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Background: It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption. However, there is currently no evidence to support the speculation. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine reduces postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil., Methods: Patients were randomized to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 h after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting., Results: The study was stopped prematurely because of five cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01 to 1.33; P = 0.031). Hypoxemia occurred 110 of 152 (72%) of dexmedetomidine group and 94 of 155 (61%) of remifentanil group patients (relative risk, 1.19; 95% CI, 1.02 to 1.40; P = 0.030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 h postoperative morphine consumption (11 mg [5 to 21] versus 6 mg [0 to 17]) and postoperative nausea and vomiting (58 of 157 [37%] versus 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45 to 0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubation and prolonged postanesthesia care unit stay., Conclusions: This trial refuted the hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia., (Copyright © 2021, the American Society of Anesthesiologists, Inc. All Rights Reserved.)

Radical cystectomy is associated with a high postoperative mortality and morbidity in older patients. We aimed to define the predictive value of comorbidity scores and determine the prognostic factors of postoperative complications. Preoperative associated morbidities were collected and graded according to the American Society of Anesthesiologists (ASA) score system, the Adult Comorbidity Evaluation (ACE) scale and the Charlson comorbidity index. Surgical complications were graded according to Clavien classification. Early and late complications were recorded. Data are from 49 consecutive patients aged ≥ 75 years who had an open surgery for bladder cancer. The most commonly associated conditions were smoking, renal insufficiency, and arterial hypertension. Incidence of early and late complications was 49% and 16%, respectively. Four and 25 death events occurred during the early and late follow-up, respectively. The incidence of morbidity and mortality were not related to ASA, ACE or Charlson scores. Preoperative malnutrition, renal insufficiency, higher need of perioperative blood transfusions, and prolonged ileus were identified as risk factors of postoperative morbidity. Late complications seemed related to low weight., Competing Interests: None

Objective: To determine the tools of therapeutic decision that push towards surgical treatment in non metastatic prostate cancer eligible to local treatment. The optimized assessment of the disease and eventual comorbidities improves the selection of patients. Patient's files will be presented in the uro-oncological multidisciplinary discussions to validate the customized therapeutic approach proposed., Materials and Methods: Literature review using Medline (National library of medicine, Pubmed) and Med Science databases based on the scientific pertinence. Research was focused on the diagnosis of prostate cancer, the evaluation of the disease and patient's characteristics, and finally the elements that are with a surgical treatment (past medical history, past surgical history, functional status, patient's comorbidities, and life expectancy)., Results: The pretherapeutic oncologic evaluation allows to estimate the risks associated with prostate cancer; it is an essential aspect of therapeutic decision. Several clinical, biological, imaging and pathological criteria allow to guide decision-making according to tumor aggressiveness and risk of recurrence, estimating the results of the different treatments proposed. On the other hand, the evaluation of lower urinary tract symptoms, urinary continence and sexual function, the integration of anatomical data, past medical and past surgical history are all essential for the therapeutic decision, in addition to the comorbidities (Charlson, ASA, ICD). These elements should be taken all together in order to decide for a radical or conservative management of PCa, they guide decision-making in patients candidate for surgery. For example, age plays a key role in the choice of treatment, even in older men at risk of developing high-risk PCa that can affect overall survival., Conclusion: The combined evaluation of the patient and disease characteristics is of utmost importance in oncology, and especially in the treatment of non-metastatic PCa. The role of the anesthesiologist in the analysis and interpretation of comorbidities remains primordial and it is essential for the selection of the right candidates for surgery after being well informed, and orienting them toward surgery in agreement with the prerogatives programs of customized care., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The surgical care pathway of neurologic patients has two aims: preventing urinary morbidity and mortality and improving their quality of life. It requires taking into account the specificities of disabilities in domains of body functions: circulatory, ventilation and digestive physiology, motor functions, sensory functions, mental functions, and skin fragility which are responsible of dependencies in this heterogeneous group of patients. This management is necessarily multidisciplinary to be optimal and through specific clinical care pathway, providing guidance to the surgical procedure: preparation of the surgery, its realization, and post-operative rehabilitation. The indication for surgery must be coordinated and validated in neuro-urology multidisciplinary staff. Preoperative stay in a physical and rehabilitation medicine center may be useful to ensure a complete assessment and anticipate problems related to surgery. The patient will be hospitalized in the urology department in a single room suited to their disabilities and handicaps. The chronic treatments should be not modified if possible. The lack of sensitivity does not dispense anesthesia to prevent autonomic hyperreflexia, the most severe complication after high complete spinal cord injury. The laparoscopy and sub-peritoneal surgery, the early removal nasogastric tube and early refeeding make it possible to early resumption of intestinal transit. In many cases, the patients should be transferred to a physical and rehabilitation medicine during post-operative period where the nursing care will be most suitable. A quickly adapted rehabilitation must be able to reduce loss of function and physical dependence., (Copyright © 2012. Published by Elsevier Masson SAS.)

