[A case of fatal cocaine overdose]. / Intoxication mortelle à la cocaïne.

Clinical, biological, and therapeutic description of a lethal case of cocaine overdose.

Quality improvement program of adult urinary tract infection management: Review and impact.

OBJECTIVE: A quality improvement program for adult urinary tract infection management was established to avoid unnecessary antibiotic treatment and to promote adequate prescription, associated with financial and time savings. METHODS: Management was integrated into a three-step approach: clinical diagnosis, bacteriological diagnosis, and therapeutic decision. For each step, areas for improvement were prioritized and implemented through corrective measures and key messages, measured by indicators. This program was applied to the whole hospital, which includes an emergency department and hospital units (672 beds). RESULTS: The diffusion of new recommendations on clinical diagnosis helped limit the use of Urine Dipstick Tests (UDT) and identify situations requiring the prescription of urine cytobacteriological test (UCBE) and antibiotic treatment: decreased annual consumption of UDTs (34%) and UCBEs (25%). The implementation of a new sampling system for UCBEs was associated with a 21% increase in conclusive analysis. Results of antimicrobial susceptibility testing were also optimized. Trainings on the proper use of antibiotics led to a 5.0% decline in global consumption. Only 23 antibiotic prescriptions for UTI resulted in pharmaceutical advice to prescribers in 2014. CONCLUSION: The program is part of a practice improvement strategy. Integrating the management of urinary tract infections into a global process helped improve each step of patient management.

Evolution of right ventricular performance after CABG.

34 patients scheduled for coronary artery bypass graft (CABG) surgery were studied during postoperative period. Right ventricular performance was specially performed with use of cardiac output computer REF-1 Edwards Lab., before Anaesthesia (T1) and at 6 investigation times after surgery during and after mechanical ventilation. The sixth first postoperative hours were marked by a decrease of cardiac index (2.56 +/- 0.4 to 2.41 +/- 0.41.mn-1.m2) and right Ventricular Ejection Fraction (RVEF) (0.48 +/- 0.07 to 0.37 +/- 0.09). The second period was the weaning period with a further drop of RVEF (0.43 +/- 0.1 to 0.36 +/- 0.07) without change in cardiac index (2.80 +/- 0.51.mn-1.m2, suggesting a ventricular post-operative and weaning depression, as previously described for the left ventricle. In addition, postoperative tachycardia (Heart rate = 59 +/- 9 at T1 to 95 +/- 14 at T7) may contribute to myocardial ischemia.

Effect of cardiopulmonary bypass on plasma concentrations of diltiazem and its two active metabolites.

Diltiazem is often used to prevent myocardial ischaemia during the perioperative period of coronary artery bypass surgery. The purpose of this study was to investigate the effect of cardiopulmonary bypass (CPB) on plasma concentrations of diltiazem and of its two main and active metabolites (N-monodemethyldiltiazem (N-desmethyldiltiazem) and desacetyldiltiazem). The patients were administered their usual treatment during the preoperative days. The last dose was administered immediately before anaesthesia. At the onset of CPB, a significant decrease in the plasma concentrations of diltiazem and its metabolites was observed, whereas the variation was slight and not significant when the plasma concentrations were corrected for haemodilution. These results confirm that the decrease observed at the initiation of the bypass procedure can be ascribed to the haemodilution induced by the CPB. During CPB, the concentrations of diltiazem and its metabolites remained constant suggesting that the rate of metabolism and excretion of the drug was altered during the bypass procedure. At the end of CPB, there was no increase of drug plasma concentrations suggesting that no redistribution of diltiazem from tissues to plasma occurred. Furthermore, this study shows that only 33% of subjects have therapeutic levels of diltiazem before anaesthesia, and that all subjects have subtherapeutic levels during and after the CPB. These results suggest that a higher chronic oral dose of the drug should be given in patients undergoing cardiac surgery with CPB.

[Comparison of the hemodynamic effects of dobutamine and enoximone in the treatment of low cardiac output after valvular surgery]. / Comparaison des effets hémodynamiques de la dobutamine et de l'énoximone dans le traitement du bas débit cardiaque après chirurgie valvulaire.

