Dose-response effect of serum butyrylcholinesterase activity after clinical doses of pancuronium.

INTRODUCTION: Low-dose pancuronium is known to affect serum cholinesterase activity (BChE); however, the dose-response effect of clinical doses of pancuronium on BChE has not been investigated. METHODS: Thirteen ASA I-II patients scheduled for elective surgery requiring muscle relaxation were enrolled in this study. All patients had normal BChE before surgery. Incremental doses of pancuronium (10, 20, 50, and 100 microg/kg) were injected in accordance with surgical needs every 45 min. BChE was measured 3 min after injection by an automatic colorimetric method. RESULTS: BChE decreased significantly in all except one patient in comparison to the baseline (P < 0.05). However all values remained within normal clinical range. A dose of 100 microg/kg yielded significant decrease in comparison to 10 microg/kg but not to other dosages. Linear regression was not significant for the dose-response relationship (P = 0.05). CONCLUSION: After clinical incremental doses of pancuronium, BChE remained within clinical range.

Twenty-nine day study of stability for six different parenteral nutrition mixtures.

: BACKGROUND: The aim of the study was to assess the particle size stability of six parenteral nutrition regimens, fitted to various pathologies, and used by the University Hospital of Limoges. The mixtures contained glucose (30 or 50%), amino acids (Hyperamine(R)25), and either long-chain triglycerides (20% Intralipide(R)) or a combination of medium and long-chain triglycerides (20% Médialipide(R)). The regimens were not supplemented. RESULTS: The visual examinations, particle size analysis and physico-chemical tests, carried out during a long storage period, did not reveal any significant evolution of the lipid emulsions. All the tested formulae were stable for 28 days at 4 degrees C plus 24 h at room temperature. CONCLUSIONS: It was concluded that the choice of lipid emulsions depends, for these formulae, on the metabolic and clinical needs of the treated patients.

Potentiation of atracurium by pancuronium during propofol-fentanyl-N2O anesthesia.

At the end of abdominal surgery deep neuromuscular blockade is required for peritoneal closure. Ideally injecting an intermediate acting drug like atracurium after a long acting drug such as pancuronium should deepen the neuromuscular block without the fear of an inadequate reversal at the completion of surgery. Thirty patients ASA I or II status, without known allergy to myorelaxant and without neuromuscular, hepatic or renal failure were included in this study. Anesthesia was induced and maintained with propofol, fentanyl, and N20. Normal core temperature was maintained by active warming of the upper part of the body. Blood electrolytes and the acid-base status were within the normal range. The accelerographic responses to Train-Of-Four supramaximal stimulation (TOF) of the ulnar nerve was monitored at the thumb. After obtaining a stable response with the accelerograph, the patients randomly received pancuronium (0.10 mg.kg-1, group I, n = 10 and group II, n = 10) or atracurium (0.50 mg.kg-1, group III, n = 10). An additional dose of atracurium (0.16 mg.kg-1, group I and III) or pancuronium (0.03 mg.kg-1, group II) was injected when the first response of TOF stimulation (T1) reached 25% of its initial value. Then the time to obtain a 25% twitch height of T1 (T25), the recovery index (RI 25-75), the delay to obtain 4 responses to TOF and an adequate recovery [TOF ratio of 0.70 (TOF70)] were monitored. Injection of 60% ED95 of atracurium after pancuronium resulted in a similar recovery of neuromuscular function as after 45% ED95 of pancuronium as shown by the same recovery of T25 (66.5 +/- 4.2 min versus 71.4 +/- 7.8 min, group I versus group II, p > 0.05) and TOF70 (131.6 +/- 15.7 min versus 144.0 +/- 17.5, group I versus II, p > 0.05). Nevertheless the RI 25-75 of group I was of intermediate duration between those of group II and III. Electrolytes and acid-base status were similar between groups at the beginning of surgery. Thus this study shows a synergistic effect of the combination of atracurium after pancuronium occurring in non hypothermic patients anesthetized without halogenated agents. Because the duration of action of the drug administered first governs the duration of action of the subsequent neuromuscular myorelaxant, the neuromuscular function should be closely monitored at the end of surgery if neuromuscular drugs are used in combination.

Pharmacokinetics of propofol and its conjugates after continuous infusion in normal and in renal failure patients: a preliminary study.

