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We report an accidental injection of epinephrine before spinal anaesthesia in a 20-year-old patient who subsequently developed immediate myocardial ischemia and global left ventricular dysfunction (ejection fraction of 20%). Hemodynamic status dramatically improved after nitroglycerin, calcium antagonists, acetyl salicylic acid and unfractionated heparin injections. Over 24 h, patient's ejection fraction fully recovered without kinetic abnormality.

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BACKGROUND AND OBJECTIVE: The use of opioids with sevoflurane for induction of anaesthesia is associated with fewer reactions to laryngoscopy but increases the risk of apnoea. Thus it is important to search for the optimal opioid dose. The aim of this study was to compare two sufentanil doses during induction with sevoflurane in young adults. METHODS: Sixty-three young patients (18-26 yr) undergoing wisdom-tooth extraction were randomly allocated to one of the two sufentanil dose groups: 0.15 microg kg(-1) (n = 33) or 0.30 microg kg(-1) (n = 30). Sufentanil was injected 1 min before sevoflurane inhalation. Sevoflurane was inhaled using the three-breath vital-capacity technique with 8% sevoflurane and 100% oxygen. The anaesthesiologist decided when to intubate the trachea. The length of time for intubation was measured. In addition, any apnoea, patient movement, adequacy of the laryngoscopic view, coughing and haemodynamic responses were recorded. RESULTS: Mean time to intubate the trachea, full laryngoscopy view and open-cord position were similar in both groups. The incidence of apnoea was higher in Group 0.30 (P < 0.05). The incidence of patient movement (P < 0.05) and coughing (P < 0.001) was lower in Group 0.30 than in Group 0.15. Sufentanil 0.30 microg kg(-1) attenuated the change in heart rate more effectively than sufentanil 0.15 microg kg(-1). Mean arterial pressure was similar and stable in both groups during induction of anaesthesia. CONCLUSIONS: In current clinical practice during sevoflurane induction, sufentanil 0.30 microg kg(-1) provided a better quality of induction than sufentanil 0.15 microg kg(-1), without significant cardiovascular depression, although the risk of apnoea is increased.

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A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.

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OBJECTIVE: To analyse current data on use of neuromuscular blocking agents (NBA) in the intensive therapy unit (ITU) patients and to propose practice guidelines. DATA SOURCES: We did a Medline search of French and English language articles on NBA administration in ITU patients from 1960 to 1998. Data were also selected from our own collection of articles and books. STUDY SELECTION: Original articles, clinical cases, letters to the editor and review articles were considered. DATA EXTRACTION: Data on pharmacology of NBA in the ITU patient were extracted, as well as data on administration patterns and cost. DATA SYNTHESIS: The indications for myorelaxation in ITU patients include either short term use, as in anaesthesia, or long term administration for facilitation of mechanical ventilation, control of increased intracranial pressure, status epilepticus, tetanus and oxygen demand in case of muscular hyperactivity, diagnostic and therapeutic procedures facilitation. A beneficial effect of NBA on the prognosis of the disease for which these agents have been used is not yet proven. Suxamethonium, because for its short onset time and duration of action, is the agent of choice for endotracheal intubation if myorelaxation is required. Among the benzylisoquinolines, atracurium and besilate of cisatracurium are convenient agents in ITU patients, whereas mivacurium is of no special interest. Among the aminosteroids, pancuronium and vecuronium are the most often used agents in the ITU. Rocuronium has not yet been extensively assessed. Myorelaxants carry risks for morbidity and mortality. The difficulty to assess the neurological status and the level of sedation is a recognised adverse effect. An accidental disconnection from the circuit and the resulting asphyxia is nowadays recognised without delay by the ventilator. NBAs increase the rate of bronchopulmonary infections. Cardiovascular complications include extreme bradycardia or sinus arrest following vecuronium administration, and cardiac arrest after suxamethonium injection mainly in burned or traumatised patients. Conversely to anaesthesia, NBAs do not carry a significant risk for anaphylactic or anaphylactoid complications in the ITU. Tachyphylaxis occurs mainly in burns and other pathologies modifying acetylcholine receptors. Neuromuscular complications include myopathy from steroids, postparalytic syndrome, deconditioning syndrome and intensive care polyneuropathy. Prolonged curarisation after discontinuation of NBA administration has a multifactorial origin and must be differentiated from neuromuscular complications. For prolonged neuromuscular blockade, pancuronium, vecuronium and atracurium are the agents of choice. The association with an adequate sedation is essential. Assessment of depth of neuromuscular blockade is not based on clinical symptoms but on train-of-four (TOF) twitch monitoring. A convenient basic relaxation is usually obtained with the suppression of the two last responses to TOF. CONCLUSION: The use of NBA in ITU patient should result from a rational decision making procedure, the blockade titrated with a TOF monitor and maintained as superficially and shortly as possible.

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The authors report the case of a 43-year-old man experiencing a migraine attack with coma requiring a treatment in an intensive care unit for 9 days. The probable triggering cause as a cerebral arteriography.

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Mivacurium is a new neuromuscular blocking agent with a short acting time of about 30 min, due to a fast hydrolysis by pseudocholinesterases. This metabolism carries a risk for prolonged neuromuscular block in case of an acquired or congenital pseudocholinesterase deficiency. We report the case of a 75-year-old woman who experienced a neuromuscular block prolonged for 10 h after a single dose of 0.35 mg.kg-1 of mivacurium, because of a major pseudocholinesterase (1800 UI.L-1, normal value: 5400-13200 UI.L-1). The likely cause was a congenital deficiency by a homozygote genetic mutation, as usual causes of an acquired deficiency had been eliminated.

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