Forty patients developed low cardiac output states after surgery for mitral valve disease or with associated cardiac disease and were randomly allocated to two treatment groups, one group to receive Dobutamine (D) and the other Enoximone (E), a phosphodiesterase inhibitor. Haemodynamic assessment covered a 24 hour period but treatment was continued for as long as was necessary. An improvement was observed from the 15th minute of treatment. At the second hour, the cardiac index had increased by 55% in Group E and by 59% in Group D whilst the heart rate increased by only 12% in Group E compared to 30% in Group D. The right and left heart filling pressures decreased by 25 to 27% in the 2 groups. The systemic arterial resistances fell by 36 to 37% without any significant changes in systemic or pulmonary arterial pressures. No significant difference was demonstrated in the haemodynamic responses to Dobutamine and Enoximone in this study. The duration of treatment was significantly shorter in Group E than in Group D (59 +/- 22 hrs vs 86 +/- 49 hrs) as was the patient's stay in the intensive care unit (92 +/- 37 hrs vs 155 +/- 129 hrs). The duration of assisted ventilation was the same in the two groups. These results suggest that Enoximone is as effective as Dobutamine in the treatment of low cardiac output after mitral valve surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arrhythmia in patients with low cardiac output after valvular surgery. Randomized, double-blind comparative study of dobutamine versus enoximone]. / Arythmies chez les patients en bas débit cardiaque après chirurgie valvulaire. Etude randomisée, aveugle et comparative dobutamine versus énoximone.

Forty patients with low cardiac output (cardiac index less than 2.2 l/mn/m2 and pulmonary wedge pressure greater than 15 mmHg) after valvular surgery were randomised into two groups. Patients in Group 1 were given 5 to 10 micrograms/Kg/mn of Dobutamine (D) and those In Group 2 a bolus of Enoximone (E) 1 mg/kg followed by an intravenous infusion of 5 to 10 micrograms/Kg/mn. Holter ECG monitoring over 42.65 +/- 6.02 hrs (24-48 hours) was obtained and interpreted blindly in 37/40 patients (19 Group D and 18 Group E). The results were analysed by the t and X2 tests. A p value of less than .05 was considered statistically significant. The two groups were comparable. No deaths occurred during the protocol period. The total duration of inotropic therapy (86 +/- 49 hours) and the period spent in the intensive care unit (155 +/- 129 hours) were longer in Group D than in Group E (60 +/- 23 hrs and 92 +/- 37 hrs, respectively; p less than .05). Antiarrhythmic therapy was used more often in Group D (4 patients) than in group E (1 patient) (p = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)

[Automatic implantable defibrillators; subdiaphragmatic insertion]. / Défibrillateur automatique implantable; mise en place sous-diaphragmatique du boîtier.

Although the material and techniques of implantation of the electrodes of implantable defibrillators have been improved, the abdominal implantation of the generator remains widely used as described by Mirowski in 1980. Despite a progressive reduction in their size, the generators remain bulky and a source of local complications. The risks and discomfort of implantation in the abdominal wall led the authors to try subdiaphragmatic implantation in 22 patients. There was no morbidity with perfect healing in all 22 cases. The mean follow-up period was 11 months. The patients felt very comfortable, a significant advance with respect to abdominal implantations.

[Problems posed by calcium antagonists and anesthesia: pharmacology, interactions, indications]. / Problèmes posés par les antagonistes calciques et l'anesthésie: pharmacologie, interactions, indications.

Calcium-channel inhibitors are widely used in therapeutics. Many patients administered calcium channel inhibitors undergo surgical procedures and the cardiologists or the anaesthesiologists are concerned with pharmacological interactions with anaesthetic agents such as halogenated gases. The combination of calcium channel inhibitors and halogenated anaesthetics may exert an additive effect on myocardial depression, conduction disturbances and arterial vasodilatation. The continuation of oral calcium channel inhibitors until the day of surgery is recommended provided the use of enflurane is restrained. Calcium-channel inhibitors such as dihydropyridines are currently administered intravenously to control intra and postoperative arterial hypertension while verapamil and diltiazem are used to treat supraventricular arrhythmias and myocardial ischaemic episodes. In patients with cardiac disease, haemodynamic monitoring may allow to anticipate or to treat episodes of cardiac dysfunction associated with I.V. calcium-channel inhibitors during the perioperative period.

