Annales françaises d'anesthèsie et de rèanimation
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The recent studies focusing on the pharmacokinetics of tramadol in children contributed to the increase popularity of tramadol as an analgesic alternative in clinical practice. Tramadol is a racemic mixture of 2 enantiomers that have comparable pharmacokinetic profile and this lack of difference is also observed with their main active metabolite, O-demethyl tramadol (M1). The serum concentrations of this metabolite depend largely on the activity of the cytochrome P450 and particularly of the enzyme CYP2D6 which reaches its maturity in the newborn. Nevertheless, the interindividual variability observed in the pharmacokinetics of tramadol and consequently in the pharmacodynamic profile is mainly due to the genetic polymorphism of cytochrome P450.
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Ann Fr Anesth Reanim · May 2007
Review[What is the contribution of Stewart's concept in acid-base disorders analysis?].
To explain the different approaches for interpreting acid-base disorders; to develop the Stewart model which offers some advantages for the pathophysiological understanding and the clinical interpretation of acid-base imbalances. ⋯ Due to its simplicity, the traditional Henderson-Hasselbalch approach of acid-base disorders, remains commonly used. However, it gives an inadequate pathophysiological analysis which may conduct to a false diagnosis, especially with complex acid-base imbalances. Despite its apparent complexity, the Stewart concept permits to understand precisely the mechanisms of acid-base disorders. It has to become the most appropriate approach to analyse complex acid-base abnormalities.
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Ann Fr Anesth Reanim · May 2007
Review[Hierarchical strategy for treating elevated intracranial pressure in severe traumatic brain injury].
The objective of the treatment of intracranial hypertension is to decrease intracranial pressure (ICP) while maintaining cerebral blood flow (CBF). Despite numerous treatments, none of them associates total efficiency and security. Systemic secondary cerebral injuries, which are responsible for cerebral ischemia, lead us to administer non specific treatments in order to optimize CBF and cerebral oxygenation. ⋯ In case of refractory intracranial hypertension, it may be useful to deepen neurosedation. Controlled hypocapnia and barbiturates remain a third line therapy providing to monitor and maintain an appropriate CBF and cerebral oxygenation. Controlled hypothermia and decompressive craniectomy must be individually discussed.
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Ann Fr Anesth Reanim · Apr 2007
Review[Critical analysis of noninflammatory treatments of sepsis: lessons learned from previous trials].
A large number of immunomodulatory therapies has been evaluated in patients with severe sepsis and septic shock. Until recently, none of these treatments has ever demonstrated any benefit in terms of decreased mortality. Many biases could interfere with the results of these clinical trials linked to poor comprehension of immune response, pharmacological errors, selection bias, and mistakes in the evaluation of the patients and in the interpretation of the results. Based on these methodological flaws, the authors try to define directions for future clinical trials.
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Ann Fr Anesth Reanim · Apr 2007
Review[Potential benefits of non-anti-infective treatments of septic shock: a critical analysis of literature].
Among numerous non anti-infective treatments proposed in the management of severe sepsis and septic shock, early administration of steroids and recombinant human activated protein C are the most studied and the major source of debate. Patients with functional adrenal insufficiency appear to be the best cases for early treatment with low doses of hydrocortisone. However, definition of adrenal dysfunction, interpretation of cortisol blood concentration and its appropriateness, investigation of the hypothamalo-pituitary-adrenal axis and value of corticotropin stimulation test are matter of discussion. ⋯ Structure of the PROWESS pivotal study, post hoc analyses of numerous subgroups, use of severity scoring system for selection of the patients, unproven mechanisms of action of activated Protein C, interactions with combined treatments represent major sources of confusion and of debate in the analysis of the trials. Non anti-infective treatments should be considered in selected patients when appropriate conventional treatments have been implemented. Use of these new treatments should bring additional improvement in the prognosis in severely ill patients at high risk of death.