Objective: To compare the results of retroperitoneal laparoscopic adrenalectomy using the antegrade and retrograde approach., Materials and Methods: We performed an analysis of a single-center series of 279 retroperitoneal laparoscopic adrenalectomies from 1996 to 2010. We compared 172 cases performed with an antegrade approach and 107 with a retrograde approach without dissection of the renal hilum and initial control of the adrenal vein in comparable populations., Results: The operative time was shorter in the group treated with the retrograde technique, 101±51 vs 140±40 minutes, respectively (Student's t test, P<.001). Blood loss was similar in both groups, 85±224 vs 80±126 mL, respectively (P=NS). Hemodynamic instability was defined as the maximal systolic blood pressure minus the minimal systolic blood pressure divided the maximal systolic blood pressure. It was lower in the group who underwent the retrograde technique (32.7 vs 37.6 mL; Student's t test, P=.005) with a lower perioperative consumption of ephedrine (2.2 vs 5.1 mg, P=.004) and atropine (0.09 vs 0.22 mg, P=.026). No difference was found between the 2 groups in the frequency of perioperative complications or postoperative mortality (1 death in each group of causes unrelated to the surgery)., Conclusion: Retroperitoneal laparoscopic adrenalectomy using a retrograde approach is a safe and reproducible technique. It makes it possible to perform adrenalectomy without dissection of the renal hilum, with a reduction in the operative time. The good hemodynamic stability observed with this technique makes it very attractive for the treatment of pheochromocytoma., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The esCCO monitor (ECG- estimated Continuous Cardiac Output, Nihon Kohden(®)) is a new non-invasive tool for estimating cardiac output (CO). It derives CO from the pulse wave transit time (PWTT) estimated by the ECG and the plethysmographic wave. An initial calibration is needed to refine the relation linking pulse pressure (measured by arterial pressure cuff) to PWTT. To assess the accuracy and reliability of the esCCO system, we performed an analysis of agreement of CO values obtained by transthoracic echocardiography (TTE)., Methods: Thirty-eight intensive care unit patients were prospectively included. CO was determined simultaneously using esCCO (CO(esCCO)) and TTE (CO(TTE)) as our reference method., Results: A total of 103 paired readings from 38 patients were collected. The correlation coefficient between CO(esCCO) and CO(TTE) was 0.61 (P<0.001). The Bland and Altman analysis corrected for repeated measures showed a bias of -1.6 litre min(-1) and limits of agreement from -4.7 to +1.5 litre min(-1), with a percentage error (2 sd/mean CO) of 49%. The correlation for CO changes was significant (R=0.63, P<0.001), but the concordance rate was poor (73%). Polar plot analysis showed an angular bias of -9° with radial limits of agreement from -54° to +36°. The bias appeared to correlate with systemic vascular resistance (R=-0.45, P<0.001)., Conclusions: In critically ill patients, the performance of the esCCO monitor was not clinically acceptable, and this monitor cannot be recommended in this setting. Moreover, the esCCO failed to trend CO data reliably.

