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B. Vallet *, Y. Blanloeil , B. Cholley , G. Orliaguet , S. Pierre , B. Tavernier a a Pole d’anesthesie reanimation, hopital Huriez, CHRU de Lille, rue Polonovski, 59037 Lille cedex, France b Service d’anesthesie-reanimation chirurgicale, hopital G.-et-R.-Laennec, CHU de Nantes, 44093 Nantes cedex 1, France c Service d’anesthesie-reanimation, hopital europeen Georges-Pompidou, 20, rue Leblanc, 75908 Paris cedex 15, France d Service d’anesthesie-reanimation, hopital universitaire Necker–Enfants-Malades, universite Paris Descartes, Assistance publique–Hopitaux de Paris, 149, rue de Sevres, 75743 Paris cedex 15, France e Institut Claudius-Regaud, 20–24, rue du Pont-Saint-Pierre, 31052 Toulouse Cedex, France

To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition.Prospective observational.We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1cm or tracheal stenosis on the chest x-ray) and 77 control patients.Cormack grades 3-4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th-75th percentiles]) were higher in the goitre group (1 [0 - 4]) than in the control group (0 [0 - 1]; p=0.001), corresponding to an increase in slightly difficult intubation (IDS 1-5: 36/80 vs. 15/77; p0.05). However, incidence of moderate to major difficulty in intubation (IDS5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (or =30%) and reduced mouth opening (4.4cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre.Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.

The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.

The aim of this study was to assess the value of central venous oxygen saturation (ScvO(2)) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003).Prospective, observational.Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO(2) (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO(2) measured before BT (oror=70%). Results are expressed as median.The ScvO(2) before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO(2) increased significantly (from 57.8 to 68.5%) in the group with initial ScvO(2) less than 70% whereas it was unchanged in patients with initial ScvO(2) greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO(2) greater or equal 70% before BT while 13 patients with ScvO(2) less than 70% were not detected by these same criteria.ScvO(2) could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.

Cerebral vasospasm, a recognized complication of aneurysmal subarachnoid haemorrhage, can lead to delayed ischaemic neurological deficit, and death. The systematic administration of nimodipine confers a modest but real benefit against delayed ischaemic damage. When vasospasm occurs, triple-H therapy (hypervolaemia, hypertension, and haemodilution) has long been advocated in order to increase flow, but its usefulness remains unclear. Cardiac output optimization using inotropic drugs might also be considered in selected patients. In practice, only correction of volume depletion and induced hypertension (after aneurysm has been secured) can be recommended. In addition, according to phase II randomized trials, promising new treatments for vasospasm or its ischaemic complications include magnesium sulfate, the selective endothelin A-receptor antagonist clazosentan, and statins. The simple and safe profile of prophylactic use of statins appears particularly attractive. However, all these potential candidates need further validation through (on-going) clinical phase III trials.

We report the occurrence of a sustained hypotension (vasoplegia) following thoracic phaeochromocytoma surgery. Diagnosis of spinal cord injury was done by magnetic nuclear resonance (MNR) showing surgical "Horsley wax" inside the vertebral canal and ischaemic signal inside the anterior part of the spine cord. Removal of "Horsley wax" dramatically improved arterial blood pressure but did not correct all neurologic disorders. Haemodynamic disorders related to spinal cord injury are rare after thoracotomy, and may have been enhanced by the haemodynamic instability typically associated with phaeochromocytoma surgery. Early diagnosis has to be done by MNR.

To analyze the current knowledge concerning xenon anaesthesia.References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files.All categories of articles on this topic have been selected.Articles have been analysed for history, biophysics, pharmacology, toxicity and environmental effects and using prospect.The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and arety of xenon limit its widespread use in clinical practice. The developement of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas. Reducing its cost will help xenon to find its place among anaesthetic agents. An European multicentric clinical trial under submission will contribute to the discussion of the opportunity for xenon introduction in anaesthesia.

To evaluate the incidence of cardiac deaths following noncardiac nonvascular surgery.Retrospective survey.All patients undergoing mainly endocrinous and digestive surgery in a University department of general surgery between 1991 and 1996.Analysis of all deaths occurring intra- and postoperatively, until discharge of the patients. Demographic and medical data, including patent myocardial ischaemia and risk factors for coronary artery disease, were recorded and compared with a control group including all patients undergoing surgery from January to September 1996.In the 8,700 patients who underwent mainly endocrine neck surgery (66%), or intra-abdominal surgery (31%), the mortality rate (n = 96) was 1.1% (95% confidence interval [95% CI] = 0.9-1.3%). Patent myocardial ischaemia or high risk factors for coronary artery disease were existing in 24% of patients with neck surgery, 31% of those with intra-abdominal surgery, and in 60% of the deceased patients (P0.01 vs control group). Those who died were older, were in a higher ASA physical class, and had undergone an emergency procedure more often than patients of the control group (P0.002 for each parameter). Two cardiac deaths, in patients with a patent cardiopathy, were recorded (cardiac mortality: 0.02%; 95% CI = 0.003-0.08%). The main cause of death was infection (n = 46), followed by haemorrhage (n = 12). Seven deaths remained unexplained.This study suggests that cardiac morbidity is a rare cause of death after noncardiac nonvascular surgery.

To assess the reactivity of sarcoplasmic reticulum to caffeine, using the skinned muscle fibre tension test and to compare it with the reference in vitro contracture test in the diagnosis of malignant hyperthermia (HM) susceptibility.Laboratory investigation.Muscle biopsies from 63 patients, including 29 classified as susceptible to MH (MHS) and 34 classified as non-susceptible (MHN) according to criteria of the European and the North American MH groups.The reactivity to caffeine and halothane of skinned muscle fibres was compared, according to the type of fibres, with the data of the in vitro contracture test. The type of fibres (type I: oxidative, slow; type II: glycolytic, fast) were determined with strontium dose-response curves.The reactivity to caffeine was significantly lower in the MHS group, for both type I and type II skinned fibres. However, in comparison with the data of the in vitro contracture tests, using the ROC curve analysis, the best sensitivity-specificity compromise was 90%-71% and 74%-84% for type I and type II skinned fibres respectively.The skinned muscle fibre tension test cannot be used instead of the in vitro contracture test for the diagnostic of MHS. However, it may strengthen the data of the latter.

The aim of this study was to verify whether a relationship exists between neuroleptic malignant syndrome (NMS) and anaesthetic-induced malignant hyperthermia (MH) or not. The in vitro halothane-caffeine tests were performed on muscle tissue obtained from 32 patients with documented NMS episodes. The diagnosis of NMS relied on Levenson's criteria. The results, expressed in accordance with the criteria of the European MH Group, defined 29 subjects as MH non-susceptible. Three patients were classified as MH equivocal. These findings demonstrate the lack of any link between NMS and MH. Therefore, patients with a history of NMS are not likely to be at risk of developing MH and special measures against MH are not required for anaesthesia in these patients.