the occurrence of postoperative urinary dysfunction. Studies on the urodynamic effects of various anaesthetic agents are rare. The parasympatholytic drugs increase bladder capacity, decrease the rate of bladder contractions and cause downward trends in urethral resistance. The barbiturates and halothane produce similar effects on urethral resistance. The anaesthetic agents decrease the intrabladder pressure and inhibit the micturition reflex. Halothane decreases bladder contractions and increases its capacity measured by the cystometrogram. Urinary retention is a side effect of opioids, particularly after intrathecal or epidural administration. Epidural morphine relaxes the detrusor muscle with a corresponding increase in the maximal bladder capacity. Spinal opioids influence the function of the lower urinary tract, by direct spinal action on the sacral nociceptive neurons and autonomic fibres, as well as by an effect on supraspinal centres. Naloxone increases detrusor pressure, decreases bladder capacity, and causes a need to void. Urinary retention is less common after a short-acting (lidocaine 5%) than after a long-acting agent (bupivacaine 0.5%). After spinal anaesthesia, detrusor strength and the ability to void restarts with the return of sacral sensation to pinprick. A single episode of bladder overdistention can result in significant morbidity. Overfilling of the bladder can stretch and damage the detrusor muscle, leading to atony of the bladder wall, so that recovery of micturition may not occur when the bladder is emptied. On the other hand, the excessive use of an indwelling catheter can lead to urinary tract infection, urethral stricture and prolonged hospital stay. Short-term prophylactic catheterisation is recommended in patients with obstructive symptoms. Patients at risk for urinary retention should be stimulated to void and provided a quiet environment in which to do so. They should be encouraged to seat, stand or ambulate as early as possible. The alpha 1 adrenergic receptor blocking agents have been used for treatment of organic or functional urinary retention. It is essential to make sure the bladder empties regularly in the postoperative period, especially in day-case surgery or in patients receiving opioid analgesia or after epidural anaesthesia.

[Management of intraoperative erection by penile block]. / Traitement de l'érection peropératoire par le bloc pénien.

Erection during endoscopic or penile surgery is a troublesome event. In this case report, the erection was first treated with intracavernous injection of etilefrine (8 mg) and detumescence was obtained rapidly. However, one hour later, the erection occurred again. Therefore a dorsal penile nerve block was performed by the median route, using 8 mL of 0.25% bupivacaine injected into the subpubic space. Mechanisms and treatments of intraoperative erections are discussed. Repeated intracavernous injections of vasoactive drugs may be dangerous, whereas a penile nerve block carries a lower risk of cardiovascular complications and provides an improved postoperative analgesia.