[Recovery of neuromuscular block after continuous infusion of cisatracurium in patients with renal dysfunction]. / Récupération du bloc neuromusculaire après perfusion continue de cisatracurium chez l'insuffisant rénal.

OBJECTIVE: Study of the recovery of neuromuscular block after continuous infusion of cisatracurium in patients with renal dysfunction. STUDY DESIGN: Prospective case-control study. PATIENTS: Forty adult patients scheduled for urological surgery were assigned to two groups according to the creatinine clearance (CC) as a measure of the renal function: group IR (CC < 60 mL.min-1) or group NR (CC > or = 60 mL.min-1). METHODS: After premedication with hydroxyzine, anaesthesia was induced with propofol, sufentanil and cisatracurium (0.15 mg.kg-1), and maintained using isoflurane, sufentanil and a continuous infusion of cisatracurium (0.12 mg.kg-1.h-1) adjusted for maintained a post-tetanic count < or = 5. Neuromuscular transmission was monitored at the adductor pollicis using accelerography (TOF Gard). Onset and recovery times in both groups were compared using Student's t test. RESULTS: Infusion time and total dose of cisatracurium were comparable in both groups. Onset times were 3.9 +/- 0.8 min and 3.5 +/- 0.6 min in groups IR and NR respectively. After the infusion, the time to train-of-four ratio of 0.8 were not different in both groups: 77 +/- 18 min (group IR) and 73 +/- 13 min (group NR). However, the spontaneous recovery intervals 25%-75% were delayed in group IR (20 +/- 9 min vs 14 +/- 5 min p < 0.05). CONCLUSION: There are minor differences in the pharmacodynamics of cisatracurium between patients with normal or impaired renal function. Nevertheless, a marked interindividual variability in the recovery parameters was observed in patients with renal dysfunction.

[Patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy]. / Sédation contrôlée par le patient avec du propofol au cours de la lithotritie extracorporelle rénale.

OBJECTIVE: Evaluation of patient-controlled sedation with propofol for extracorporeal shock wave lithotripsy (ESWL) using an EDAP LT01 lithotriptor. STUDY DESIGN: Prospective clinical study. PATIENTS: Fifty consecutive patients, ASA I or II, aged 18-65 years. METHODS: Patients received 50 mg of propofol five minutes before ESWL, then they self-administered 50 mg bolus doses of propofol with a ten minutes lock-out interval. Pain (1-100 mm VAS) and sedation (four points scale) were assessed every five minutes. Patient satisfaction was recorded at the end of the procedure. Pharmacokinetic simulation was done with the Marsh's data set. RESULTS: Three patients were excluded. Patients received a mean propofol dose of 147 +/- 68 mg during the procedure with a mean duration of 47 +/- 8 minutes. The median of the higher sedation scores was 2 (drowsy) and mean maximal VAS was 40 +/- 20 mm (10-70). No complications were recorded. Thirty-nine patients (83%) were satisfied or very satisfied by patient-controlled sedation. CONCLUSION: Patient-controlled sedation with propofol is a safe and efficient mode of administration of an hypnotic agent for ESWL.

Road accident statistics: discrepancies between police and hospital data in a French island.

In most developed countries, information on road crashes are routinely collected by the police. However, comparison of police records and hospital data underlines a deficit of the number of road accidents in the routine statistics. In La Réunion, a French overseas dependency, an epidemiological study of injuries leading to hospitalisation or deaths has been performed from June 1993 to June 1994. The comparison between hospital data and police records showed that only 37.3% of non-fatally traffic-injured in-patients were recorded by the police. Length of stay in hospital, physician in charge of the first aid, urban place of the crash, type of vehicle involved, day and time of the crash and blood alcohol concentration were significantly associated with the presence in the police file. Police overestimated the severity of the injuries. Police notified 100 deaths on the 115 counted by the study. In France, non-fatally traffic-injured should be followed 30 days to improve quality of police death records. A capture-recapture method was used to estimate the total number of injured people. The capture-recapture method consists in merging information from several sources of notification to determine the real number of cases in the population and the exhaustivity of each source. We estimated that 346 subjects were injured in one month whereas police data recorded only 87 and hospital data 137. This method seems interesting to use in routine after validation when unique personal identifiers are available.