The pharmacokinetics of propofol, 2,6 diisopropylphenol, were compared in 6 end-stage renal failure patients aged 66.3 +/- 12.1 years and in 5 normal patients aged 45.5 +/- 13.5 years. Anesthesia was induced with propofol (2 and 2.5 mg.kg-1 respectively) and fentanyl (0.1 mg). Anesthesia was maintained with propofol (9 and 10 mg.kg-1 x h-1 respectively). Patients breathed spontaneously a 50 per cent oxygen in nitrous oxide mixture. Two ml blood samples were taken during anesthesia and at regular intervals until up to 24 hours after infusion. Plasma levels of propofol were determined by HPLC with electrochemical detection. Propofol conjugates were determined after hydrolysis with beta glucuronidase or HCl. Results were expressed as median [lower-upper percentiles]. Propofol clearance (1.53 [1.02-2.10] L.min-1 x kg-1 versus 1.65 [1.39-1.78] L.min-1 x kg-1 in normal patients), and half-lives elimination were not modified by renal failure. Renal failure patients exhibited a higher volume of distribution at steady state as compared to normal patients (19.28 [11.71-76.81] L.kg-1 versus 8.60 [6.58-9.81] L.kg-1, p < 0.05). Renal failure did not affect the production of conjugates but they accumulated in blood of renal failure patients. Despite this, no difference in time to eyes opening and propofol concentration were observed, confirming the absence of clinical effect of these metabolites.

[Prolonged brachial plexus block with bupivacaine]. / Bloc prolongé du plexus brachial à la bupivacaïne.

A prolonged brachial plexus block with bupivacaine hydrochloride is described. Anaesthesia was induced with 40 ml of a solution made of equal parts of 0.50% bupivacaine hydrochloride and distilled water. Reversal of the motor block began 24 h later. Total recovery was observed 30 h after the onset of anaesthesia. Neurotoxicity of bupivacaine hydrochloride was known to be weak and could not explain the increased length of the block. The dilution of 0.50% bupivacaine hydrochloride resulted in a very low osmolality (141 mosm X kg-1 vs 242 mosm X kg-1 for 0.25% bupivacaine hydrochloride commercial solution). Whether this low osmolality caused nerve lesions was unknown. Postoperative exploration revealed a bilateral slowing down of conduction in the brachial plexus of this 73 year old patient. The importance of this finding could not be assessed.

[Pulse oximeter. Clinical assessment in the recovery room]. / L'oxymètre de pouls. Evaluation clinique en salle de réveil.

Fifty unselected recovery room patients were monitored using a Nellcor N101 pulse oximeter. Non invasive SaO2 values were compared with simultaneous spectrophotometric measurements made on arterial blood samples (Co-oximeter). Mean pulse oximeter SaO2 was 86.9 +/- 6.08%, with extreme values of 68 and 95.5%. Arterial blood SaO2 was 91.25 +/- 6.28%, with extreme values of 66 and 100%. Linear regression analysis showed a good correlation between the two sets of measures (r = 0.97; p less than 0.005). Twenty one patients had a SaO2 below 90% (mean: 84.83 +/- 5.93%); their measured arterial SaO2 was of 86.14 +/- 6.32%. The correlation between the two sets of low values was good (r = 0.96; p less than 0.05). Pulse oximetry was a non invasive reliable method, but there were some limits to its clinical use. Hypothermia or shock vasoconstriction precluded the measurement of SaO2. Restlessness or shivering were responsible of probe dysfunction and false alarms. False SaO2 readings may result from high levels of carboxyhaemoglobin or dye infusion. Also, each disposable finger probe was reused for a mean of five patients, its cost being relatively high (170 FF, i.e. 28.3 US dollars).

[Prevention of postoperative nausea and vomiting by ondansetron]. / Prévention des nausées et vomissements postopératoires par l'ondansétron.

