Search

L’anestesia della chirurgia tiroidea riguarda pazienti di qualsiasi eta. La valutazione preoperatoria mira a valutare lo stato tiroideo, la ripercussione locale della patologia tiroidea sulla filiera aerea e i rischi legati al contesto clinico. L’exeresi della tiroide non costituisce mai un’urgenza assoluta, tanto da richiedere prima dell’intervento l’eutiroidismo. La preparazione medica, riducendo l’ormonosintesi o gli effetti centrali e periferici degli ormoni tiroidei, e particolarmente indicata per prevenire la rarissima ma temibile crisi tireotossica. Per la cervicotomia l’anestesia generale e la tecnica di scelta. Essa potra essere associata a blocco del plesso cervicale superficiale per migliorare l’analgesia perioperatoria. I postumi operatori sono semplici nella maggior parte dei casi. Il monitoraggio postoperatorio mira a controllare le complicanze emorragiche che possono mettere in gioco la prognosi vitale e le lesioni degli elementi in contatto con la ghiandola, come le paratiroidi e i nervi ricorrenti. La lesione ricorrenziale, quando e bilaterale, puo essere associata a un’insufficienza respiratoria acuta la cui delicata gestione richiede un ambiente di rianimazione. Questa morbilita dopo tiroidectomia e favorita dai reinterventi e dalla chirurgia oncologica, che necessita di dissezioni estese. Nonostante una semplificazione della gestione dei pazienti tiroidectomizzati, queste gravi complicanze rappresentano un limite importante per la messa in atto di questa chirurgia in ambulatorio.

La mortalidad de la sepsis grave (definida como una disfuncion o hipoperfusion organica inducida por una infeccion) y del shock septico (hipotension arterial refractaria a la reposicion liquida, asociada a la disfuncion o hipoperfusion organica) tratada en una unidad de reanimacion sigue siendo elevada (del orden del 45%), mientras que se espera un aumento de su incidencia en los proximos 25 anos (por el incremento de su deteccion). No obstante, se ha podido registrar recientemente una disminucion significativa de su mortalidad en varios ensayos terapeuticos aislados, basados en una monitorizacion dirigida hacia el tratamiento global de la oxigenacion tisular o que empleaba nuevas vias de tratamiento, que son sobre todo la utilizacion de corticoides en dosis moderadas, la modulacion de la activacion de la hemostasia por la proteina C activada y la aplicacion sistematica de referenciales de cuidados en la reanimacion. Al igual que en el infarto de miocardio, la combinacion de estas nuevas medidas terapeuticas debe realizarse en un ambito global de optimizacion precoz y rapida (6-24 horas). Este nuevo esquema de tratamiento deberia garantizar en el futuro una reduccion considerable de la mortalidad y de la morbilidad de la sepsis (reduccion esperada del 25% durante los proximos 5-10 anos).

Las mordeduras y los aranazos de animales son un motivo frecuente de consulta. En la mayoria de los casos, se trata de un animal de compania. El nino, que a veces es brusco o poco confiado cuando encuentra un animal conocido o desconocido, esta especialmente expuesto. La gravedad de la lesion tiene una correlacion directa con la localizacion (a menudo la cara, debido a la poca estatura del paciente) y con la extension de la mordedura, asi como con el estado vacunal antitetanico del nino. El pronostico se relaciona con la precocidad del tratamiento de la herida septica mediante limpieza, lavado y desinfeccion. La indicacion de antibioticoterapia debe valorarse en funcion del animal que ha producido la mordedura, de la localizacion y de la demora del tratamiento. En caso de envenenamientos por venenos que provoquen reacciones alergicas (himenopteros, etc.), el tratamiento puede ir de medidas locales simples a las medidas contra el shock anafilactico. En algunos venenos citotoxicos (vibora, etc.), existen sueros antiveneno y sus indicaciones de empleo se basan en los criterios clinicos.

Hospital information system manages patient's hospitalization information across different applications and databases. As statistics are performed with difficulties on these different databases, the university hospital of Lille developed an anesthesia data warehouse. This common structure stores data related to anesthesia procedures and patient hospital stay. In that way, the joint analysis on intervention's events and patient's outcome is possible. However, data quality remains one of the main issues in this kind of project. Indeed, errors in patient identifier result in difficulties to link data between the different sources. This problem will be approached in the next phase of the project.

