[Infections of soft tissues by bacterial synergism]. / Infections des parties molles par synergie bactérienne.

The treatment of synergistic bacterial soft tissue infections includes usually surgical debridements and radical excisions of necrotic tissues, antibiotic therapy and volumic resuscitation. Hyperbaric oxygen therapy did not prove efficient in these plurimicrobial infections. Their severity is due to virulence synergy of aerobic and anaerobic micro organisms in the involved areas. Sixty patients were admitted in the Surgical Intensive Care Unit (december 1980-march 1989) for severe synergistic soft tissue infections. From 1980 to the end of 1983 the initial surgical treatment was extensive with wide excisions. The antibiotic therapy was selected primarily against anaerobes and gram negative rods. Since 1984 antibiotic therapy was changed to take into account all the micro-organisms found in the initial cultures, especially encountered streptococci species (43 times/60 patients). Initial surgery, after fluid resuscitation and antibiotic therapy, included debridements, colostomy in case of perineal lesion and excisions limited to the really necrotic areas. Under antibiotic therapy according to the bacteriological results, surgical management was performed daily during the first week, later when required. In these series, 14 patients died (23.3%). The mortality during the first period (1980-1983) was high: 7/2 (31.8%) and decreased to 7/38 (18.4%) in the second period (1984-1989). Cellulitis is potentially a highly lethal infection. Early recognition as well as adequate medical and surgical management may be lifesaving.

[Recurrent nerve paralysis and Claude Bernard-Horner syndrome following an interscalene block of the brachial plexus]. / Paralysie récurrentielle et syndrome de Claude Bernard-Horner après blocage interscalénique du plexus brachial.

The association of a recurrent laryngeal block with a Horner's syndrome occurred in one patient after right interscalene brachial plexus block. Hoarseness was the main clinical symptom of recurrent paralysis and lasted 4 h. The subsequent course was totally uneventful and required no specific treatment. But the interscalene route of brachial plexus block may be potentially hazardous in the patient with a full stomach.

[Severity scores underestimate the seriousness of acute renal failure after emergency surgery]. / Les scores de gravité sous-estiment la sévérité de l'insuffisance rénale aiguë après chirurgie en urgence.

OBJECTIVES: The predictive value of APACHE II and SAPS severity scores were evaluated in a group of patients with acute renal failure admitted in ICU after emergency surgery. The criteria of poor prognosis identified in the 24 hours following admission were also evaluated. STUDY DESIGN: Open prospective study. PATIENTS AND METHODS: During 22 months, we included every patient admitted in ICU after emergency surgery with a serum creatinine concentration > or = 130 mumol.L-1. Clinical and biological parameters were collected in the first 24 hours following admission and the severity scores were calculated. Prediction of hospital outcome, based on APACHE II score, was calculated. The standard mortality ratio (observed mortality/predicted mortality) was calculated. Accuracy of SAPS and APACHE II score was compared using ROC curves and comparison of the areas under the curves. RESULTS: Death in ICU occurred in 44% of the patients while hospital mortality was 51%. The standard mortality ratio for APACHE II score was 1.35. The areas under the curves for SAPS and APACHE II scores were not statistically different. The criteria of poor prognosis, identified in the first 24 hours following admission, were cardiovascular failure, oliguria and sepsis. CONCLUSION: Conventional severity scores are inaccurate for prediction of mortality in patients with acute renal failure following emergency surgery.

[Initial clinical experiences with the Storz Modulith SL 20 lithotripter: the results 3 months after a single session]. / Première expérience clinique du lithotripteur Storz Modulith SL 20: résultats à trois mois après une séance unique.

The objective of this study was to evaluate the performances of the Storz Modulith SL20 lithotriptor. Fifty patients with a total of 52 renal (31) or ureteric (21) stones were treated, in a single session, between June and October 1993. The mean stone diameter was 7.9 mm. All patients were reviewed after 3 months. The complete success rate, with radiological cure, was 65% at 3 months. The partial success rate, defined as fragmentation of the stone with persistence of residual fragments less than 3 mm in diameter, not requiring further treatment, was 12% at 3 months. The failure rate at 3 months was 23%. The commonest complication was renal colic in 12 patients (24%). Two patients developed an extrarenal haematoma. The Modulith SL20 possesses a good detection system: firing is well tolerated under minimal analgesia. Our success rates are slightly lower than those obtained by other teams using the same apparatus.

Beta-adrenergic receptor function is acutely altered in surgical patients.

Catecholamine-induced desensitization of beta-adrenergic receptors resulting in hyporesponsiveness to further stimulation has been frequently reported after an increase in endogenous catecholamines. To examine the possibility of beta-adrenoceptor desensitization due to intraoperative adrenergic activation (surgical stress), the alterations of human lymphocyte beta-adrenergic receptor density and affinity observed after anesthesia and surgery were studied using (-)125I-iodocyanopindolol binding in 19 patients undergoing noncardiac surgical procedures with general anesthesia (thiopental, fentanyl, and halothane or isoflurane). In 13 patients, repeated determinations of plasma levels of norepinephrine and epinephrine showed an increase during the surgical procedure (norepinephrine +60%; epinephrine +60%); this change was not observed in the remaining patients. A significant postoperative increase in receptor density (Bmax +25%) and a significant decrease of receptor affinity for isoproterenol (IC50 +22%) were found in the patients who experienced intraoperative adrenergic activation. By contrast, no significant change in beta-receptor density or affinity was found in the patients who had normal intraoperative adrenergic activation. In addition, heart rate responses to the postoperative changes in plasma catecholamines (an index of cardiac sensitivity to agonist) were significantly attenuated in patients who experienced both intraoperative adrenergic activation and a decrease in affinity of beta-receptor for agonist, suggesting hyporesponsiveness to beta stimulation. We conclude that beta-adrenergic receptors and, consequently, beta-adrenergic responsiveness might be altered by perioperative adrenergic activation in surgical patients.

The effects of halothane on the human beta-adrenergic receptor of lymphocyte membranes.

The effects of halothane on beta-adrenergic receptor antagonist interaction were studied using the membranes of human lymphocytes as a model. Membrane preparations of lymphocytes were obtained from blood samples withdrawn from seven healthy young volunteers. Beta-receptor studies were performed using (-)125I iodocyanopindolol (125ICP) binding. Non-specific binding was determined in the presence of (-)isoproterenol. Beta-receptor density (Bmax) and the dissociation constant (KD) for 125ICP were determined from saturation curves. Beta-receptor affinity for agonists evaluated by the IC50 (the concentration of isoproterenol required to inhibit 50% of specific 125ICP binding) and the dissociation constant (KL) for isoproterenol was established from competition curves. The effect of halothane 1%, in an air oxygen mixture (oxygen fraction: 0.3) administered by tonometry during ligand membrane incubation, on beta-adrenergic receptor, was compared to that of control experiments not exposed to halothane. Halothane produced a moderate but significant decrease of Bmax (-10%) and a significant increase in non-specific binding (+30%), while KD, IC50, and KL were unchanged. The authors conclude that halothane, in vitro, decreases beta-adrenergic receptor density. This effect could be mediated by an alteration of the receptor in the membrane due to action of halothane on the lipid phase of the membrane.