[Right bronchial rupture during intubation with carlens tube].
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Aged↗
Biomedical subjects
M Fischler
Publications and source records attributed to M Fischler.
[Emergency cardiac transplantation].
Emergency cardiac transplantation is a controversial subject in the present context of a lack of donor organs. There are few reports in the literature, which the authors review to suggest a practical approach which is clearly not consensual. The results in the literature report an extramortality of 10 to 30% if the indication of transplantation is that of an emergency. The poor results of emergency transplantation in the present day context of lack of donor organs have led the authors to abandon this indication. They only transplant patients in a stable condition without failure of organs other than the heart.
Actuarial Analysis↗
Validation of a simple method assessing nitric oxide and nitrogen dioxide concentrations.
Monitoring of nitric oxide (NO) and nitrogen dioxide (NO2) is a prerequisite for the clinical use of NO. Chemiluminescence, the reference method, cannot be used as a routine in clinical practice in view of its cost and other restraints. This study was performed to evaluate a device using an electrochemical method (Polytrons NO and NO2, Dräger). Forty-nine simultaneous measurements of NO and various oxides of nitrogen (NOx) concentrations by the two apparatus were performed. NO measurements by means of these two methods are very well correlated (r = 0.96; p < 10(-5)). The mean difference according to the method of Bland and Altman was 2.8 +/- 1.7 ppm, with the limits of agreement at -0.6 and +6.2 ppm (confidence interval of 95%). There was also a good correlation between measurements of NO2 obtained via Polytrons and NOx via chemiluminescence (r = 0.84; p < 10(-5)). However, NO2 measurements obtained via Polytrons may be insufficient to exclude potential toxicity of NO2 due to the inability to detect measurements in the ppb-range. This study demonstrates that devices designed for industrial purposes (Polytrons NO and NO2, Dräger) can be used for clinical purposes.
Administration, Inhalation↗
Is it possible to improve the shape of right double-lumen endobronchial tubes?
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Bronchi↗
Double lung transplantation without cardiopulmonary bypass: arterial to end-tidal carbon dioxide partial pressure differences.
Bilateral lung transplantation without cardiopulmonary bypass consists of two sequential single lung transplantations. Variations in ventilatory status during the procedure led us to study the (PaCO2-PE'CO2) gradient to see if PE'CO2 might reflect PaCO2. The gradient was studied in 14 patients at six times during operation. (PaCO2-PE'CO2) (kPa) was mean 1.97 (SD 0.7) after induction, 3.2 (1.4) during single lung ventilation, 1.9 (1.1) after clamping of the contralateral pulmonary artery, 2.96 (1.6) after ventilation and vascularization of the first transplant and the remaining native lung, 0.99 (0.8) during single lung ventilation with the first transplant and 1.3 (0.8) during ventilation of both transplants. With ventilation by the allograft lung(s) alone, the small (PaCO2-PE'CO2) value demonstrated improvement in ventilatory status, enabled PaCO2 to be assessed by PE'CO2 and demonstrated efficiency of the grafts.
Adult↗
Single lung transplantation for pulmonary lymphangiomyomatosis. Unexpected need for extracorporeal circulation.
The present case describes an acute respiratory-related hemodynamic failure during a single left lung transplantation in a 32-year-old woman suffering from end-stage pulmonary lymphangiomyomatosis. During the first 5 min of single right lung ventilation, a progressive increase in airway pressure and decrease in tidal volume associated with a decrease in arterial pressure and Spo2 occurred that were successfully countered by reventilation of the left lung. Proper positioning of the double-lumen tube was confirmed with a fiberoptic bronchoscope. Despite deliberate hypoventilation, within a few respiratory cycles, each further attempt at single lung ventilation was followed by abrupt hypotension, increase in pulmonary artery pressure, while airway pressure rose and tidal volume collapsed. The surgical team saw no signs of right pneumothorax. In these circumstances, cardiopulmonary bypass was required to perform pneumonectomy and grafting. Postoperatively a right anterior pneumothorax remained undiscovered on standard radiograph but was later revealed on soft radiograph. This acute intraoperative respiratory failure could equally well have been related to air trapping, in which case, however, deliberate hypoventilation would have been effective. In addition, the striking difference between the progressive onset of the first episode of hemodynamic failure and the immediate onset of the others argues in favor of a pneumothorax being at cause. Patients with pulmonary lymphangiomyomatosis are at high risk for intraoperative pneumothorax, but in our case, it could not be confirmed and treated during the surgical procedure without putting the patient at high risk for lung injury because of pleurodesis due to earlier pleural abrasion. This case again clearly shows the need to have cardiopulmonary bypass whenever single lung transplantation is performed.