Resume Les morsures et les griffures d'animaux sont un motif frequent de consultation. Dans la majorite des cas, il s'agit d'un animal de compagnie. La gravite de la lesion est directement correlee a la localisation et a l'etendue de la morsure ainsi qu'au statut vaccinal antitetanique du patient. Le pronostic est lie a la vitesse de prise en charge de la plaie septique par nettoyage, parage et desinfection. L'indication de l'antibiotherapie est a discuter en fonction de l'animal mordeur, de la localisation de la plaie et du delai de la prise en charge. En cas d'envenimations par des venins induisant des reactions allergiques (hymenopteres…), le traitement ira du simple traitement local au traitement du choc anaphylactique. Pour certains venins cytotoxiques (vipere…), il existe des serums antivenin dont les indications d'utilisation sont basees sur des criteres cliniques.

Resume Le transport arteriel en O 2 ( TaO 2 = Q × CaO 2 , avec Q : debit cardiaque, et CaO 2 , concentration arterielle en O 2 ) adapte aux besoins ( VO 2 ) de l’organisme en cas d’anemie aigue est celui qui permet d’obtenir TaO 2 > TaO 2 crit ( TaO 2 crit : TaO 2 critique, valeur pour laquelle toute diminution de TaO 2 s’accompagne d’une baisse de VO 2 ). La necessite d’un apport en globules rouges pour un sujet donne repose donc sur la determination d’un CaO 2 crit, et donc d’un taux d’hemoglobine ([ Hb ]) critique ([ Hb ] crit ) puisque CaO 2 ≈ 1,39 × [ Hb ] × SaO 2 (avec SaO 2 : saturation arterielle en O 2 ). La possibilite de reponse de l’organisme par une augmentation de Q est tout aussi determinante que [ Hb ] dans la decision de transfusion puisque CaO 2 crit est inversement proportionnel a Qcrit ( Qcrit : valeur critique de Q ). La saturation veineuse en O 2 du sang veineux mele ( SvO 2 ) est une grandeur qui integre les differents parametres de l’oxygenation tissulaire puisque SvO 2 = SaO 2 –VO 2 /( Q × [ Hb] × 1,39). Pour TaO 2 crit, SvO 2 est de l’ordre de 40 % et l’extraction peripherique de l’O 2 , ERO 2 , est de l’ordre de 60 % pour SaO 2 ≈ 100 %. Une grandeur telle que la SvO 2 centrale, ou ScvO 2 — bien correlee a la SvO 2 mesuree par catheter de Swan-Ganz — peut etre aisement recueillie sur voie veineuse centrale (equipee ou non de fibres optiques) et peut faciliter la decision et le suivi transfusionnels chez le patient presentant une baisse rapide de [ Hb ].

Resume Le monitorage de la saturation en O 2 du sang veineux mele (SvO 2 ) obtenue a l’aide de catheters arteriels pulmonaires munis de fibres optiques trouve sa place dans la prise en charge des patients en etat de choc. La SvO 2 est un reflet de la balance entre le transport en O 2 systemique et la consommation en O 2 (VO 2 ) par les tissus. Le monitorage concomitant du debit cardiaque (DC) continu et de la SvO 2 , rendu possible par certains catheters arteriels pulmonaires, facilite l’interpretation des modifications de la SvO 2 . En effet, une diminution de SvO 2 peut resulter d’une baisse de la saturation arterielle en O 2 , de l’hemoglobine ou du DC ou d’une augmentation de VO 2 . La SvO 2 est un outil d’appreciation de l’extraction peripherique de l’O 2 (EO 2 ) selon une relation SvO 2 = 1 – EO 2 . La SvO 2 ne permet pas correctement l’appreciation de l’oxygenation tissulaire lorsqu’il existe un trouble de l’EO 2 comme au cours du choc septique. La saturation en O 2 du sang veineux central (ScvO 2 ) est plus facilement mesurable que la SvO 2 et il existe une bonne correlation entre ces deux parametres. L’utilisation recente de la ScvO 2 au sein d’un service d’urgence dans un protocole d’optimisation initiale de l’hemodynamique au cours du sepsis severe a permis une diminution absolue de la mortalite hospitaliere de 16 % ( p = 0,009).