High-power Nd:YAG laser picosecond pulse delivery by a polymer-coated silver hollow-glass waveguide.

An oscillator-amplifier high-power Nd:YAG laser system was used for transmission of a single 50-ps-long pulse or a train of pulses through a cyclic olefin polymer-coated silver hollow-glass waveguide. The maximum energy that was transmitted was 150 mJ for the train of pulses and 40 mJ for the single pulse, from which followed a delivered power of 100 GW/cm(2) . The characteristics that were obtained make these waveguides promising for the delivery of high-power laser pulses in medical as well as other applications.

Injuries in a problematic socioeconomic context: a population-based study in Réunion, Indian Ocean, 1993-1994. GEAR. Groupement d'Etude sur les Accidents à la Réunion.

BACKGROUND: This study was designed to estimate the incidence and describe the characteristics of injuries during a one-year period in the French island of Réunion, Indian Ocean, a defined geographic population with socioeconomic problems. METHODS: Cases were injuries from accidents (unintentional injuries), self-inflicted injuries (suicides and attempted suicides), or injuries purposely inflicted by other people, that resulted in hospital admission or death. Patients and injury characteristics were recorded prospectively, alternately every other week, in all emergency rooms on the island; all death certificates were studied. RESULTS: The overall annual incidence of injuries was 1578 per 100,000 residents. The three main causes of injury were (i) falls on the same level (23.6%), (ii) poisoning (23.0%) and (iii) traffic accidents (21.5%). Of the traffic accident cases, 44% were motorcyclists (mostly mopeds) and more than half of the cases were 15-25 years old. Suicides and attempted suicides accounted for 80.9% of poisonings, 35.5% of immediately fatal injuries, and 19.6% of non-fatal injuries. Homicides and assaults accounted for 8.3% of all injuries. The employment rate was lower for injured patients than in the total Réunion population (standardized ratio for males: 74; P < 0.001). Half of the injured hospitalized patients had an Injury Severity Score < 5 and 8 days after hospitalization, 83.5% of patients had returned home. CONCLUSION: Injury epidemiology may be affected by different demographic, socioeconomic, cultural and geographical factors. Targeted studies are therefore necessary to guide injury prevention measures.

Disability and handicap 5 years after a head injury: a population-based study.

A population-based cohort of 407 head trauma patients has been studied since 1986 to estimate the prevalence of long-term disabilities and handicaps by means of a structured questionnaire. Five years later, 6-1 patients were deceased and 36 were lost to follow-up. Prevalence of subjective and behavioral complaints was high whatever the initial head trauma severity. Lethality in severe head injuries was 56%, and half of the survivors remained disabled. In minor and moderate head injured patients, most disabilities were related to extracranial injuries. Taking all disabilities into consideration, each year 24 per 100,000 patients of such a population are likely to suffer from at least one long-lasting disability, including 10 per 100,000 whose disabilities are due to extracranial injuries. Head injuries induce long-lasting handicap in 9 per 100,000 habitants which is severe in 2 per 100,000. These figures point to the need of reinforcing preventive actions and long-term care of these patients.

Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome.