Introduction: Remifentanil is a powerful morphinic agonist often ordered for anaesthesia. The use of peroperative large doses of this opioid increases the risk to develop postoperative hyperalgesia and acute tolerance. But how early these effects can occur? Despite the fact that these effects could be masked during the preoperative time because of general anaesthesia, it seems they could occur precociously. In order to try to describe this time, this study evaluated the acute tolerance under general anaesthesia requiring large doses of remifentanil by using an effective peroperative monitoring of nociception: the continuous pupillary diameter monitoring., Materials and Methods: In this prospective observational clinical study, a continuous infusion of remifentanil was started at a range of 0.3 microg/kg/min after induction of anaesthesia by using propofol (TIVA), remifentanil bolus and cisatracurium. The pupil monitoring started 10 min later (T+10 min) and lasted until the surgical incision (T+65 min). So, there was no surgical stimulus during this time., Results: Thirty patients undergoing major cardiac or vascular surgery were included in this study. The continuous pupil diameter evaluation showed a significant increase of the pupil diameter from T+45 min. No significant variation of heart rate, blood pressure, bispectral index (BIS) values were observed., Discussion: The development of acute remifentanil tolerance could possibly explain these results. If evaluations with continuous pupillary diameter monitoring are still limited, these results suggest that the use of powerful opioids such as remifentanil should be associated with a N-methyl-D-aspartate (NMDA) receptor antagonist agent, including short time administrations.

Age should not be a limiting factor for optimal surgical care of cancer. Preoperative assessment and therapeutic line decision must be a multidisciplinary team work. A specific geriatric oncology consultation would help assessing the level of autonomy or dependence, the patient cognitive functions and his nutritional status. The preoperative interview and clinical examination aim to assess the overall general health of the patient and to detect cardiovascular, pulmonary and neurological disorders which are the main postoperative factors of morbidity and mortality, other than related to tumor itself. Many scores of surgical risk assessment have been proposed. The Charlson index and the CIRS-G are the most widely used. Because of pharmacokinetic and pharmacodynamic changes related to age, new anesthesia techniques, such as target intravenous anesthesia (TIVA), which allow fine adjustment of anesthesia level according to the patient individual parameters (age, weight, height, sex) will be preferred. The most frequent postoperative complications are those related to hypothermia, pain and postoperative cognitive dysfunction. The main objective of the preoperative care of the elderly person is a rapid return to autonomy in a familiar environment., ((c) 2009 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate compliance with clinical practice guidelines concerning prophylactic antibiotics in urological surgery., Material and Methods: Thirty per cent of the medical charts for the first 288 patients operated in 2005 and requiring prophylactic antibiotics were selected at random. On this sample of 84 patients, compliance with the CHU de Toulouse (Toulouse teaching hospital) and société française d'anesthésie et de réanimation (SFAR) (French Society of Anaesthesia and Intensive Care), prophylactic antibiotic guidelines were investigated according to the method recommended by the Centre de coordination de da lutte dontre des infections nosocomiales (CCLIN) Ouest (Nosocomial Infection Control Coordination Centre) which analyses the indication, type of antibiotic, time of administration and duration of treatment., Results: The compliance rate with the indication was 88.1%. When prophylactic antibiotics were effectively administered, compliance with guidelines were 91.9% for type of antibiotic and 72.9% for time of administration. The duration was excessive in one case. The overall compliance rate was 58.3%., Conclusion: Prophylactic antibiotic guidelines were inadequately applied, especially concerning the time of administration. Further progress must be made in terms of compliance with guidelines and recording of administration, which must be repeatedly evaluated.

Background: Using the intubation difficulty scale (IDS), we sought to confirm that obese patients are more difficult to intubate than lean patients. We assessed classical bedside tests and included neck circumference., Methods: We prospectively compared the incidence of difficult tracheal intubation in 70 obese [body mass index (BMI) > or = 30 kg/m(2)] and 61 lean patients (BMI < 30 kg/m(2)). The IDS scores, categorized as difficult intubation (IDS > 5) or not (IDS < or = 5), and the patient data, were compared between lean and obese patients. Preoperative measurements [BMI, neck circumference (at the level of the thyroid cartilage), width of mouth opening, sternomental distance, and thyromental distance], medical history of obstructive sleep apnea syndrome, and several scores (Mallampati, Wilson, El Ganzouri) were recorded. The view during direct laryngoscopy was graded, and the IDS was recorded. We then compared patients with IDS < or = 5 and > 5, concerning each item., Results: The results indicate that difficult tracheal intubation is more frequent in obese than in lean patients (14.3% vs 3%; P = 0.03). In the patients with IDS > 5, thyromental distance, BMI, large neck circumference, and higher Mallampati score were the only predictors of potential intubation problems., Conclusion: We found that problematic intubation was associated with thyromental distance, increasing neck circumference, BMI, and a Mallampati score of > or = 3. Neck circumference should be assessed preoperatively to predict difficult intubation.

