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Objective. – To evaluate the combination of inhalational induction with sevoflurane and fiberoptic intubation through a specific facial mask for anticipated difficult tracheal intubation (DI) in adults.Study design. – Prospective study.Patients and methods. – Eighteen consecutive patients at risk of DI. After premedication made of hydroxyzine 2 mg kg–1, preoxygenation, 0.1 μg kg–1 sufentanil was administered (T0), then, inhalational induction was started: sevoflurane 8% in 100% O2 l min–1. After 1 min, sevoflurane was decreased to 5% and, if necessary, adapted to obtain an adequate depth of anaesthesia (Ramsay score > 3). Fiberoptic bronchoscopy was performed through a Fibroxy™ mask. BP was measured every 2.5 min, HR, SpO2, RR were recorded. The results were analyzed by Newman-Keuls test.Results. – Intubation was easily realized but it was necessary to assist ventilation in patients presenting prolonged apnea lasting more than 30 s (5 out of 9 patients who presented apnea during procedure). Intubation was quickly realized (T+ 4 ± 3 min). Haemodynamics and saturation were not altered during procedure. Inhalatory induction using sevoflurane costs 6 € 10 versus 16 € 80 for intravenous target controlled propofol anesthesia (using only one preconditionned syringe).Conclusion. – Inhalational induction with sevoflurane and fiberoptic intubation appeared easy, fast and cheap. [Copyright &y& Elsevier]

Objectives: To assess the feasibility and safety of a new technique of fiberoptic bronchoscopy (FOB) tracheal intubation (TI) with noninvasive ventilation (NIV) via an endoscopic full facial mask with two openings, in case of acute respiratory failure (ARF) temporally improved by NIV, but requiring a mechanical ventilation.Study design: Clinical, prospective, open, non-comparative trial of feasibility with direct individual profit.Patients: Sixteen patients with ARF (age : 60 ± 17 years, PaO2 = 59 ± 16 mmHg, PaCO2 = 64 ± 26 mmHg, PaO2/FIO2= 142 ± 70 before NIV) (m ± SD), requiring TI. Including were : TI necessity (SpO2 < 90 % or hypercapnic despite NIV, dependence of NIV, exhaustion, septic syndrome), clinical and SpO2 improvement with NIV.Methods: After IV injection of 5 mg midazolam and topical anesthesia (TA) of the nose, the endoscopic mask (modified Fibroxy™, Pe´ters) was applied to the face, fixed with elastic straps, then connected to the ventilatory support system with IPAP=20 cmH2O, EPAP = 5 to 12 cmH2O, FIO2 = 1. A tube was slid on the FOB. As soon as SpO2⟦⟦⟦nbsp〉 94 %, the extremity of the FOB, was inserted through the lower opening of the mask, slid in the nostril, positioned in front of the glottis for AL, then pushed in the trachea authorizing AL and IV injection of 0.15 mg.kg–1 of etomidate (Ramsay⟦⟦⟦nbsp〉3). The tube was then slid in the trachea, then, FOB was removed from trachea.Results: The FOB intubation was easy at the patientˈs, without any failure or any complication. The procedure was 6.7 ± 2 min. SpO2 significantly improved during TI, from 84 ± 5 % (FIO2 = 0,6 ± 3) to 97 ± 1 ( FIO2 = 1 ± 0), without decrease in oxygen saturation off 90 %. Arterial pressure decreased only after the 5th min. The quantities of midazolam and of etomidate used were 4.6 ± 2 mg and 12 ± 4 mg. Three patients benefited from EPAP > 10 cmH2O.Conclusion: Fiberoptic tracheal intubation with NIV via an adapted endoscopic facial mask is a safe technique in patient with ARF temporally improved by NIV. This procedure requires TA and conscious sedation. [Copyright &y& Elsevier]