Resume But de l’etude : Les premiers resultats, obtenus apres transplantation d’une seule main chez l’homme, ont confirme la faisabilite de la technique qui nous conduit a realiser la premiere greffe des deux mains en janvier 2000. Cet article decrit les resultats 18 mois apres la transplantation. Patient et methodes : Le receveur, 33 ans, avait ete ampute des deux mains en 1996 a la suite de l’explosion d’une fusee artisanale. Le donneur, 18 ans, etait en etat de mort cerebral a la suite d’un traumatisme crânien. Les deux avant-bras preleves ont ete transportes a Lyon et prepares par deux equipes chirurgicales qui ont individualise tous les elements vasculonerveux, les tendons des greffons. Parallelement, deux equipes travaillaient sur les deux moignons en individualisant les memes structures. La transplantation a constitue apres osteosynthese, a suturer les arteres, les veines, les nerfs, a reconnecter les tendons et les muscles avant de fermer la peau. Le traitement immunosuppresseur classique, a 18 mois, associe tacrolimus, mycophenolate, mofetil, prednisone. Resultats : Aucune complication chirurgicale n’est survenue et aucun signe clinique de reaction du greffon contre l’hote ne s’est manifeste. Deux episodes de rejet ont pu etre controles facilement en augmentant les doses de glucocorticoides. La regeneration nerveuse a permis de retrouver une sensibilite et une motricite satisfaisante associee a une reorganisation corticale demontrant une surprenante plasticite cerebrale. La qualite de vie est considerablement amelioree. Conclusion : Le resultat fonctionnel parait au moins aussi bon qu’apres une double reimplantation de mains et le traitement immunosuppresseur conventionnel s’avere efficace pour prevenir le rejet.

Resume Objectifs : Preciser les habitudes en matiere de prescription de bilan de coagulation preoperatoire et evaluer l’impact sur les habitudes de prescription de la prise de connaissance des resultats de la premiere partie de l’enquete et d’une information medicale repetee. Type d’etude : Etude epidemiologique descriptive et comparative. Patients et methodes : L’etude a ete menee en deux temps sur deux journees au cours de deux annees consecutives (1998 et 1999). Elle concernait 22 cliniques privees de la region Nord-Pas-de-Calais. Un questionnaire facile et bref etait a completer par les anesthesistes des cliniques participantes pour chacun des patients admis au bloc operatoire. Celui-ci s’interessait notamment a la presence ou non d’un bilan d’hemostase, a son prescripteur eventuel et aux examens biologiques demandes. Les resultats de la premiere partie de l’enquete (1998) ont ete presentes a plusieurs reprises aux anesthesistes concernes. Ils ont ete discutes et confrontes aux recommandations d’experts avant que la meme enquete ne soit repetee en 1999. Resultats : En 1998, un bilan a ete prescrit pour 81 % des patients ( n = 662) et plus d’une fois sur deux a l’initiative d’un anesthesiste. Dans moins de 5 % des cas il existait une ou plusieurs anomalies dont la moitie etaient previsibles au vu des antecedents des patients. Un seul des patients enrole dans l’enquete a presente un probleme hemorragique alors qu’il avait un bilan de coagulation normal. Un an apres, la prescription d’un bilan de coagulation preoperatoire concernait 75 % des patients ( n = 400), ce qui represente une diminution faible mais significative du nombre de prescriptions par rapport a 1998 ( p Conclusions: Dans cette etude, l’information medicale repetee des praticiens entre les deux temps de l’enquete n’a pas permis de diminuer de facon importante le nombre de prescriptions de bilan de coagulation preoperatoire. Ces resultats plaident en faveur d’une approche differente de l’expose des connaissances scientifiques pour esperer modifier les comportements.

Background: Crohn’s disease is associated with vascular injury and dysregulation of the intestinal immune system which together can provide disturbance of mesenteric circulation functional properties. Aim: To evaluate the vascular reactivity of mesenteric arteries from patients with Crohn’s disease. Methods: Phenylephrine-induced contractions were assessed from 10 patients with Crohn’s disease and 8 control organ donors. NG-nitro-L-arginine-methyl-ester (L-NAME) was used to test the presence of inducible NO synthase. Endothelium dependent and independent relaxation was assessed using acetylcholine, bradykinin, calcium ionophore A23187 and sodium nitroprusside. Results: The contractile response to phenylephrine was significantly decreased in arteries without endothelium from patients with Crohn’s disease. Exposure to the NO synthase inhibitor L-NAME restored the contractile response to phenylephrine. Relaxation remained unaltered in both groups. Conclusion: These data provide direct evidence for fading of contraction caused by phenylephrine in Crohn’s disease. The restored mesenteric artery tone by a specific NO synthase inhibitor suggests that an increased production for NO in vascular smooth muscle might be responsible of this altered vascular reactivity.