To determine what consequences cognitive, behavioural or somatic impairments had on disabilities and recovery after a head injury (HI), a population-based sample of 231 adult patients was studied 5 years after an HI. Eighty lower-limb-injured (LLI) patients were considered as controls. Sixty-four LLI and 176 HI patients were reviewed (114 minor, 35 moderate, and 27 severe HI). Prevalence values of headaches (44-54%), dizziness (26-37%), and anxiety (47-63%) were not significantly different in the three HI severity groups, but were significantly lower in patients with an isolated limb injury (12-15%). Memory problems and depressive mood increased with injury severity. Mental impairments were frequent in severe HI patients (18-40% of patients). In minor and moderate HI patients, most disabilities were related to associated injuries. According to the Glasgow Outcome Scale (GOS), recovery was not considered as good because of somatic, behavioural or cognitive complaints in 2.5%, 5.7% and 59.2% of surviving patients in each of the above HI groups. Somatic or behavioural complaints may have considerable consequences in some minor HI patients, and the long-term management of certain patients needs improvement because these impairments are misunderstood.

[Characteristics of head trauma in children: epidemiology and a 5-year follow-up]. / Particularités des traumatismes crâniens chez les enfants: épidémiologie et suivi à 5 ans.

BACKGROUND: Accidents are the major cause of morbidity and mortality in children. The aim of this population-based study was to describe characteristics of head injuries leading to hospitalization in children less than 15 years old, in a defined geographic population (Aquitaine: 2.7 millions inhabitants) and the longterm outcome (5-year follow up) of a sample of these patients. PATIENTS AND METHODS: Hospitalized patients, residents of the region, were included in a prospective study during 13 weeks spread over the whole year in 1986 in all emergency services of the region. The follow-up study concerned patients hospitalized in 3 hospitals (a trauma I level center, a pediatric hospital and a general hospital), with a sampling frame taking into account the overall injury severity. Impairments, disabilities and handicaps were assessed with a structured questionnaire five years later and results in children compared with those of adults. RESULT: Annual incidence of hospitalized head injuries in children was 294/100,000 inhabitants. The lethality was 0.3% in hospitalized patients. Ninety-two percent of head injuries were minor. In the youngest patients, the most frequent circumstances were a fall at home. The traffic accidents rate increased with age from 14% to 53% in the 10-14 years old children. Five years later, 104 children were reviewed (83 minor and 21 moderate or severe head injuries). Children complained less often of somatic symptoms than adults. Two children had disabilities in daily life activities, including one whose minor head injury eventually worsened and one after a very severe brain injury. According to the Glasgow Outcome Scale three patients had a poor recovery (2 severe and 1 moderate disability). CONCLUSIONS: Origin and mechanisms of head injuries in childhood were similar than in previous studies. Incidence was higher because of a higher proportion of minor head injuries. Disabilities and poor recovery happened in children with brain lesions or in one children with a minor head injury complicated by a severe anoxia. Anxiety and depression should be better studied in these children.

[Evaluation of cognitive functions after anesthesia with propofol]. / Evaluation des fonctions cognitives après anesthésie au propofol.

OBJECTIVES: To assess the disturbances and delay of recovery of cognitive functions following propofol anaesthesia, and to evaluate a series of simple cognitive recovery tests. STUDY DESIGN: Prospective comparative non randomized clinical study. PATIENTS: Two groups of non premedicated patients, of ASA physical class 1 and 2 were studied. The control group (n = 11) included patients undergoing gastric fibroscopy under local anaesthesia. The propofol group (n = 22) consisted of patients scheduled for coloscopy under propofol anaesthesia. METHODS: The gastric fibroscopy was performed under local anaesthesia with lidocaine and the coloscopy under general anaesthesia with propofol as the sole anaesthetic. Five cognitive tests, designed to assess short-term memory, delayed memory, the ability to plan complex tasks, attention, and language comprehension were conducted the day before, and 1 hour, 3 hours and 6 hours after the endoscopy. RESULTS: The cognitive functions remained significantly depressed for at least 3 hours after anaesthesia, and recovered fully about 6 hours after the cessation of propofol administration. The capacity for planning was the most heavily affected. CONCLUSIONS: Complete recovery can be evaluated by simple cognitive tests, which showed that cognitive functions are impaired over a longer period than psychomotor functions. Oral instructions may therefore not be fully understood by the patient within 3 hours after anaesthesia, emphasizing the importance of written instructions and the essential role played by a well-informed accompanying person.

