Effect of preoperative renin-angiotensin system blockade on hypertension following coronary surgery.

Renin-angiotensin system activation is suspected of being involved in postcoronary surgery hypertension, but appears to be useful in maintaining blood pressure during anesthesia and cardiopulmonary bypass. To clarify these points, 19 patients were compared: ten as a control group and nine who received captopril during two days before surgery. Anesthesia was the same for the two groups, and cardiopulmonary bypass ensured nonpulsatile flow rates. Anesthesia induced a slight decrease in the mean arterial blood pressure of the treated group (91.1 +/- 3.3 mm Hg to 83.3 +/- 3.9 mm Hg), which did not occur in the control group (89.9 +/- 5.8 mm Hg to 89.7 +/- 4.9 mm Hg). During cardiopulmonary bypass, the mean arterial blood pressure was maintained at comparable levels in the two groups (65.6 +/- 3.5 mm Hg in the control group, 72.6 +/- 3.0 mm Hg in the treated group), with same pump flow rates. After cardiopulmonary bypass, the mean arterial blood pressure returned nearly to prebypass values. Postoperatively, three patients in the control group and four in the treated group developed hypertension. Thus, preoperative renin-angiotensin system blockade by a converting-enzyme inhibitor did not impair blood pressure regulation during anesthesia and cardiopulmonary bypass, but failed to prevent hypertension following coronary surgery.

A comparative study of controlled-release morphine (CRM) suspension and CRM tablets in chronic cancer pain.

This study compared the efficacy and the adverse effects of controlled-release morphine (CRM) suspension (SAR 213) and CRM tablets (Moscontin) in the treatment of cancer pain. This multicenter, randomized, double-blind, double-dummy, crossover study was carried out on 52 patients. Each patient received both study treatments given at an equivalent dosage of morphine during each of two 7-day periods. The primary outcome variable was the severity of pain assessed three times daily by means of a visual analogue scale. Secondary criteria of efficacy were the severity of pain assessed by verbal rating scale, the need for "rescue" doses of immediate-release morphine, treatment preference, and indices of quality of life (activity, mood, sleep). There were no statistically significant differences in the parameters assessed when comparing the two groups. This study shows that, when prescribed at the same doses, CRM suspension and CRM tablets have similar efficacy and adverse effects, as well as the same duration of action. The results of this first clinical study carried out on CRM suspension are especially relevant for patients with cancer pain who have difficulty swallowing.

Intraventricular administration of morphine in patients with neoplastic intractable pain.

Since February 1981, eight patients with neoplastic intractable pain have been treated by intracerebroventricular administration of small doses of morphine. Morphine was injected into the cerebrospinal fluid through a ventricular reservoir either by direct puncture or by self-administration. Clinical results were very good, and there were no deleterious effects.

[Pre- and postoperative antihypertensive treatment with calcium antagonist in pheochromocytoma]. / Traitement antihypertenseur par antagoniste calcique préopératoire et peropératoire en cas de phéochromocytome.

Medical preparation for pheochromocytoma surgery requires adrenergic blockade and restoration of euvolemia. Usually, this preoperative preparation consisted essentially of sequential and progressive adrenergic antagonism, alpha then beta blockade. This therapy is not easy to introduce and exposes to blood pressure collapses after tumor removal. By contrast, calcium channel blocking drugs like dihydropyridines offer efficacy and safety. Moreover, new intravenous (IV) agents (nicardipine, diltiazem) provide useful therapeutic tools to control, rapidly and with a dose-dependent effect, any undesired hemodynamic event during surgery. As a demonstration of this new therapeutic strategy for management of pheochromocytoma resection, we report here the cases of two patients who were exclusively treated with dihydropyridines. A 61 year-old woman and a 41 year-old man were scheduled for pheochromocytoma resection (left and right adrenal tumors, respectively). Both patients received dihydropyridines for preoperative preparation (nicardipine and nifedipine, respectively, 60 mg/day). This treatment allowed a good control of arterial blood pressure (BP) (from 210/110 to 170/90 and 180/100 to 140/80 mmHg, respectively) and was maintained up to the morning of the operative day. After patient installation on the operating-table, IV nicardipine infusion was started (2 mg/hour). Anesthesia consisted of high doses of fentanyl, flunitrazepam and vecuronium. Hemodynamic measurements (radial artery and Swan ganz catheters) allowed adjustment of nicardipine infusion rate to maintain peripheral arterial resistances under 1,000 dynes.s.cm-5, and adequate volume loading. A hypertensive crisis (270/130 mmHg) occurred at the time of the intubation in the first case but responded to higher infusion rate of nicardipine (5 mg/10 min).(ABSTRACT TRUNCATED AT 250 WORDS)

