Search

Near infrared spectroscopy (NIRS) seems to be an interesting technology to study microcirculatory dysfunction. These alterations have been described after cardiac surgery under cardiopulmonary bypass. We report two case study reports with monitoring of StO(2) and reperfusion slope after an ischemic challenge. These two parameters are early altered notably in case of cardiac dysfunction (decrease of StO(2) and reperfusion slope). We discuss the interest of microcirculatory measurement in this context., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: As the susceptibility of staphylococcal strains to glycopeptides rises, it is becoming necessary to increase vancomycin dosages., Objective: To evaluate an administration protocol for vancomycin using continuous infusion with a loading dose of 30 mg/kg followed by 30 mg/kg per 24h in intensive care patients presenting creatinine clearance (CLc) greater than 50., Results: A total of 22 patients were included in the study. Serum vancomycin concentrations after 24h (C24h) ranged from 25 to 30 mg/l in seven of 14 patients with CLc less than 120 ml/min (50 %), compared with three patients (21 %) with C24h greater than 35 mg/l and four patients (29 %) with C24 h less than 25 mg/l. However, C24h was less than 20mg/l for the eight patients with CLc greater or equal to 120 ml/min. Bacteriological data was available for eight of the 14 patients with CLc less than 120 ml/min, and in these eight patients, the C24h/MIC was greater or equal to 8; seven of these patients had an AUC/MIC greater or equal to 350., Conclusion: Assay of serum vancomycin concentrations after 24h of treatment is necessary to enable rapid adjustment of vancomycin concentration in order to improve therapeutic efficacy or avoid nephrotoxicity., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

We report the case of a 31-year-old pregnant patient in the 33rd week of gestation, with no history of dyslipidaemia, admitted for sub-acute epigastric pain. The milky aspect of blood samples was remarkable. Blood analysis showed a moderate increase in pancreatic enzymes but a major hyperlipaemia: triglyceridaemia 113 g/l and total cholesterolaemia 25 g/l. We suspected a hypertriglyceridemia-induced pancreatitis in pregnancy. The diagnosis was confirmed by CT-scan. Abdominal echography showed no abnormalities in biliary duct. After few hours, a caesarean was performed for acute fetal distress. The patient was admitted to the intensive care unit where a decrease of hypertriglyceridemia was already observed. Only one plasmapheresis was performed. Heparin was introduced. Rapid clinical improvement allowed discharge from intensive care at day 3. This case report illustrates lipid decrease with undertaken treatments. We discuss the management of hypertriglyceridemia-induced pancreatitis in pregnancy.

Objective: The practice of anaesthesiology has the potential for transmitting a number of infectious agents to the patient. In France, several recent cases have been identified, so that a wide survey on anaesthesiology practice has been enhanced., Methods: An anonymous questionnaire, based on the recommendations of the French Society of Anaesthesiology and Intensive Care (Sfar), was send to 8,771 anaesthesiologists and intensive care practitioners and to 2,070 nurses practicing anaesthesiology., Results: A total of 1,343 questionnaires were analyzed (response rate of 12.4%). The study shows that some recommendations were routinely applied, such as: availability of alcohol-based hand hygiene solution in operating rooms (94%), use of antimicrobial filters for respiratory circuits (99%), use of single-use laryngoscope blades (77%), aseptic technique for central venous catheterization (99%), hand hygiene after contact with body fluids (96%). In contrast, the study showed that some recommendations were partially applied: hand hygiene practice (52%), wear of gloves when a risk of blood exposure exists (23%), cleaning of reusable laryngoscope blades (19%), and incorrect wear of masks (71%). The reuse of the same syringe for several patients was described in 2% of the responses., Conclusion: This results, similar to those previously described in the literature, must be followed by appropriate training and education of anaesthesia personnel, implementation of the recommendations, and evaluation of practices. Reuse of the same syringe for several patients have to be eradicated because of the high risk of viral transmission.

We report a case of spontaneous hepatic rupture secondary to HELLP syndrome. A favourable evolution was observed after massive transfusion and surgical management limited to hepatic packing. Subcapsular hepatic haematoma is a rare complication of preeclampsia occurring mainly in the context of HELLP syndrome. A high maternal and foetal mortality is observed. Different therapeutic options are presented including medical, surgical and radiological interventions. A unique strategy cannot be defined. Multidisciplinary approach seems mandatory. Surgery should remain as less aggressive as possible.

