A novel supraclavicular approach to brachial plexus block.

We describe a novel supraclavicular approach to the brachial plexus. Designated as the intersternocleidomastoid technique, this new approach was tested in unembalmed cadavers. It was then applied for evaluation to 150 ASA grade I or II patients scheduled for elective surgery or physiotherapy of the upper limb or for treatment of reflex sympathetic dystrophy associated with painful shoulder. The new approach was easy to master because of a very simple surface landmark, i.e., the triangle formed by the sternocleidomastoid heads, which were visible and palpable in most patients studied (90%). The procedure was effective intraoperatively, providing satisfactory anesthesia in 140 patients (93%), partially satisfactory blocks in 6 (4%), and unsatisfactory blocks in only 4 (3%). The catheter entry point is cephalad enough not to obscure the surgical field on the shoulder. Catheter insertion was successful in 63 of 70 patients. Postoperative analgesia was provided for 48 h or more in 45 patients and for 24 h in 18 patients. Only minor complications were observed: asymptomatic phrenic nerve block in 89 patients (60%), transient Horner's syndrome in 15 (10%), transient recurrent laryngeal nerve blockade in 2, and misplacement of the catheter into the subclavian vein in 1 patient. No pneumothorax was observed.

[Prolonged apnea after suxamethonium administration during staphylococcal toxic shock]. / Apnée prolongée après administration suxaméthonium au cours d'un choc toxique staphylococcique.

A toxic shock syndrome occurred after a femoral nail removal requiring revision surgery. After administration of suxamethonium (1 mg.kg-1), an apnoea prolonged over 45 minutes was observed. The trachea was extubated 105 minutes after suxamethonium administration. For the nail removal, two days before, the anaesthetic had been given by the same anaesthesiologist, with a similar protocol. Apnoea extended over 20 minutes. The day of the revision surgery, plasma cholinesterase activity was 410 UI.L-1 and reached 910 UI.L-1, 9 months later. Dibucaine number was 20 and fluorure number 17. The apnoea was in relation with a genetic plasma cholinesterase deficiency increased by the toxic shock syndrome. Shock and hepatic insufficiency were suspected to contribute to the decrease in plasma cholinesterase. Suxamethonium should be avoided in case of toxic shock syndrome.

Additive effects of dihydralazine during enflurane or isoflurane hypotensive anaesthesia for spinal fusion.

Sixteen patients (13-38 yr) undergoing spinal fusion for scoliosis under controlled hypotension were studied to determine the haemodynamic and neuroendocrine responses to IV dihydralazine (1.0 mg.kg-1) followed by 0.5 and 1 MAC of enflurane or isoflurane. Twenty minutes after dihydralazine administration mean arterial pressure (-20 per cent) and systemic vascular resistance (-50 per cent) decreased, and cardiac index (+57 per cent), heart rate (+37 per cent) and intrapulmonary shunt increased. Plasma renin activity and aldosterone and norepinephrine levels increased. Further decreases in mean arterial pressure and in systemic vascular resistance were observed when 0.5 MAC enflurane or isoflurane were added. With 1 MAC anaesthetic levels a further decrease in mean arterial pressure was observed in both groups, but pressure fell to a lower level with isoflurane than with enflurane (p less than 0.01). The reduction of arterial blood pressure to a level of 50-60 mmHg for three to four hours was easy to control and was free of complications. The preliminary IV administration of dihydralazine allowed a reduced volatile agent concentration which attenuated undesirable haemodynamic effects, in spite of renin and norepinephrine release, and permitted a rapid intraoperative awakening.

[Hemodynamic study during the postoperative period in coronary patients undergoing non-cardiac surgery. The role of mechanical ventilation and sedation]. / Etude hémodynamique au cours de la période postopératoire chez le coronarien en chirurgie non-cardiaque. Intérêt de la ventilation mécanique et de la sédation.

The initial period of postoperative rewarming is frequently marked by rapid increases in metabolic rate and myocardial work leading to haemodynamic instability. In order to test the beneficial effect of mechanical respiratory support with sedation in the postoperative period, 18 patients with coronary artery disease operated upon for abdominal or orthopedic surgery were submitted to a hemodynamic study. The patients were divided in two groups. In group II intravenous nitrates were administered perioperatively. Postoperative hemodynamic profiles were similar in both group. No perioperative signs of myocardial ischemia were detected. Prolonged ventilation with sedation can prevent the hemodynamic stress of recovery.

[Lung infection and acute adult respiratory distress syndrome during surgical resuscitation]. / Infections pulmonaires et syndrome de détresse respiratoire aiguë de l'adulte en réanimation chirurgicale.