Background: Halothane and isoflurane affect differently endothelium-dependent and -independent vasorelaxation at 95% O 2 . In addition, hypoxic vascular response might involve endothelium-dependent and -independent mechanisms. Therefore, we investigated, in rabbit aortic rings, 1) the influence of halothane and isoflurane on vasodilation at 95% O 2 and on hypoxic-induced vasorelaxation at 0% O 2 and 2) the influence of halothane and isoflurane on endothelium-dependent and -independent post-hypoxic vascular response. Methods: Endothelium-intact and endothelium-denuded rabbit aortic rings were used. Phenylephrine precontracted rings were exposed, at 95% O 2 , to acetylcholine (ACh, 10 -9 to 10 -4 M) or sodium nitroprusside (SNP, 10 -9 to 10 -4 M) in the presence or absence of anaesthetic at 1 or 2 MAC. Precontracted rings were also exposed to an acute reduction in O 2 from 95% to 0% followed by an acute reoxygenation with 95% O 2 in the absence or presence of anaesthetic at 1 or 2 MAC. Results: At 95% O 2 , halothane decreased endothelium-dependent relaxation to ACh, while endothelium-independent relaxation to SNP was decreased only at 2 MAC. Isoflurane did not modify ACh- or SNP-induced relaxation. At 0% O 2 , neither halothane nor isoflurane altered the hypoxic vascular relaxation. Post-hypoxic response was not changed either. Conclusion: Our results indicate that halothane and isoflurane do not alter vascular hypoxic response in conductance arteries.

Septic shock is reported as the most common cause of death in intensive care units. Worldwide data indicate a 30 to 60% mortality rate. This death rate has not really changed since the early 1970s despite improved antibiotic therapy, cardiovascular support, and various advances in the management and treatment of sepsis. Septic shock pathophysiology may be related to several altered blood vessel functions associated or not with obvious anatomical injury. Normally, endothelial cells act as a signaling sensor for blood messages to vascular smooth muscle cells. They play a pivotal role in the regulation of local vascular tone. Endothelial injury due to systemic inflammation and induction of the coagulation cascade has been well recognized in the pathophysiology of septic shock. A better understanding of endothelial cell abnormalities occurring during septic shock might prove to be a good way to optimize septic shock therapy.

Simulation has become essential in all situations where reality was too risky, too expensive, difficult to manage or inaccessible. In anaesthesia, the low rate of accidents and incidents, as well as the necessity to assure patient's safety, limit education and training in crisis management. The progress in data processing allowed the development of realistic anaesthesia simulators, associating the usual environment of an operating room, and made possible the simulation of a wide range of events. Most clinical incidents, mishaps, or manipulation errors can be simulated. A video recording allows the focus of attention on human factors. We assessed simulators in three European University hospitals. In Brussels as in Leiden, simulation was mainly used for training in crisis management. In Basel, the complete operating room staff participated in sessions, including also surgical simulation and improvement of communication within the team was one of the main goals. Simulation is valuable for residents' training, as well as continuing medical education, in crisis management and a better understanding of human factors. It remains without risk for the patient, with video possibilities improving the repetition of selected cases. However, its use for evaluation seems to be premature, due to the absence of studies demonstrating the validity and reproducibility of the results gained with simulation. Beyond technical limits which are amended continuously, the development of simulation is hindered by the very high cost of equipment and instructors.

