[Severe hypophosphatemia and grave head trauma]

The authors report the case of an 18-year-old man with polytrauma, who died at the third day of its accident from brain death and who presented during his stay in the intensive care unit, a deep hypophosphatemia. Two physiopathologic mechanisms were presumed: increase of renal losses and intracellular transfer of phosphorus. Consequences, as well as the indications and the therapeutic modalities of hypophosphatemia are discussed.

[Gas embolism and flexible Ecoflac type bag]

Gas embolism at the end of infusion is a well known hazard, that should have disappeared with the use of flexible bags. However, some cases have been reported after pressure infusion. This experimental study evaluates the risk for gas embolism with Ecoflac type flexible bags. These bags are safe under normal pressure infusion conditions with a pneumatic sleeve, because of their texture and pliability; indeed, only minimal air volumes could be expelled, without any risk even in children. However, to be on the safe side, the manufacturer recommends to expel any residual air before pressure administration. This recommendation applies to any bag containing residual air, and since many people are not aware of this, it is rarely put into practice.

Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict

PURPOSE

To identify preoperative factors associated with high blood losses during liver transplantation for chronic end-stage liver disease.

METHODS

Four hundred and ten consecutive patients were included in this retrospective study. Blood losses were calculated, based on transfusion requirements. The population was divided into two groups: the upper quartile was defined as the high blood loss (HBL) group and the lower three quartiles as the low blood loss group. Fourteen preoperative variables were collected. Qualitative variables consisted of the type of hepatopathy, Child-Pugh's classification, sex, the surgical team's experience, previous abdominal surgery and portal hypertension. Quantitative variables were age, hemoglobin concentration Hb, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen concentration, fibrin degradation products (FDP) and euglobulin lysis time. Univariate analysis and stepwise multivariate analysis were conducted.

RESULTS

Patients in the HBL group required 12 units of red blood cell or more to maintain a Hb >/= 100g*L(-1). HBL was associated with severe liver disease, previous abdominal surgery, use of a venovenous bypass and little surgical experience in orthotopic liver transplantation (OLT). In the HBL group several hemostatic parameters were more disturbed before surgery. The multivariate analysis disclosed three independent variables associated with HBL: Hb and FDP concentrations and previous upper abdominal surgery. When combined, these resulted in a high specificity (98%) but low sensitivity to predict blood loss.

CONCLUSION

Despite our efforts we were unable to identify predictive risk factors of bleeding during OLT even in a homogeneous population. Centres should evaluate their practice individually in an attempt to identify patients at high risk of being transfused.

[Liver transplantation in a patient with hemophilia A and end stage liver failure]

We report the case of a 50 year-old man factor VIII deficient haemophiliac and hepatitis C cirrhosis. The patient underwent orthotopic liver transplantation because of episodes of variceal bleeding and encephalopathy. He received factor VIII replacement therapy perioperatively. Factor VIII returned to normal within 24 hours postoperatively and factor VIII replacement was stopped. Liver transplantation can be considered as definitive therapy for haemophilia.

Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve-blocking sequence

BACKGROUND

Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve-blocking.

METHODS

The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected.

RESULTS

The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine-bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred.

CONCLUSION

This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.

Does N-acetylcysteine improve hemodynamics and graft function in liver transplantation?

The release of toxic oxidative free radicals induced by ischemia and reperfusion may jeopardize liver graft function. N-acetylcysteine (NAC) has shown protective effects on hypothermic and warm ischemia reperfusion liver injury in animals. NAC improves hemodynamics and survival rates in patients with fulminant hepatic failure. The aim of this study was to investigate whether intraoperative treatment with NAC would improve hemodynamics and postoperative graft function in liver transplantation. Sixty patients with chronic end-stage liver disease were included in a prospective randomized placebo-controlled study. NAC or the same volume of 5% glucose was started during the anhepatic phase. Hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Postoperative graft function was assessed by measurements of aminotransferases, prothrombin time, and monoethylglycinexylidide test over the 3 first postoperative days. Patient demographics were similar before the infusion of NAC or glucose. Hemodynamic parameters, oxygen consumption, oxygen delivery, oxygen extraction ratio, and lactates were not different throughout the procedure. One hour after the revascularization of the hepatic artery, the oxygen extraction ratio by the liver was similar (17% +/- 7.6% v 17% +/- 6.2%) in both groups. Postoperative graft function was comparable within the 3 first postoperative days. This study failed to show any beneficial effect of the intraoperative administration of NAC on hemodynamics and graft function in liver transplantation in patients with chronic liver disease.

