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L’infusione e un atto praticato molto comunemente nel campo ospedaliero. Questo atto, spesso demandato al personale paramedico, comporta alcune specificita tanto nel posizionamento e nel controllo che nella scelta del materiale di infusione volto a rispondere alla prescrizione medica. Questa scelta e ampia, andando dalla semplice infusione con regolazione a rotella alla somministrazione di agenti farmacologici con siringa motorizzata con obiettivo di concentrazione, e richiede una buona conoscenza dei differenti sistemi esistenti. L’obiettivo di questo articolo e quello di precisare i tipi di accesso possibili per il posizionamento di un’infusione e di prendere in considerazione i vantaggi e i limiti dei sistemi disponibili.

Resume La transplantation pulmonaire (TP) est le seul traitement qui puisse etre propose pour permettre la survie des patients en insuffisance respiratoire terminale. L’objectif de notre etude est d’explorer les progres realises au cours des deux dernieres decennies pour demontrer l’efficacite et la securite de ce traitement. Methodes Analyse retrospective d’une cohorte monocentrique des 600 premiers patients ayant eu consecutivement une TP a l’hopital Foch (Suresnes, France) entre 1988 et 2014. Cette cohorte a ete divisee en 3 groupes chronologiques de 200 patients (1988–2004, 2004–2011, 2011–2014) Resultats La duree d’attente, la mortalite perioperatoire, l’incidence des rejets aigus cellulaires de la premiere annee et du rejet chronique (RC) a 5 ans ont toutes diminue. La survie actuarielle globale a 1 et 5 ans, de 78 % et 57 % pour les 600 patients, est passee a 86 % et 75 % pour les 200 derniers (> 2011). Elle est meilleure a 5 ans pour la mucoviscidose (68 %) que pour l’emphyseme (54 %) et la fibrose pulmonaire (37 %). Pour les 200 derniers patients, elle est a 5 ans de 81 % pour la mucoviscidose, de 78 % pour l’emphyseme et de 47 % pour les fibroses. Elle est de 60 % a 5 ans en cas de transplantation dite de super-urgence. Une surveillance attentive et prolongee doit detecter les complications proliferatives et gerer l’hypertension et la toxicite renale medicamenteuse. Conclusion En 25 ans, des progres considerables en TP ont hisse cette procedure au rang de therapeutique reconnue de l’insuffisance respiratoire chronique terminale.

Resume Objectif Faire la synthese des connaissances actuelles sur la couverture contraceptive en France et dans le monde, decrire l’efficacite des differents types contraceptifs, decrire les caracteristiques des femmes utilisant une contraception, les situations d’echecs contraceptifs et decrire les differents risques medicaux lies aux methodes contraceptives. Methodes Consultation de la base de donnees Medline, et des rapports nationaux ou internationaux sur la contraception en France et dans les pays du monde. Resultats La couverture contraceptive en France est elevee : 97 % des femmes en 2013 utilisant une methode contraceptive (parmi les femmes fertiles, actives sexuellement et sans desir de grossesse), avec notamment une majorite d’utilisation de methodes medicales (72 % d’utilisation de pilules et autres contraceptions hormonales, dispositifs intra-uterins et 25 % d’utilisation de methodes barrieres, naturelles et traditionnelles). La crise de la pilule de 2013 a remis en cause l’utilisation de la contraception œstro-progestative et l’information delivree par les medecins, mais la pilule reste le premier mode de contraception suivi ensuite par le dispositif intra-uterin, les preservatifs, les methodes dites traditionnelles ou naturelles. La couverture contraceptive au cours de la vie change selon une norme definie : preservatifs, pilule, dispositif intra-uterin. La contraception definitive est tres peu choisie et peu proposee. La contraception en France reste une contraception principalement feminine. Les femmes et les couples doivent etre informees sur l’ensemble des methodes contraceptives, qui leur permette de choisir la methode adaptee a leur etat de sante, leurs conditions de vie et leur sexualite.

Purpose Pre-formed donor-specific antibodies (pf-DSA) are associated with worse outcome after lung transplantation (LTx) and might limit access to LTx. A virtual crossmatch (CXM)-based strategy for perioperative desensitization protocol has been used for immunized LTx candidates since 2012 at Foch hospital. We compared the outcome of desensitized LTx candidates with high pf-DSA mean fluorescence intensity (MFI) and those with low or no pf-DSA, not desensitized. Methods For all consecutive LTx recipients (January 2012-March 2018), freedom from CLAD and graft survival were assessed by Kaplan-Meier analysis and Cox proportional-hazards multivariate analysis. Results We compared outcomes for desensitized patients with high pf-DSA (n=39) and those with no (n=216) or low pf-DSAs (n=66). The desensitization protocol decreased the level of immunodominant pf-DSA (class I/II) at 1, 3, and 6 month post-LTx (p Conclusion The desensitization protocol in LTx recipients with high pf-DSAs was associated with satisfactory outcome, with cleared high pf-DSAs after desensitization identified as an independent predictor of graft survival.