The evaluation of benzene in different environments such as indoor (with and without tobacco smoke), a city area, countryside, gas stations and near exhaust pipes from cars running on different types of fuels was performed. The samples were analyzed using gas chromatography (GC) with flame ionization detection (FID) and tandem mass spectrometric detection (MS/MS) (to confirm the identification of benzene in the air samples). Operating conditions for the GC-MS analysis were optimized as well as the sampling and sample preparation. The results obtained in this work indicate that i) the type of fuel directly influences the benzene concentration in the air. Gasoline with additives provided the highest amount of benzene followed by unleaded gasoline and diesel; ii) the benzene concentration in the gas station was always higher than the advisable limit established by law (5 μg m⁻³) and during the unloading of gasoline the achieved concentration was 8371 μg m⁻³; iii) the data from the countryside (Taliscas) and the urban city (Matosinhos) were below 5 μg m⁻³ except 5 days after a fire on a petroleum refinery plant located near the city; iv) it was proven that in coffee shops where smoking is allowed the benzene concentration is higher (6 μg m⁻³) than in coffee shops where this is forbidden (4 μg m⁻³). This method may also be helpful for environmental analytical chemists who use GC-MS/MS for the confirmation or/and quantification of benzene.

Purpose: In dogs intoxicated with bupivacaine, clonidine is effective to treat conduction disturbances and dobutamine corrects myocardial depression. We report the case of a patient who experienced severe bupivacaine cardiotoxicity and who was treated successfully using these medications., Clinical Features: In a patient with pre-existing heart failure a surgical procedure to fix a humeral fracture was necessary. Preoperatively, heart failure was controlled with transcutaneous nitroglycerin and iv deslanoside. A bupivacaine bolus was administered iv accidentally (a mixture of bupivacaine 75 mg, 15 micro g clonidine). The patient developed nodal rhythm with extreme bradycardia, severe shock and convulsions. Seizures were controlled with thiopentone/succinylcholine. Epinephrine iv boluses (0.1 mg x 3) restored blood pressure (BP) to 50/30 mmHg and heart rate (HR) to 60 (nodal rhythm). Following 75 micro g clonidine iv, BP rose to 90/70 and HR to 90 min. Cardiac rhythm reverted to sinus rhythm with first degree atrio-ventricular block. Echocardiography showed hyperkinesia and relative hypovolemia that was controlled with iv administration of terlipressin and glucagon. Subsequent dobutamine infusion stabilized hemodynamic conditions. It was decided to proceed with surgery using a midazolam/sufentanil based general anesthetic. In the intensive care unit, recovery, extubation and weaning from the dobutamine infusion were realized within 16 hr of the event., Conclusions: In this patient with preoperative heart failure, clonidine was effective to treat bupivacaine induced conduction disturbances. Epinephrine and dobutamine were effective to treat myocardial depression and terlipressin effectively controlled vasodilatation.

Objectives: To assess the feasibility and safety of a new technique of fiberoptic bronchoscopy (FOB) tracheal intubation (TI) with noninvasive ventilation (NIV) via an endoscopic full facial mask with two openings, in case of acute respiratory failure (ARF) temporally improved by NIV, but requiring a mechanical ventilation., Study Design: Clinical, prospective, open, noncomparative trial of feasibility with direct individual profit., Patients: Sixteen patients with ARF (age: 60 +/- 17 years, PaO2 = 59 +/- 16 mmHg, PaCO2 = 64 +/- 26 mmHg, PaO2/FIO2 = 142 +/- 70 before NIV) (m +/- SD), requiring TI. Including were: TI necessity (SpO2 < 90% or hypercapnic despite NIV, dependence of NIV, exhaustion, septic syndrome), clinical and SpO2 improvement with NIV., Methods: After i.v. injection of 5 mg midazolam and topical anesthesia (TA) of the nose, the endoscopic mask (modified Fibroxy, Péters) was applied to the face, fixed with elastic straps, then connected to the ventilatory support system with IPAP = 20 cmH2O, EPAP = 5 to 12 cmH2O, FIO2 = 1. A tube was slid on the FOB. As soon as SpO2[[[nbsp] 94%, the extremity of the FOB, was inserted through the lower opening of the mask, slid in the nostril, positioned in front of the glottis for AL, then pushed in the trachea authorizing AL and i.v. injection of 0.15 mg.kg-1 of etomidate (Ramsay[[[nbsp]3). The tube was then slid in the trachea, then, FOB was removed from trachea., Results: The FOB intubation was easy at the patient's, without any failure or any complication. The procedure was 6.7 +/- 2 min. SpO2 significantly improved during TI, from 84 +/- 5% (FIO2 = 0.6 +/- 3) to 97 +/- 1 (FIO2 = 1 +/- 0), without decrease in oxygen saturation off 90%. Arterial pressure decreased only after the 5th min. The quantities of midazolam and of etomidate used were 4.6 +/- 2 mg and 12 +/- 4 mg. Three patients benefited from EPAP > 10 cmH2O., Conclusion: Fiberoptic tracheal intubation with NIV via an adapted endoscopic facial mask is a safe technique in patient with ARF temporally improved by NIV. This procedure requires TA and conscious sedation.

