Search

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

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).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.A total of 103 paired readings from 38 patients were collected. The correlation coefficient between CO(esCCO) and CO(TTE) was 0.61 (P0.001). 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, P0.001), 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, P0.001).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.

Resume Introduction Le remifentanil est un puissant agoniste morphinique largement prescrit en anesthesie. Il lui est reconnu des effets hyperalgiques en periode postoperatoire. Mais a partir de quand ces effets d’hyperalgesie et de tolerance apparaissent-ils ? Bien qu’ils soient possiblement masques en pratique clinique durant le temps peroperatoire sous anesthesie generale, il semble qu’ils puissent apparaitre tres precocement. Pour tenter d’identifier le delai d’apparition de cette tolerance aigue, ce travail propose d’appliquer une technique d’evaluation de la douleur en continu, fondee sur la variation du diametre pupillaire de patients soumis a une anesthesie generale requerant de fortes doses de remifentanil. Materiels et methodes Apres induction d’une anesthesie associant du propofol (AIVOC), un bolus de remifentanil et de cisatracurium, etait initiee une perfusion continue de remifentanil a 0,3 μg/kg par minute. Le monitorage pupillaire debutait dix minutes plus tard (T + 10 minutes) et se poursuivait pendant la preparation a l’intervention, en dehors de tout stimulus chirurgical, jusqu’a l’incision cutanee qui marquait la fin de l’etude (T + 65 minutes). Resultats Trente patients programmes pour beneficier d’une chirurgie cardiaque ou vasculaire ont ete inclus dans cette etude. Au cours de cette periode, une augmentation significative du diametre pupillaire par rapport a la valeur initiale de reference des T + 45 min etait constatee. Elle persistait jusqu’a la fin de l’etude. Aucune variation significative de la frequence cardiaque, de la pression arterielle ou des valeurs d’index bispectral (BIS) n’etait observee. Discussion Une explication possible a ces resultats serait notamment l’existence des la 45 e minute d’une tolerance au remifentanil a fortes doses, phenomene potentiellement pourvoyeur d’hyperalgesie. Malgre les possibles limites des techniques d’evaluation pupillometrique de la douleur sur une periode d’une heure, ces resultats suggerent que des lors que cet agent est prescrit, et meme sur une courte periode, il y a une possible expression de l’hyperalgesie. Il parait donc indispensable de preceder son administration d’un agent anti- N -methyl- d -aspartate (NMDA).

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.

Introduction Le reflexe de dilatation pupillaire (RDP) lors d’une stimulation cutanee electrique permet d’evaluer la sensibilite individuelle a la douleur. Il a ete rapporte une interaction pharmacodynamique entre le propofol et le remifentanil [1] . Nous evaluons a l’aide d’un pupillometre (Algiscan, IDMed*) les variations de RDP lors de differentes concentrations de propofol pour une meme concentration de remifentanil (1 ng/mL). Patients et methodes Le video pupillometre Algiscan (IDMed*) permet une stimulation de 100 Hz durant 1 s a intensite croissante (10 a 60 mA). Avant l’incision chirurgicale, les patients sont anesthesies en AIVOC par propofol remifentanil (1 ng/mL). Chaque patient a ete teste lors de 3 objectifs de concentration de propofol (2–6 ng/mL). Nous evaluons la reactivite pupillaire en comparant les variations du RDP (%), lors de 3 concentrations de propofol. Nous observons pour ces memes etats les variations de la TAM, frequence cardiaque, BIS et du reflexe photomoteur (RPM). Tests statistiques entre les 3 objectifs concentrations: mediane, Anova. Resultats Nous analysons les donnees de 38 patients successifs, 114 mesures ont ete realisees. On n’a pas observe de variations significatives lors des 3 concentrations de propofol de la frequence cardiaque. Les valeurs de la tension arterielle, du BIS du RDP et du RPM sont significativement plus basses lors de la concentration maximale ( Tableau 1 ). Discussion L’algiscan* permet d’objectiver une diminution du RDP lors de forte concentration du propofol. Cela montre une diminution de la reponse pupillaire par le propofol lors d’une stimulation nociceptive electrique. Differents travaux montrent un effet anti nociceptif du propofol au niveau medullaire [2] . Cette approche pharmacodynamique peut aider a optimiser individuellement l’interaction avec le morphinique d’autant qu’il existe des patients non repondeurs a cet effet.