[Beta blockers and anesthesia]. / Bêta-bloquants et anesthésie.

Beta-adrenoceptor antagonists (BB) demonstrate a competitive antagonism with endogenous catecholamines. Beta-1 receptor blockade mediates the depressive action on contractility, heart rate and atrio-ventricular conduction. Beta-2 receptor blockade mediates vascular, bronchial and uterine smooth muscle constriction. BB with beta-1 selective and intrinsec sympathomimetic activity do not increase systemic vascular resistance. BB are mostly used to treat ischaemic heart disease, hypertension and arrhythmias. Bradycardia, hypotension and bronchospasm are the main hazards in BB treated patients undergoing anaesthesia. However giving BB with premedication to patients taking usely this treatment allows better perioperative haemodynamic stability and avoids rebound effect. Experimentally, oxprenolol reverses regional dysfunction in ischaemic myocardium under halothane anaesthesia. During and after anaesthesia, intravenous (i.v.) BB must be used with caution to treat hypertension associated with tachycardia. In controlled hypotension, i.v. BB potentialise other agents. In phaechromocytoma surgery, alpha-blocking drugs are essential but additional BB can control tachycardia successfully. In coronary artery bypass surgery, giving BB prior to induction decreases cardiac enzymes serum levels. Esmolol, a new ultra-short-acting BB, would control perioperative tachycardia and hypertension without risk of prolonged cardiac depression.

[Fulminant mediastinitis from Streptococcus pneumoniae following cardiac surgery]. / Médiastinite fulminante à Streptococcus pneumoniae après chirurgie cardiaque.

A 62-year-old patient was scheduled for coronary artery bypass surgery because of tritroncular coronary artery disease. The early postoperative period was uncomplicated until the 10th postoperative day when purulent fluid appeared from the sternal wound. Cultures of blood, wound and mediastinal tissues yielded Streptococcus pneumoniae with decreased susceptibility to penicillin G. Despite prompt surgical debridement and appropriate antibiotics, a septic shock with multiorgan failure occurred and the patient died on the 19th postoperative day. Although Streptococcus pneumoniae is uncommonly implicated in postoperative mediatinitis, it frequently leads to multiple organ failure and death.

[Vascular effects of urapidil administrated during extracorporeal circulation]. / Effets vasculaires de l'urapidil administré en cours de circulation extracorporelle.

Urapidil exerts a combined central sympathetic and peripheral alpha-1 adrenergic receptor inhibition. Urapidil induces arterial vasodilation but its effects on venous capacitance are more difficult to assess. During cardiopulmonary bypass with constant perfusion index (2.4 l.min-1 x m-2) total peripheral resistance varies similarly as to arterial pressure and, as the apparatus venous reservoir is filled continuously by simple gravity from the right atrium, a decrease in venous blood reservoir level reflects an increased venous capacitance. Twenty-six patients undergoing cardiac surgery were anaesthetized with fentanyl and midazolam and randomly assigned to one of two groups. During normothermic cardiopulmonary bypass, group 1 was administered i.v. urapidil 12.5 mg and group 2 a placebo. In group 1, arterial pressure decreased by 33 +/- 14% (mean +/- SD) at the second minute while total peripheral resistance decreased from 1,384 +/- 255 to 927 +/- 193 dyn.s.cm-5. Then this two parameters regained group 2 values after the eighth minute. Reservoir blood level was lower in group 1 than in group 2 from the second to the eight minute (p < 0.05) with maximum effect at 7 minutes. It is concluded that urapidil exerts arterial and venous dilation. Its arterial effects seem greater during normothermic cardiopulmonary bypass than in normal conditions and its maximum venous effects seem to occur after its maximum arterial effects. The short duration of action may be due to the small dose administered.

[Anesthesia consultation in cardiovascular and thoracic surgery. A survey of patient and physician satisfaction]. / Consultation d'anesthésie de chirurgie cardiovasculaire et thoracique. Enquête de satisfaction des patients et des médecins.