Objectives: To assess the feasibility and safety of non invasive positive-pressure ventilation (NIPPV) via a face mask to performing fiberoptic bronchoscopy (FOB) in patients with COPD contraindicating FOB in spontaneous ventilation., Study Design: Clinical, prospective, open, non comparative trial of feasibility., Patients: Ten consecutive COPD patients (71 +/- 5 year-old, PaO2 = 53 +/- 13 mmHg and PaCO2 = 67 +/- 11 mmHg), without any sign of acute respiratory failure, admitted to the intensive care unit for pneumonia requiring a bronchoalveolar lavage (BAL). Including were: PaO2 < 70 mmHg despite nasal O2 delivered at 3 L.min-1, PaCO2 > 50 mmHg, improvement of SpO2 with NIPPV before FOB., Methods: Topical anaesthesia of the nose and pharynx was obtained with a 5% lidocaine spray. NIPPV was administered using a ventilatory support system Evita 4 (Dräger) applied through a full facial mask secured to the patient with elastic straps. Patients were first allowed to acclimate for 5 min with NIPPV (IPAP = 16 cmH2O, EPAP = 0 and trigger of 0.3 cm H2O while a FIO2 kept at 0.7). A T-adapter Medisize (Péters) was attached to the facial mask. The tip of the FOB was inserted through the nose. Topical anaesthesia of the vocal cords was obtained with 1% lidocaine solution (3 mL). The FOB was inserted into the trachea up to a bronchial sub-segment. BAL was performed by instillation of 100 mL of saline solution. After FOB, the NIPPV was maintained for 5 min. Heart rate, SpO2 were measured continuously and arterial pressure at 2 min intervals. Arterial blood gas values were obtained just prior NIPPV and after 15 min and 60 min NIPPV disconnection., Results: FOB duration was 11 +/- 4 min. SpO2 significantly improved during FOB (from de 91 +/- 4.7% to 97% +/- 1.7) without decrease of oxygen saturation lower than 90%. There were no changes in PaCO2 and PaO2 during the hour following the end of procedure. FOB under NIPPV was performed in all patients without complications and was very well tolerated in eight patients. After NPPV disconnecting, one patient required again NIPPV for 15 min. No patient required endotracheal intubation within 24 hours. All patients survived., Conclusion: Application of NIPPV during FOB is a safe technic for maintaining adequate gas exchange in hypoxaemic and hypercapnic COPD patients not in acute respiratory failure. After the end of the procedure a close surveillance in the intensive care unit is essential.

We report the case of a 65-year-old man treated with intravenous acyclovir and amoxicilline for meningoencephalitis. Six days later, he suddenly developed acute renal failure, associated with central nervous system symptoms. The high acyclovir concentration in plasma and spinal fluid confirmed the hypothesis of acyclovir toxicity. Continuous haemofiltration resulted in a rapid amendment of neurologic and renal symptoms. Despite the high therapeutic index of acyclovir, manifestations of neurotoxicity and nephrotoxicity are not a rare event. The risk is increased in the elderly and in patients with renal insufficiency. Rapid intravenous injections are contraindicated. Continuous haemofiltration is rapidly efficient. The value of acyclovir concentration determination in plasma and spinal fluid are stressed.