C. Auboyer

Prevention of nosocomial pneumonia in intubated patients : respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis

Chronic microaspiration through a tracheal cuff is the main culprit in the penetration and colonization of the lower respiratory tract. A total of 145 patients intubated for more than 3 days were randomly assigned to a double nosocomial pneumonia (NP) prevention: 1-Prevention of aspiration by hourly subglottic secretion drainage (SSD) with a specific endotracheal tube (HI-LO Evac tube, Mallinckrodt); 2-Prevention of gastric colonization using either sucralfate or antacids. Four random groups were defined, similar in age and severity of illness. Subglottic secretion drainage treatment was associated with: a) a twice lower incidence of NP (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3±5 days, SSD: 16.2±11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD:+21.3%, SSD:+6.6%) and in subglottic secretions (no-SSD:+33.4%, SSD:+2.1%). Sucralfate was not associated with a significantly lower incidence of NP (antacids: 23.6%, sucralfate: 17.8%), but with a lower increase in the colonization rate in subglottic and gastric aspirates, from admission to end-point day.

Fonction respiratoire postopératoire et cholécystectomie par voie cœlioscopique

Open cholecystectomy is associated with characteristic changes in pulmonary function showing a restrictive pattern. Laparoscopic cholecystectomy without opening of the peritoneal cavity could be an alternative in reducing postoperative respiratory dysfunction. Having given their informed consent, 13 healthy ASA1 patients (age : 41 ± 18 yrs) undergoing laparoscopic cholecystectomy were enrolled in this study, in order to assess their postoperative pulmonary function tests (forced vital capacity [FRC], forced expiratory volume [FEV1], functional residual capacity [FRC]) before operation (T0) and 4 h (T4), 24 h (T24), 48 h (T48) after surgery. Anaesthesia technique was the same associating propofol-atracurium-fentanyl, 50 % N2O/O2. Ventilation was adapted to maintain end-tidal carbon dioxide pressure up to 30–35 mmHg. Postoperative analgesic regimen consisted of paracetamol-ketoprofen. Mean length of surgery was 84 ± 15 min ; mean duration of anaesthesia was 110 ± 24 min. An immediate and harmonious restrictive breathing pattern developed postoperatively. Postoperative FVC measured 65 % (T4), 63 % (T24), 72 % (T48) of preoperative function (p 0.001), without change in FEV1/CV and FRC ; a significant hypoxia occurred (T0 : 86 mmHg, T4: 80 mmHG, T24 : 75 mmHg, T48 : 81 mmHg [p < 0.05]). Laparoscopic cholecystectomy resulted in less postoperative respiratory dysfunction than conventional cholecystectomy, as previously reported ; this restrictive pattern observed without changes in FRC was similar to that following lower abdominal surgery.Open cholecystectomy is associated with characteristic changes in pulmonary function showing a restrictive pattern. Laparoscopic cholecystectomy without opening of the peritoneal cavity could be an alternative in reducing postoperative respiratory dysfunction. Having given their informed consent, 13 healthy ASA1 patients (age: 41 +/- 18 yrs) undergoing laparoscopic cholecystectomy were enrolled in this study, in order to assess their postoperative pulmonary function tests (forced vital capacity [FRC], forced expiratory volume [FEV1], functional residual capacity [FRC]) before operation (T0) and 4 h (T4), 24 h (T24), 48 h (T48) after surgery. Anaesthesia technique was the same associating propofol-atracurium-fentanyl, 50% N2O/O2. Ventilation was adapted to maintain end-tidal carbon dioxide pressure up to 30-35 mmHg. Postoperative analgesic regimen consisted of paracetamol-ketoprofen. Mean length of surgery was 84 +/- 15 min; mean duration of anaesthesia was 110 +/- 24 min. An immediate and harmonious restrictive breathing pattern developed postoperatively. Postoperative FVC measured 65% (T4), 63% (T24), 72% (T48) of preoperative function (p 0.001), without change in FEV1/CV and FRC; a significant hypoxia occurred (T0: 86 mmHg, T4: 80 mmHg, T24: 75 mmHg, T48: 81 mmHg [p < 0.05]). Laparoscopic cholecystectomy resulted in less postoperative respiratory dysfunction than conventional cholecystectomy, as previously reported; this restrictive pattern observed without changes in FRC was similar to that following lower abdominal surgery.

Rôle neurotoxique du glycocolle et de ses dérivés au cours de la résection transuréthrale de la prostate

72-year-old patient underwent an elective transurethral resection of the prostate (TURP) performed with a spinal anaesthesia. The irrigation solution contained glycine at a concentration of 15 g · l−1. The patients level of consciousness deteriorated over the next 4 hours. He went in an areflexic coma with pupillar areflexia and left mydriasis. The diagnosis of TUR syndrome was substantiated by a sodium blood concentration of 98 mmol · l−1, an osmotic gap of 48 mosmol · kg−1 and blood ammonia at 415 μmol · l−1. To investigate the pathophysiological role of glycine and its metabolites, their concentrations were measured by chromatography and spectrometry in plasma and CSF 8, 24 and 48 hours postoperatively. Glycine and its metabolites (serine, alanine, glyoxilic acid and glycolic acid) accumulated during the postoperative period in both blood and CSF. The central nervous system is in direct contact with these neurotropic compounds. Glycine is an inhibitory neurotransmitter, whereas glyoxilic acid and glycolic acid are considered as to be neurotoxic.