OBJECTIVE: To assess the quality of the preadmission anaesthetic consultation prior to cardiovascular and thoracic surgery with a satisfaction inquiry. STUDY DESIGN: Prospective study with a questionnaire, extended over a period of two months. PERSONS: Patients and anaesthetists of the cardiothoracic surgical service. METHODS: The inquiry, which took place after completion of the consultation was achieved by a person non member of the staff. Anaesthetists were questioned on the medical content, its exhaustive character and its value for the patient's perioperative care. RESULTS: Out of the 273 patients included in the study, 121 agreed to answer the questionnaire. Participation in the study was more significant in older patients (58 +/- 20 vs 51 +/- 24 years) and following shorter waiting time (WT) [15 +/- 13 (0-60) vs 25 +/- 18 (0-66) min]. The duration of the consultation (DC) was not different between the two groups [29 +/- 12 (8-70) vs 31 +/- 14 (6-75) min]. However patients' participation increased when the DC exceeded by 0.6 the sum of DC and WT [DC > 0.6 (DC + WT)]. The analogic score (AS) assessing reduction in preoperative anxiety was 8.4 +/- 1.5 (2-10). Finally, 108 patients out of 121 considered to have been well informed about the anaesthetic [AS = 8.7 +/- 1.2 (4-10)], 113 considered the preadmission consultation as a useful procedure [AS = 8.6 +/- 1.5 (2-10)]) and for 41 a personalized follow-up by the same anaesthetist was valuable. Only three operations had to be postponed the day before surgery. One third of the anaesthetists considered that the consultation improved the clinical and therapeutic management of the patients. CONCLUSION: This inquiry showed that the preadmission anaesthesia consultation was considered as benefitful by patients and anaesthetists. However the participation of patients in this study was poor. Subsequently to the inquiry information forms have been produced and handed to the patient prior to the consultation.

[CK-MB isoenzyme in the diagnosis of myocardial infarction after myocardial revascularization surgery]. / Isoenzyme CK-MB dans le diagnostic d'infarctus myocardique après chirurgie de revascularisation myocardique.

The usefulness of measuring serum MB creatine kinase activity (CK-MB) for the diagnosis of per- and postoperative myocardial infarction (MI) was assessed in 104 patients undergoing coronary artery bypass grafts. In each patient, 15 samples were taken during the week which followed the surgical procedure. New Q waves were considered to be a criteria of MI. 19 patients developed new Q waves (MI group), whereas 57 had no significant ECG changes (control group); 13 showed only ST changes, whilst 15 had unassessable recordings. In the MI group, CK-MB was greater than in the control group, both at the first peak (8 to 10 h after induction of anaesthesia) and at the greater peak (13 to 21 h after induction) (p less than 0.05). Significant differences were also seen between both groups between 8 and 32 h after induction, but there was also a large overlap. An area under the curve (AUC) greater than 50,000 IU.l-1.min-1 had a positive predictive value of 0.64, and an AUC less than 50,000 IU.l-1.min-1 a negative predictive value of 0.89 if all the groups of patients were taken into account. An AUC greater than 65,000 IU.l-1.min-1 was always seen in MI patients, but only 25% of MI patients had a value greater than this threshold. There were no significant differences between the patient groups in the first peak time, nor in the CK-MB/total CK ratio. CK-MB appeared therefore as a less reliable criterium of per- and postoperative MI during coronary artery bypass operations than previously reported, especially when intermediate values are found.

[Plasma concentrations of diltiazem and its metabolites in coronary surgery: relation with preoperative treatment]. / Concentrations plasmatiques du diltiazem et de ses métabolites en chirugie coronarienne: relation avec le traitement préopératoire.