This study was carried out to assess the efficacy of oral ondansetron, a new 5HT3 receptor antagonist, in patients undergoing thyroid surgery. It included 60 patients, randomly assigned to two groups, and receiving orally, 1 h before induction of anaesthesia, either 8 mg of ondansetron (n = 29) or a placebo (n = 30). One patient was excluded. The same anaesthetic protocol, consisting of 3 to 5 micrograms.kg-1 of fentanyl, 4 to 6 mg.kg-1 of thiopentone, and 0.5 mg.kg-1 of atracurium, was used in all. Anaesthesia was maintained with 50% nitrous oxide in oxygen with 0.8 to 1% endtidal concentration of isoflurane and additional boluses of 0.1 mg of fentanyl as required. The incidence and intensity of nausea, graded mild, moderate or severe, and the incidence of vomiting were recorded postoperatively. During the first twelve hours after surgery, 40% of patients in the placebo group had nausea (16.7% mild, 20% moderate and 6.7% severe), and 50% vomited. In the ondansetron group, nausea and vomiting occurred in 13.8% and 20.4% of patients respectively. The 4 patients in the latter group complained of major nausea. The differences between the groups were statistically significant: p = 0.025 for nausea and p = 0.042 for vomiting. It is concluded that oral ondansetron, 8 mg taken orally 1 h before surgery, significantly reduces the incidence of nausea and vomiting during the first twelve postoperative hours. As it is easy to use and has no side-effects, it might be of interest in day-case surgery patients, despite its high cost.

[Anaphylactic shock caused by fibrin glue]. / Choc anaphylactique à la colle biologique.

We observed a case of anaphylactic shock in a 68-year-old woman after a nasal intramucosal injection of fibrin glue for telangiectasies therapy. The tests showed an allergy to aprotinin contained in the glue. In the previous years, glue and aprotinin had been administered to the patient several times for nasal bleeding.

[Measurement of tympanic temperature by infrared and thermocouple thermometry. A comparative study]. / Mesure de la température tympanique par thermomètre à infrarouges et par thermocouple. Etude comparative.

OBJECTIVE: To compare tympanic temperatures obtained with an infrared thermometer Core Check 2090A (IVAC), non in contact with the tympanic membrane, to values obtained with a thermocouple thermometer Mon-A-Therm (Mallinckrodt) in contact with it, and to assess whether the differences depend on the person measuring the temperature. STUDY DESIGN: Prospective comparative open study. PATIENTS: The study included 150 adults in whom the tympanic temperatures were measured at their admission to recovery room by 10 nurse anaesthetists. METHODS: Each thermometer was inserted in the same patient into an external acoustic meatus. The median and range of the temperature differences were used to assess the bias and the accuracy of the measures. Their reliability was analyzed with consideration of the measuring person and the presence of irrelevant values, defined as a temperature difference over 0.3 degrees C. RESULTS: The temperatures obtained with both devices were similar (36.2 +/- 0.7 degrees C with IVAC thermometer vs 36.2 +/- 0.8 degrees C with Mallinckrodt thermometer). The median value of the differences was 0 degrees C, with a range of 2.5 degrees C (maximum value + 1.5 degrees C, minimum value: -1 degree C). Nineteen patients could be qualified as hypothermic (temperature < 36.5 degrees C) with one thermometer and normothermic (temperature > or = 36.5 degrees C) with the other. Among them, only 9 (6%) had temperature differences above 0.3 degrees C. The temperature differences were not different according to the measuring nurse. Nevertheless two of them obtained major differences or irrelevant figures. CONCLUSIONS: As compared to the thermocouple thermometry, infrared thermometry has no bias but a low precision. The measurement error does not allow the recognition of hypothermia in 6% of patients. The error may be made by the measuring person and/or related to the anatomy and the patency of the external acoustic meatus. Tympanic infrared thermometry seems to be a convenient method for temperature measurements at short time intervals in the recovery room, provided its limitations are kept in mind.

[Role of vitamin C on adrenocortical effects of etomidate]. / Rôle de la vitamine C sur les effets corticosurrénaliens de l'étomidate.

