Biomedical subjects
E Bavoux
Publications and source records attributed to E Bavoux.
Relation between plasma lactate and blood cyanide concentrations in acute cyanide poisoning.
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Clinical and bacteriologic survey of epidural analgesia in patients in the intensive care unit.
BACKGROUND: The risk of bacterial contamination related to epidural analgesia in patients cared for in the intensive care unit has not been assessed. Thus the authors studied patients who received care in the intensive care unit who were given epidural analgesia for more than 48 h to determine the rates of local, epidural catheter, and spinal space infection and to identify risk factors. METHODS: Each patient receiving epidural analgesia for longer than 48 h was examined daily for local and general signs of infection. A swab sample for culture was taken if there was local discharge; all epidural catheters were cultured on withdrawal. All patients underwent weekly neurologic monitoring for 1 month; those with positive epidural catheter cultures had one spinal magnetic resonance image scan. RESULTS: The 75 patients cared for in the intensive care unit who were studied had been receiving epidural analgesia for a median of 4 days (interquartile range, 3.5 to 5 days). Twenty-seven patients had signs of local inflammation (erythema or local discharge), and nine of these had infections. All the patients who had both local signs also had infection. All nine infections were local (12%), but four patients also had epidural catheter infections (5.3%). No patient with erythema alone or without local signs had a positive epidural catheter culture. No spinal space infection was diagnosed. Staphylococcus epidermidis was the most frequently cultured microorganism. Local infection was treated by removing the epidural catheter without any antibiotics. Concomitant infection at other sites (21 of 75 patients, or 28%), antibiotic therapy (64 of 75 patients, or 85%), the duration of epidural analgesia, and the insertion site level of the epidural catheter were not identified as risk factors for epidural analgesia-related infections. CONCLUSIONS: The risk of epidural analgesia-related infection in patients in the intensive care unit seems to be low. The presence of two local signs of inflammation is a strong predictor of local and epidural catheter infection.
[Heart-lung transplantation and double lung transplantation. 33 cases].
Between June 1986 and October 1989, 29 heart lung transplantations and 4 double lung transplantations were performed at the Marie Lannelongue Hospital, Paris. The early and later course of these patients was studied. The actuarial survival rates at one and two years were 65 percent and 55 percent respectively. Bacterial infection was the main cause of early death. Late morbidity was predominantly due to cytomegalovirus infection and episodes of rejection. Respiratory function, evaluated in 19 long-term survivors, was usually normal. Only 3 patients developed a functional pattern of severe obliterative bronchiolitis probably related to uncontrolled rejections. The indications of the different types of lung transplantation are discussed: in cases of primary pulmonary hypertension or Eisenmenger's complex, heart lung transplantation is the only possible procedure. In patients with respiratory failure without cardiac dysfunction, double lung transplantation gives good functional results and makes an extra heart available for transplantation in another patient. Single lung transplantation, which gives worse functional results with a similar mortality rate, must be reserved for patients who are unable to undergo double lung transplantation.
[Anesthesia and intensive care for heart-lung transplantation].