Introduction La maladie a nouveau coronavirus 2019 (COVID-19) a actuellement un taux de progression rapide mondial. Le nombre de cas severes rapportes chez les greffes d’organes solides reste limite, mais leur statut d’immunodeprime fait supposer un risque eleve de complications liees au SARS-Cov-2. L’insuffisance respiratoire aigue liee au syndrome de detresse respiratoire aigue (SDRA), qui se developpe chez environ 5 % des patients, reste la cause principale de deces. Il est maintenant etabli qu’un sous-groupe de patients porteurs d’infection severe COVID-19 developpe un syndrome de tempete cytokinique associe au risque de deces, chez qui des traitements immunomodulateurs pourraient etre benefiques. Les options therapeutiques, entre autres, incluent les corticoides a doses elevees, mais il etait anticipe une balance risque–benefice defavorable a leur utilisation au tout debut de l’epidemie. Une autre question dans la population des transplantes pulmonaires (TxP) est l’eventuel role prophylactique de l’azithromycine au long cours sur l’acquisition du SARS-Cov-2, frequemment administre dans cette population specifique en cas de la dysfonction chronique du greffon. Resultats Nous rapportons 2 cas severes de SDRA-COVID-19 hyper-inflammatoires ayant menace leur pronostic vital, survenus au sein de notre cohorte monocentrique de greffes pulmonaires malgre un traitement d’azithromycine faible-dose au long cours. Un traitement par methylprednisone a doses elevees (2 mg/kg/j), debute precocement apres le debut du SDRA sous ventilation mecanique, a permis une recuperation pulmonaire rapide et ad integrum chez les 2 patients. Conclusion Ces 2 cas de SDRA-COVID-19 suggerent : – que des formes graves peuvent survenir malgre un traitement au long-court d’azithromycine faible-dose apres TxP ; – le benefice de l’utilisation precoce des corticoides a dose elevee en cas de survenue de SDRA-COVID-19 hyper-inflammatoire apres TxP, comme observe recemment dans un essai therapeutique testant l’efficacite de la dexamethasone au sein d’une population generale de patients.

Purpose Fast-tracking in cardiothoracic surgery is highly challenging. Early postoperative extubation an aspect of this strategy. The objective of the present study was to report our whole experience of immediate end-surgery extubation (OR extubation) after lung transplantation. Methods This retrospective study was apporved by the Ethical Board of the French Society for Anesthesia and Intensive Care. All consecutive patients undergoing double-lung transplantation from 2012 to 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The strategy is possible due to short acting drugs and a strict cardio-respiratory weaning protocol based on inhaled nitric oxyde and ECMO removale at end-surgery when is possible (see Figure). The aims of the study were: to identify predictive factors of immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible in one third of patients after lung transplantation. It requires transdisciplinary collaboration. It forecasts a positive outcome.

Purpose Fast-tracking in cardiac-thoracic surgery is highly challenging. It requires multimodal and transdisciplinary collaboration. Early postoperative extubation in the operating room (OR) is an aspect of this strategy1. The objective of the present study was to report our whole experience of immediate end-surgery extubation after lung transplantation. Methods The Ethical Board of the French Society for Anesthesia and Intensive Care approved this analysis of the prospectively Lung Transplant database. All consecutive patients undergoing double-lung transplantation from January 2012 to December 2018 were analyzed, except repeated transplantation during the study period, and transplantation under cardiopulmonary bypass. The cardio-respiratory weaning protocol has been previously published2 (Figure). The aims of the study were: to identify factors predicting immediate extubation, and to compare outcome among patients. Results Among the 410 patients included, 142 (34.6%) were extubated in the OR. Predictive factors for OR extubation are reported in Table 1. Postoperative outcomes are summarized in Table 2. Conclusion Immediate extubation via a fast-tracking protocol is feasible after lung transplantation. It forecasts a positive outcome. It requires transdisciplinary collaboration.

