Search

Cerebral air embolism due to pulmonary tuberculosis is an extremely rare cause of stroke. We report an unusual case of a presentation of cerebral air embolism likely due to pulmonary tuberculosis lesions during a severe cough. We discuss the relationship between the pulmonary tuberculosis and the occurrence of the cerebral air embolism. A 55-year-old man with lung tuberculosis suddenly experienced a nontraumatic loss of consciousness after a severe cough. The magnetic resonance imaging confirmed an ischemic stroke due to cerebral air embolism. The thoracic scan revealed tuberculosis with a parenchymatous cavity. Patients with intrapulmonary tuberculosis cavities should be strongly considered for surgical repair and should be warned about the risk of rupture of the cavity in the situation of increasing thoracic pressure. How to cite this article: Bouaggad A, Moussaoui M, Abassi O, Hassen S, Essodegui F. Massive Cerebral Air Embolism Causing Stroke Secondary to Pulmonary Tuberculosis. Indian J Crit Care Med 2021;25(8):942–944.

Background: Symptomatic pleural effusion following ventriculoperitoneal shunt (VPS) insertion is very rare and poorly understood in the literature in contrary to other mechanical complications. Case Description: We report a case of 15 month-year-old girl who had VP shunt for congenital hydrocephalus. Twelve months after surgery, she was diagnosed with massive hydrothorax. Chest X-ray and thoracoabdominal CT scan confirmed the right pleurisy and showed the tip of the peritoneal catheter in the general peritoneal cavity. We made thoracic drainage of the transudative pleural effusion. When we released the chest tube, 24 h after, the girl showed a respiratory distress again and the effusion resumed at the X-ray control. Her symptoms abated after the realization of a ventriculoatrial shunt “VAS.” Repeat chest X-ray confirmed the resolution of the hydrothorax. Conclusion: Despite the not yet well-understood mechanism of this rare and important VPS complication, management is simple based on X-ray confirmation, thoracentesis with biological analysis, and catheter replacement, especially in atrium “VAS.”

Resume Introduction. – Un travail recent a montre que la neostigmine (500 μg) injectee en intra-articulaire procure une analgesie postoperatoire (APO) sans effets secondaires. Le but de ce travail a ete d’etudier si l’adjonction de cette molecule au cours du bloc plexique par voie axillaire (BPA) aurait assure une APO efficace sans nausees ni vomissements. Materiel et methodes. – Il s’agit d’etude prospective en double aveugle incluant 90 patients ASA 1-2 programmes pour une chirurgie orthopedique ou reparatrice sous BPA par neurostimulation (15 ml de lidocaine 2 % et 15 ml de bupivacaine 0,5 %). Les patients ont ete randomises en 3 groupes de 30. Le premier groupe temoin (TGr) recevait 1 ml de serum physiologique par voie axillaire ; le deuxieme groupe (NAGr) 500 μg (1 ml) de neostigmine par voie axillaire et le troisieme groupe (NSGr) 500 μg (1 ml) de neostigmine par voie sous-cutanee. La douleur a ete evaluee par l’EVA, la consommation du ketoprofene ainsi que la frequence des nausees et vomissements durant les 24 premieres heures. Une injection de ketoprofene en perfusion lente etait realisee chaque fois que l’EVA ≥ 4. L’analyse statistique a fait appel a une ANOVA et aux tests de Kruskal Wallis et de Fisher ; p Resultats. – Il n’a pas ete trouve de difference entre les 3 groupes concernant les parametres demographiques (âge, poids, sexe et taille) et hemodynamiques peroperatoires. Les scores d’EVA etaient plus bas dans le groupe NAGr (2,1 ± 1,8) que dans le NSGr (3,1 ± 1,4) et le TGr (4,5 ± 2) (p = 0,001). La consommation moyenne de ketoprofene le premier jour etait de 127 ± 65 mg pour le NAGr VS 150 ± 53 mg pour le NSGr et 200 ± 50 pour le TGr (p = 0,02). L’incidence des nausees et vomissements etait de 3,5 % dans le NAGr vs 6,8 % dans le NSGr et 0 % dans le TGr. Conclusion. – La neostigmine par voie axillaire a procure une APO efficace avec peu de nausees et vomissements.

Resume Objectif : Etudier l’effet de l’adjonction de la clonidine a la lidocaine sur la douleur postoperatoire apres realisation d’une anesthesie locale intraveineuse. Type d’etude : Etude prospective randomisee en double aveugle. Patients et methodes : Etude portant sur 45 malades, repartis au hasard en deux groupes : groupe 1 (n = 25) recevant 3 mg·kg–1 de lidocaine 0,5 % + serum physiologique et groupe 2 (n = 20) recevant un melange de 3 mg·kg–1 de lidocaine 0,5 % et de clonidine (150 μg). L’analgesie postoperatoire a ete evaluee par l’echelle visuelle analogique (EVA) et le delai de la premiere demande en antalgiques (ketoprofene). L’incidence des effets secondaires apres la levee du garrot a ete etudiee. L’analyse statistique a ete realisee par le χ2, l’Anova et le test de Kruskall Wallis. Le seuil de signification retenu a ete p