Concentrations of pefloxacin in plasma and tissue after administration as surgical prophylaxis

Plasma and epiploic-fat drug concentrations determined by high-performance liquid chromatography and fat penetration of pefloxacin and its metabolite (norfloxacin) given for antimicrobial prophylaxis were studied in patients scheduled for colorectal surgery. Concentrations of pefloxacin in plasma decreased about 40% from the beginning of the operation to closure of the peritoneum, and corresponding levels in epiploic fat stayed stable. The plasma and tissue norfloxacin concentrations were very low. Concentrations of pefloxacin in tissue were greater than MIC at which 90% of isolates are inhibited for sensitive bacteria (members of the family Enterobacteriaceae). The penetration of pefloxacin into epiploic fat was about 32%.

[Facial diplegia in the course of childhood Lyme disease: bilateral enhancement of the facial nerve and MRI after injection of gadolinium]

We report a rare case of Lyme disease presenting as a bilateral seventh cranial nerve palsy and meningitis. The MR appearance was an enhancement of the internal auditory canal segment and mastoid segment of the seventh cranial nerve, in the absence of parenchymal lesions. One should consider Lyme disease in the differential diagnosis of bilateral seventh cranial nerve palsy with enhancement.

Orthotopic liver transplantation with preservation of portocaval flow compared with venovenous bypass

Conventional liver transplantation requires cross-clamping of the hepatic pedicle and inferior vena cava, leading to severe hemodynamic and metabolic disturbances, usually attenuated by the use of venovenous bypass. A more recent surgical technique, piggyback with temporary portocaval shunting, preserves both caval and portal blood flows. The aim of this study was to compare the two methods prospectively. Forty-four patients with chronic liver disease were studied. Local anatomic conditions guided the surgeon to choose the easiest way to remove the native liver. Anesthetic management was standardized. Hemodynamic and metabolic changes were assessed by use of routine tests at specific periods. Graft function was evaluated by measurement of aminotransferases and monoethylglycinexylidide (MEGX) test 12, 24, 48, and 72 hours postoperatively. Conventional liver transplantation with venovenous bypass was performed in 26 patients, and the piggyback with temporary portocaval shunting was performed in 15 patients. ANOVA showed that cardiac output and systemic oxygen delivery were better maintained before revascularization in the piggyback group. Metabolic changes were comparable, and hyperfibrinolytic activity was detected in both groups. Graft function was comparable and satisfactory within the 3 first postoperative days. Piggyback with temporary portocaval shunting provided better intraoperative hemodynamics and tissue oxygenation than liver transplantation with venovenous bypass.

Early assessment of transplanted liver function: lignocaine clearance test (MEGX)

The purpose of this study was to assess the value of lignocaine biotransformation into monoethylglycinexylidide (MEGX) and conventional liver function tests in the early post-operative period as an indicator of graft function and as a diagnostic tool for complications after hepatic transplantation. Monoethylglycinexylidide formation, plasma bilirubin, aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), factor V index (FVI) and prothrombin time index (PTI) were measured in 71 patients undergoing 80 liver transplantations respectively at 12 (T1), 24 (T2), 48 (T3) and 72 h (T4) after liver graft revascularization. Patients were divided into two group according to the post-operative outcome. Patients with favourable outcome (n = 59) had significantly higher monoethylglycinexylidide synthesis, higher factor V index and prothrombin time index plasma concentrations, lower bilirubin, ASAT and ALAT plasma concentration (P < 0.0001 at T2 and T3) than those with complicated time course (n = 21). Monoethylglycinexylidide synthesis was the best discriminant of a favourable outcome, whereas bilirubin and ALAT concentrations were associated with complications (bilirubin for primary non function [PNF], ALAT for acute rejection). Thus, the combination of parameters at T2 was a very efficient predictor of primary non function, acute rejection and an uncomplicated time course.

Early discovery of a traumatic carotid-cavernous sinus fistula by jugular venous oxygen saturation monitoring. Case report

This report describes the early diagnosis, due to an acute increase of jugular venous oxygen saturation occurring 20 hours after trauma, of a traumatic carotid-cavernous sinus fistula after severe head injury. Hyperemia in severe head injury should be treated only after an intracerebral arteriovenous communication has been excluded.