Purpose The thundering evolution of lung transplantation management during the past ten years and primary graft dysfunction (PGD) new definition have led to new predictive factors of PGD. Therefore, we retrospectively analyzed a monocenter database using a machine-learning method, to determine the predictive factors of grade 3 PGD (PGD3), defined as a PaO2/FiO2 ratio Methods We included all double lung transplantation from 2012 to 2019 and excluded multi-organ transplant, cardiopulmonary bypass, or repeated transplantation during the study period for the same patient. Recipient, donor and intraoperative data were added in a gradient boosting algorithm step-by-step according to standard transplantation stages. Dataset was split randomly as 80% training set and 20% testing set. Relationship between predictive factors and PGD3 was represented as ShHapley Additive exPlanation (SHAP) values. Results A total 478 patients were included in the analysis, 83 (17.3%) had PGD3. Highest performance analysis was achieved at the end-surgery stage (0.87, IC95 [0.867-0.873]) with 6 predictive factors: being under ECMO at some point in the intervention and whatever the reason for its implementation is a predictor; a recipient low total lung capacity is a predictor; ECMO is a predictor whatever the time of implantation; having a cystic fibrosis or a COPD/emphysema is protective while having a lung pulmonary fibrosis or another pathology is predictive. Conclusion Gradient boosting predicted PGD3 with high performance using variables available at the end of double lung transplantation. The implementation of strategies adapted to modifiable variables could make it possible to limit the occurrence of a PGD or its severity.

Purpose Lactic acidosis has been recently propose as independently associated with longer intubation times and length of stay in lung transplantation(1). However, there is no data on the association between elevated blood lactate concentration (BLC) and grade 3 primary graft dysfunction at day 3 after lung transplantation (PGD3). The purpose of the study was to investigate the profile of BLC during double-lung transplantation and it association with PGD3. Methods We performed a retrospective observational study of all bilateral lung transplantations at the Foch Hospital from January 2012 to December 2019, excluding those on bridge-to-transplantation, under cardiopulmonary bypass, and multiple-organ transplantation. BLC was measured at every key time of the invention: initially, at every pulmonary artery clamping or declamping, and at end-surgery stage. The ethical committee of the French Society of Anesthesia and Critical Care (SFAR) approved the study. The evolution of intraoperative BLC was evaluated with a paired T-test with Holm correction to compare lactate. AUC was constructed to determine Sp and Se. The optimal threshold of lactates variable used for separation of PGD3 was calculated using the Youden-index. Results Over 478 patients were included, 83 (17.3%) had a PGD3. BLC evolution during surgery is illustrated in figure 1. The median of BLC at end-surgery was 2 [1.5 - 3.1] and 3.3 [2.4 - 4.9] mmol/L in no PGD3 and PGD3 groups respectively, p = 0.02. BLC kinetic illustrated by its variability was the best predictive factor of PGD3 (AUC=0.84, Se= 77.03, Sp=79.82%). Conclusion Hyperlactatemia reflects anaerobic metabolism during peroperative hemodynamic unstable conditions and poor oxygen exchange after implantation of the grafts. Blood lactate variability during surgery is associated with PGD3.1. Worrell SG, et al. Is Lactic Acidosis After Lung Transplantation Associated With Worse Outcomes The Annals of Thoracic Surgery. 2020 Aug;110(2):434-40.

Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT.Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval).Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia.This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.

We reviewed our experience with tracheal extubation in the operating room (E-OR) among cystic fibrosis patients requiring bilateral lung transplantation to evaluate safety and determine predictive factors of E-OR.The charts of 89 recipients (from May 2007 to June 2013) were analysed. Patients were divided into E-OR and E-ICU (intensive care unit extubation) groups. Data are expressed as numbers (percentages) or medians [25th-75th percentiles].There were 41 patients in the E-OR group (46%). Donor and recipient characteristics were similar between groups. Intraoperative complications occurred less frequently in the E-OR group, and fluid and transfusion requirements were lower. Postoperative courses were different in the E-OR group, including a lower rate of grade 3 primary graft dysfunction (0 compared with 19 patients, P0.0001) and shorter ICU (5.0 [3.7-7.2] compared with 11.5 [7.0-15.5] days) and hospital stays (22.0 [18.0-25.5] compared with 33.0 [25.0-56.5] days, respectively; P0.0001 for both). The 1 yr survival rates were similar: 95% in the E-OR group and 98% in the E-ICU group. A statistical model built on a development cohort of 60 randomly selected patients predicted 95% of E-OR instances in this cohort and 82% of E-OR instances in the validation cohort (28 patients). Predictive factors were complications during single-lung ventilation (second graft implantation), complications during bipulmonary ventilation (end of surgery), and the ratio of arterial partial pressure of oxygen to fractional inspired oxygen (end of surgery).Our protocol allowed for extubation of 46% of bilateral lung transplant patients without increased postoperative risks.

