Need for mechanical ventilation in the treatment of acute infections complicating bone marrow transplantation.
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Bone Marrow Transplantation↗
Biomedical subjects
J L Blache
Publications and source records attributed to J L Blache.
[Pulmonary edema after laryngospasm].
A case is reported of rapidly resolving pulmonary oedema following post-extubation laryngospasm in a 23 year-old healthy man who underwent emergency resection of a rectal polyp. The laryngospasm occurred immediately after extubation and resolved after administration of curare. The patient was reintubated and auscultation disclosed bilateral coarse and moist rales. Chest X-ray displayed a right pulmonary opacity. Because of the deteriorating respiratory status, mechanical ventilation was used with positive end-expiratory pressure for 18 h. Chest examination, chest X-ray and arterial blood gas levels improved steadily and the patient was discharged 24 h later. Pulmonary oedema associated with upper airway obstruction seems to be related to hypoxic pulmonary vasoconstriction and the largely subatmospheric transpulmonary pressure gradients generated while trying to breathe against a closed glottis. In addition, this increased negative intra-alveolar pressure was responsible for significant changes in cardiovascular function: right ventricular blood volume, right ventricular ejection fraction and left ventricular after-load increased, while left ventricular ejection fraction decreased. These changes favoured a rise in left atrial and pulmonary blood volumes, with transudation of fluid from the capillaries into the alveoli. Because of the severe consequences of respiratory failure, any patient who suffers acute upper airway obstruction should be observed in the recovery room for at least 3 h in order not to miss this rarely developing, but fortunately rapidly reversible, syndrome.
Adult↗
[Comparative effect of halothane and isoflurane on peroperative cardiac arrhythmias].
Cardiac arrhythmias were studied in twenty ASA class 1 patients under general anesthesia using halothane or isoflurane to supplement nitrous oxide in oxygen. The study began during the maintenance period, once the expiratory MAC value had reached a stable level of 1, and stopped one hour later. Both intubation and recovery periods were excluded. The end-tidal gas concentration was measured for carbon monoxide and vapours. The ECG was recorded on a magnetic tape. The incidence of arrhythmias was higher in the halothane group when compared to the isoflurane group (p less than 0.05). The main types of arrhythmias observed were supraventricular and ventricular ectopic beats. None of the arrhythmias observed were serious; in particular the ventricular beats were all unifocal and occasional. Heart rate measured at 10 min intervals tended to be more rapid in the isoflurane group.
Adult↗
[Comparison of the hemodynamic effects of midazolam-fentanyl and thiopental-fentanyl combinations in the induction of general anesthesia].
The hemodynamic changes during anesthetic induction for elective abdominal aortic surgery were studied in two groups of patients. Group M (9 patients) received midazolam 0.3 mg . kg-1 and fentanyl 6 micrograms . kg-1. Group T (10 patients) received thiopentone 6 mg . kg-1 and fentanyl 5 micrograms . kg-1. The radial and pulmonary arteries were catheterized under local anesthesia. An intravenous infusion was administered in order to normalize pulmonary wedge pressure. Systemic and pulmonary arterial pressures, pulmonary wedge pressure, cardiac output and heart rate were measured after the infusion and 5 min after intubation. Mean arterial pressure showed a statistically significant reduction in both groups. Cardiac index remained unchanged in group M, but was significantly diminished in group T. There was no significant reduction in the systemic vascular resistance index for group M, but group T showed a statistically significant increase. This study confirmed the good hemodynamic tolerance of the midazolam induction technique, even with a high dose of 0.3 mg . kg-1.
Adult↗
[Effects of surgery on plasma amino acids levels].