[Prolonged traumatic and vascular coma: prognostic and therapeutic indications based on hemodynamic and metabolic studies]. / Comas traumatiques et vasculaires prolongés: indications pronostiques et thérapeutiques d'après une étude hémodynamique et métabolique

From haemodynamic and metabolic investigation of 65 comatose subjects following cranial traumatism or cerebral vascular accident, the following prognostic and therapeutic indications emerged: The isolated increase in oxygen pressure in the jugular vein to above 50 mm Hg, the simultaneous decrease in circulation of the brain to below of 30 ml/100g/min., and of the brain consumption of oxygen to below 1.5 ml/100g/min., combined with a loss of autoregulation and a decrease in carbon dioxide reactivity indicate that prognosis is very poor. Induced arterial hypertension, associated with hyperventilation, partially corrects brain hypoperfusion in coma from bulbo-pontine lesions. Sodium penthiobarbital and sodium gamma hydroxybutyrate and have the effect of reducing oxygen metabolism which might have some therapeutic value during the acute phase of coma. Clomipramine which has a stimulating effect on oxygen metabolism should be kept in reserve for the chronic phase of prolonged coma.

[Comparison of the effects of epsilon-aminocaproic acid and aprotinin on intra- and postoperative bleeding in heart surgery]. / Comparaison des effets de l'acide epsilon-aminocaproïque et de l'aprotinine sur le saignement per- et post-opératoire en chirurgie cardiaque.

Excessive bleeding during and after cardiac surgery with cardiopulmonary bypass is a real problem in this kind of surgery. The use of prophylactic high doses of aprotinin (APROT) reduces blood loss in this context but this treatment is expensive. Some investigators have advocated that epsilon-aminocaproic acid (EACA), a cheaper antifibrinolytic drug, could reduce blood loss in cardiac surgery. The goal of this prospective study was to determine if EACA is as effective as APROT for this clinical condition. Sixty patients undergoing elective surgery for cardiac disease were randomly allocated to one of the two groups. Drugs were administered after induction of anesthesia at a dose of 2.10(6) UIK in the APROT group or 5 g in the EACA group. The same dose was added to the priming of the cardiopulmonary bypass circuit. Until the skin closure the patients received 5.10(5) UIK/h of APROT or 2 g/h of EACA. Bleeding during and after surgery was not different between the two groups. No complication, directly due to the treatment administered, was observed. EACA seems to be as effective as APROT to reduce intra and post cardiac surgery blood loss. EACA has the advantage of being cheaper (treatment is approximately 200 times cheaper), therefore allowing a wider use.

[Intraventricular morphine analgesia. Apropos of 4 cases, 1 with self-administration]. / Analgésie morphinique par voie ventriculaire. A propos de quatre cas dont un avec auto-administration.

Intractable pain in four patients enduring disseminated cancer was treated by intraventricular morphine. For all these patients, previous efficiency of opiates therapy had been assessed by a positive trial of epidural injections of morphine. The latter method had to be stopped and a switch to intraventricular morphine was motivated in three cases by a local non-tolerance to the subarachnoid catheter. In one case, an intraventricular system was inserted at the first onset. In all cases, the intraventricular system consisted of a Holter type device, using a reservoir subcutaneously implanted in the frontal scalp and connected at right-angle with a catheter inserted in the lateral ventricle. Trial times were respectively of eight days, one month, two months and seven months, with a self administration system in one case. In comparison with the epidural and lumbar intrathecal administration of morphine, the authors insist upon the quality of analgesia obtained, the absence of respiratory depression, the comfort and minimal daily quantities of morphine injected (inferior to one mg daily in three cases). Enlightened by these four cases, the authors also discuss of relative importance of the spinal and brain mechanisms involved in morphine analgesia.