La anestesia para cirugia toracica presenta diversos aspectos especificos que conviene conocer para adaptar el manejo de los pacientes durante todo el periodo perioperatorio. En primer lugar, la disminucion de la funcion respiratoria secundaria a la reduccion del parenquima requiere una evaluacion preoperatoria de calidad para determinar la operabilidad (evaluacion del riesgo cardiaco, exploraciones funcionales respiratorias, etc.) y para limitar la morbimortalidad postoperatoria. Para facilitar la intervencion quirurgica, la inmovilidad del parenquima se obtiene mediante un control de las vias aereas basado en una tecnica de exclusion pulmonar, cuyas modalidades (tubo de intubacion de doble luz, bloqueador bronquial) se adaptaran al paciente y al procedimiento previsto. En todos los casos, una exploracion fibroendoscopica permite determinar la calidad de la colocacion del dispositivo escogido. Por otra parte, uno de los objetivos principales peroperatorios es evitar la aparicion de lesiones alveolares utilizando una estrategia ventilatoria protectora tanto en ventilacion bipulmonar como en ventilacion unipulmonar durante la cirugia. Por ultimo, la fase postoperatoria debe tener como finalidad una recuperacion rapida de la anatomia del paciente, lo que requiere una estrategia de control del dolor optima, asi como la implementacion de programas de rehabilitacion postoperatoria o, mas recientemente, de preparacion multimodal preoperatoria aun denominada «prehabilitacion». En ultima instancia, el conjunto de estas tecnicas puede servir en otras intervenciones (esofagectomia, manejo de la hemoptisis), por lo que su conocimiento es util para cualquier medico.

L’anestesia per chirurgia toracica riveste un certo numero di specificita che e opportuno conoscere per adattare la gestione dei pazienti per tutto il periodo perioperatorio. In primo luogo, la riduzione della funzione polmonare conseguente a una riduzione del parenchima richiede una valutazione preoperatoria per determinare l’operabilita (valutazione del rischio cardiaco, test di funzionalita polmonare, ecc.) e per limitare la morbimortalita postoperatoria. Per facilitare la procedura chirurgica, l’immobilita del parenchima si ottiene con un controllo delle vie aeree basato su una tecnica di esclusione polmonare le cui modalita (sonda di intubazione a due vie, bloccatore bronchiale) saranno adattate al paziente e alla procedura prevista. In ogni caso, un esame mediante fibroscopia permette di qualificare la qualita del posizionamento del dispositivo scelto. Peraltro, uno dei principali obiettivi intraoperatori e di evitare la comparsa di lesioni alveolari mediante il ricorso a una strategia ventilatoria protettiva allo stesso tempo in ventilazione bipolmonare e in ventilazione monopolmonare durante l’intervento chirurgico. Infine, la fase postoperatoria deve mirare a un ritorno rapido all’autonomia del paziente, e cio richiede una strategia di controllo del dolore ottimale, nonche l’attuazione di programmi di riabilitazione postoperatoria o, piu recentemente, di una preparazione multimodale preoperatoria, chiamata anche “preabilitazione”. Da ultimo, tutte queste tecniche possono interessare altri interventi (esofagectomia, gestione dell’emottisi) e la loro conoscenza e utile per ogni medico.

In the context of lung transplant (LT), because of diagnostic difficulties, antibody-mediated rejection (AMR) remains a matter of debate. We retrospectively analyzed an LT cohort at Foch Hospital to demonstrate the impact of AMR on LT prognosis. AMR diagnosis requires association of clinical symptoms, donor-specific antibodies (DSAs), and C4d(+) staining and/or histological patterns consistent with AMR. Prospective categorization split patients into four groups: (i) DSA positive, AMR positive (DSA(pos) AMR(pos) ); (ii) DSA positive, AMR negative (DSA(pos) AMR(neg) ); (iii) DSA limited, AMR negative (DSA(Lim) ; equal to one specificity, with mean fluorescence intensity of 500-1000 once); and (iv) DSA negative, AMR negative (DSA(neg) ). AMR treatment consisted of a combination of plasmapheresis, intravenous immunoglobulin and rituximab. Among 206 transplanted patients, 10.7% were DSA(pos) AMR(pos) (n = 22), 40.3% were DSA(pos) AMR(neg) (n = 84), 6% were DSA(Lim) (n = 13) and 43% were DSA(neg) (n = 88). Analysis of acute cellular rejection at month 12 showed higher cumulative numbers (mean plus or minus standard deviation) in the DSA(pos) AMR(pos) group (2.1 ± 1.7) compared with DSA(pos) AMR(neg) (1 ± 1.2), DSA(Lim) (0.75 ± 1), and DSA(neg) (0.7 ± 1.23) groups. Multivariate analysis demonstrated AMR as a risk factor for chronic lung allograft dysfunction (hazard ratio [HR] 8.7) and graft loss (HR 7.56) for DSA(pos) AMR(pos) patients. Our results show a negative impact of AMR on LT clinical course and advocate for an early active diagnostic approach and evaluation of therapeutic strategies to improve prognosis.