This study was carried out to assess whether the adrenal inhibition induced by etomidate could be prevented by associating ascorbic acid with etomidate, as a protective effect of ascorbic acid administered three hours after etomidate has been described. Sixteen ASA 1 or 2 patients, less than 65 years old, free of endocrine disease, were included. At induction of anaesthesia, eight of them (group B) were given an infusion of ascorbic acid 1 g, in 500 ml of 5% glucose. Group A patients (n = 8) were given 500 ml of 5% glucose. Anaesthesia was induced with etomidate 0.3 mg.kg-1, fentanyl 0.005 mg.kg-1 and vecuronium 0.1 mg.kg-1. Maintenance was carried out using a continuous infusion of etomidate (0.1 mg.kg-1.h-1 for 10 min, followed by 0.01 to 0.02 mg.kg-1.h-1). Additional boluses of fentanyl or diazepam (10 mg) were administered when arterial blood pressure or heart rate were 20% greater than preanaesthetic values. The number of injections required was the same in both groups. Plasma cortisol concentrations were measured by radioimmunoassay (RIA) before anaesthesia (T0), 4 h (T4) and 24 h (T24) after the end of surgery. Blood ACTH levels were also assessed by RIA at T0 and T4. The adrenal insufficiency at T4 had completely ended at T24. In fact, the relative decrease in cortisol levels was greater in patients treated with ascorbic acid (T4/T0: 47.6 +/- 9% in group A vs 76.5 +/- 33% in group B, p less than 0.05); this was suggestive of a higher degree of adrenal inhibition in patients receiving ascorbic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pros and cons of adding an accessory breathing system to the main circle circuit. II. Arguments against their use]. / Pour ou contre les circuits anesthésiques accessoires. II. Arguments contre leur utilisation.

When compared to the circle system alternative breathing systems (ABS) are of no benefit. When the only indication of an ABS is emergency oxygen administration it should be connected to the O2 pipeline upstream from the flowmeter bank and the vaporiser. The use of an ABS for anaesthesia maintenance is no longer justified because of the difficulties in monitoring pressure, flow and concentrations of the gas mixture, the cost of gas and vapour administered at a high flow and the resulting pollution. The use of an ABS for very short anaesthetics is only acceptable if the administered gas mixture is monitored.

[Anesthetic equipment: fresh gas delivery systems. II. Electronic systems]. / Appareil d'anesthésie: systèmes d'alimentation en gaz frais. II. Systèmes électroniques.

OBJECTIVES: To analyse the design, functioning, benefits and drawbacks of electronic fresh gas delivery units (FGDUs) included in anaesthetic machines marketed in France in 1999. DATA SOURCES: Articles were obtained from a Medline review (1980-1999; search terms: anaesthetic machine, flowmeter, vaporizer), textbooks and personal files; specific data were also provided by manufacturers. STUDY SELECTION AND DATA EXTRACTION: The articles were analysed in considering the differences between mechanical and electronic FGDUs. DATA SYNTHESIS: Four anaesthetic machines out of 11 are equipped with electronic FGDUs. In comparison to mechanical units, they include the following benefits: wide range of accurate gas flow, especially in the low flow range, with analog and digital display; intermittent delivery of each gas, which is essential for automated gas delivery and quantitative anaesthesia or target controlled (FET vapor) inhalational anaesthesia; facilitated oxygen ratio control; possibility to print the gas and vapor flows on the automated anaesthetic record; interruption of gas flow when the main switch of the machine is set to off; and absence of risk for retropollution. Three FGDUs out of four are adapted for gas delivery to an accessory (ancillary) anaesthetic circuit. However, only one of them delivers a gas flow up to 30 L.min-1. The specificity of the ADU AS/3 (Datex-Ohmeda) is the bypass vaporizer included in the FGDU with an exchangeable vaporizing chamber (cassette). The specificity of the Julian (Dräger) is the delivery of fresh gas limited to the expiratory phase during mechanical ventilation. The specificity of the the FGDU from Kion (Siemens) is the possibility to act as an open circuit ventilator, similar to a Servoventilator. The specificity of the PhysioFlex is an FGDU included in the circle circuit, each gas and liquid anaesthetic being directly injected into the circuit. Data from the French medical device surveillance commission indicate that the main failures occur in the power supply device and the microprocessor.

[Anesthesia equipment: fresh gas delivery systems. I. Mecanical systems with rotameters and calibrated vaporizers]. / Appareil d'anesthésie: systèmes d'alimentation en gaz frais. I. Systèmes mécaniques avec rotamètres et vaporisateurs calibrés.