Objective: To study the morbidity and haemodynamic parameters on a consecutive series of adrenalectomies performed Jbr phaeochromocytoma by retroperitoneal laparoscopy., Material and Methods: The study population comprised 23 phaeochromocytomas in 20 patients treated by controlled retroperitoneal laparoscopic surgery. The following parameters were studied: intraoperatively: operating time, blood loss, blood pressure, heart rate, and postoperatively: infectious, haemorrhagic and thromboembolic complications., Results: The mean operating time was 156 minutes (range: 105-224). Mean blood loss was 58 ml (range: 0-300). Intraoperatively, 1500 of patients presented a peak SBP >220 mmHg and 70% presented a peak SBP >200 mmHg. In contrast, 200 of patients presented a nadir SBP <60 mmHg, but no patient presented a nadir SBP less than 40 mmHg. One case of intraoperative haemorrhage was observed (4.3%). Three postoperative complications (1 case of respiratory distress, 1 case of haemorrhagic shock, and 1 abscess) were observed (13%)., Conclusion: Laparoscopic surgery for phaeochromocytoma is associated with a risk of haemodynamic instability. Phaeochromocytoma surgery should therejbre continue to be performed in specialized centres (surgical, anaesthetic and endocrinological).

Objective: Glutamine (Gln)-supplemented total parenteral nutrition (TPN) improves clinical outcome after planned surgery, but the benefits of Gln-TPN for critically ill (intensive care unit; ICU) patients are still debated., Design: Prospective, double-blind, controlled, randomized trial., Setting: ICUs in 16 hospitals in France., Patients: One-hundred fourteen ICU patients admitted for multiple trauma (38), complicated surgery (65), or pancreatitis (11)., Interventions: Patients were randomized to receive isocaloric isonitrogenous TPN via a central venous catheter providing 37.5 kcal and 1.5 g amino acids.kg-1.day-1 supplemented with either L-alanyl-L-glutamine dipeptide (0.5 g.kg-1.day-1; Ala-Gln group, n=58) or L-alanine+L-proline (control group, n=56) over at least 5 days., Measurements and Main Results: Complicated clinical outcome was defined a priori by the occurrence of infectious complications (according to the criteria of the Centers for Disease Control and Prevention), wound complication, or death. The two groups were compared by chi-square test on an intention-to-treat basis. The two groups did not differ at inclusion for type and severity of injury (mean simplified acute physiology score II, 30 vs. 30.5; mean injury severity score, 44.9 vs. 42.3). Similar volumes of TPN were administered in both groups. Ala-Gln-supplemented TPN was associated with a lower incidence of complicated outcome (41% vs. 61%; p<.05), which was mainly due to a reduced infection rate per patient (mean, 0.45 vs. 0.71; p<.05) and incidence of pneumonia (10 vs. 19; p<.05). Early death rate during treatment and 6-month survival were not different. Hyperglycemia was less frequent (20 vs. 30 patients; p<.05) and there were fewer insulin-requiring patients (14 vs. 22; p<.05) in the Ala-Gln group., Conclusions: TPN supplemented with Ala-Gln dipeptide in ICU patients is associated with a reduced rate of infectious complications and better metabolic tolerance.

Objective: The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture., Methods: A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up., Results: In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3., Conclusions: In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Purpose: The aim of this study was to evaluate the feasibility and safety of endovascular repair in acute traumatic aortic rupture on the basis of our experience with 16 patients., Materials and Methods: From January 1996 to December 2001,16 patients, with a mean age 36 years, underwent repair of traumatic rupture of the aorta with the use of stent-grafts. All patients presented with coexisting injuries and 9 of 16 patients were hemodynamically unstable because of other injury. After a delay ranging from 9 to 245 days (mean 78 days), aortic stent-grafting was performed by a multidisciplinary team. All patients had regular follow-up with spiral CT and transesophageal echocardiogram., Results: Stent-graft placement was successful in all patients with exclusion of false aneurysm. The duration of the procedure was about 120 min and mechanical respiratory assistance could be removed immediately in 80% of patients. Mean stay in the intensive care unit was 24 hours. One complication was noted: compression of the left main stem bronchus successfully treated with endoprosthesis. Maximum follow-up was 7 years., Conclusion: Endovascular stent-graft repair is a valuable technique and is emerging as an alternative technique for treating thoracic aortic injury in patients in whom coexisting injury increases the surgical risk.