Purpose Lung transplantation (LT) is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use extended criteria donors. However, the use lung donors over 65 years old is rarely reported especially among a population of young cystic fibrosis (CF) recipient. Methods We report a single center experience of lung transplantations for CF recipients between January 2005 and september 2019. Two cohorts were built and compared according to lung donor age Results Among this period, 378 bilateral lung transplantations (BLT) for CF were performed. 344 BLT were done with donors aged Conclusion Use of donor lungs over 65 years for CF recipients allows donor pool extension without compromising early and midterm results. However, longer follow up is needed to appreciate long term results.

Purpose The extreme difficulty of carrying out randomized studies in lung transplantation leads us to consider statistical methods derived from artificial intelligence. Previous studies in kidney and liver transplantations, as well as in heart surgery, showed better predictive ability than traditional statistical analysis to predict postoperative outcomes. Methods We analyzed a prospective database of all 410 double lung transplantations performed in our center, from January 2012 to June 2018. We used a Random Forest approach over 284 variables, in order to predict one-year mortality. Performance of the predictive model is evaluated at successive temporal stages of the transplantation process. Variables are incrementally acquired during the process, starting with patient-only variables at stage 1, ending with patient, donor and surgery-related measurements at stage 12. At each stage of the process, a machine-learning model has been trained based on available variables. A 80-20-cross-validation procedure has been performed at each stage, and repeated 40 times, resulting in a set of 40 area under ROC curve scores, whose distribution has been summarized using boxplots (median, 25 and 75 percentiles). Gini score allowed to each variable its weight in the model. Results The AUROC performance starts at 0.65 for step 1 and reaches 0.75 (figure) at the final step. Gini score found Lung Allocation Score as the best predictor of one-year mortality (3.17), followed by hyperlactatemia at second lung implantation (2.62), PaO2/FiO2 ratio at end-surgery (2.46) and age (2.35). Second lung ischemic time was a the 20th position in Gini Score (1.6). Conclusion Conclusion: Machine-learning approach is feasible to predict one-year mortality after lung transplantation. This study is encouraging to go further in the analysis of our database.

We used an automated bispectral index (BIS)-guided dual-loop controller to determine propofol and remifentanil requirements during general anaesthesia in obese and lean surgical patients.Obese patients, BMI35 kg m(-2), and lean patients (25 kg m(-2)) having laparoscopic procedures were prospectively evaluated in this multicentre single-blind study. The automated controller targeted BIS between 40 and 60 by adjusting propofol and remifentanil administration. Propofol and remifentanil consumptions were calculated using both total body weight (TBW) and ideal body weight (IBW). Results are expressed as medians (inter-quartile range).Thirty obese [BMI=43 (40-49) kg m(-2)] and 29 lean [BMI=23 (21-25) kg m(-2)] patients completed the study. BIS was between 40 and 60 during 84 (69-91)% vs 85 (78-92)% of the anaesthetic time, P=0.46. The amount of propofol given during induction [1.2 (1.1-1.6) vs 1.3 (1.0-1.7) mg kg(-1), P=0.47] and maintenance [5.2 (4.1-6) vs 5.3 (4.7-6.4) mg kg(-1) h(-1), P=0.39] calculated using TBW was similar between the two groups. The dual-loop controller delivered half as much remifentanil to the obese patients during induction [1.0 (0.8-1.6) vs 2.2 (1.5-2.7) µg kg(-1), P0.001] and maintenance [0.12 (0.07-0.16) vs 0.25 (0.17-0.29) µg kg(-1) min(-1), P0.001] calculated using TBW. But when remifentanil consumption was calculated using IBW, the amounts were similar during induction at 2.2 (1.6-3.5) vs 2.0 (1.6-3.0) µg kg(-1) IBW, P=0.48, and during maintenance at 0.26 (0.16-0.34) vs 0.27 (0.18-0.33 ) µg kg(-1) min(-1), P=0.50.The amount of propofol-remifentanil administered by the controller is consistent with current knowledge, propofol is best dosed using TBW whereas remifentanil is best dosed using IBW.NCT00779844.

En un paciente que se encuentra en reanimacion y presenta un cuadro de insuficiencia respiratoria aguda, el estudio por imagen se hace indispensable ante una agravacion de la hematosis y si el traslado del paciente expone a un riesgo considerable. En la actualidad, la realizacion de una ecografia pleuropulmonar es de rigor tras una valoracion semiologica simple y especifica, con la ventaja de que se trata de un metodo reproducible. Por eso, se ha convertido en una tecnica alternativa segura y fiable, de aprendizaje y realizacion simples. Esto permite que el clinico, tanto en una instancia prehospitalaria como en el hospital, pueda contar rapidamente con datos relativos al estado pulmonar de un paciente y orientarse con sensatez en el proceso diagnostico y terapeutico.