[Chronic cervico-brachial neuralgia treated by cervical epidural injection of corticosteroids. Long-term results]. / Névralgie cervico-brachiale chronique traitée par injection péridurale cervicale de corticoïdes. Résultats à long terme.

OBJECTIVE: To assess long-term results of a single cervical epidural corticosteroid injection (CECI) in patients suffering from chronic cervicobrachial neuralgia (CCBN). STUDY DESIGN: Open prospective study. PATIENTS: A CECI was performed in 29 patients suffering for more than 12 months from a non-compressive and non-surgical CCBN with permanent pain for at least three months non relieved by an adequately conducted medical treatment. METHODS: The cervical epidural space was injected (C7-T1, 18 G needle) with an increasing volume (maximum 10 mL) of isotonic saline solution to exacerbate patient's cervicobrachial pain. The patients then received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg.mL-1). The pain decrease was estimated on a visual analogic scale (VAS), in comparison to intensity of pain rated at 100 mm before CECI. RESULTS: The mean volume injected into the epidural space was 6 +/- 2 mL. It increased pain in 26 out of 29 patients. After 3 months, a success rate of 83% was obtained, with a pain rate of 12 mm on VAS. Concerning mid- and long-term results, pain relief remained stable for at least 24 months (mean follow-up: 48 +/- 18 months). Simultaneously, the need for analgesics decreased significantly. CONCLUSION: A single CECI in patients suffering from non-compressive and non-surgical CCBN results in long-lasting pain relief.

Long-term results of cervical epidural steroid injection with and without morphine in chronic cervical radicular pain.

To evaluate the long-term effectiveness of a single cervical epidural steroid injection (CESI) performed with or without morphine, 24 patients, without need of surgery, but suffering for more than 12 months from cervical radicular pain, were included in a prospective and randomised study. The cervical epidural space was injected (C7-D1; 18-ga needle) with an increasing volume (10 ml maximum) of isotonic saline solution to exacerbate the patient's radicular pain. The patients were then randomly allocated to 2 groups: the steroid group (group S, n = 14) received an equivalent volume of 0.5% lidocaine plus triamcinolone acetonide (10 mg/ml) and the steroid plus morphine group (group S + M, n = 10) received the same combination plus 2.5 mg of morphine sulphate. Pain relief was assessed as the percentage of pain decrease on a visual analogue scale on day 1 and at months 1, 3, 6, 8 and 12 after CESI, up to 48 months. Anthropometric data between the 2 groups were similar. The mean volume injected in the epidural space was: 6.6 +/- 2.1 and 6.3 +/- 1.9 ml in groups S and S + M, respectively, and this volume exacerbated pain in 21 of 24 patients. Despite observing a better transient improvement the day after CESI in the S + M group, long-term results did not differ. The success rate was 78.5% in group S and 80% in group S + M providing pain relief of 86.8 +/- 14.7% and 86.9 +/- 17.9%, respectively. Pain relief remained stable with time (mean follow-up: 43 +/- 18.1 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of bupivacaine on cellular oxygen consumption and adenine nucleotide metabolism.

Previous studies on isolated mitochondria have shown an alteration of mitochondrial metabolism by local anesthetics, with an inhibition of adenosine triphosphate synthesis. To show that the same is true for mitochondria intracellularly the effects of the local anesthetic bupivacaine on cellular energy metabolism were studied on cultured fibroblasts. Cells in suspension were analyzed for oxygen consumption using a polarographic method with a Clark electrode, and for cytosol and mitochondrial adenine nucleotides by high performance liquid chromatography. Bupivacaine produced a dose-dependent inhibition of oxygen consumption (50% inhibition at 1.5 mM). After incubation in the presence of bupivacaine, adenosine triphosphate and total adenine nucleotides decreased in the cells, as did the adenylate energy charge. These results demonstrate that bupivacaine interacts with cellular energy metabolism and leads to a depletion of high-energy phosphates. Such intracellular mechanisms could explain in part bupivacaine-induced myocardial depression.