Swallowing and respiration are well-coordinated and interdependent functions. When one of these processes is impaired, the consequence may be negative for the other. This article describes the mechanisms of the disorders of swallowing, the effects of tracheotomy or intubation and mechanical ventilation on swallowing, and the procedures used to assess and treat perturbation of swallowing. Combining a basic understanding of these concepts with practical management can increase safe and efficient oral intake in patients after artificial ventilation.

Background: Datura stramonium is a hallucinogenic plant that causes serious poisoning. Due to its easy availability and strong anticholinergic properties, substance users and teens may use Datura stramonium as a drug. Consumption of any part of the plant can result in severe toxicity., Case Reports: 3 cases of acute self-poisoning by ingestion of Datura stramonium are reported. The patients presented with a typical anticholinergic syndrome: agitation, confusion, hallucinations and combative behaviour; all of them had mydriasis, but dry mouth and tachycardia were less common. All these 3 subjects had a good prognosis but have required hospitalisation because of severe psychiatric derangement with agitated behaviour. The patients were favourably managed with only symptomatic treatment., Discussion: This article reviews the clinical syndrome associated with the toxicity. The severity of hallucinations and confusion, associated with pupillary dilation, flushing, dry mouth, and tachycardia, are related with Datura intoxication. Symptomatic treatment is efficient., Conclusion: Primary care physicians might be informed about the abuse of Datura stramonium, often associated with substance misuse, and the need to educate risk-patients.

Objective: To review the current data on the duration of an antibiotic treatment., Methods: Analysis of recent and older articles on criteria of discontinuation of an antibiotic treatment in intensive care patients., Synthesis: In intensive care patients the initiation of an antibiotic therapy is more or less codified, in spite of numerous existing problems. The duration of its maintenance, although based on scientific data depends mainly on a multitude of variables. The first step is to assess the therapeutic efficiency in considering the regression of clinical manifestations, the normalization of the acute phase reactants, the sterility of bacteriological samples and the absence of relapse at therapy discontinuation. An assessment after 48 hours is essential, in order to decide the maintenance or the modification of therapy. Finally the indication of bitherapy is considered. The theoretical duration of antibiotic therapy is determined in taking into account the involved microbial agent(s), the centre of infection, the bacterial inoculum, the patient, the presence of foreign material, and the administered antibiotic.

The bactericidal activity of beta-lactams is time-dependent, and the time spent above the MIC (T > MIC) is the best predictor of efficacy. A prospective, randomized, open-label study was conducted in intensive care unit (ICU) patients with gram-negative rod infections to compare the efficacy of cefepime given as a continuous versus an intermittent infusion. Of the 18 patients included to date, 14 had severe pneumonia and four bacteremia. All patients received amikacin, 15 mg/kg/d, and cefepime, 4 g/d. Patients were randomized to cefepime administration as a continuous infusion (Group 1, n = 9) or as an intermittent infusion (Group 2, n = 9, 2 g every 12 h). No significant differences were found between the two groups for age, sex, initial infection, IGS II score (46 vs 48, NS) or the MIC of the gram-negative organism. Mechanical ventilation and hospital stay durations, recovery rates, and pharmacokinetic parameters (24-h AUIC, 12-h AUIC, T > MIC, and T > 5 x MIC) were compared in the two groups using the chi-square and Mann-Whitney tests. P values < 0.05 were considered statistically significant. There were no significant differences for mechanical ventilation duration, recovery rate, hospital stay duration (34 vs 36 days, NS), 24-h AUIC (624 vs 473, NS), or the 12-h AUIC (235 vs 238, NS). There were two interesting findings: T > MIC was significantly (P < 0.05) higher in Group 1 (23.84 +/- 0.2) than in Group 2 (20.7 +/- 3), and T > 5 x MIC was also significantly (P < 0.01) higher in Group 1 (23.61 +/- 0.6) than in Group 2 (16.6 +/- 6). Although clinical outcomes were similar in the two groups, it is reasonable to assume that the longer time spent with a cefepime level above the MIC in the continuous infusion group was associated with a more stable bactericidal effect.