Resume Objectif Faire le point sur l'effet des agents anesthesiques haloganes et intraveineux sur la vasomotricite arterielle. Source de donnees La recherche a ete effectuee a partir de la base de donnees MEDLINE. Les mots cles « vascular smooth muscle, endothelium «, ont ete utilises separement et en association avec chacun des agents anesthesiques: « halothane, isoflurane, enflurane, desflurane, sevoflurane, thiopental, propofol, ketamine, etomidate «. D'autres sources ont ete des revues generales et des ouvrages sur le thame. Selection et extraction des travaux Les travaux experimentaux parus depuis 1975 ont ete analyses et selectionnes sur leur pertinence methodologique. Synthase des donnees La vasomotricite arterielle met en jeu deux structures anatomiques constitutives de la paroi vasculaire l'endothelium et le muscle lisse. Sa regulation est soumise in vivo a des facteurs neurogeniques, hormonaux et metaboliques, dont il est necessaire de s'affranchir pour l'etude de l'effet propre des agents anesthesiques sur le couple endothelium-muscle lisse. L'etude in vitro, sur organes isoles, met en evidence que les haloganes entrainent une attenuation de la contraction induite par differents agents, independamment de l'endothelium. Cet effet resulte de mouvements calciques complexes, aboutissant a la diminution de la concentration de calcium dans la cellule musculaire lisse, principalement par inhibition de l'influx calcique transsarcolemmal. Les haloganes diminuent la vasorelaxation. Leur point d'impact est encore mal elucide mais etroitement lie a l'oxyde nitrique. Les agents intraveineux, propofol, barbituriques, ketamine, etomidate inhibent la vasoconstriction induite, avec une intensite variable selon les produits. Le propofol est l'inhibiteur le plus puissant, le thiopental est le moins inhibiteur. Tous les agents intraveineux inhibent la vasorelaxation, dependante et independante de l'endothelium. Des travaux complementaires sont necessaires pour preciser le mecanisme et le site exacts des effets observes in vitro. L'etude de l'effet vasculaire des agents anesthesiques dans des atteintes de l'endothelium, pourrait, par exemple, permettre indirectement de determiner le role exact de ce dernier dans les effets vasculaires observes.

Percutaneous transluminal coronary angioplasty (PTCA) is today a procedure of choice in many patients with atherosclerotic coronary artery disease. Despite high rates of initial success, restenosis, occurring in 30 to 40 percent of patients within the first six months, remains the major problem limiting the long-term efficacy of the procedure. Animal models have enhanced our knowledge in the understanding of the mechanisms involved in the restenotic process after experimental angioplasty. In fact, the two known determinants of restenosis are the proliferative and migrative response of underlying smooth muscle cells with production of extracellular matrix and the recently highlighted vascular remodeling. Endothelium, which regenerates from the leading edge of the de-endothelialized area within the weeks following arterial injury, is of particular interest in the modulation of the healing process after the procedure. Endothelial dysfunction, as an imbalance between relaxing and contracting factors, between anti- and pro-coagulant mediators or growth-inhibiting and growth-promoting factors, occurs at sites of regenerating endothelium. Experimental studies, using drugs that enhance endothelium-derived relaxing factors release or drugs that diminish endothelium-derived contracting factors production, have often been shown to be effective in the restenosis prevention. Thus, impairment in endothelial cell function may be considered as one of the major regulatory element in the restenotic process. This review discusses the interactions between endothelial and smooth muscle cells and has for aim to point out the major role of endothelial cells in the development of neointimal thickening and arterial remodeling.

Volatile anaesthetics induce hypotension by both indirect and direct effects; they have been reported to inhibit vasoconstriction produced by a variety of agonists. These studies were performed to see if halothane, enflurane and isoflurane attenuate endothelin-1-evoked contraction and if they interact with endothelium-dependent or -independent vasoactive substances. Rat aortic rings were suspended in aerated Krebs' solution (37 degrees C) and contracted by incremental doses of endothelin-1 5 x 10(-10) to 5 x 10(-8) mol litre-1. Volatile anaesthetics at 1 and 2 MAC were tested on endothelium intact and denuded rings. They were tested also on L-NAME incubated endothelium intact and indomethacin-incubated endothelium intact and denuded rings. Responses to endothelin-1 were compared in the presence and absence of volatile anaesthetics. Isoflurane at 1 and 2 MAC concentration, and enflurane at 2 MAC, induced a rightward shift of the dose-response curve obtained with endothelin-1 in both endothelium denuded and intact rings, associated with a decrease in maximal tension generated in the latter rings. In L-NAME-incubated endothelium intact rings and in indomethacin endothelium denuded rings, the anaesthetics induced a rightward shift of the dose-response curve without modification of maximal tension. In indomethacin-incubated endothelium intact rings there was significant attenuation of endothelin-1 contraction in control rings which was not enhanced by volatile anaesthetics in treated rings. The present study indicates that isoflurane at 1 and 2 MAC, and enflurane at 2 MAC, significantly decreased endothelin-1-induced contraction of isolated rat aorta. This inhibition was observed in both intact and denuded rings and probably involves mechanisms within the smooth muscle. Nevertheless, our results suggest that part of the anaesthetic-induced inhibition of endothelin-1-evoked vasocontraction involves an "indomethacin-like" effect on an endothelial-derived vasoconstricting cyclo-oxygenase product.