Predictive factors of hyperfibrinolytic activity during liver transplantation in cirrhotic patients

Hyperfibrinolytic activity occurs frequently during liver transplantation in cirrhotic patients. In order to identify those patients at high risk for increased intraoperative blood loss before operation, we determined predictive indicators of hyperfibrinolysis. We studied 56 cirrhotic patients undergoing liver transplantation with the same anaesthetic procedure and transfusion regimen. The preoperative coagulation patterns of the 11 patients who experienced acute intraoperative hyperfibrinolytic activity were compared with those of the 45 patients who did not suffer this complication. Before surgery, patients with intraoperative hyperfibrinolysis had decreased prothrombin time (PT) and euglobulin lysis time (ELT), and increased thrombin time (TT) and fibrinogen degradation products (FDP), whereas alpha angle and maximum amplitude (MA) were reduced on thrombelastography. Stepwise multivariate analysis disclosed three components which were significantly linked with occurrence of hyperfibrinolysis: TT, FDP and MA. Their sensitivity, specificity, positive and negative predictive values demonstrated that patients with FDP > or = 48 mg litre-1 and MA < or = 35 mm before incision had 100% probability of developing hyperfibrinolytic activity during transplantation.

Mixed venous oxygen saturation monitoring during liver transplantation

High mixed venous oxygen saturation (SVO2) values due to limited oxygen extraction capacities are reported in some patients with severe liver disease. The aim of this study was to evaluate the usefulness of SVO2 monitoring to assess adequate oxygen supply in such patients scheduled for liver transplantation. Nineteen patients with oxygen extraction ratio below 12% were analysed and compared to 20 patients with a pre-operative ratio over 17%. The two groups were comparable with regard to initial pathology, preload and haemoglobin levels. SVO2 values measured discontinuously by co-oximetry were unaffected by the first part of surgery and the clamping period in patients with low oxygen extraction ratio. In these patients, SVO2 was never correlated to oxygen supply during the whole procedure whereas good correlation was noted before and after unclamping in the other group. Tissue hypoxia detected by a dependent oxygen consumption-oxygen supply relationship occurred at clamping and unclamping in patients with initial low oxygen extraction capacities. It is concluded that expensive SVO2 continuous monitoring may not be effective in reflecting changes in oxygen supply in anaesthetized patients with initial severely impaired oxygen extraction capacity.

[Monitoring of hemostasis during liver transplantation: contribution of thromboelastography]

Monitoring of coagulation is mandatory during liver transplantation (LT). Standard coagulation tests may be routinely used. However, they give static information and may be inadequate in case of severe coagulation defect. Interest has been recently focused on thromboelastography (TEG) which could give more suitable and rapid information in these cases. Few studies have evaluated the clinical interest of TEG compared to conventional tests. This comparison was the aim of the present study, performed in 89 patients scheduled for LT. The anaesthetic management as well as procedure of transfusion were similar in all patients. Before unclamping, 5000 KIU.kg-1 of aprotinin were injected. Routine tests and TEG were performed at the beginning and end of both pre-anhepatic and anhepatic phases, and 5, 30, 60, and 120 min after the revascularisation of the new liver. A phase of hypocoagulability was observed after unclamping. Biological signs included an increase in activated thromboplastin time, a reduction of alpha angle and maximum amplitude on TEG with a lengthening of its r + k component. A strong correlation existed between maximum amplitude and platelets, maximum amplitude and fibrinogen, alpha and fibrinogen at each time of the surgical procedure. Euglobulin lysis time decreased significantly after clamping, whereas fibrin degradation products increased at the same time. However, typical fibrinolysis with a clot lysis index (CLI) below 55% was only observed in 15 patients. Twelve of them had a CLI value reaching 0%, associated with severe generalized oozing. Aprotinin (200,000 to 600,000 KIU) corrected these abnormalities. These results show that TEG may not be very helpful to determine whether platelets or fibrinogen are involved in the phase of hypocoagulability detected after unclamping.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anesthesia for non-specific surgery in a post-transplantation patient]