OBJECTIVES: To analyse the design, performance, failures, the checking before use of mechanical fresh gas delivery units (FGDUs) equipped with bobbin or ball-flowmeters delivering a continuous gas flow and calibrated vaporizers, marketed in France in 1999. DATA SOURCES: Articles were obtained from a Medline review (1960-1999; search terms: anaesthetic machine, flowmeter, vaporizer), textbooks and personal files; specific data were provided by manufacturers. STUDY SELECTION AND DATA EXTRACTION: The articles were considered for performance data, benefits and drawbacks, and characteristics, as well as the risks carried by mechanical FGDUs. DATA SYNTHESIS: Seven anaesthetic machines out of 11 are equipped with mechanical FGDUs, including rotameters delivering a gas mixture up to 30 L.min-1, calibrated vaporizers and an O2-flush valve delivering at least 500 mL O2 per second (30 L.min-1). These units allow closed circuit anaesthesia. They carry a risk for barotrauma as three out of them can deliver at the gas outlet of the FGDUs a gas mixture at a pressure reaching 3.5 bars and four others at a pressure of 150-200 mmHg. They also carry a risk for hypoxia, either from a preferential leak of oxygen at the corresponding rotameter or the O2-flush valve, or from a leak of fresh gas mixture either in a vaporizer or the selectatec manifold. The vaporizers carry a risk for vapor delivery at a concentration differing notably from the value set on the concentration dial. Therefore their accuracy must be checked periodically and the FGDUs checked for a leak after the addition to or the removal of a vaporizer from the selectatec manifold. The optimal technique for leak detection is the negative pressure test.

[Acute respiratory distress caused by a mediastinal pancreatic pseudocyst]. / Détresse respiratoire aiguë consécutive à un pseudokyste pancréatique médiastinal.

The pseudocyst of the pancreas is a frequent complication of acute pancreatitis. However to intrathoracic localization remains exceptional. A case of acute respiratory insufficiency in a 66-year-old man in whom artificial ventilation was required for such a complication is reported. This case stresses the difficulty often encountered for the differential diagnosis of these liquid tumors. The clinical signs are variable and non specific, especially in case of absence of any history of pancreatitis. The radiographic studies, in particular ultrasonography and CT-scanner defines its liquid nature and its connections. Endoscopy examination confirms its retro-oesophageal extension due to the migration through the oesophageal hiatus. Only the percutaneous needle aspiration of a collection or an associated pleural effusion confirms the diagnosis by the high content of amylases. The treatment of this type of localisation is surgical and essentially consists of an internal derivation.

[Infusion of propofol or closed-circuit isoflurane. A study of cost]. / Propofol en perfusion ou isoflurane en circuit fermé. Etude du coût.

The choice of an anaesthetic agent is influenced by its cost. The use of a circle absorber system decreases the cost of the maintenance of anaesthesia with halogenated agents. Fast recovery and low incidence of postoperative nausea and vomiting are the main advantages of propofol. The cost of propofol can limit its use for the maintenance of anaesthesia except for short procedures. This prospective study compared in 50 ASA 1 and 2 patients the cost of anaesthesia with either propofol (group P, n = 25) or the association thiopentone-isoflurane administered with a rebreathing circuit (group I, n = 25). Patients were premedicated the evening before surgery with 2.5 mg lorazepam. Anaesthesia was induced with either propofol (2-3 mg.kg-1) or thiopentone (4-6 mg.kg-1) and maintained with either propofol (6-10 mg.kg-1.h-1) in group P or isoflurane continuously injected as liquid in the expiratory limb of the circuit in group I. The side effects of anaesthesia and the delay of recovery and discharge from the recovery room were assessed. Peroperative cost of anaesthesia included nitrous oxide, isoflurane and i.v. agents, fluids volumes and disposable devices. The total cost of anaesthesia included also the recovery room stay. The mean duration of anaesthesia was not significantly different between the two groups (109.4 +/- 7.1 min vs 107.3 +/- 7.3 min group P vs group I). The delay lf recovery (eyes opening) was shorter in the propofol group (14.4 +/- 1.3 min vs 19.4 +/- 1.4 min) as well as the delay of discharge from the recovery room (70 +/- 4 min, vs 82.4 +/- 4.6 min).(ABSTRACT TRUNCATED AT 250 WORDS)

[Accidental deep hypothermia and circulatory arrest. Treatment with extracorporeal circulation]. / Hypothermie profonde accidentelle et arrêt circulatoire. Traitement par circulation extracorporelle.

