Search PubMed⌕ Search

Biomedical subjects

D Grimaud

Publications and source records attributed to D Grimaud.

At least 55 records · Page 3Linked to original sources
PubMed1996

[Maternal mortality in Nice. Results of a reproductive age mortality survey using death registries in the Nice University Hospital, 1986-1993].

OBJECTIVE: To define the rate of maternal death on the basis of maternal deaths recorded from January 1986 to May 1993. To determine whether the patients had received "standard" quality health care. METHOD: A Reproductive Age Mortality Survey was performed retrospectively on causes of death in women from 14 to 45 years of age; death registries and clinical records at the Nice University Hospital were used. RESULTS: There were 23 cases of pregnancy-associated death. Maternal mortality was 32.9 per 100000 live births. According to the INSERM survey, the "real" national rate would be 18.3 per 100000. This is a classical underestimation. The overmortality in Nice is partially explained by the AIDS epidemic which was the major cause of female deaths between 14 and 45 years (96/322). Nevertheless, there was an unsatisfactorily large number of cases in which standard obstetrical practises were not applied. This was often due to a combination of factors including poor obstetrical surveillance, insufficient attention by physicians, poor organisation of obstetrical care in the emergency room and referrals. Cesarean section was implicated in 7 out of 12 maternal deaths during the third trimester of pregnancy (58%). The cause of certain maternal deaths remained unexplained; amniotic embolus was always suggested. Unfortunately, an autopsy was performed in only 36% of the cases and its quality was insufficient to determine certain diagnosis.

Adolescent↗
PubMed1995

[Effect of postoperative complications on nutritional status: therapeutic consequences].

The occurrence of a postoperative complication represents an additional stress factor for patients and leads in many cases rapidly to a malnutrition status. Thus a nutritional support is required as soon as the foreseeable duration of starvation has a longer duration than one week. Considering its lower risk of septic complications and lower cost, enteral feeding should be initiated as soon as possible. Appraisal of caloric needs with standard formulas often leads to inappropriate nutritional management. Therefore the requirements should be assessed by indirect calorimetry if available. Nutritional support is a part of the management of a postoperative septic patient. It must be initiated when initial phase of haemodynamic instability is amended. Branched chain amino acids, medium chain triglycerides and other specific nutrients have failed to demonstrate a real clinical beneficial effect. In case of acute respiratory failure, nutritional support must be cautious with regard to caloric load, as carbohydrates may increase CO2 production and lipids may worsen hypoxaemia. In case of postoperative acute renal failure, nutritional management is facilitated by continuous haemofiltration techniques allowing an unlimited nutrient intake. Solutions containing only essential amino acids are not recommended. During severe acute pancreatitis, enteral feeding is indicated when ileus does not permit the use of the intestinal tract. Jejunal access must be preferred to stomach or duodenum. Lipid emulsions can be used safely if serum triglyceride concentrations remain below 4 g.L-1 during infusion and below 2 g.L-1 between infusions.

Calorimetry, Indirect↗
PubMed1995

Effect of severity of surgery on metabolic control and insulin requirements in insulin-dependent diabetic patients.

We have evaluated insulin requirements and the relationship between hormonal variables, changes in blood glucose and insulin requirements in insulin-dependent diabetic patients undergoing two degrees of severity of surgery: minor (vitrectomy) and major (gastrectomy, bowel resection, hip replacement). The study began just before induction and ended 2 h after surgery. Blood glucose concentrations were comparable in both groups but the total amount of insulin given was significantly greater in the major surgery group. Plasma noradrenaline and cortisol concentrations increased significantly during major surgery and there were significant correlations between the increase in these counter-regulatory hormones and the amount of insulin administered. We conclude that the metabolic changes occurring during surgery were small, but at the cost of a marked increase in insulin requirements during major surgery. Increased sympathetic nervous system activity seems to have been implicated in the increase in insulin requirements.

Adult↗
PubMed1994

[Osmolality and brain].