The increase of non specific surgeries in transplanted patients may be related to the better survival achieved by the efficacy of immunosuppressive therapy and improved surgical and intensive care conditions. Therefore, the anaesthetist may be mandated to give anaesthesia in such patients, treated in hospitals which are not involved in transplantation procedures. The ignorance of the main physiologic and pharmacological changes in the new grafted organ as well as the knowledge of high risks of rejection or infection contribute to the anxiety often encountered in front of these patients. The denervated heart is unable to respond to stimulations requiring the integrity of autonomic neural mechanisms. Modulation of cardiac output depends on intrinsic activity (Frank-Starling mechanism) and therefore of end diastolic volume (preload). The denervated transplanted lung shows inability to elicit cough reflex; the latter is totally abolished in case of tracheal anastomosis. These physiologic changes have no deleterious effects on early cardiac and pulmonary functions following transplantation. In the same way, renal, liver or pancreatic functions are restored after respective replacement. However chronic rejection occurs frequently in 50% of patients in a mean time of 5 years following surgery except for liver transplanted patients which seem to be better protected. It results in a progressive decrease in organ function tests. The preoperative assessment requires primary contact with the transplant center. This communication should give precious information about the last biological and functional results as well as about the immunosuppressive therapy. Standard preoperative investigations include measurements of haemoglobin, urea, electrolyte and creatinine concentrations, liver tests, ECG, chest X-ray and coagulation pattern. Previsible difficult intubation should be detected in case of previous pancreas transplantation. Immunosuppressive therapy and other treatments should not be disrupted until surgery. Usual premedication may be used. Previsional peroperative transfusion requires specific packed red blood cells, fresh frozen plasma and platelets in order to reduce CMV contamination and GVH reactions. Locoregional or general anaesthesia may be used with respect to usual contraindications. Special attention should be given in cardiac transplanted patients in order to maintain adequate preload. As atropine is ineffective, bradycardia may be treated by isoprenaline. Patients with lung transplants require a reduction of vascular loading and of hydratation and early postoperative pulmonary physiotherapy. Pancreas transplanted patients often suffer from severe cardiac diseases (coronaropathy). The immunosuppressive therapy modifies the pharmacological behavior of many anaesthetic agents. Ciclosporine enhances mainly the effects of muscle relaxants. Peroperative invasive monitoring requires full aseptic techniques. Invasive monitoring should be discussed in terms of benefit-risk ratio.(ABSTRACT TRUNCATED AT 400 WORDS)

Tissue oxygenation during liver transplantation

OBJECTIVES

a) To assess perioperative changes in tissue oxygenation parameters during liver transplantation; b) to evaluate the need for venovenous bypass as hemodynamic support; and c) to assess the efficacy of mixed venous oxygen saturation monitoring and the importance of lactate determinations in the management of patients following liver transplantation.

DESIGN

Prospective case series.

SETTING

Liver transplant unit in a university hospital.

PATIENTS

A total of 68 consecutive patients undergoing liver transplantation. The entire population was analyzed before and after transplantation, dividing the patients into two groups, based on whether their initial cardiac index was higher (n = 37) or lower (n = 31) than 4.5 L/min/m2.

MEASUREMENTS

Hemodynamic measurements and blood gas analyses were made before incision, before vascular clamping (including hepatic artery, portal vein and inferior vena cava), during the anhepatic phase, and at 5, 30, 60, and 120 mins following unclamping. Oxygen transport and oxygen consumption values were calculated. Serum lactate concentrations were measured by enzymatic technique.

MAIN RESULTS

Mixed venous oxygen saturation was correlated with oxygen transport (Do2) in the whole population in which an abnormal oxygen consumption (Vo2)-Do2-dependent relationship occurred from the beginning of operation until 30 mins following unclamping. The comparison between hyperdynamic patients (initial cardiac index greater than 4.5 L/min/m2) with impaired tissue oxygenation and normodynamic patients showed that mixed venous oxygen saturation failed to correlate with Do2 when the cardiac index was greater than 4.5 L/min/m2 and that the Vo2-Do2 dependency was only noted in these patients. The serum lactate concentrations were similar in both groups.

CONCLUSIONS

The Vo2-Do2-dependent relationship and mixed venous oxygen saturation-Do2 correlation noted in the 68 studied patients suggest the need for venovenous bypass and the reliability of mixed venous oxygen saturation monitoring in all patients scheduled for liver transplantation. However, a sharper comparison between hyperdynamic and normodynamic patients demonstrated the lack of efficacy of mixed venous oxygen saturation monitoring in predicting adequate tissue oxygenation in the first group and the mandatory need for venous shunting to limit tissue hypoxia which occurred despite its use only in these patients. Lactic acidosis appeared similarly in both groups and could not be linked to tissue hypoxia.