Introduction De multiples causes de dysphagie peuvent etre retrouvees. Parmi celles-ci, un obstacle extrinseque, comme les osteophytes de vertebres cervicales arthrosiques, peut etre responsable d’une obstruction pharyngo-œsophagienne haute. Bien que frequemment retrouves chez les sujets âges dysphagiques, les osteophytes cervicaux ne sont que rarement responsables de dysphagie severe. Nous rapportons le cas d’une jeune patiente. Observation Une femme de 43 ans est adressee en medecine interne pour l’exploration d’une dysphagie severe aux solides et aux liquides avec fibroscopie œso-gastroduodenale normale (y compris les biopsies systematiques). Elle a pour antecedent un ulcere gastrique, des douleurs articulaires chroniques, une rosacee et une agression a l’arme blanche ancienne avec des lesions au niveau du bras droit, du diaphragme et un pneumothorax. Cliniquement, il existe une stase salivaire, des troubles de la deglutition avec douleurs et fausses routes, pas de perte d’appetit. Malgre une alimentation lente (> 1 h par repas), precautionneuse et hypercalorique, ces troubles sont responsables d’une perte de poids de plus de 10 kg en 6 mois. Le reste de l’examen est sans particularite, il n’y pas de fievre, de signe infectieux, de deficit neurologique, de trouble respiratoire. Pas de troubles du transit, ni reflux gastro-œsophagien. Le bilan biologique standard est sans particularite, il n’y a pas de syndrome inflammatoire, pas de carence nutritionnelle, le bilan thyroidien et martial sont normaux. Le bilan auto-immun est negatif (Ac anti-recepteur de l’acetylcholine, anti-MUSK, anti-ADN natif, antinucleaire a 1/80) hormis les anticorps anti-Mi2b au DOT myosite mais a titre faible. Les CPK sont normales, un electromyogramme des 4 membres et des muscles cervicaux ne montre pas d’anomalie, permettant d’exclure une pathologie neuromusculaire systemique. Une manometrie œsophagienne ne retrouve pas d’anomalie de la motricite œsophagienne ou de pathologie des sphincters superieur et inferieur de l’œsophage. Un scanner cervico-thoraco-abdomino-pelvien retrouve en premiere lecture de l’arthrose moderee entre C4 et C7. L’examen fibroscopique ORL ne visualise pas d’obstacle, ni paralysie des cordes vocales. Finalement, la realisation d’un transit œso-gastroduodenal met en evidence des becs osseux osteophytiques marginaux anterieurs en C4–C5 et C5–C6 entrainant une empreinte sur la face posterieure de l’œsophage pouvant expliquer la dysphagie. Il n’est visualise de diverticule de Zenker. En reprenant l’interrogatoire, la patiente revele avoir ete victime de multiples traumatismes dans l’enfance et l’adolescence (maltraitance) pouvant etre responsables d’arthrose precoce. Devant la severite des symptomes avec echec des mesures d’adaptation dietetiques, une solution chirurgicale est envisagee. Les reconstructions 3D au scanner precisent la compression de l’œsophage par de volumineux osteophytes anterieurs. Discussion La dysphagie liee a une osteophytose cervicale anterieure resulte d’une compression mecanique extrinseque par un ou plusieurs osteophytes volumineux (> 10 mm), principalement au niveau C3–C5 [1] mais aussi de phenomenes inflammatoires locaux lies a l’irritation des tissus. Bien que connu depuis longtemps, peu de cas ont ete rapportes dans la litterature, principalement chez les sujets âges. Chez le sujet âge, une dysphagie peut aussi etre associee a une maladie de Forestier (ou hyperostose vertebrale engainante) mais la presence d’anomalies osseuses n’est pas suffisante pour retenir leur responsabilite et un bilan etiologique exhaustif doit etre entrepris, comprenant une etude videoradiographique de la deglutition (TOGD). Un traitement conservateur (mesures dietetiques, AINS, reeducation a la deglutition) doit etre entrepris le plus tot possible. Une intervention chirurgicale, risquee, (resection des osteophytes) doit etre envisagee pour les cas refractaires ou severes, avant que les compressions n’entrainent des degâts irreversibles sur la motricite de l’œsophage. L’experience dans la litterature montre qu’elle ameliore les symptomes dans la majorite des cas [1] . Conclusion Parmi les causes de dysphagie, l’existence d’osteophyte vertebraux cervicaux est a rechercher, y compris chez le sujet jeune, par la realisation d’un transit œso-gastroduodenal. Sa presentation atypique peut parfois etre severe et necessiter un traitement chirurgical.

Resume Nous rapportons la survenue d’une hyperthermie maligne chez un jeune patient de 21 ans polytraumatise. Ce cas presente pour particularites : une survenue brutale apres 4 heures de chirurgie ; une association de multiples facteurs declenchants et un diagnostic genetique prefere aux tests habituels de declenchement sur biopsie musculaire compte tenu d’anesthesies generales iteratives programmees. Les differents points sont discutes avec proposition d’un arbre diagnostique adapte au contexte.