Adult↗
[The Univent tube: a substitute to double lumen tubes].
The Univent tube was designed as an alternative to double lumen endotracheal tubes. It is a conventional single lumen tube with an additional small channel within the concave anterior wall portion that houses a movable bronchial blocker used for lung isolation. A thin lumen in the blocker itself allows lung deflation and various ventilatory patterns (oxygen inflow, CPAP, jet-ventilation) in the blocked lung. Main indications for the Univent tube include difficult intubation, risk of aspiration and planned postoperative ventilation. The "blind" insertion of the bronchial balloon carries a high risk of primary malpositioning or secondary displacement that may cause a loss of the lung isolation or even tracheal obstruction. Initial insertion with fiberoptic bronchoscope is therefore required and this device must also be available during the whole period of one lung ventilation. High pressures generated by the bronchial cuff and higher cost than that of double lumen endotracheal tubes are two other factors that limit the use of the Univent tube.
Humans↗
[Doppler preoperative evaluation of the prevalence of functional abnormalities of palmar arches in children].
Thromboembolic events and inadequate palmar collateral circulation are the two main mechanisms of hand ischaemia following radial artery cannulation. The latter cause may be detected in adults with Allen's test, which is difficult to perform and to interpret in children. Therefore we investigated preoperatively in children the permeability of palmar arches with doppler ultrasound, prior to radial artery cannulation. Thirty-five children (20 M/15 F), aged between 6 months and 14 years (mean = 4.2 years) were scheduled for doppler ultrasound study of their palmar arches before undergoing a major neurosurgical procedure. This study was performed with a 8 MHz directional doppler probe according to Marcillon's technique. Blood flow in superficial palmar arch and in pad of the thumb were identified. Alterations in flow caused by compression of the radial artery were noted. Results were expressed in qualitative terms: functional arch (normal doppler), moderately functional or non-functional arch (abnormal doppler). In the latter cases, the artery was not cannulated. An anomaly in one or both palmar arches was seen in 43% of children (95% confidence interval: 25-60%). The incidence was comparable on both sides (right: 34%; left: 31%) with a mean probability of 33% (95% confidence interval: 17-49%). The probability of a controlateral anomaly, when one hand was abnormal, reached 70%, e.g., twice that of the first hand (p < 0.01). This indicates a relatively low incidence of asymmetry (20%) and therefore a high incidence of a bilateral anomaly (23%).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
[Risk evaluation of oxygen desaturation after buprenorphine or morphine administration during the early postoperative period].
The purpose of this study, conducted in a PACU in the early recovery period of orthopaedic procedures under general anaesthesia, was to compare the time course of O2 arterial saturation (SpO2), measured by pulse oximetry, after the intramuscular administration of either buprenorphine (0.30 mg) or morphine (10 mg). The rate of patients who had an episode of O2 desaturation (defined as a SpO2 under 95%) was similar in both groups: 73% after buprenorphine vs 67% after morphine. The cumulative duration of desaturation episodes was higher following buprenorphine (p < 10(-5). Finally, in patients who had at least one episode of arterial desaturation, the mean duration of these episodes was identical in both groups. However the average number of episodes per patient was significantly higher in the buprenorphine group. These results should lead us to be cautious with the use of buprenorphine during the early recovery period, especially as this as this agent has specific characteristics such as a long duration of action and resistance to naloxone.
Adult↗
Interpleural infusion of 2% lidocaine with 1:200,000 epinephrine for postthoracotomy analgesia.