A modification of serum osmolarity induces always movements of water across cell membranes and therefore variations of cell volume of all tissues, including brain. To avoid a severe cell dehydration or hyperhydration, the organism has several regulation means called osmoregulation. Cerebral osmoregulation is essential as the brain is contained in a unexpandable box. In comparison with other organs, this phenomenon is complex and particular as: 1) cerebral volume consists of 3 sub spaces (intracellular, extracellular and cerebrospinal fluid [CSF]); 2) exists a blood-brain barrier (BBB) which behaves functionally as a semi-permeable membrane, essentially sensitive to osmolar disturbances. This brain volume regulation mechanism is working whatever the nature of the solutes initiating the osmotic deviation (sodium, glucose, mannitol...). Cerebral osmoregulation results from intracerebral osmolar modifications. Thus, every variation of plasma osmolarity elicits a similar variation of intracerebral osmolarity. This phenomenon results from modifications of the brain cell "protective" osmoles content. When the osmolar disturbance occurs quickly (in a few hours), cerebral osmoregulation is not complete. It results essentially from modifications of brain cell inorganic solutes content, i.e. electrolytes (Na, K, Cl) which originate from plasma, CSF and extracellular brain spaces uptake. When the osmolar disturbance is more progressive, cerebral osmoregulation is complete. The brain volume returns then to its initial value, by increasing its brain cell electrolytes, but above all organic "idiogenic" osmoles content. These idiogenic osmoles are identified as amino acids, polyols and trimethylamines. During treatment, the delayed normalization of brain osmolarity compared with plasma osmolarity prescribes a slow correction of the osmolar disturbance, as much as it is a chronic one.

Blood-Brain Barrier↗
PubMed1994

[Acid-base equilibrium and the brain].

In physiological conditions, the regulation of acid-base balance in brain maintains a noteworthy stability of cerebral pH. During systemic metabolic acid-base imbalances cerebral pH is well controlled as the blood/brain barrier is slowly and poorly permeable to electrolytes (HCO3- and H+). Cerebral pH is regulated by a modulation of the respiratory drive, triggered by the early alterations of interstitial fluid pH, close to medullary chemoreceptors. As blood/brain barrier is highly permeable to Co2, CSF pH is corrected in a few hours, even in case of severe metabolic acidosis and alkalosis. Conversely, during ventilatory acidosis and alkalosis the cerebral pH varies in the same direction and in the same range than blood pH. Therefore, the brain is better protected against metabolic than ventilatory acid-base imbalances. Ventilatory acidosis and alkalosis are able to impair cerebral blood flow and brain activity through interstitial pH alterations. During respiratory acidosis, [HCO3-] increases in extracellular fluids to control cerebral pH by two main ways: a carbonic anhydrase activation at the blood/brain and blood/CSF barriers level and an increase in chloride shift in glial cells (HCO3- exchanged for Cl-). During respiratory alkalosis, [HCO3-] decreases in extracellular fluids by the opposite changes in HCO3- transport and by an increase in lactic acid synthesis by cerebral cells. The treatment of metabolic acidosis with bicarbonates may induce a cerebral acidosis and worsen a cerebral oedema during ketoacidosis. Moderate hypocapnia carried out to treat intracranial hypertension is mainly effective when cerebral blood flow is high and vascular CO2 reactivity maintained. Hypocapnia may restore an altered cerebral blood flow autoregulation. Instrumental hypocapnia requires a control of cerebral perfusion pressure and cerebral arteriovenous difference for oxygen, to select patients for whom this kind of treatment may be of benefit, to choose the optimal level of hypocapnia and to avoid any deleterious effect. If hypocapnia is maintained over several days, an adaptation of CSF pH may limit the therapeutic effect on the cerebral blood flow and the intracranial pressure.

Acid-Base Equilibrium↗
PubMed1994

Comparison of two methods of i.v. insulin administration in the diabetic patient during the perioperative period.

We have examined the effects of two types of insulin therapy (continuous i.v. infusion (group A: 1.25 u. h-1) and direct i.v. bolus administration of 10 u. every 2 h (group B: 10 u./2 h)) on the metabolic and endocrine responses to surgery in 60 adult diabetic patients undergoing general anaesthesia for elective procedures. Blood glucose concentrations were measured every 15 min from just before induction of anaesthesia until 2 h after surgery. Plasma ketone bodies, lactate, pyruvate, insulin, C-peptide and counter-regulatory hormone concentrations were measured also. Blood glucose concentrations were comparable in both groups, except at 60 min, because of fluctuating blood glucose concentrations in group B. In each group, one patient became hyperglycaemic. One case of hypoglycaemia occurred in group B. There were no statistically significant differences for the other data except for C-peptide. We conclude that, during the operative period, the administration of a direct i.v. bolus of insulin 10 u. every 2 h is a simple and effective method to control blood glucose concentrations; the method can be used when an insulin infusion pump is not available.

Adult↗
PubMed1994

Intraoperative glycaemic control in non-insulin-dependent and insulin-dependent diabetes.