Background: Stent grafting is emerging as a new treatment for several pathological conditions involving the thoracic aorta. We studied the feasibility and safety of this technique for delayed treatment of ruptures of the aortic isthmus., Methods and Results: Nine patients (14 to 76 years old; mean, 37 years; male/female ratio, 8/1) underwent stent grafting of the aortic isthmus in subacute (n=5) or chronic (n=4) aortic traumatic rupture after a motor accident. In subacute ruptures, this treatment was delayed (1 to 8 months; mean, 5.4 months) because of the severity of other associated injuries. Stent grafting was technically successful (defined as complete exclusion of the pseudoaneurysmal sac) in all patients. Short-term fever and biological inflammatory syndrome occurred in 3 patients. Two major complications occurred: in 1 patient, an early occlusion of the left subclavian artery was treated by placement of 2 Palmaz stents. In another patient, an atelectasis related to an increase of preexisting compression of the left main bronchus by the pseudoaneurysmal sac was successfully treated by temporary placement of an endobronchial silicone stent. Mean follow-up was 11.6 months (range, 3 to 21 months). Thrombosis of the pseudoaneurysmal sac was found in all patients., Conclusions: In the absence of available extended follow-up about the safety and effectiveness of endovascular grafting, this approach seems to be a viable therapeutic option for traumatic rupture of the aortic isthmus, but appropriately controlled prospective studies are needed before we can recommend its widespread use.

Nitric oxide (NO) is a free radical gas and a short-lived messenger which has many paracrine functions. Direct assessment of NO production is very difficult in vivo. However, the paranasal cavities generate a high amount of NO which diffuses in the nasal cavity where it can be easily measured. Several studies have suggested alterations of the NO production in heart failure. Thus, we assessed nasal NO concentration in normal subjects and in heart failure patients. The nasal NO concentration averaged 227 +/- 10 ppb in the control group (n = 20), and 210 +/- 10, 198 +/- 20 and 159 +/- 54 ppb in New York Heart Association (NYHA) class II (n = 30), III (n = 28) and IV (n = 7) patients, respectively (mean +/- standard error [SE], not significant using analysis of variance [ANOVA]). Nasal NO level was not influenced by age, sex or etiology of the heart failure or by treatment with frusemide, angiotensin-converting enzyme inhibitor or digoxin. However, treatment with NO-releasing drugs (nitrates or molsidomine) significantly decreased the nasal NO level in heart failure patients. A two-way ANOVA revealed that treatment with a NO-releasing drug influenced nasal NO concentration (P = 0.0005), whereas NYHA class did not (P = 0.23), with a trend towards an interaction between the two parameters (P = 0.09): the inhibitory effect of NO-releasing drug on nasal NO concentration was more pronounced in severe heart failure. In an additional group of 12 patients (NYHA class II or III), the nasal NO concentration was 174 +/- 19 ppb during NO-releasing drug treatment and increased to 231 +/- 27 ppb 3 days after withdrawal of the nitrates (P = 0.0007 using paired t-test). Conversely, the nasal NO concentration in another group of seven patients (NYHA class II or III) was 219 +/- 32 ppb without nitrate treatment and decreased to 188 +/- 28 ppb 7 days after nitrate addition (P = 0.02 using paired t-test). In contrast, the nasal NO concentration in another group of ten ischemic patients without heart failure was 203 +/- 25 ppb without nitrate treatment and was similar (207 +/- 28 ppb) 7 days after nitrate addition (not significant using paired t-test). In conclusion, nasal NO production is normal in heart failure, except in patients receiving NO-releasing drugs. Nasal NO concentration could be useful for investigating the mechanism(s) by which exogenous NO donors decrease endogenous NO production.