This study was aimed at comparing pre- and immediately postoperative plasma amino acids levels in ten patients undergoing moderately important surgery and anaesthetised using the same protocol. Amino acid levels were measured using and automatic analyser equipped with an ion exchanger column. Changes in total blood amino acid levels showed wide variations. It is difficult to assess the role played by possible changes in blood volume, and for this reason results are expressed as a percentage of total amino acid levels. Under such conditions, findings were as follows: - taurine and alamine rose significantly; - there was a significant fall in serine, citrulline, alpha- amino-butyric acid and isoleucine. The results of this study differed markedly from findings reported in the literature: the authors noted a fall in plasma amino acid levels both in relation to preoperative levels as well as in relation to "normal" levels in the literature. This could be related to haemodilution, this hypothesis being supported by the fall in total aminogram in eight of the ten patients of the group. The most notable fact in the variations seen in this study was the rise in plasma alamine levels which could be indicative of a fall in gluconeogenesis. This hypothesis requires confirmation.
Adult↗
[Value of the determination of urinary 3-methylhistidine (3 MEHIS) in the evaluation of postoperative muscular catabolism].
Daily estimations of urinary 3 methylhistidine, creatinine and total nitrogen were carried out during the first four post-operative days in sixteen patients who had undergone uncomplicated abdominal surgery and receiving parenteral alimentation. Figures obtained for 3 methylhistidine (19.36 +/- 4.48 mumol/kg as a cumulative for the 4 days) could be used to assess the catabolism of muscular protein during this period at approximately 320 g for a 70 kg subject, i.e. approximately twice that found in the healthy adult. There was a good correlation between 3 MEHIS and creatinine. Muscular catabolism is hence proportional to the degree of lean body mass. By contrast, there was no correlation between the excretion of 3 MEHIS and nitrogen excretion. Finally, study of the effect of qualitative and quantitative variations in nitrogen intake on muscular proteolysis did not make possible any conclusion at present. Further studies are hence necessary.
Abdomen↗
[Branched amino acids. Role and value in parenteral nutrition].
The authors undertook a general review of the principal studies concerning branched amino acid (B.A.A.) and justifying their use in large doses during parenteral alimentation. Certain particular features emerge concerning valine, isoleucine and leucine which render these three amino acids particularly valuable:--their metabolism is essentially mascular and they escape hepatic control in great part, in contrast to other amion acids;--broken down by muscle, they represent a significant source of energy, sometimes the only available, but may also be used in numerous metabolic processes;--particularly sensitive to hormonal actions, their metabolism is in addition regulated by different non-hormonal factors;--their regulatory role of insulin secretion is considered to be important by many authors;--their original behaviour in certain pathological circumstances, and in particular in malnutrition states, the post-agressive phase and in hepatic failure, has resulted in progress in the physiopathology of these pathological states and above all led to valuable therapeutic deductions;--their toxicity is negligeable and they may be given in large amounts during parenteral alimentation without causin intolerance reactions or severe disturbances in plasma aminograms.
Amino Acids, Branched-Chain↗
[Bacteroides fragilis septicemia].
On the basis of eight cases of Bacteroides fragilis septicaemia, the authors review recent data from the literature related to this topic. They first note the increasing prevalence, accounting for approximately 10 per cent of all septicaemias at the present time. They note that the most frequent portals of entry are sites of localised suppuration, related on the one hand to digestive or gynaecological surgery and, secondly, to the post-partum or post-abortum period. From a therapeutic standpoint, they stress the important role of imidazole derivatives (metronidazole or tinidazole) which are the most effective antibiotics at present. Certain authors even suggest their use on a preventive basis in high risk subjects.
Adult↗
A reappraisal of preoperative chemoradiation for localized pancreatic head ductal adenocarcinoma in a 5-year single-institution experience.
