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During the last 8 years 51 cases of acute post-traumatic or post-operative cholecystitis were observed in our intensive care unit. Twelve patients benefited from ultrasonically guided percutaneous cholecystostomy under television control. Diagnosis was made by ultrasonic examination and was based on the finding of an enlarged and tender gallbladder with an abnormally thick wall, sometimes with a double wall, and on the presence of sludge. Immediate cholangiography revealed spontaneous perforation in 4 patients who were operated upon at once. The other patients were treated by percutaneous cholecystostomy only with apparent success. The frequency, physiopathology, diagnosis and treatment of acute post-aggressive cholecystitis are discussed, with special reference to this new therapeutic approach.

Nineteen intensive care patients with shock and acute respiratory failure were studied using two different fiber-optic catheters used for the continuous measurement of mixed venous blood oxygen saturation (SVO2). In groupe I patients (n = 11), a Swan-Ganz catheter with optic fibres emitting light characterized by three different wavelengths was used (Opticath Oximetrix). In groupe II patients (n = 8), a Sat-one Edwards catheter was used instead (only two different wavelengths). All the patients were studied in the early stages of shock, once all the calibration procedures had been carried out. An increase in FIO2, using PEEP, fluid replacement therapy and vasoactive drugs or diuretics all improved the cardio-respiratory status of each patient. After each new therapeutic procedure, SVO2 was measured in blood samples obtained from these catheters, and from the pulmonary artery (to give the reference value, using an OSM3 Hemoximeter). Over a period of 1.5 to 6 h, 119 measurements were carried out in Group I, and 91 in Group II. The correlation coefficient was higher with the Oximetrix catheter than with the Edwards one (r = 0.970 and 0.855 respectively; p less than 0.001). Moreover, the 24 h spontaneous drift of the former catheter was less than that of the latter (+3.3 +/- 3.1% vs. +9.3 +/- 7%, p less than 0.05). This study showed that a catheter with optic fibres emitting a light with three wavelengths is more accurate than one emitting only two for the measurement of changes in SVO2 in critically ill patients.

Changes in mixed venous blood oxygen saturation (SvO2) were studied in 2 groups of patients. Group I patients (n = 10) were all hypoxaemic, suffering from acute respiratory failure, requiring that FIO2 be maintained at 1 throughout the study; respiratory and haemodynamic conditions were improved using PEEP and cardiovascular support. On the other hand, Group II patients (n = 13) were non-hypoxaemic patients with circulatory shock in whom FIO2 was gradually increased, and the haemodynamic status was improved using positive inotropic drugs (dopamine, dobutamine, adrenaline, amrinone). All 23 patients had a Swan-Ganz catheter set up for monitoring; all the usual haemodynamic and respiratory parameters were measured. Haematocrit values were kept at the same level throughout the study. Haemodynamic parameters were measured each time a new therapeutic procedure was carried out. No close relationship between SvO2 changes and changes in cardiac index or O2 consumption were found. However, a close relationship existed between changes in SvO2 and changes in O2 extraction (EAO2): SvO2 = -EAO2 + 102 (Group I; r = 0.90, n = 54); SvO2 = -1.2 EAO2 + 103 (Group II; r = 0.93, n = 66). A strong relationship was also found between changes in SvO2 and in FIO2 in each patient of Group II. In the complicated physiological set-up of an intensive care patient, SvO2 reflects oxygen extraction. A fall in SvO2 is related to an altered oxygen demand: oxygen supply ratio. In the most seriously ill patients, there is no relationship between changes in SvO2 and cardiac index.

Polyarteritis nodosa (PAN), with a fatal outcome, developed during the course of a therapeutically controlled Graves'disease. A review of the published literature confirms that two mechanisms may be involved in the onset of PAN in hyperthyroid patients: an immune response, which is probable in the case reported, or a toxic effect related to the treatment of the hyperthyroidism. This case also emphasizes the therapeutical difficulties encountered, in spite of the corticoid and cyclophosphamide associated treatment with plasmapheresis.

Among 606 patients on maintenance dialysis in the same unit, 111 (18.3%) underwent various surgical procedures. 14 additional patients on dialysis in other units were included in this group. A total of 138 surgical procedures were performed in these 125 patients, of which 112 were on hemodialysis. In 57 patients, surgery was warranted by a complication directly related to the chronic renal failure. In 81 patients, surgery was indicated because of an associated condition, a complication resulting from therapy, or a coincidental surgical affection. After these 138 procedures, 27 post-operative complications (19,6 %) and 15 deaths (10,86 %) were reported. The mean age for deceased patients is 66 years. These findings show that surgical morbidity and mortality, even after major procedures, are not prohibitive in patients on dialysis, if certain measures are taken during dialysis, anesthesia, surgery, and post-operative care. These measures are reviewed in the study.

High frequency jet ventilation (HFJV) is a new ventilation technique which ensures satisfactory gas exchanges with tidal volumes of about 2 ml . kg-1. A gas mixture under high pressure is "chopped up" by an electrically-controlled solenoid valve and delivered to the patient by an injection system. A specific heater-humidifier is required for optimal humidity and warmth of the gas mixture. HFJV creates a positive end-expiratory pressure effect in the alveoles, and the increase of mean intratracheal pressure observed accurately reflects the increase of mean alveolar pressure. Convection by direct alveolar ventilation plays a determinant role in CO2 clearance under HFJV, the other gas transport mechanisms being accessory. In respiratory failure with shock HFJV is better tolerated haemodynamically than conventional ventilation. The main indications of the new technique are ENT surgery, thoracic and tracheal surgery, lithotripsy, broncho-pleural and oesophago-tracheal fistulae and circulatory shock.

Fifty cases of post-stress acute acalculous cholecystitis were observed during the past 9 years, mainly after major surgery or trauma. The apparently increasing incidence over the last 4 years (42 cases) could probably be explained by a better diagnostic approach of this condition by routine use of ultrasonography. No specific etiological factor could be found; however total parenteral nutrition and/or sepsis and/or use of narcotics could possibly play a role in the appearance of this complication. Although diagnosis can occasionally be suspected in the basis of abdominal and infectious signs, diagnosis was made primarily on the following ultrasonographic signs: enlarged gallbladder with thickened wall, sludge, and occasionally a double-wall aspect and a pericholecystic collection. In this series, most of the patients were treated by cholecystectomy, but a new therapeutic approach was used in 10 cases: percutaneous transhepatic drainage under sonographic control. Outcome is still poor, with a 50 p. 100 mortality rate.