[Pulse oximetry and thoracopulmonary surgery]. / Oxymétrie de pouls et chirurgie thoracopulmonaire.

Arterial blood gases are invasive and they provide intermittent information only. On the other hand, pulse oximetry is non invasive, providing continuous monitoring of SaO2 (SpO2). A study was therefore carried out in twelve patients undergoing lung and intrathoracic surgery to determine whether pulse oximetry was a reliable method of monitoring. The SpO2 values obtained using a Physiocontrol Oximeter (Lifestat 1600) were compared with those given by blood gas measurements (SaO2). When ventilation was switched to one-lung ventilation, PaO2 fell in all cases, whatever the method of monitoring, with PaCO2 remaining constant. 46 paired values of SaO2 were compared using linear regression analysis. Correlation between the two methods was good (r = 0.95; p less than 0.001). Pulse oximetry would therefore seem to provide a reliable method of continuous noninvasive and accurate monitoring of oxygenation during lung surgery.

[Vascular effects of adenosine-triphosphate]. / Effets vasculaires de l'adénosine-triphosphate.

This study assessed the effects of adenosine triphosphate (ATP) on systemic vascular resistances during the hypothermic cardiopulmonary bypass phase of cardiac surgery. Twenty patients scheduled for cardiac surgery were randomly divided into an ATP group (n = 10), and a placebo group (n = 10). Anaesthesia was similar for all the patients (diazepam, fentanyl and pancuronium). During the heart arrest phase, and as soon as the arterial pressure, the level in the venous return reservoir, and the pump flow rate had all been in steady state for 5 min, ATP or placebo was injected into the venous line of the oxygenator. Injection speed was doubled every three minutes, twice. The following ATP doses were administered: 0.012, 0.025 and 0.05 mg.kg-1.min-1. The level in the venous return reservoir was kept constant. Mean arterial pressure (MAP) and pump flow rate (DP) were assessed every half minute. Systemic vascular resistances were calculated with the relationship MAP/DP. Changes in vascular capacitance were directly proportional to changes in DP as the heart had been excluded, and all the blood returned to the pump, the blood volume being kept constant. MAP and DP remained unchanged in the placebo group. In the opposite ATP induced a dose-related systemic vasodilation: MAP decreased from 82.8 +/- 12.5 mmHg (control) to 66.0 +/- 14.8 mmHg, 59.8 +/- 10.6 mmHg, and 49.0 +/- 4.7 mmHg with 0.012, 0.025 and 0.05 mg.kg-1.min-1 ATP respectively. The MAP returned to preinfusion control levels when the ATP infusion was discontinued (90.0 +/- 17.8 mmHg). The DP, and therefore venous return, did not change, neither during ATP infusion, nor after its discontinuation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the efficacy and tolerance of flumazenil in antagonism of the effects of flunitrazepam on the central nervous system]. / Evaluation de l'efficacité et de la tolérance du flumazénil dans l'antagonisme des effets du flunitrazépam sur le système nerveux central.

The efficacy and tolerance of flumazenil were assessed in a double-blind randomized multicentre trial on 120 ASA I or II patients aged 40.3 +/- 13.9 years. They were anaesthetized with flunitrazepam (25.1 +/- 10.5 micrograms.kg-1.h-1), fentanyl (4.4 +/- 1.9 micrograms.kg-1.h-1) and either vecuronium or pancuronium; residual neuromuscular blockade was antagonized at the end of surgery. 61 patients received flumazenil and 59 a placebo. Sedation comprehension and temporo-spatial orientation were scored at 0, 5, 15, 30, 60, 120 and 240 min after the administration of flumazenil or placebo. Local and general tolerances were evaluated 1 h and 24 h after administration. At the 24th h, the observer's assessment of consciousness, pain, respiration, coughing and vomiting were noted, as well as his identification, or not, of flumazenil or the placebo and their efficacy. Both groups were statistically homogeneous and comparable. Significant and marked efficacy was noted between the 5th and 30th min. There was no difference, at 24 h, between the flumazenil and placebo groups. In most cases, flumazenil was identified by the observer and its efficacy felt to be excellent. No major untoward effect of flumazenil was noted; however a mild and short lasting anxiety occurred in three patients. Tolerance was deemed to be excellent.