Myocardial infarction is rare during pregnancy and is associated with a high maternal and foetal mortality rate. We report the case of a 32-year-old woman at 38 weeks gestation who developed a myocardial infarction with spontaneous coronary dissection treated with coronary angioplasty and who needed an emergency caesarean section. We discuss the anaesthetic management of urgent caesarean section in this context.

Au cours du sepsis severe, la presence d’elements membranaires bacteriens est responsable de l’activation et de la liberation de mediateurs de l’inflammation. Alors qu’une correlation entre la gravite de l’etat infectieux et l’activation de la coagulation est connue depuis plus de trente ans [1], l’interaction entre inflammation et coagulation a ete mise en evidence plus recemment. Plusieurs etudes ont demontre que le systeme de coagulation est active par les mediateurs inflammatoires, eux-memes actives par le systeme de coagulation [2]. L’endothelium est fortement implique dans ce processus [3]. Sous l’action d’une endotoxine, ses proprietes changent passant d’un etat normalement profibrinolytique et anticoagulant a un etat antifibrinolytique et procoagulant [2]. Le facteur tissulaire (FT) d’origine monocytaire et endotheliale est l’acteur principal du declenchement de la coagulation [4]. L’activation rapide et excessive de la coagulation est responsable de la formation de depots de fibrine dans la microcirculation, provoquant l’apparition de zones focales d’hypoperfusion, de necrose tissulaire et, au final, du developpement du syndrome de defaillance multiviscerale (SDMV) [5]. L’inhibiteur naturel du FT (tissue factor pathway inhibitor, TFPI) synthetise par l’endothelium, l’antithrombine (AT) et la proteine C (PC), elle-meme synthetisee par le foie et interagissant avec l’endothelium, jouent un role central dans la modulation de la coagulation.

Adequate tissue perfusion is an essential component of oxygenation in critically ill and high-risk surgical patients. Tissue oxygenation is satisfied when tissue oxygen demand corresponds to oxygen consumption (VO2), which is defined as the product of oxygen delivery (DO2) by the oxygen extraction ratio (O2ER) [1]. Under conditions where DO2 does not meet oxygen demand tissue dysoxia occurs leading to organ failure. Early identification and correction of tissue hypoperfusion, focusing on cardiac output and tissue oxygen supply, is of particular importance and may improve outcomes [2]. However, the presence of apparent normal macro circulatory parameters does not ensure adequate oxygen supply and the absence of compromised tissue perfusion [3], [4]; and oxygen-derived variables are poorly correlated with anaerobic metabolism [5] and may, therefore, be normal when tissue dysoxia is present due to microcirculatory deficit [6]. This leads to difficulties in interpreting oxygen-derived variables for detecting tissue hypoxia: A low VO2 may be due either to tissue hypoxia whatever its mechanism (e.g., sepsis, hypovolemia) or to reduced oxygen demand without hypoxia [7]. In addition, monitoring tissue dysoxia and the adequacy of tissue oxygenation is difficult to achieve, while measuring VO2 in intensive care unit (ICU) and surgical patients requires the insertion of invasive pulmonary arterial catheters.