The value of intrapleural analgesia after thoracotomy is still controversial. We investigated the pharmacokinetics of interpleural analgesia in 14 patients with and without thoracic drainage (Groups TD+ and TD-, respectively) to determine the safety of the technique. The infusion led to a high steady-state concentration (Css) of 5.91 +/- 2.46 mg/mL in Group TD-. We then performed a placebo-controlled double-blind study on 16 patients to evaluate the analgesic effects of an interpleural infusion of 2% lidocaine using intravenous patient-controlled analgesia (PCA) with morphine and a visual analog scale score (VAS). In both studies an initial bolus of 3 mg/kg of 2% lidocaine was followed by an infusion of 1 mg.kg-1.h-1 for 48 h. The VAS score was slightly reduced after the bolus (6.6 +/- 1.0 vs 8.7 +/- 0.3; P < 0.05 vs the placebo group) but the cumulative doses of morphine were similar in both groups. There was a slight, but not sustained, improvement in pulmonary function test. In conclusion, interpleural analgesia by continuous infusion of lidocaine is poor after thoracotomy and may lead to blood levels in the toxic range.
Aged↗
[Ambulatory surgery. Anesthesia techniques].
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Ambulatory Surgical Procedures↗
[Anesthesia for tracheobronchial laser surgery].
Laser, performed using a rigid bronchoscope, permits the re-establishment of a sufficient tracheal airway diameter. This procedure requires a 15 to 60 minutes general anaesthesia including a neuromuscular blockade, a high frequency jet ventilation being delivered via the side channel of the bronchoscope. Concerning an adult patient of an average weight, presetting of the ventilator includes a supply pressure of 3 or 4 bar, a low I/E ratio and a frequency ranging between 60 and 120 cycles/min. During laser resection, the inspired oxygen concentration should always be less than 50 per cent to limit the risk of combustion. Oxygen desaturation episodes are related either to the placement of the bronchoscope in a mainstem bronchus or to a preexisting COPD. A few hours stay in a recovery room in mandatory knowing the risk of redo or reintubation.
Anesthesia, General↗
Clonidine premedication for coronary artery bypass grafting under high-dose alfentanil anesthesia: intraoperative and postoperative hemodynamic study.
The purpose of this study was to assess the efficacy of clonidine in achieving perioperative hemodynamic stability in patients undergoing coronary artery bypass grafting performed under high-dose alfentanil anesthesia. Twenty-four patients with left ventricular ejection fraction greater than 0.5 were prospectively studied in a double-blind manner; those requiring emergency procedures were excluded. They were randomized to receive either oral clonidine or placebo together with their premedication. Induction of anesthesia was achieved with 10 mg of alfentanil infused over 5 minutes followed by a continuous infusion of 60 mg/h during 1 hour, or until sternotomy, and then 30 mg/h until the end of surgery. Hemodynamic responses to noxious stimuli were treated with additional alfentanil boluses and isoflurane when these were unsuccessful. Intraoperative hemodynamic profile analyses showed a continuous increase in systemic vascular resistance and mean arterial pressure in the clonidine group from the time of skin incision until the onset of bypass, whereas the cardiac output profiles remained similar in the two groups. The number of additional alfentanil boluses was similar. Isoflurane requirements (1/11 v 4/13) were not significantly different, but only a few patients required this therapy. The postbypass hemodynamic profiles were similar. Severe hemodynamic impairment occurred in the clonidine group during warming in the postoperative period: this group showed a drop in systemic vascular resistance index (1276 +/- 347 v 1757 +/- 415 dyn.sec.cm-5.m2) that could not be compensated for by an increase in cardiac output despite normal filling pressures, causing hypotension (66 +/- 10 v 79 +/- 16 mmHg). This hemodynamic status led to greater requirements for vasoactive agents and inotropics in this group.(ABSTRACT TRUNCATED AT 250 WORDS)
Alfentanil↗
[Healing of bronchial anastomoses in single and double pulmonary transplantations].
Bilateral single lung transplantation (BSLT) (the procedure of choice for double lung replacement) and single lung transplantation (SLT) have at present a low incidence of anastomotic problems. In our experience, we have recorded no death related to anastomotic problems and 4 complications occurred for 33 anastomoses with a follow up of at least 2 months. A stent was temporarily inserted for two patients. The decrease of anastomotic complications is confirmed in the literature. It is one of the reasons why the number of SLT and BSLT performed all over the world increases rapidily to the detriment of heart lung transplantation.
Adult↗
Bilateral single lung transplantation. Complications and results in 14 patients.