We have compared intraoperative glycaemic control, insulin requirements and metabolic and endocrine variables in 40 non-insulin-dependent diabetic patients (NIDDM) and 40 insulin-dependent diabetic patients (IDDM) undergoing general anaesthesia for elective procedures. Two i.v. insulin regimens were used: continuous i.v. infusion (group A: 1.25 u.h-1) and repeated i.v. boluses (10 u./2 h). Blood concentrations of glucose were measured every 15 min from just before induction of anaesthesia until 2 h after surgery. Plasma lactate and pyruvate concentrations, ketone bodies, C-peptide and counter-regulatory hormones were also measured. Glycaemia did not differ significantly in the two types of diabetes, regardless of the insulin therapy used. The amounts of insulin administered were similar in NIDDM and IDDM. There was no significant difference for other metabolic variables. Plasma concentrations of growth hormone (GH) increased significantly during surgery, especially in IDDM patients, but this change did not alter intraoperative glycaemic control. We conclude that mean glycaemic control, insulin requirements and development of ketone bodies in NIDDM and IDDM patients did not differ during the operative period, regardless of the insulin regimen used. Therefore, during the operative period, it is not necessary to modify the insulin regimen according to the type of diabetes. The consequences of increased plasma GH concentrations on glycaemic control in IDDM patients after operation are unknown.

Adult↗
PubMed1994

[Coagulation disorders after endoscopic resection of the prostate].

Endoscopic resection of the prostate is a well defined surgical procedure. Nevertheless, certain coagulation disorders (hypercoagulability with risk of deep vein thrombosis, haemorrhage) can raise special problems. In patients not given heparin prophylaxis, the incidence of deep vein thrombosis is 10% in transurethral resections of the prostate (TURP). The risk is higher for cancer. Among the diagnostic tools (D-dimer assay, continuous Doppler, pulsed echo-Doppler, thermography, plethysmography, ...) ascending phlebography or pulmonary angiography in case of suspected pulmonary emboli remains the gold standard. Haemorrhage is rarely related to defribination but frequently to dilution coagulopathy favoured by high blood pressure, resorption of irrigation fluid, deficient haemostasis with loss of coagulation factors or massive transfusions. Only clinically patent coagulation disorders leading to haemorrhage should be treated. For dilution coagulopathies and diffuse intravascular coagulation, treatment is based on viro-inactive fresh plasma infusion. Aprotinine is the first choice in case of fibrinolysis.

Antifibrinolytic Agents↗
PubMed1993

[Epidural anesthesia and prevention of autonomic hyperreflexia in a paraplegic parturient].

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.

Adult↗
PubMed1993

Clinical pharmacology of nicardipine in liver transplant patients.

Slow calcium channel antagonists are widely used among transplanted patients suffering from hypertension, although some of them tend to reduce hepatic blood flow. The aim of our study was to determine the pharmacological properties of nicardipine in transplanted patients with hypertension. Ten hours after liver transplantation, six patients (three men, three women) received 5 mg of intravenous nicardipine to prevent high blood pressure during intensive care. Prior to the administration and during the study (at the completion of the infusion, 3, 5, 10, 15, 20, 30, 45, and 60 min after infusion), the systemic and splanchnic parameters were measured (Swan Ganz catheter). Blood samples were drawn simultaneously from radial artery and free hepatic veins, in order to obtain the hepatic extraction of nicardipine. The hepatic extraction ratio was around 70% for the first 3 min, then decreased and remained stable thereafter, around 45%, showing a non linear first-pass metabolism pattern. Plasma hepatic clearance of nicardipine (699-850 ml/min) was close to total plasma clearance throughout the study (978 +/- 222 ml/min, from 71 to 87%) and half of the estimated hepatic plasma flow values at the same times (1467-1770 ml/min, from 44 to 51%). No statistically significant changes were observed in cardiac output and hepatic blood flow during the study, although there was a decrease in mean arterial blood pressure from 87 +/- 6 mmHg baseline level to 76 +/- 3 mmHg, 60 min after administration. Nicardipine chlorhydrate seems to be appropriate in post operative liver transplant patients when blood pressure must be decreased. Nicardipine safely lowers peripheral resistance, and does not induce changes in hepatic blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

[Changes in plasma histamine and catecholamines levels after injection of chymopapain in chemonucleolysis].

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.

Adult↗
PubMed1991

[Energy substrates in parenteral nutrition].

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.

Carbohydrate Metabolism↗