Objectives: To evaluate the development of resistance to fosfomycin or fucidic acid in severe infections caused by methicillin-resistant Staphylococcus aureus (MRSA) and to assess the relationship with serum levels of vancomycin, Methods: A retrospective study was performed in patients hospitalized in our intensive care unit during a 3-year period (1993-1995) who were treated for severe MRSA infection with continuous infusion vacomycin and fosfomycin or fucidic acid. We analyzed the development of resistance and serum levels of vancomycin., Results: During this period, only 20 patients received continuous infusion vancomycin plus fucidic acid or fosfomycin. MSRA resistant to fucidic or fosfomycin developed in 9. Vancomycin serum levels were significantly lower in patients who developed resistance to focidic acid or fosfomycin, both during the first 5 days of treatment (16.68 +/- 1.07 micrograms/ml vs. 22.64 +/- 1.05 mg/ml, p < 0.01) and throughout treatment duration (17.29 +/- 1.07 micrograms/ml vs. 21.85 +/- 0.78 microgram/ml, p < 0.01)., Conclusions: Our findings confirm that in spite of continuous vancomycin infusion at an initial rate of 2 g/24 h, Staphylococcus aureus resistance to fosfomycin or fucidic acid an develop during ongoing treatment. Vancomycin levels of at least 20 micrograms/ml should be obtained as rapidly as possible.

The aim of the study was to compare changes in blood pressure (BP) and heart rate (HR) variability, catecholamine and neuropeptide Y (NPY) plasma levels induced by passive head-up tilt in normal and sino-aortic denervated (SAD) chloralose-anaesthetized dogs. In controls, 80 degrees head-up tilt test failed to change BP and increased HR. Plasma noradrenaline and NPY levels (but not adrenaline) significantly rose. In SAD dogs, head-up tilt test induced a marked and reproducible decrease in BP without any change in HR or noradrenaline and NPY plasma levels. In SAD dogs, spectral analysis in supine position was characterized by reduced variability in the high frequency (HF) band of the HR spectrum without changes in low frequency (LF) bands of both HR and systolic blood pressure (SBP). Head-up tilt test increased the LF component of SBP variability and decreased the HF component of HR variability in controls but failed to modify HR and BP variabilities in SAD dogs. In conclusion, sino-aortic denervation in dogs elicits a reproducible postural fall in BP with impaired adaptation of sympathetic nervous system activity. This model may be of value in evaluating the pharmacological effects of drugs for the management of orthostatic hypotension.

The present paper investigates the effects of two anaesthetic drugs (pentobarbital and etomidate) on both short-term variabilities of systolic blood pressure (SBP) and heart rate (HR) using fast Fourier transformation and catecholamine plasma levels. HR and BP were continuously recorded through an arterial catheter and blood samples were taken from the jugular vein. Spectral analysis was performed first in the conscious state and six minutes after induction of anaesthesia on a series of 256 consecutive BP and HR values (delta t: 2 Hz). The area under the curve (AUC) was determined in the low-frequency component of the SBP (LF: 40-150 mHz), in the high-frequency band of HR (HF: respiratory frequency +/- 50 mHz) and in the total frequency spectra. Results were normalized by calculation of the ratio between AUC of LF and HF and the total AUC of the corresponding spectrum (TS). Etomidate (2 mg/kg i.v.) induced a significant increase in TS and LF without changing the LF/TS ratio or the HR variability when compared with the awake period. Catecholamine plasma levels did not change. In contrast, pentobarbital (30 mg/kg i.v.) decreased the values of LF, HF, LF/TS and HF/TS and catecholamine plasma levels. These results suggest that pentobarbital decreases the activity of the two components of the autonomic nervous system whereas etomidate induces only minimal changes.

Among 37 patients that are admitted for a more than 3 days breathing reanimation, 19 are ventilated with bacterial filter Pall BB 22 15 and 18 with Darex Hygrobac, exchanged every days and connected to the Y piece. In this study, 6 patients are ventilated with a humidifier (pilot population). For these 43 patients, 130 protected swabs were made with the RCS Biotest placed on the expired gaz. The day of the taking off the expiratory tube was rinsed with 100 ml of aseptic water which are strained on the membrane. The two filters give very good and comparable bacteriological results. The filters prevents nosocomial pulmonary infections making a bacterial frontier between the patient and the respirator and reducing aerial contamination from one patient to another.