A comparison between lidocaine alone and lidocaine with meperidine for continuous spinal anesthesia.

BACKGROUND AND OBJECTIVES: Experimental investigations have demonstrated a synergistic interaction between opioids and local anesthetics. This study aims to assess the effective benefit-risk ratio of continuous spinal anesthesia (CSA) induced with either 1.6% lidocaine alone or in combination with 1% meperidine. METHODS: Thirty-four elderly patients (80.7 +/- 7.3 years) operated on for fracture of the neck of the femur were randomly allocated to two groups. In the first group (n = 15), CSA was induced with lidocaine 1.6% plain, whereas in the second group (n = 19) 1% meperidine was added. Reinjections were performed in both groups using lidocaine 1.6% alone. RESULTS: In the lidocaine group, 43 +/- 13 mg was used for induction whereas in the other group the addition of 18 +/- 5 mg of meperidine significantly reduced the dose of lidocaine required to 28 +/- 8 mg (p < 0.001). Delay between two reinjections was increased to 51 +/- 7 minutes in the lidocaine plus meperidine group, compared to 35 +/- 6 minutes in the lidocaine group (p < 0.001). Ephedrine was required for 9 out of the 19 patients in the lidocaine plus meperidine group, whereas it was required for only two patients in the other group (p = 0.05). Mean plasma concentrations of meperidine 1 hour and 3 hours after induction was 45.5 +/- 12 ng/ml and 59 +/- 22 ng/ml, respectively, and drowsiness was observed in 95% of the patients in the second group. Delay before requirement for pain medication was 2.2 +/- 2 hours in the lidocaine group and 14.1 +/- 8 hours in the lidocaine plus meperidine group (p < 0.001). CONCLUSIONS: The association of 1% meperidine with 1.6% lidocaine during the induction of CSA decreases the initial induction dose, prolongs analgesia, produces initial drowsiness, and provides long-lasting pain relief. However, such benefits are offset by some impairment of hemodynamic stability that is likely to make this combination of drugs unacceptable as an enhanced analgesic technique.

The endocrine pancreas in brain-dead donors. A prospective study in 25 patients.

To determine whether hyperglycemia in brain-dead donors is a sign of endocrine pancreas insufficiency, we studied pancreatic function in 25 consecutive brain dead patients. Blood samples were drawn at 2-hr intervals from donor referral until organ procurement to analyze glucose, insulin, and C-peptide levels. After donor retrieval, two specimens were taken from the pancreas for a subsequent immunohistochemical examination. At referral mean glycemia was 13.60 +/- 1.49 mmol/L, and there was a large range of plasma glucose levels (4.6-31.6). Of 25 patients, 16 had glycemia above 10 mmol/L. At organ procurement a mean of 20 hr later, mean glycemia as 8.61 +/- 0.58 mmol/L (P < 0.005 with paired t test), and only 5 patients had glycemia above 10 mmol/L. Hyperglycemia was associated with elevated insulin and C-peptide levels during donor management. An elevated C-peptide/glucose molar ratio might be considered a sign of peripheral insulin resistance. Hyperglycemia above 25 mmol/L could not be related to the amount of glucose administered during donor maintenance. Severe hyperglycemia had a natural tendency to be partly corrected. Histologic and immunohistochemical examinations were available in 17 cases and can be considered normal. It is concluded that endocrine pancreatic function can be considered effective after brain death. The mechanism of the relative insulin resistance of these patients requires further study. Blood glucose levels, in the range observed in this study, are not a good donor criterion of endocrine pancreatic function before pancreas transplantation.

Posttraumatic disablement: a prospective study of impairment, disability, and handicap.