[Peroperative massive pulmonary embolism of tumoral origin. Value of extensive monitoring]

A case is reported of a 47-year-old female patient who suffered from massive tumour embolism during a nephrectomy for a renal carcinoma invading the inferior vena cava. Intraoperative monitoring consisted in direct blood pressure measurement (radial artery cannula), central haemodynamic monitoring (Swan-Ganz catheter), pulse oximetry and capnography. During the surgical manipulation of the suprahepatic vena cava, Petco2 suddenly decreased (from 25 mmHg to 14 mmHg), together with Spo2 (from 99% to 89%), and the mean pulmonary arterial pressure increased from 18 mmHg to 40 mmHg. The drop in arterial blood pressure to 50/30 mmHg, initiated an immediate sternotomy. After clamping the superior and inferior venae cavae, numerous tumour fragments were removed from the pulmonary artery. Cardiac activity restarted after internal cardiac massage, 1 mg adrenaline, 1 g calcium chloride and 150 mmol of molar sodium bicarbonate. The whole procedure lasted 30 min. Arterial blood pressure became stable at 110/50 mmHg, pulmonary arterial and wedge pressures at 20 and 5 mmHg. The Spo2 increased to 98%, and Petco2 to 25 mmHg. The nephrectomy was then carried out, the patient being given 5 micrograms.kg-1.min-1 dobutamine and 3 micrograms.kg-1.min-1 dopamine. At the end of surgery, systolic blood pressure was 120 mmHg, mean pulmonary arterial pressure 25 mmHg, and PaCO2 34 mmHg. The patient left the intensive care unit after twelve days. After one year of follow-up, no complication had occurred. The value of cardiopulmonary bypass in nephrectomy for renal carcinoma invading the vena cava, or the renal vein, is discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of urapidil on the cardiovascular response to intratracheal intubation]

The effects of urapidil on the haemodynamic response to endotracheal intubation were compared to that of placebo in two groups of 25 patients scheduled for general surgery. Normal saline solution or 0.4 mg.kg-1 urapidil were injected 3 min before induction of anaesthesia with 3 micrograms.kg-1 fentanyl, 0.3 mg.kg-1 etomidate and 0.1 mg.kg-1 vecuronium. Blood pressure (Pasys, Padia, Pa) and heart rate were measured continuously by servoplethysmomanometry before giving the test drug (T0), at the time when the lowest blood pressure was recorded during the three minute period between giving the drug and induction (T1), at the time when the lowest blood pressure was recorded during the three minute period between induction and endotracheal intubation (T2), at the time when the highest blood pressure was recorded immediately after intubation (T3), three minutes after intubation (T4), five minutes after intubation (T5), and at the time when the lowest blood pressure was recorded after surgery had been started (T6). It was planned to give a 25 mg urapidil dose to any patient, from either group, who had a Pasys greater than 200 mmHg for more than 60 sec. Giving urapidil lowered Pasys (T1) by 16%, whilst heart rate increased by 12%. The blood pressure peak due to endotracheal intubation was lower in those patients who had been given urapidil than in the placebo group (T3; p less than 0.05). Six patients in the latter group required the 25 mg urapidil dose, versus 2 in the urapidil group. The preventive effects of urapidil seem to be similar to those obtained with other antihypertensive agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery from total intravenous anaesthesia. Propofol versus midazolam-flumazenil

The aim of this study was to compare recovery assessed with the Newman, deletion af a's and postbox tests after total intravenous anaesthsia for procedures lasting more than 90 min, with either propofol (PPF) or midazolam (MDZ), reversed or not by flumazenil (FMZ). Thirty patients scheduled for peripheral surgery were randomly allocated to 3 groups of 10, receiving by continuous infusion until the end of surgery either PPF (n = 10) or MDZ (n = 20) combined with alfentanil. FMZ was administered thereafter to 10 patients receiving MDZ until they opened their eyes on command or to a maximum dose of 1 mg. Recovery tests were performed 45, 90 and 180 min after the end of anaesthesia. Results were analysed with non-parametric tests. Recovery scores were significantly better in the PPF group at all times, reaching control values at 180 min for the three first tests. FMZ reversal did not improve the scores compared to those resulting from MDZ alone. This study provides further data in favour of PPF as far as rapid and complete recovery is concerned. The efficiency of FMZ is incomplete and only transient when administered in a single dose.