Since Shumway carried out the first successful heart-lung transplant (HLT) in Stanford in 1981, HLT has become a new therapeutic means for patients with end-stage pulmonary disease or arterial hypertension. However, it is still rarely carried out because of a lack of donors and the complexity of the surgery and postoperative course. This review described the criteria for proper donor and recipient selection, as well as the anaesthetic and postoperative management of HLT patients at Marie Lannelongue Hospital. The lack of suitable organ grafts results, at least in part, from improper donor management. Pulmonary oedema by fluid overloading and excessive haemodilution should be carefully prevented. Low doses of catecholamines and vasopressin maintain circulatory stability and convenient organ function. The indications for HLT (primary pulmonary hypertension, Eisenmenger's complex, and end-stage bronchopulmonary disease) are all characterized by severe pulmonary hypertension, hypoxaemia and cardiac failure. Careful anaesthetic induction is required to avoid circulatory collapse. Cardiopulmonary bypass (CPB) should be started early, so that mediastinal dissection may be carried out in satisfactory haemodynamic conditions. After unclamping the aorta, circulatory support with fluid and catecholamine infusion is often required. High inspired oxygen fraction and end-expiratory positive pressure may be required because of reperfusion pulmonary oedema. Blood transfusion is often needed as there are major blood losses due to dissection of the posterior mediastinum during CPB. Postoperative catecholamine administration is prolonged over several days. Negative fluid balance is often necessary to reduce pulmonary oedema. Improvement in surgical technique, early extubation, and late prescription of steroids have reduced the incidence of tracheal complications. Acute renal failure often occurs as a result of prolonged CPB, hypovolaemia, drug nephrotoxicity and sepsis. Bacterial complications (pneumonia, mediastinitis) are the main causes of early death. After the 15th postoperative day, opportunistic infections and allograft rejection are the main complications. Since 1981, major advances in HLT recipient management resulted in improved survival rates (70-80% at 1 year, and 60-70% at 2 years for the best teams). Despite the complexity of management, and the longterm threat of obliterative bronchiolitis, HLT is, at present time, the only possibility for these young patients to recover a normal quality of life.
Increased lung clearance of 99mTcDTPA in allograft lung rejection. The Paris-Sud Lung Transplant Group.
To investigate whether lung 99mTc-DTPA clearance is altered during allograft lung rejection, a group of four double lung and 24 heart-lung transplant patients was studied using serial measurement of the clearance rate of aerosolized 99mTc-DTPA (DTPA-Cl), in association with pulmonary function tests, bronchoalveolar lavage, and transbronchial lung biopsies. Using histologic diagnosis as a standard, we compared 56 episodes with normal lung histology to 32 episodes with allograft lung rejection. A control group of 20 healthy nonsmokers was used to define normal DTPA-Cl. In patients with normal lung histology, DTPA-Cl was higher than in control subjects (2.62 +/- 0.25 versus 1.20 +/- 0.12 %/min; p less than 0.001). In the episodes of allograft lung rejection, DTPA-Cl increased to 3.65 +/- 0.41 %/min (p less than 0.02) as compared with episodes of normal lung histology. The change in DTPA-Cl during allograft lung rejection was correlated (r = 0.3, p less than 0.01) with the increased percentage of lymphocytes in bronchoalveolar lavage (27.8 +/- 3.5% in rejection versus 19.9 +/- 2.2% in normal histology; p less than 0.02). Sensitivity and specificity of DTPA-Cl measurement in detecting lung rejection were 69 and 82%, respectively, versus 45 and 85% for FEV1 measurement. These results suggest that DTPA-Cl monitoring could be used in conjunction with pulmonary function testing as a noninvasive approach for the detection of lung rejection.
Ganciclovir treatment of cytomegalovirus infection in heart-lung and double-lung transplant recipients.
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[Acute drug poisoning and the cardio-vascular system].
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[Anaphylactic shock].
The anaphylactic shock is a life-threatening reaction produced by the release of pharmacologically active substances (histamine, leukotriene...) by most cells and basophils. The release of these mediators may be immunologically mediated (anaphylactic reaction a typical immediate hypersensitivity reaction mediated by IgE) or not (anaphylactic reaction when not mediated by an antigen-antibody process). These mediators in turn specific end-organ responses in the cardio-vascular system, (vasodilatation, change in inotropy, increased capillary permeability), the respiratory system (bronchospasm upper airway oedema) and the skin (urticaria). Because of its etiology (mainly drugs, contrast media and colloids) the treatment of anaphylactic or anaphylactic reactions must be prophylactic. When it occurs, its cure is based upon adrenaline and fluid loading and eventually bronchodilators.
[Chronic abuse of the analgesic nefopam (Acupan)].
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