[Value of brain metabolic studies in post-traumatic coma]. / Intérêt de l'exploration métabolique cérébrale dans les états de coma post-traumatique.

In 34 comatose patients in the acute phase, the mean hemispheric CBF is lowered as well as the CMRO2, with a quite good relation between these values and the coma level and prognostic so. The cerebral response to a PaCO2 range indicates a quite good relation with the coma level (the lowest value in the most severe comas). The cerebral autoregulation study, using Aramine induced hypertension, can separate the cases with a present autoregulation and the cases with a loss of autoregulation (the most severe and the poorest prognosis). In dynamic conditions (variation of the PaCO2 or Aramine induced hypertension), the change in CMRO2 is interesting : rather good prognosis among the patients with a normal metabolic autoregulation - poor prognosis among those whose metabolic autoregulation is lost.

[Value of intraventricular morphine analgesia in intractable neoplasm pain. Apropos of 8 cases with self-administration in 4]. / Intérêt de l'analgésie morphinique par voie ventriculaire dans les algies rebelles néoplasiques. A propos de 8 cas dont 4 avec auto-administration.

Intractable pain in 4 patients having disseminated cancer was treated by intraventricular morphine. For all these patients, previous efficiency of opiates therapy was assessed by a positive trial of epidural injections of morphine. The latter method had to be stopped and a switch to intraventricular morphine was motivated, in 3 cases, by a local non-tolérance to the subarachnoid catheter. In one case, an intraventricular system was inserted at the first onset. In all cases, the intraventricular system consisted of a "Holter" type device, using a reservoir implanted subcutaneously in the frontal scalp and connected at right-angle with a catheter inserted in the lateral ventricle. Trial times were respectively of 8 days, one month, two months and six months (this latter case still under trial). In comparison with the epidural and lumbar intrathecal administration of morphine, the authors insisted upon the quality of analgesia obtained, the absence of respiratory depression, the comfort and minimal daily quantities of morphine injected (inferior to one mg daily in three cases). Enlightened by these 4 cases, the authors also discussed the relative importance of the spinal and brain mechanisms involved in morphinic analgesia.

[The use of opioids by the regional route in the treatment of pain]. / Utilisation des morphiniques par voie régionale en algologie.

The decision to administer regional opioids either by an epidural or a subarachnoid route (intrathecal or intraventricular) necessitates a prior multiparametric analysis. When opiate therapy is definitively indicated regional opiate administration usually relays an insufficient or poorly tolerated oral route. The epidural route seems to be the best way for transient indications; the choice of the opioid drug then depends on the local or disseminated character of pain. For definitive opioid treatment, morphine is the only substance which can be used for long periods of time; the choice of the route depends on the life expectancy; epidural way combined with "open devices or half open devices" chiefly concerns patients with a poor life expectancy and a rather low daily morphine regime: a subarachnoid approach is best indicated in cases with good life expectancy, however, other criteria--intellectual, socioeconomical levels and quality of the "support system"--are important factors for the choice of the route and of the type of administration devices.

[Solar (celiac) block in intractable neoplastic pain originating in the subdiaphragmatic digestive system]. / Le bloc solaire (coeliaque) dans les algies néoplasiques rebelles de l'étage digestif sous diaphragmatique.

Neurolysis of the coeliac plexus using 45 per cent alcohol was performed by the percutaneous posterior route. Bilateral blockade was always done. Effective in immediate relief was obtained in 88 per cent of the cases and was maintained in 73 per cent one month later.