A 27-year old female was discovered at 4 a.m. lying in a wet field, the ambient temperature being of 4 degrees C. Her rectal temperature had fallen to 19 degrees C. She was comatose and failed to respond to noxious stimuli. Her pupils were dilated and fixed. Her respiratory rate was reduced to three to four breaths per min. Her blood pressure was not measurable and neither femoral or carotid pulse could be detected. The heart was in sinus rhythm with a rate of 40 b X min-1. During her transfer to hospital, she was ventilated with oxygen, a tidal volume of 300 ml and a rate of 10 b X min-1. On arrival in the emergency room, a short period of ventricular fibrillation preceded cardiac arrest. Cardiac massage and sodium bicarbonate infusion were continued during the transfer of the patient to the operating theatre. A femoro-femoral cardiopulmonary bypass was started with a bloodless priming, 3 mg X kg-1 heparin and a flow of 3,000 to 3,500 ml X min-1. Mean arterial pressure was maintained between 65 and 85 mmHg; cardiac massage was discontinued during the bypass. Within 50 min, ventricular fibrillation appeared, rectal temperature had increased to 33 degrees C. Electrical defibrillation (300 J) was successful. Cardiopulmonary bypass was stopped after 63 min. The postoperative course was uneventful, apart from transient pulmonary oedema. At the time of discharge, a week later, no loss of intellect or change in behaviour could be perceived.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of isoflurane in a closed-circuit. Economic advantages]. / Utilisation de l'isoflurane en circuit fermé. Avantages économiques.

The present study was designed to assess whether isoflurane requirement was significantly affected by fresh gas flow in a closed-circuit system. Sixty patients scheduled for orthopaedic procedures were randomly assigned into three groups. In group A (n = 20), anaesthesia was conducted with a fresh gas flow of 482.5 +/- 186.6 ml X min-1, corresponding to the patient's metabolic demand. In group B (n = 20), the fresh gas flow was 2000 ml X min-1. In group C (n = 20), it was adjusted to the ventilation minute, i.e. 7145 +/- 986 ml X min-1. Artificial ventilation was conducted using a tidal volume of 10 ml X kg-1 and a rate of 10 to 12 c X min-1. Anaesthesia was induced after 10 min denitrogenation with fentanyl (4 micrograms X kg-1), thiopentone (4 mg X kg-1) and vecuronium (0.1 mg X kg-1). FIO2 was then brought to 0.5 in nitrous oxide and was monitored continuously using a polarographic oxymeter. Liquid isoflurane was injected in the expiratory limb of the circuit using an electrical syringe driver. Alveolar concentration of isoflurane was set at 0.92 vol. % according to Lowe and Ernst. Statistical analysis was carried out using Student's test for means. Anaesthesia lasted 138 +/- 88.3 min in group A, 125.5 +/- 45.1 min in group B and 146.5 +/- 50 min in group C, no difference being significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative nausea and vomiting: cost and therapeutic algorithm. Part II: high-risk patients and late PONV]. / Nausées-vomissements postopératoires (NVPO): avantage et coût d'un algorithme thérapeutique. Partie II: sujets à risque et NVPO tardifs.