We report a case of severe pulmonary embolism diagnosed using spiral CT-scan in a patient admitted for shock associated with acute abdominal symptoms. Intraluminal clots images were visualized associated with an infiltration of mediastinal fat. Abdominal CT showed infiltration of the hepatobiliary hilum. After thrombolysis, the clinical thoracic and abdominal symptoms improved. A CT-scan at the 48(th) hour showed that the thoracic and abdominal features had disappeared. We emphasize the misleading aspect of the CT-scan images and we speculated that this infiltration could reflect the abdominal and mediastinal lymphoedema.

Irrigation of povidone iodine considered as a safe and effective procedure, is frequently used for deep infections. We report a case of intoxication by iodine in a man of 68-year-old after subcutaneous irrigations of Betadine at a concentration of 20% for a subcutaneous infection of the thigh. Abnormalities of cardiac conduction, lactic acidosis, acute renal failure, hypocalcaemia and thyroid dysfunction were the manifestations of the intoxication confirmed by a very high level of total blood iodine and urine iodine.

We analysed the data on the risk of infection during practice of locoregional anaesthesia (LRA) and propose recommendations for its prevention. The epidemiologic data show that the incidence is very low. The risk of LBA during sepsis is uncertain and the data are often contradictory. The benefit-risk ratio must be considered, specifically in obstetrics. Precautions which must be followed during the practice of LRA are discussed.

A young woman without remarkable medical history, experienced a life threatening anaphylactoid reaction after induction of general anaesthesia for an emergency curettage. Hypersensitivity reaction involving IgE antibodies against suxamethonium was proven by positive skin test and detection of specific IgE by radio-immuno assay. After intensive therapy for 2 to 3 hours, the patient exhibited rhabdomyolysis localized on both calves. This complication, which required fasciotomies, did not result in renal failure. Local and general outcome was good. Rhabdomyolysis was due to compartmental ischaemia following shock and local external compression in the lithotomy position.

A 48-yr-old patient was admitted to the ICU for cardiogenic shock and acute renal failure after coronary artery bypass graft surgery. A heparin-induced thrombocytopenia (HIT) occurred during haemodialysis with unfractioned heparin (UFH) as the anticoagulant. The dialysers, the circuits and the catheters were recurrently thrombosing and the platelet count decreased to 9 G.L-1 on postoperative day 7. UFH was discontinued. Attempts to substitute UFH with a low molecular weight heparin (LMWH) failed, due to the presence of a high cross-reactivity rate of LMWH with the heparin-dependent antibody. Intermittent haemodialysis without anticoagulation using a predilution of the dialysers failed also and resulted in recurrent clotting. After informed consent of the patient, a new natural heparinoid Orgaran (Org 10172, Organon, Oss Holland) was administered. This agent is a mixture of several non heparin low molecular weight glycosaminoglycans, with proven anticoagulant efficacy, low cross-reactivity with the HIT antibody, and a half-time prolonged over 18-25 hours. The treatment regimen consisted in a i.v. bolus of 40-45 IU.kg-1 prior to each dialysis procedure, performed every two days. The platelet count increased to 200 G.L-1, seven days after discontinuing heparin injection, and remained stable during the administration of Orgaran. No other thrombosis occurred again. Each procedure of four hours duration was monitored with the plasma anti-Xa activity and APTT test. The mean anti-Xa plasma concentrations (0.44 +/- 0.55 IU.mL-1, 30 min after injection of Orgaran) were well correlated with APTT test (r = 0.73, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

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 < 0.025); postoperative FEV1 measured respectively 60, 66 and 75% 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.

Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.

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 patient's level of consciousness deteriorated over the next 4 hours. He went in an areflexic coma with pupillary 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 mumol.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, glyoxylic 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 glyoxylic acid and glycolic acid are considered as to be neurotoxic.

A case is reported of pneumoencephalus occurring after an accidental dural puncture during a cervical epidural puncture using the loss of resistance technique. Six ml of air were injected intrathecally. The patient recovered spontaneously within five days. This complication may occur more frequently than commonly admitted. It may be difficult to differentiate between headache due to pneumoencephalus and that by stretching of the meninges due to cerebrospinal fluid leakage. Only a CT scan can help to answer this question.