Resection of localized pancreatic head ductal adenocarcinoma (LPHDA) has a limited impact on survival. Mechanisms of improvement provided by preoperative chemoradiation therapy (CRT) remain under debate. This study analyzes the outcome of patients treated for LPHDA to delineate the benefits of CRT. Among 87 patients with LPHDA, 17 had a pancreaticoduodenectomy alone (group I). Thirty-nine with initially resectable cancers received CRT with 5-fluorouracil-based chemotherapy (group II). Thirty-one with initially unresectable cancers were similarly treated by CRT (group III). Patients in groups II and III were restaged after completion of CRT. In patients with resectable disease, resection was planned. Patients in groups I and II were statistically comparable in terms of age, sex, and pretherapeutic stage. Median survival and 2-year overall survival in group I were 13.7 months and 31%, respectively. In group II, 23 patients (59%) had a pancreaticoduodenectomy (group IIa) and 16 patients (41%) did not have resection (group IIb). Median survival and 2-year overall survival were as follows: group IIa, 26.6 months and 51%; and group IIb, 6.1 months and 0%, respectively. In group IIa, pathologic examination revealed eight major responses (35%) including two sterilized specimens, and none of the patients had locoregional recurrence. In group III, none of the patients had resection, and median survival was 8 months with one 2-year survivor. Patient selection appears to play a major role with regard to results achieved with preoperative CRT followed by pancreaticoduodenectomy. However, a high histologic response rate and excellent local control can also be achieved.
Aged↗
[Satisfaction with anesthesia: a review of the existing instruments].
EVALUATING PATIENT SATISFACTION: In France, patient satisfaction is a criteria for health care facility accreditation. In this context, the anesthesia community has studied tools available for assessing satisfaction with anesthesia. LIMITATIONS OF AVAILABLE INSTRUMENTS: The construction of a satisfaction assessment instrument can be divided into three phases: design, sorting items, validation. Instruments available in the currently literature (1987-1997) focus mainly on pre, per- or postoperative management but little on overall patient satisfaction. As the concept of satisfaction concerns a variety of elements, many of the available instruments use a multidimensional approach. The areas explored however vary greatly depending on the author or the study. In addition, patient experience is rarely taken into consideration when designing instruments. FOUR INSTRUMENTS: Among the available instruments we retained 4 questionnaires: Patient Satisfaction with General Anaesthesia, Peri-operative Anesthesia Experience Scale, Iowa Satisfaction with Anesthesia Scale, and Amerstadam Preoperative Anxiety and Information Scale. These last 2 scales only assess patient information and anxiety. The Peri-operative Anesthesia Experience Scale alone is available in French (Echelle de Vécu périopératoire de l'Anesthésie). Patient satisfaction is also approached with specialized instruments designed to assess specific items. The most widely used scales assess anxiety and pain. Based on these findings, it is dear that the fundamental concept of patient satisfaction must be revisited. We propose a few points for thought.
Anesthesia↗
[A peculiar esophago-pleural fistula].
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Esophageal Fistula↗
Tolerance and feasibility of perioperative treatment with interferon-alpha 2a in advanced cancers.
BACKGROUND: Major surgery impairs the cellular immune response. In order to stimulate the immunological system during the perioperative period, we have studied the clinical and biological tolerance, and the immunological and histological effects of a perioperative treatment using progressive doses of Interferon-alpha 2a, from the third preoperative day (D-3) until the tenth postoperative day (D10). MATERIALS AND METHODS: Twenty-three patients undergoing a major surgical procedure for advanced cancer were included. The clinical and biological parameters evaluated were the body temperature and the blood cell counts. Immunological effects were evaluated by counting the total number of lymphocytes, lymphocyte subsets, natural killer cells (NK), and by analysis of the NK activity, and lymphokine-activated killer cell (LAK) assay. RESULTS: Hyperthermia was the most toxic effect of Interferon-alpha but the overall toxicity was minor, even at the highest dose level. In the early postoperative period there was a significant decrease in total lymphocytes, and in most lymphocyte subset counts when compared with D-3. Overall NK and LAK activities significantly increased from D-3 to D-1 (p < 0.02). A postoperative decrease in NK activity was noted that was not significant when compared to pretherapeutic values, whereas a significant decrease in LAK activity did occur on D4 despite the interferon treatment (p < 0.03). Since we found a dose-dependent effect on some lymphocyte subsets, there was not a clear dose-dependent effect on NK and LAK activities. CONCLUSIONS: Perioperative alpha 2a administration is a safe treatment in advanced cancer patients that may allow a postoperative preservation of NK activity and a destruction of potential circulating metastatic cells. Further studies are ongoing on perioperative immunotherapy in advanced cancer patients.
Adolescent↗