La perfusion es un procedimiento que se realiza con mucha frecuencia en el ambito hospitalario. Esta practica, a menudo efectuada por tecnicos sanitarios, incluye aspectos especificos en cuanto a la colocacion, el control y la eleccion del material de perfusion a efectos de cumplir con la prescripcion medica. La opcion es amplia, desde la perfusion simple con venoclisis hasta la administracion de agentes farmacologicos a traves de una jeringa autopropulsada con objetivo de concentracion. Esto exige conocer bien los diversos sistemas. El proposito de este articulo es describir las vias de acceso de una perfusion y analizar las ventajas y los limites de los sistemas disponibles.

El protoxido de nitrogeno u oxido nitroso es un agente volatil que se utiliza en el ambito medico desde hace mas de 150 anos. Sus propiedades farmacologicas constituyen su particularidad, ya que posee al mismo tiempo propiedades analgesicas, de tipo no morfinico a traves de una accion supraespinal, propiedades euforizantes que le han valido la denominacion de «gas de la risa» y propiedades ansioliticas o incluso anestesicas leves, por lo que se utiliza ampliamente como agente anestesico volatil adyuvante. Con el fin de garantizar su inocuidad y eficacia maxima, se han definido con precision sus condiciones de empleo, tales como la necesidad de informar previamente al paciente cuando se utiliza con fines analgesicos (reduccion del foco de fractura, punciones diversas), un uso exclusivamente asociado a la administracion de oxigeno, la utilizacion de dispositivos especiales para su administracion con valvulas antirretorno o sistemas de ventilacion especificos en el quirofano para limitar la contaminacion ambiental, etc. Por otra parte, este agente posee algunas contraindicaciones, como por ejemplo en pacientes que presentan deficit conocidos o probables de vitamina B12 o de folatos y las ocupaciones aereas de cavidades no extensibles. Por ultimo, se han descrito algunos efectos indeseables como nauseas, vomitos postoperatorios y efectos neurotoxicos que limitan y condicionan su uso.

II protossido d’azoto e un agente volatile utilizzato in campo medico da piu di 150 anni. Le sue proprieta farmacologiche ne costituiscono la particolarita, poiche esso presenta al tempo stesso proprieta analgesiche, di tipo non morfinico, che passano attraverso un’azione sopraspinale, proprieta euforizzanti che gli valgono la denominazione di «gas esilarante» e proprieta ansiolitiche, o anche debolmente anestetiche, che lo fanno ampiamente proporre come agente anestetico volatile adiuvante. Le sue condizioni di impiego sono ormai precisate per garantirne l’innocuita e l’efficacia massima come un’informazione preliminare del paziente per un uso a fini analgesici (riduzione di un focolaio di frattura, punture diverse), un uso associato esclusivamente alla somministrazione di ossigeno, dei dispositivi particolari di somministrazione con valvole antireflusso o dei sistemi di ventilazione specifici nel blocco operatorio per limitare l’inquinamento ambientale. Tale agente antico possiede comunque un certo numero di controindicazioni al suo impiego, tra le quali si trovano i pazienti che presentano deficit noti o probabili di vitamina B12 o di folati e i versamenti aerei di cavita non estensibili. Infine,e riferito un certo numero di effetti indesiderati quali le nausee e i vomiti postoperatori, gli effetti neurotossici e via dicendo, che giustificano, infine, il suo impiego ragionato e, probabilmente, limitato.

Chest trauma: spectrum of lesions Blunt chest trauma typically occurs as part of polytrauma, usually secondary to motor vehicle accidents, sports related injuries or defenestration in Western Europe. Each chest compartment may be responsible for immediate and/or delayed complications, thus requiring a dedicated systematic and comprehensive analysis. The use of image post-processing is mandatory in order to not overlook a potentially severe injury. The purpose of this paper is to review the technical considerations of multidetector CT, and the imaging features and interpretation method for each chest compartment, in order to generate an adapted report.