OBJECTIVES: To evaluate in high-risk patients and in usual clinical conditions, the efficiency of treatments based on an algorithm on late (24 h) postoperative nausea and vomiting (PONV). STUDY DESIGN: Prospective and descriptive. METHODS: The nature and efficiency of prophylactic and curative PONV treatments was evaluated 24 h after surgery under general anesthesia in patients at high risk of PONV, one and 15 month after the introduction of a clinical and therapeutic algorithm. A risk score based on the type of surgery and patients characteristics determined the prophylactic treatment: high risk = droperidol 1.25 mg + ondansetron 4 mg; moderate risk = droperidol 1.25 mg. Cost of prophylactic and curative treatment was calculated according to the exact number of vials of antiemetics used. RESULTS: The use of the therapeutic algorithm leads to a reduction of PONV by a half (47.7% of 109 patients in 1999 vs. 24.5% of 102 patients in 2001) while twice more patients received a prophylactic treatment (32.1% vs. 75.5%). The number of patients needed to be treated (NNT) according to the algorithm to avoid PONV was 1.8 in this high-risk population. However, the relative risk to have PONV was only reduced by 66% with the combination of two antiemetics in 2001 and 22.5% patients still suffered from PONV despite the double prophylactic treatments. The relative risk of PONV without prophylactic treatment was spontaneously reduced by 25% between the two study periods (54% vs. 40%). After 15 months, the recommendations were followed in 43.1% of patients. A curative treatment was given in the same percentage of patients in 2001 and 1999 (63.4% vs. 68%), but followed the recommendations in fivefold more patients (47% vs. 9.1%). The cost of PONV treatment (prophylactic and curative) was increased by 3.5-fold between the two periods ( 55 for 109 patients vs. 190 for 102 patients). CONCLUSION: The use of a PONV therapeutic algorithm based on a scored risk was associated to a lower reduction of late PONV than already published in the literature while the cost was increased as expected. This suggests the efficacy of antiemetic prophylactic treatment might have been overestimated by large multicenter trials and is less in usual clinical conditions. Thus local evaluation of practice is required by performing quality insurance programs.

[Postoperative nausea and vomiting: cost and advantage induced by a quality insurance programme. Part I: post anaesthesia care unit]. / Nausées-vomissements postopératoires: avantage et coût d'un programme d'assurance qualité. Partie I: en salle de surveillance post-interventionnelle.

OBJECTIVES: To report the efficiency and direct cost induced by a quality insurance programme (QIP) aimed to reduce the incidence of post-operative nausea and vomiting (PONV) in the post-anaesthesia care unit. TYPE OF STUDY: Prospective and descriptive study. METHODS: The occurrence and treatment of PONV were prospectively recorded in the post-anaesthesia care unit in a standardised file before and following therapeutic recommendations made by volunteers component of a QIP. Prophylaxis was administered to patients according to a score of risks based on the type of surgery and patient characteristics. The real cost induced by this change of practice was evaluated according to pharmacists' accounts over 1 year. RESULTS: The QIP was associated to a 33.5% reduction of PONV relative risk and a 50% increase in prophylactic treatments. When this reduction of PONV was extrapolated to the total number of anaesthesia over 1 year, this QIP avoided PONV in 770 patients each year. The increase of cost reached 3572 as the cost by patient receiving a prophylactic treatment increased from 0.66 to 1. CONCLUSION: Despite an increase in the individual cost of PONV prophylaxis, the selection of patients by a "home" score of risk limits the indications of prophylactic treatment. Thus the increase in cost remains in acceptable ranges.

[Propofol in the surgery of the aortic bifurcation. Comparison with isoflurane]. / Le propofol dans la chirurgie du carrefour aortique. Comparaison avec l'isoflurane.

Two groups of nine patients each, all undergoing surgery for aorto-bifemoral prosthesis, were studied. They were premedicated with 10 mg morphine and 1 mg flunitrazepam. A Swan-Ganz catheter was then inserted. Cardiac output was measured by thermodilution. Haemodynamic parameters were measured before induction (t0), 15 min after intubation (t1), 10 min after the start of the surgical procedure (t2), 5 min before clamping the aorta (t3), whilst the aorta was clamped (t4), and a few minutes after unclamping. Group A received 2 mg X kg-1 propofol at induction, anaesthesia being maintained with 100 micrograms X kg-1 X min-1 propofol. Group B received 4 mg X kg-1 thiopentone, followed by isoflurane at the dose of 0.9 vol. %. Both groups received 5 micrograms X kg-1 fentanyl and 0.1 mg X kg-1 vecuronium to ease intubation. Artificial respiration was carried out with a mixture of 40% oxygen and 60% nitrous oxide. The fall in blood pressure between t2 and t3 was significantly more important in the propofol group (-16%). In the same group, the systolic blood pressure and heart rate fell by 23 and 19% respectively after induction (p less than 0.05); the cardiac index fell by 20% and the systemic vascular resistances did not change. The fall in blood pressure, heart rate and cardiac index were not significant for group B. The haemodynamic changes due to clamping of the aorta were not significant between or within groups. In group A, one patient presented with bradycardia, hypotension and myocardial ischaemia, and another died of postoperative ventricular fibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)