Introduction L’infarctus du myocarde (IDM) dans le peri-partum est une maladie rare (1/10 000) dont l’incidence semble augmenter. La mortalite maternelle est alors elevee, allant de 5,1 a 7,3 %. L’objectif de cette etude est d’observer la prise en charge anesthesique et obstetricale et d’en evaluer le pronostic. Materiel et methodes Etude descriptive et retrospective de 2000 a 2012, maternite Jeanne de Flandre, CHRU de Lille. L’analyse de 958 dossiers a permis de selectionner 15 patientes. Onze patientes ayant un antecedent d’IDM (groupe 1), 2 patientes ayant eu un IDM au cours de la grossesse (groupe 2) et 2 patientes ayant presente un IDM dans le post partum (groupe 3). Trois scores de risque ont ete evalues : ASA, CARPREG et WHO. Resultats La moyenne des scores ASA est de 2. Les scores CARPREG et ASA sont significativement lies. Sur 60 046 accouchements entre 2000 et 2012, la survenue d’un IDM au cours du peri-partum est de 1 sur 15 000. Les âges moyens sont de 33 ans dans les groupes 1 et 2 et de 28 ans dans le groupe 3. La moitie de notre population presentait un tabagisme actif preconceptionnel, sevre pour 77 % dans le groupe 1 et 100 % dans les groupes 2 et 3. Dans le groupe 1, 5 accouchements etaient programmes : 2 par cesarienne sous AG et 3 par voie basse (AVB) avec analgesie peridurale (APD), dont 2 aboutirent a une cesarienne en urgence sous AG. Les 6 autres accouchements n’etaient pas programmes. Leur issue : 1 AVB avec une rachianalgesie (RA) de fin de travail, 4 AVB avec APD et 1 cesarienne en urgence sous AG. Une induction sequence rapide a ete realisee pour toutes les patientes beneficiant d’une AG avec bonne stabilite hemodynamique. Une patiente a beneficie d’un monitorage hemodynamique non invasif par le NICOM®. Les protocoles d’induction et d’entretien des APD ont ete realises avec des doses fractionnees d’agents non adrenalines adjuves de sufentanil. Le Kardegic 75 etait maintenu pour chacune, aucun hematome peri-medullaire n’est survenu. Les 2 patientes du groupe 2 ont accouche par cesarienne sous AG en urgence. Une patiente en decompensation cardiaque a beneficie d’une induction avec opiaces (2 mcg/Kg). Seule l’ocytocine a ete employee comme utero-tonique. Les patientes du groupe 1 n’ont presente aucun episode cardiaque. Aucun deces n’etait retrouve dans notre population. Discussion Aucun lien n’a ete retrouve entre les scores utilises et la survenue de complications, ils permettent d’organiser le suivi. La cesarienne programmee evite un travail long, la RA etant le plus souvent contre-indiquee du fait des modifications hemodynamiques induites. L’APD et la peri-rachianesthesie combinee peuvent etre employees. L’AVB limite les risques lies a l’anesthesie et a la chirurgie, a condition de reduire la charge du travail cardiaque, notamment en controlant la douleur, grâce a l’analgesie peridurale. Ni notre etude, ni la revue de la litterature recente ne confirment le pessimisme entourant les patientes enceintes aux antecedents d’IDM ou presentant un IDM dans le peri-partum. La gestion de la cardiopathie ischemique demeure, cependant un defi avant et pendant la grossesse.

The purpose of this review is to draw up a statement on current knowledge available on the more recent hydroxyethyl starch (HES).References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files.All categories of articles on this topic have been selected.Articles have been analysed for biophysics, pharmacology, toxicity, side effects, clinical effects and using prospect of HES.The first HES was made available in the United States in 1970. The development of a new generation of HES restarted the discussion on clinical interest and the limits in the use of these macromolecules. This interest is also strengthened today by the recent data attached to plasma substitution in intensive care or perioperative resuscitation. The interest for crystalloids and colloids is still widely debated, and among the latter, the relative interest of the HES last generation compared to older ones. Recent HES development is in line with a decrease molecular weight, change rate molar substitution and to amend the glucose to hydroxyethyl report. The ultimate goal is to reduce the side effects of these molecules preventing their use. Side effects are dominated by haemostasis and renal dysfunction. The latest developments are the so-called HES "balanced" solutions.

To analyze the current knowledge related to xenon anaesthesia.References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files.All categories of articles on this topic have been selected.Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect.The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas.Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.

A questionnaire for self-assessment, the Amsterdam Preoperative Anxiety and Information Scale (APAIS) translated into French has been compared to a background questionnaire to validate their use as screening tool and assessment of anxiety and information needs of patients.An epidemiological study was conducted anonymously. Patients completed a questionnaire comprising a French version of APAIS and Spielberger Anxiety Inventory (STAI). A study of correlation between scores for each questionnaire was conducted. A high level of anxiety was investigated.So 1800 questionnaires were distributed, 1504 were usable. The first 100 questionnaires have confirmed the internal validity of the questionnaire APAIS. The following questionnaires in 1404 accounted 49.7% of men 55.7 ± 15.7 years old and 50.2% of women 50.8 ± 15.2 years old. The correlation coefficient (r) between STAI state and appeasement was of 0.675 (P0.001). A score higher than 10/20 by APAIS corresponded to 73% of patients with high anxiety by Spielberger's inventory. No correlation was found between the STAI state and the need for information (r=0.252; P0.001).APAIS, in its French version, assesses anxiety and information needs of patients. This questionnaire has metrological capabilities and ease of execution that make it a screening tool for use in anesthesia consultation. A score above 10 out of 20 reflects a high level of anxiety.