[Hemodynamics and hepatic transplantation using a veno-venous shunt: influence of the preoperative hyperkinetic state]

The routine use of a veno-venous bypass is not accepted by all surgical liver transplantation teams. The putative benefits (maintaining haemodynamic stability during the anhepatic phase, reducing blood losses, avoiding renal failure) are counterbalanced by the real risks of air embolism or thromboembolism. A severe preclamping hyperkinetic haemodynamic status represents an elective indication for some authors, whilst it is a reduced cardiac function for others. Two groups of ten patients undergoing liver transplantation, with a porto-femoro-axillary venous bypass (flow rate 2 to 2.5 l.min-1), were studied retrospectively. They differed by their pre-clamping cardiac index (CI), greater than 5 l.min-1.m-2 in group A and less than 4.5 l.min-1.m-2 in group B. The same anaesthetic protocol was used in all patients consisting in fentanyl, thiopentone, pancuronium, and midazolam. The use of blood products and biological parameters did not differ between the two series of patients. The CI decreased by 30% and systemic vascular resistances (Rsa) increased by 48% in group A after clamping, without any deleterious effects on oxygen delivery; similarly, in group B, CI fell by 15% and Rsa increased by 20%. After unclamping, CI rose by greater than 50%, and Rsa decreased in both groups. No differences were seen between the two series 5 min after revascularisation. The release of vasoactive agents by the cold ischaemic graft could explain this. These results suggest that veno-venous bypass could be beneficial in the 2 different preoperative haemodynamic profiles studied. The low decrease in CI in hyperkinetic patients allowed tissue oxygenation to be maintained at adequate levels during the anhepatic phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Propofol in elderly high risk patients. A comparison of haemodynamic effects with thiopentone during induction of anaesthesia

Twenty elderly patients of ASA grade 3 or 4, received either propofol 1 mg/kg or thiopentone 2 mg/kg for induction of anaesthesia. These doses provided a convenient level of anaesthesia for all patients. There were no significant intra- or intergroup haemodynamic changes, with the exception of a decrease in diastolic pressure and rate-pressure product after propofol. It is concluded that propofol 1 mg/kg can be used to induce anaesthesia in elderly high risk patients without deleterious cardiovascular effects.

[Perforation of the pulmonary artery during the insertion of a Swan-Ganz catheter]

An accidental rupture of the pulmonary artery in a 77 year old female patient is reported. She was admitted for total mastectomy, but her past medical history revealed an old myocardial infarct, treated arterial hypertension and asthma. She was under heparin as well for her varicose veins. Her clinical examination revealed a patient in mild chronic heart failure. It was therefore decided to carry out invasive monitoring during surgery and the recovery period. A Swan-Ganz catheter was put up. Its progression was controlled by looking at the pressure curves. Several attempts were made to obtain a wedge pressure, with no success. During these attempts, the patient developed a cough followed by massive haemoptysis. Despite adequate resuscitative measures, the patient died before a surgical procedure could be attempted. Postmortem examination showed the rupture to be 9 cm away from the origin of the pulmonary artery. This unfortunate accident confirmed that the following three factors, all present in this patient, should call for extreme care in the setting-up of Swan-Ganz catheters: age greater than 60 years, pulmonary arterial hypertension and anticoagulant therapy.

[The Kontron ABT 4000 respirator. Description, working mechanism and evaluation]

The ABT 4000 ventilator is aimed at being used in operating theatres, as it can be used in an open or a closed circuit, as well as for short periods of artificial ventilation with room air with or without added oxygen. This paper gives a description of the apparatus easy to understand, as well as an analysis of the workings of this constant volume ventilator controlled by microprocessor.

[Anesthesia for surgery of insulinoma]

The difficulties of interpretation of blood sugar level changes during the postoperative period in the anaesthetic management of insulinoma are discussed. Several specific means reduced the errors in the assessment of the hyperglycemic rebound which occurred after the removal of the tumour. They consisted of continuous sugar infusion accorded to measured glucose levels, in order to maintain a constant blood sugar value between 50 and 70 mg X 100 ml-1 before removal of the insulinoma. Furthermore, analgesia was provided by high doses fentanyl. Sugar containing solutes were avoided during the procedure. Glucose levels rose slowly after tumour removal and reached 170 mg X 100 ml-1 at 120 min. This rebound was known to be of no help in ascertaining complete resection. Simultaneous determinations of blood glucose and insulin were obtained. The value of portal blood insulin was found to be normal (12.3 mU X l-1) 30 min after insulinoma removal. Turner's index calculated every 30 min decreased simultaneously (143) and reached a normal value at 120 min (39). These results, obtained during the surgical procedure all the more easily because of rapid laboratory procedures, could be better arguments in determining whether tumour removal has been complete.