Background Although many physiological and pathological conditions affect minimal alveolar concentration (MAC), there are no reliable data on the MAC for halogenated anaesthetics during left ventricular hypertrophy (LVH) and congestive heart failure (CHF). The aim of this experimental study was to determine the MAC values of halothane, isoflurane, and sevoflurane in rats, at early and later stages of cardiomyopathic hypertrophy. Methods LVH was induced by ascending aortic stenosis in 3–4-week-old rats. LVH and CHF in each animal were assessed weekly by echocardiography. MAC of halothane, isoflurane, and sevoflurane was determined using the tail-clamp technique in spontaneously breathing rats from each group. Response vs no-response data were analysed using logistic regression analysis. Data are medians (95% confidence interval). Results The MAC of halothane [1.30% (1.26–1.34)], isoflurane [1.52% (1.48–1.57)], and sevoflurane [2.93% (2.78–3.07)] in rats with LVH was not different from sham-operated rats [respectively, 1.23% (1.20–1.26), 1.52% (1.47–1.56), and 2.90% (2.79–3.00)]. Conversely, the MAC of halothane [1.44 (1.39–1.50)] and isoflurane [1.74 (1.69–1.78)], but not sevoflurane [2.99 (2.93–3.06)], was significantly increased in rats with CHF. Conclusions MAC values for halothane, isoflurane, and sevoflurane were unchanged in rats with pressure-induced overload LVH. Conversely, the MAC for halothane and isoflurane, but not sevoflurane, was significantly increased in rats with CHF.

Resume Malgre des resultats cliniques controverses en traumatologie crânienne, l'hypothermie reste une therapeutique encore preconisee et largement etudiee pour de multiples raisons. Des effets protecteurs sont demontres apres ischemie cerebrale dans les etudes animales et apres arret cardiaque chez l'homme. Par ailleurs, l'importance et la duree d'un episode d'hyperthermie sont des facteurs independants d'aggravation du pronostic apres une agression cerebrale ischemique ou traumatique. De plus, il existe une etroite correlation entre niveau de PIC et niveau de temperature, et l'hypothermie permet une diminution de l'hypertension intracrânienne. Cependant, de nombreux problemes restent a resoudre et expliquent probablement les discordances entre les etudes cliniques : la mesure directe de la temperature cerebrale, les liens entre PIC, temperature et PaCO2, les modalites (duree et profondeur) de l'hypothermie therapeutique, et enfin, les conditions precises de refroidissement et surtout de rechauffement. Ces problematiques sont importantes a maitriser meme s'il s'agit seulement de lutter contre l'hyperthermie.

Introduction L’evaluation objective de therapeutiques antalgiques en cas de douleurs chroniques de type algoneurodystrophie ou CPRS (Complex Regional Pain Syndrome) constitue un veritable challenge [1] . L’Analgesia Nociception Index (ANI) est un outil d’hetero-evaluation de la douleur basee sur ses effets sur le systeme nerveux autonome. L’objectif de cette etude est d’evaluer l’interet de ANI comparativement a l’Echelle Visuelle Analogique (EVA) chez des patients traites par blocs peri-nerveux en ambulatoire [2] . Materiel et methodes Apres accord du CCP (ID RCB : 2011-A01676-35) et recueil du consentement, les patient(e)s adultes souffrant de CPRS aux membres inferieurs ou superieurs avec confirmation a la scintigraphie osseuse etaient eligibles. Les criteres d’exclusion etaient le refus, l’infection locale ou generale, l’arythmie cardiaque et la prise de betabloquants. Avant la realisation d’un bloc peri-nerveux, chaque patient remplissait un questionnaire d’anxiete et de gene fonctionnelle articulaire. Apres 5 minutes d’enregistrement au repos, l’EVA et l’ANI etaient collectes avant et apres stimulation algogene standardisee. Cette mesure etait repetee apres la pratique du bloc sous echographie realise en condition aseptique avec mise en place d’un catheter peri-nerveux (Contiplex BBRAUN) avec administration de 10 mL de Naropeine 0,2 %. La comparaison a porte sur les periodes avant-apres bloc regional (test t de Student apparie) et sur le calcul du coefficient kappa de concordance. Une valeur de p Resultats Parmi les 30 patients, 8 hommes ont ete inclus dans cette etude monocentrique prospective. L’EVA au repos et a la stimulation diminuait significativement apres le bloc tandis que l’ANI s’elevait significativement. L’amplitude de la reponse de l’ANI etait faiblement correlee a l’amplitude de baisse de l’EVA (r = 0,05) si la concordance dans la reponse est bonne : K = 0,88. La courbe ROC determinant la capacite de l’ANI de detecter une douleur moderee a severe presentait une aire sous la courbe de 0,65 avec un point d’inflexion pour une valeur de 69 avec une sensibilite et une specificite de 0,77 et 0,70 respectivement. L’anxiete ne ressort pas comme correlee aux mesures de l’EVA ( Tableau 1 ). Discussion Une valeur d’ANI ne permet pas de discriminer de facon satisfaisante les patients en fonction de l’intensite de leur douleur avant un bloc en cas de CPRS. Toutefois, la variation de la valeur renseigne correctement du succes de la technique.

Island arc basaltic rocks (basalts and basic andesites with SiO 2 P - T conditions. The temperatures obtained from the geothermometers based upon the distribution of the major elements are in good agreement with the data from trace element geothermometers.