Between November 1989 and April 1991, 14 bilateral single lung transplantations (BSLT) were performed at our institution using the technique we have described without omentoplasty and rarely cardiopulmonary bypass. The indications included emphysema (8), cystic fibrosis (3), infected fibrosis (1), alveolar microlithiasis (1) and lymphocytic interstitial pneumonitis (1). Maximum mean pulmonary artery pressure was 53 mmHg and minimal right ventricular ejection fraction was 15%. Two patients experienced bronchial complications: 1 complete left bronchial dehiscence, 1 late partial stenosis which required a temporary insertion of a stent. One patient had a posterior dehiscence which healed spontaneously. Five patients died postoperatively (3 of infection, 1 after a volume mismatch and 1 after a circulating anticoagulant). BSLT is the technique of choice for double lung transplantation in adults and heart lung transplantation has very few indications in infected end-stage pulmonary disease. We hope that modification of our immunosuppressive regimen will decrease postoperative mortality.
Adult↗
Anesthesia for bilateral lung transplantation without cardiopulmonary bypass: initial experience and review of intraoperative problems.
Bilateral lung transplantation (BLT) is a recently described procedure based on two sequential single-lung transplantations (SLT), which are performed by a transverse sternobithoracotomy. It does not require either cardiac arrest or routine use of cardiopulmonary bypass (CPB). The intraoperative management of 10 patients suffering from end-stage pulmonary disease is reported. Implantation of the first graft is quite similar to a SLT. Problems encountered during this procedure (ie, hypoxemia, hypercapnia, or low cardiac output) were due to restricted pulmonary and cardiac reserve. Preoperative and intraoperative assessment of the recipient's respiratory and cardiac status was, therefore, of prime importance. Mild preoperative pulmonary hypertension, well-preserved right ventricular function, and removal of the less well-perfused lung limited these difficulties; no patient required partial CPB at this stage. During the second lung implantation, gas exchange was provided by the first grafted lung. Measurements of pulmonary vascular resistance (PVR), venous admixture (Qva/Qt), and dead space (VD/VT) assessed with the arterial-to-end-tidal CO2 difference were used to confirm the adequacy of perfusion and V/Q matching. In one patient, partial CPB was instituted because of surgical difficulty related to inadequate size matching of the lungs. In the other patients, first graft function was satisfactory and the second graft was implanted without CPB. With chest closure, PVR returned to nearly normal values (range, 57-293, mean 167 dynes.s.cm-5) and Qva/Qt increased (range, 3 to 36, mean 20%). This limited series demonstrates that CPB is optional during this procedure. Good selection of recipients and donors, good lung preservation methods, and a short duration of cold ischemia are essential to success.
Adolescent↗
[Apropos of an accidental peridural injection].
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Heparin↗
[Etomidate modifies hemodynamic response to fentanyl in patients with impaired left ventricular function].
The haemodynamic effects and the side-effects of anaesthesia using high doses of fentanyl were compared in two groups of 12 patients each. All the patients had poor left ventricular function and were scheduled for elective coronary artery bypass graft surgery or valvular replacement. Patients were randomly assigned to either group. In group EF, patients were given 5 micrograms.kg-1 of fentanyl, followed by 0.3 mg.kg-1 of etomidate. Once they had lost consciousness, they were given 15 mg of pancuronium and 25 micrograms.kg-1 of fentanyl over a 5 min period. Patients in group F received the full 30 micrograms.kg-1 dose of fentanyl over a 5 min period, followed by 15 mg of pancuronium. The patients were intubated 2 min after the end of the fentanyl infusion. They were mechanically ventilated with 100% oxygen. Anaesthesia was maintained with a continuous infusion of fentanyl (total dose 100 micrograms.kg-1). The usual haemodynamic parameters were monitored and calculated, as well as pain during injection of the drugs, myoclonia, chest wall rigidity and the time to loss of consciousness. The two groups were comparable with respect to age, weight, height and surgery. One third of the patients in group EF complained of pain during etomidate injection. The time required to loose consciousness was shorter in group EF (55 +/- 16 sec) than in group F (177 +/- 56 sec) (p < 0.001). The cardiac index decrease in group EF (2.0 +/- 0.4 l.min-1.m-2 vs. 1.9 +/- 0.4 l.min-1.m-2) (p < 0.05), respectively between the time just before tracheal intubation (T1), and 10 min after tracheal intubation (T3).(ABSTRACT TRUNCATED AT 250 WORDS)
Anesthesia, Intravenous↗