Preoperative oral administration of calcium channel blocking agents has been found ineffective to prevent perioperative myocardial ischaemia. Our hypothesis was that low plasma concentrations may account for this inefficiency. Twenty-three male patients, scheduled for surgical myocardial revascularisation, were administered their usual anti-anginal treatment, including 180 to 360 mg of diltiazem since more than one week. The usual dosage was given at 8.00 p.m. on the day before surgery. On the morning of surgery, after withdrawal of a first blood sample, 60 mg of diltiazem were administered per month before the induction of anaesthesia. The anaesthesia was obtained with fentanyl, midazolam or flunitrazepam, pancuronium and isoflurane as required. The cardiopulmonary bypass (CPB) was associated with total haemodilution with Ringer's Lactate and a membrane oxygenator. A second blood sample was withdrawn after CPB. Plasma concentrations of diltiazem and its two active metabolites, N-monodemethyldiltiazem (MA) and desacetyldiltiazem (M1), were assessed by HPLC. Plasma diltiazem concentrations decreased from 78 +/- 66 (mean +/- SD) to 51 +/- 42 micrograms.l-1 (p < 0.05) with wide individual variations. These concentrations were under therapeutic levels in 18 out of 23 patients before (p < 0.05) with wide individual variations. These concentrations were under therapeutic levels in 18 out of 23 patients before induction and in 22 patients after CPB. The metabolite/diltiazem ratios remained constant. A dosage-plasma concentration relationship was observed preoperatively with diltiazem and MA. It is concluded that plasma concentrations of diltiazem should be optimized preoperatively in order to prevent myocardial ischaemia.

[Anesthesia for carotid endarterectomy]. / Anestesia para la endarterectomía carotídea.

Carotid endarterectomy (CE) is among the most common vascular procedures. Recent studies have examined indications for CE and the usefulness of multiple vascular procedures, and have compared general and locoregional anesthesia. Randomized prospective trials have confirmed that the efficacy of CE exceeds 70% in patients experiencing a transient ischemic attack (TIA) with an ipsilateral stenotic carotid lesion. When both carotid surgery and coronary revascularization are indicated, CE can be performed two weeks before or concurrent with coronary artery bypass. The greatest risk in CE is of neurological complications (usually < 6%); the risk of myocardial infarction (MI) is < 4%. General anesthesia is most comfortable for the patient and the surgeon. Barbiturates, opiates and isoflurane are widely employed. Cerebral monitoring involves residual pressure after clamping, although that approach is unreliable. Other forms of hemodynamic (cerebral flow with 133Xe, transcranial Doppler, jugular SvO2, conjunctival PO2) and electrical monitoring (EEG, somatosensory evoked potentials) are often unavailable, are expensive or require trained personnel. Locoregional anesthesia (cervical nerve block or cervical epidural anesthesia) can be monitored more reliably, allows therapeutic maneuvers such as carotid unclamping, placement of an intracarotid stent, increasing of arterial pressure to be carried out. Regional anesthesia decreases the incidence of intraluminal shunts. Blood pressure and heart rate are higher during cervical block than during general anesthesia, but hypertension is more common during general anesthesia. A randomized controlled trial comparing general anesthesia and cervical block found no significant differences in mortality, MI or TIA. Regional anesthesia is more cost-effective, given that less intensive care and shorter hospital stays are required.

[A comparison of 3.5% dextran 40 and 4% albumin used as volume expansion solutions following heart surgery. Effects on the hemodynamic parameters and the oncotic colloidal pressure]. / Comparaison dextran 40 à 3.5% versus albumine à 4% utilisés comme solutés d'expansion volémique après chirurgie cardiaque. Effets sur les paramètres hémodynamiques et la pression oncotique colloïdale.

Dextran 40 (3.5%), a synthetic colloid solution used as a volaemic expander was compared to albumin 4% in 30 patients (15 in each group) during the first twenty hours after cardiac surgery. The patients were administered 500-600 ml.m-2 either dextran 40 or albumin at a rate of 10-12 ml.kg-1 x h-1 between 2nd and 4th postoperative hour. In the two groups, heart rate and mean arterial pressure did not change significantly but left and right filling pressures and cardiac index increased similarly. Colloid oncotic pressure and haemoglobin varied in the same way in the two groups. Proteinemia and albuminaemia were increased significantly in the albumin group during all the study. Diuresis was not different in the two groups. No side effect was observed. Dextran 40 was efficient and could be used as a volaemic expander after cardiac surgery.