The aim of this study was to assess the value of central venous oxygen saturation (ScvO(2)) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003).Prospective, observational.Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO(2) (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO(2) measured before BT (oror=70%). Results are expressed as median.The ScvO(2) before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO(2) increased significantly (from 57.8 to 68.5%) in the group with initial ScvO(2) less than 70% whereas it was unchanged in patients with initial ScvO(2) greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO(2) greater or equal 70% before BT while 13 patients with ScvO(2) less than 70% were not detected by these same criteria.ScvO(2) could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.

Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation.Prospective, observational study.Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating area under the receiver operated curves (AUC).BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932+/-0.26) and SE (AUC: 0.926+/-0.27). There was however no difference between RE and SE to predict analgesic requirement.Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.

In power electronics, design of power supply is always tending to miniaturization. Passive components represent the main part of the volume. Integrating these elements is a major keypoint to reach a high level of reduction. In order to achieve this, different works have already begun in the world [1], [2] and [3]. In this paper, we will present research on volumes of passive components reduction, inductor-transformer-capacitor. This is fundamental for the miniaturization of all structures of power electronics. One way to achieve this goal is to combine these three passive elements in only one passive component called LCT. We will see how physical limits of this association are constrained by the possible capacitor value considering the dielectric performances. In a second part, a new topology of converter called mixed energy transfer (MET) structure adapted to the LCT is introduced; it can offer industrial interests in a near future. This topology will be compared with more classic ones to demonstrate its advantages.

The peri-operative management of patients undergoing surgery for phaeochromocytoma or paraganglioma with calcium channel blockers (CCB) and their impact on postoperative morbidity and mortality were studied. The medical records of 105 patients undergoing surgery between 1991 and 2002 were analysed retrospectively. In all patients, the calcium channel blocker nicardipine was used for the peri-operative management of haemodynamic changes. Sixty-five patients (61.9%) showed transient intra-operative hypertension. Systolic blood pressure (SBP)220 mmHg and SBP180 mmHg for10 consecutive minutes was observed in 14 (13%) and four patients (2.8%), respectively. SBP80 mmHg for10 consecutive minutes occurred in 13 patients (12.3%). Eleven patients (10.4%) developed postoperative complications and three patients died (2.8%). The median (range) ICU and hospital length of stay were, respectively, 1 (0-7) day and 10 (2-35) days. The sole use of calcium channel blockers for the peri-operative management of phaeochromocytoma and paraganglioma resection does not prevent all haemodynamic changes; however, its use was associated with a low morbidity and mortality.

In 2003, asplenia had involved 250000 patients in France. These patients are at risk of severe infection, mostly with capsulated bacteria as pneumococci, meningococci and Haemophilus. The higher mortality and morbidity due to infection in asplenic patient led in June 2003 a French expert committee to propose preventive management based on vaccination and antibioprophylaxis.Update article.For vaccination, two vaccines against pneumococci are available. The first one, the antipolysaccharide (Pneumo 23) is recommended for adults. It is effective for the majority of the serotypes even if its efficacy can be variable. The second one a conjugated pneumococcal vaccine (Prenevar) is used for children under two years because it has higher activity on antibiotic resistant strains therefore increasing antibiotic prophylaxis efficiency. When splenectomy is required, vaccination against pneumococci, Haemophilus (b type) and C meningococci must be performed at least 15 days before surgery, in order to get better immune stimulation. In case of emergency, vaccines have to be administrated within 30 days after surgery. Antibioprophylaxis is based on cefazolin injection before splenectomy and by postoperative intravenous amoxicillin administration. As soon as oral intake is allowed, antibioprophylaxis is continued for at least two years in adults and five years in children. Both antibiotic and vaccination have been reported to reduce pneumococcus infections.