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Pregnancy in a patient suffering from high spinal cord lesions is unusual and can lead to serious autonomic hyperreflexia during delivery. Epidural anaesthesia has been suggested as a means of decreasing such a risk. This clinical report presents the case of a paraplegic patient with lesions above the T3 level who had spinal anaesthesia for a Caesarean section. Her first delivery, six years earlier and without spinal anaesthesia was complicated by serious autonomic hyperreflexia with severe hypertension, seizures and inhalation. These symptoms were at first interpreted as eclampsia. For the Caesarean section, spinal anaesthesia using 0.25% bupivacaine in divided doses presented no difficulty, in spite of important lordosis, and permitted the delivery of a newborn with an Apgar score of 10 at one minute. The upper sympathetic level reached (T4-T6) was assessed by the discontinuing of muscular spasticity and contractures elicited by cutaneous stimuli. At the present time, spinal anaesthesia is the best method for preventing autonomic hyperreflexia. General anaesthesia, especially with halothane, is effective, but requires a deeper anaesthesia with the risk of serious hypotension and its possible repercussions on the fetus. Moreover it does not decrease the risk of autonomic hyperreflexia during the postoperative period.

Life-threatening accident during anesthesia scarcely happen but the consequences may be dramatic. We report our experience of an allergo-anesthesia consultation created since 1985 in Nice hospital. 452 patients have been investigated: 1) 109 for life-threatening anaphylactic and anaphylactoid drug reactions. They have been investigated by: skin tests intradermal reactions (IDR) and prick tests with substances used during anesthesia (drugs and latex) and for all the muscle relaxants; the radioabsorbent test (RAST) for the muscles relaxants, propofol and latex; the human basophilic degranulation test (HBDT) for all the other drugs. We used the imputability decision table to classify the reactions. When anaphylaxis diagnosis was established (14) an "allergy card" was given to patients which identified the drugs to which they had a positive reaction. 62 patients have presented an anaphylaxis: 57 due to muscle relaxants (37 due to suxamethonium), 4 to latex and 1 to a gelatin. Patients were subsequently contacted and 50 of the 58 have responded. 18 of these patients have received 22 new anesthesias. Without exception, the advises to avoid a drug have been followed, 17 patients have a positive reaction to a muscle relaxant. In four of these, another muscle relaxant (skin test negative) was used without any trouble. For the other 13 who had shown a cross reactivity, all the muscle relaxants had been rejected and another anesthetic technique have been used: local anesthesia (3 cases), epidural (2 cases) associated or not with narcotics (propofol, midazolam), general anesthesia (propofol, midazolam, droperidol, phenoperidine). These drugs were all skin test negative.(ABSTRACT TRUNCATED AT 250 WORDS)

The most appropriate nutriment for total parenteral feeding (TPF) must be nutritionally efficient, safe and easy to use. Glucose is the most used carbohydrate as it has most of these qualities, as well as a high rate of metabolism by all tissues. It has not been clearly demonstrated that the administration of exogenous insulin with glucose improves nitrogen retention. Substitutes for glucose, such as fructose, maltose, galactose or polyols (xylitol, surbitol, glycerol) are not really superior to glucose itself. On the other hand, they have major side-effects. Therefore, they are not much used as energy substrates for TPF, at least not for long term TPF. Intravenous fat emulsions have taken an important place as a source of energy during TPF. Fat emulsions containing long chain triglycerides (LCT) supply essential fatty acids (EFA) (linolenic and linoleic acids), thus preventing EFA deficiency. The metabolism of fat emulsions is influenced by various factors: age, metabolic and nutritional status, the amount of glucose intake, insulin deficiency, sepsis, heparin therapy. Recently, medium chain triglycerides (MCT) have been proposed as an alternative energy source. The latter are cleared more rapidly from the blood, and are therefore less liable to be deposited in the liver and adipose tissue; they are also oxidized more quickly and more completely. MCT are safe to use at a rate of less than 0.12 g.kg-1.h-1 and with a MCT/LCT ratio less than 3 to 1. The simultaneous administration of glucose prevents an acceleration of ketogenesis. MCT/LCT emulsions are a safe and effective source of calories. It is important that those patients for whom such nutriment may be of particular interest should be identified. Fat emulsions associated with glucose seem to be more efficient in terms of nitrogen sparing effect than glucose alone. They also avoid the problems due to the infusion of large amounts of glucose (excessive carbon dioxide production, fatty infiltration of the liver), while there is no EFA deficiency. If the infusion of TPF nutriment must be continuous in intensive care patients, or during the postoperative period, cyclic nocturnal parenteral nutrition over a 12 or 16 hour period may be used in patients who are not in a catabolic state, or only mildly so. This is a safe and efficient method of nutritional support, which reduces the incidence rate of TPF-induced cholestasis.