This study was designed to evaluate both the frequency and the course of impairments, disabilities, and handicaps resulting from trauma. It was conducted in Aquitaine, France, on a sample of 1005 trauma patients (mean ISS, 10.5 +/- 0.3) in which severe trauma (ISS > 25) was rather overrepresented (169 of 1005). A prospective follow-up of disablement according to the WHO classification was based on medical examinations performed 6 and 12 months after the trauma. Of 664 survivors reviewed at 6 months, the findings were cross tabulated with Injury Severity Score (ISS) and age. There was a good relationship between ISS and the mean length of stay in the hospital (r = 0.46; p < 0.001), the duration of rehabilitation, and the time away from work or school. Out of this sample of 1005 patients with rather major injuries, 73% of the survivors suffered from at least one impairment, with a consistently lower frequency in children whatever the severity. At least one disability was encountered in 52.3% of these patients depending on both ISS and age. Handicap was noted in at least 26% of the cases. Between the sixth month and the end of the first year, the minimal handicap regression was 35.8%, whereas the minimal regression of the disability rate was 19.5%. The best improvement was observed essentially in the low ISS categories. Whereas for minor trauma the course of disablement seems to be fixed 1 year after the injury, such is not the case for severe trauma.

[Spontaneous splenic rupture disclosing a pheochromocytoma]. / Rupture spontanée de rate révélant un phéochromocytome.

Clinical manifestation of a phaeochromocytoma may range from no symptoms to an acute abdominal emergency. These abdominal emergencies are related to haemorrhagic necrosis of the tumour, or massive bleeding in the retroperitoneal space. The authors report a case of splenic rupture revealing a phaeochromocytoma. The mechanism of splenic rupture is discussed as is the conservative treatment of phaeochromocytoma during splenic surgery. The authors observed no correlation between plasma catecholamine concentration and blood pressure.

[Use of homologous erythrocyte concentrates. Analysis of economical factors]. / Consommation de concentrés érythrocytaires homologues--Analyse des facteurs d'économie.

The factors involved in reducing consumption of bank packed red cells (PRC) were studied over three one year periods (1983, 1987 and 1989) in a Department of Vascular and General Surgery. The effects of autologous blood salvage (started in 1987), associated with the management of homologous blood by a branch of the blood bank inside the operating theater suite were assessed. In 1989, intentional normovolaemic haemodilution became virtually systematic, on top of the intraoperative blood salvage, for all patients due to undergo surgery with a risk of severe blood loss. The number of surgical procedures carried out during those three years did not vary. However, in the same time, the annual consumption of homologous PRC decreased by an overall 56% (36.7% between 1983 and 1987, and 29.8% between 1987 and 1989). This decrease was mostly due to a fall in prescription in the operating theaters, and not in the wards. In the same time, albumin consumption increased sixfold. Such transfusional policies can only be carried out if there is good cooperation between the blood bank and the prescribers of blood products.

[Hemodynamic, coagulation and glycoregulation changes induced by brain death]. / Perturbations de l'hémodynamique, de la coagulation et de la glycorégulation induites par la mort cérébrale.

Brain death results in various changes in circulation haemostasis, acid-base balance and glycoregulation. This study was carried out between February 1988 and December 1988 in 91 patients with brain death. Age range was between 6 and 58 years. The cause of brain death was brain trauma (71%) and vascular malformations (26%). In all patients a cardio-vascular collapse occurred at the moment of brain death, requiring an intravascular loading (466.3 +/- 240.3 ml.h-1) with crystalloids and albumin. Dopamine was used in 70% of cases at the dose of 3 micrograms.kg.min-1 to improve kidney and splanchnic perfusion. No alterations of acid-base balance were observed in these patients who admitted for organ donation in a short delay (17.1 +/- 6 h). Haemostasis was modified in all patients but the alterations occurred before the brain death and were related to brain injury. Further investigations are required for a better understanding of glycoregulation changes as they could influence pancreatic transplant survival. Hormonal changes have also to be more extensively studied for possible physiopathologic causes of the variations. A better understanding of these alterations will be of benefit for management of patients in brain death and potential organ donors.