Non cardiogenic pulmonary edema (PE) is frequently observed during the postoperative period. 56 patients with postoperative PE were divided into two groups: ARDS, acute respiratory distress syndrom and NHPE, non hemodynamic PE. The incidence of primary pulmonary infection and pulmonary superinfection were investigated. Both groups were not different except for the level of PaO2 lower in ARDS. Mortality was higher in ARDS (80%) than in NHPE (42%). Pulmonary primary infection and superinfection were respectively observed in 33 and 10%, and 23 and 15% of ARDS and NHPE. Blood cultures were more frequently positive during abdominal sepsis than during pneumonia. Viral etiology was thrice noted in 13 pneumonitis. Value of diagnostic methods for respiratory infections is discussed.

[Hemodynamic effects of flunitrazepam in coronary patients. Postoperative study immediately after digestive tract and orthopedic surgery]. / Effets hémodynamiques du flunitrazépam chez le coronarien. Etude en période postopératoire immédiate après chirurgie digestive et orthopédique.

The present study was designed to evaluate the haemodynamic effects of flunitrazepam used for sedation in the post operative period after abdominal or orthopedic surgery. Patients with coronary artery disease (C.A.D.) were divided in two groups; in group II stable cardiac failure was present. Results did not show any significant haemodynamic changes after flunitrazepam in both groups. Flunitrazepam is a haemodynamic secure and valuable agent for sedation during recovery for patients with C.A.D. even in stable cardiac failure.

[Prophylactic antibiotic therapy with cefamandole in total hip surgery replacement using Charnley's tent. A randomized study]. / Antibiothérapie prophylactique par le céfamandole dans la chirurgie de la prothèse totale de hanche sous tente de Charnley. Etude randomisée.

A randomized study of one-day prophylactic antibiotic therapy in total hip arthroplasty was performed in 93 procedures in 84 patients. All patients were operated by the same surgeons with use of a clean air system. They were divided into two groups: K- without antibiotic, and K+ with intravenous cefamandole, 1.5 g before incision followed by 1.5 g every four hours up to the 24th postoperative hour. Clinical follow up by the surgeons included four examinations within the first year. There was no significant difference in age, repartition of sexes or acquired physical defects between the two groups. Major deep infections requiring revision surgery occurred early in one case in K+ and early in four cases and late in one in K6. Nine patients had bilateral hip replacement. Only one infection was observed, in the only patient who did not receive cefamandole for either procedure. Physical disability had no influence on infection. Microbial organisms isolated from deep infection foci were not consistently identical with pathogens previously identified in wound drainage fluid. Staphylococcus aureus was responsible for 4 of 6 deep infections. One-day prophylactic antibiotic therapy by cefamandole decreases the incidence of deep infection at the surgical site in total hip arthroplasty with use of a clean air system.

[Hemodynamic effects of flunitrazepam in cardiac patients during anesthetic induction]. / Effets hémodynamiques du flunitrazépam chez le malade cardiaque lors de l'induction anesthésique.

The hemodynamic effects of flunitrazepam were studied in eight coronary patients (group I) and in six patients with compensated cardiac failure (group II) during the induction of anesthesia with droperidol 5 mg and fentanyl 4 micrograms . kg-1. A right sided cardiac catheterization was performed to measure cardiac output by thermodilution. In coronary patients, the hemodynamic parameters were only slightly modified (NS). Cardiac output (-12.7%) and oxygen consumption (-20.4%) decreased; Pvo2 increased from 6.4 +/- 0.1 to 7.3 +/- 0.3 kPa. In patients with cardiac failure, significant cardiovascular changes were not observed. Arterial pressure (-13%), cardiac output (-2.6%), oxygen consumption (-6%) and systemic vascular resistance (-13.4%) decreased; Pvo2 increased from 6.4 +/- 0.5 to 6.8 +/- 0.7 kPa. In both groups, heart rate and pulmonary capillary wedge pressure were unchanged. There was only a significant difference (p less than 0.05) between the decrease in systemic resistance in group II and in the absence of change in systemic resistance in group I. Decrease in oxygen consumption be decrease in oxygen demand could explain the slight decrease in cardiac output. Flunitrazepam was a good hypnotic for the induction of anesthesia in normovolaemic coronary patients and in patients with compensated cardiac failure.

Prostaglandin E1 inhibits acute cell dehydration thirst.

Intraperitoneally injected PGE1 (100 micrograms/Kg) inhibits specifically the drinking induced by both IP and IV 2 M NaCl (6 ml/Kg) and compound 48/80 (100 micrograms/Kg, IP). Probenecid (150 mg/Kg, IP) which is not a dipsogen, has no effect on the PGE1 induced inhibition of acute cell dehydration thirst. It is concluded the PGE1 acts upon the peripheral mast cells, inhibiting their secretion and thus affecting the water intake associated with the activation of these cells either by hypertonicity or specific stimulants of amine release. These results raise the possibility that endogenous prostaglandins might be involved in the modulation of some of the signals which convey to the brain information on the tonicity of the body fluids.