Because pruritus, erythema and tachycardia are observed in some patients during chemonucleolysis, a prospective study was designed to investigate the plasma levels of histamine and catecholamines occurring after an injection of chymopapain. Thirteen patients (11 men and 2 women), mean age 38 +/- 11 years, were studied. They all had negative prick skin tests, human basophil degranulation tests (HBDT) and radio-absorbent tests (RAST) to chymopapain. The patients were premedicated with 100 mg hydroxyzine and 3 g tranexamic acid. Sedation was carried out using 0.1 mg.kg-1 droperidol and 0.02 mg.kg-1 phenoperidine. The nucleosus pulposus was visualized with 3 ml of contrast medium (lopamiron 300); 2 ml of chymopapain were then injected. Blood samples were obtained at T1 (after the contrast medium, but before the chymopapain), and then 5, 10, 15, 20 and 30 minutes after the chymopapain. The usual haemodynamic parameters were recorded at the same times. Four patients had clinical signs (group I), whereas the other nine (group II) did not. There was an increase in histamine levels in three patients from group 1, as well as in two in group II (up to 33 nmol.l-1). However, mean histamine and catecholamines levels were comparable in both groups at all times, and between times, of sampling. There therefore was no relationship between clinical signs and the release of histamine or catecholamines. The premedication with an antihistamine may have protected the patients, but the signs reported by four patients may also be due to the chymopapain itself.

A cas is reported of a 23-year-old man who voluntarily took a massive dose of arsenic (at least 8 g). In spite of the ingested amount and the acute nature of the poisoning, the patient survived 8 days. Gastrointestinal, neurologic and cardiac features were predominant including nausea, vomiting, choleroid diarrhoea, encephalopathy, peripheral neuropathy, and finally a fatal toxic cardiomyopathy. Metabolic acidosis, moderate cytolysis and an anticoagulant effect were also observed. This unique characteristic was partly due to a circulating anticoagulant with prothrombinase activity, as well as direct antivitamin K activity. Postmortem examination revealed: a congestive oesophagitis; a necrosing gastritis involving all the stomach wall; diffuse hepatic steatosis; skin lesions with vascular congestion and dermoepidermal detachment; discrete subepicardial congestive lesions. Arsenic was found in all tissues.

The properties of propofol in emulsion given by continuous intravenous infusion to spontaneously breathing patients have been well studied. Thirty randomized voluntary premedicated patients undergoing dental extraction were anaesthetized with propofol (2.5 mg X kg-1 IVD, and 9 mg X kg-1 X h-1) or with propanidid (9 mg X kg-1 IVD, and 60 mg X kg-1 X h-1), supplemented with nitrous oxide in oxygen and fentanyl. Induction, maintenance and recovery times had the same characteristics. Highly significant differences occurred between the two groups regarding the increase in heart rate, apnoea and recovery time. This study showed that propofol was an eminently suitable agent for continuous intravenous anaesthesia in spontaneously breathing patients for dental surgery.