L’anesthésie par bloc du plexus brachial par une voie axillaire (BPBVA) est une technique de référence pour un grand nombre d’actes chirurgicaux du membre supérieur. Le but de cette étude est d’évaluer la qualité du BPBVA par neurostimulation dans notre pratique quotidienne. Matériel et méthode : Etude prospective menée au service de chirurgie plastique-réparatrice et de traumatoorthopédie étalée sur 12 mois. Quatre vingt cinq patients ont été inclus, répartis en deux groupes : groupe U (chirurgie urgente) et groupe P (chirurgie programmée). Ont été évalués de façon comparative le délai d’installation, la durée d’action et la qualité de l’anesthésie en fonction du caractère urgent ou réglé de la chirurgie. Résultats : les deux groupes sont comparables concernant les données démographiques, alors que le délai d’installation est plus long en cas de chirurgie urgente. Le taux d’échec est plus important quand il s’agissait de chirurgie réalisée en urgence. Conclusion : L’anesthésie du plexus brachial par voie axillaire grâce à la neurostimulation est une technique anesthésique permettant d’éviter les complications graves liées à l’anesthésie générale., Maroc Médical, Vol. 26, No 1 (2004)

Les complications respiratoires post-opératoires après chirurgie carcinologique de l’oesophage, représentent une cause majeure de morbidité et de mortalité post-opératoires. Cette étude rétrospective évalue l’incidence de ces complications et tente de déterminer les facteurs favorisants chez 35 patients ayant eu une oesophagectomie pour tumeur maligne entre janvier 1990 et décembre 1997. L’analyse univariée porte sur les paramètres suivants : l’âge, les antécédents de bronchopneumopathies chroniques, la dénutrition, la voie d’abord chirurgicale, et la durée de l’intervention. Dix neuf malades soit 54% ont présenté une complication respiratoire. La mortalité globale était de 14% dont plus de 1/3 par une complication pulmonaire. Ces complications sont représentées par : 9 pneumopathies, dont 5 compliquées par un syndrome de détresse respiratoire aiguë, 4 épanchements pleuraux, 2 pneumothorax, et 4 cas d’encombrement bronchique majeur. L’analyse de tous ces facteurs a permis de relever une valeur prédictive positive du risque respiratoire pour les antécédents de broncho-pneumopathies chronique (p, Maroc Médical, Vol. 22, No 4 (2000)

To determine current clinical neuromuscular use in Morocco anesthetic practice.Clinical practice survey.Anesthesiologists were invited to answer anonymously to question about neuromuscular blocking agents (NMBA): pharmacology, monitoring and antagonism drug use. Corrected yates test was used to compare qualitative parameters and variance analysis for quantitative parameters. P0.05 was considered as significant.We had 171 answers, 54% were paramedics (n=93) and 46% (n=78) were physicians (20% global effective in Morocco). Fifty-five percent were seniors. Vecuronium was the most NMBA used in Morocco for 51% of the anesthesiologists. Mean action time of NMBA was underestimate in more than 60% of the staff questioned specially for seniors (24.6%) than juniors (19.2%). Residual neuromuscular blockade was evaluated only by clinical and spirometric parameters in 72%. TOF monitor was used in 18% more in military hospitals (36%) and insurance clinics (40%) than private hospitals (12.5%). Administration of reversal drugs was systematic in 5.8% of anesthesiologists, frequent for 36.3% and rare for 55%.This study show an underestimation of residual neuromuscular blockade, poor neuromuscular monitor use and lack of knowledge of NMBA specially for senior anesthesiologists and in private hospitals. We should elaborate Moroccan guideline for NMBA use and provide formal training programs for our anesthetic staff.

This is a report of two cases of tetraplegia complicating fat embolism after fracture of long bones. In the first case, a 26 year-old male sustained fractures of femur and tibia. One day after admission, the patient became comatose (Glasgow coma score = 6) with dyspnaea and petechiae present on the anterior chest wall. In second case, a 22 year-old man with a fracture of tibia and humerus, suffered two days after admission from similar signs of fat embolism (dyspnaea, Glasgow score coma = 6, petechiae). A tetraplegia occurred after 7 days in the first patient and 6 days in the second. No lesions were visible on brain CT scan. Magnetic resonance imaging showed relative high-intensity areas on T2 weighted views. The outcome at three weeks was favourable, without neurologic sequelae.

Floating thrombus of the ascending aorta is a rare and often ignored cause of peripheral embolic events. We report the observation of a patient presenting recurrent peripheral embolic demonstrations: acute ischemia of the right lower limb complicated of a thigh amputation and transient cerebrovascular accident. The assessment by angioscanner highlighted a 40-mm thrombus of the ascending aorta. The thrombus was removed surgically. This diagnosis should not be ignored in the assessment of an embolic pathology with the risk of severe functional after-effects caused by an important diagnostic delay.

We report two cases of tetraplegia caused by cervical stab wounds. In the first one, in a 34-year-old patient, the injury caused an immediate tetraplegia from cervical spine section and had a rapid lethal outcome. The second case occurred in a 30-year-old woman, who experienced a progressive tetraplegia associated with a Brown-Sequard syndrome from an oedema of the bulbo-spinal junction. Three months later, the motor recovery was satisfactory, however a thermo-algesic hemi-anaesthesia still persisted after the 6th month.

The purpose of this study is to specify the incidence, the risk and prognostic factors of the ARF. Transverse study about all the patients hospitalized in our department during one year. The incidence of the ARF was 18%. The state of shock, sepsis, high SAPS and advanced age were the main risk factors of the ARF happening. The mean number of multiple organ failure was 3.8 +/- 1.4 in the died patients versus 2.2 +/- 0.3 in the survivors. The whole mortality was about 46.3%. In our department, the incidence of the ARF is lower than in the literature. Age, SAPS, sepsis and state of shock are the main risk factors. ARF mortality is still high particularly in the case of shock or multiple organ failure.

BACKGROUND To see if early tracheostomy (fifth day) reduces duration of mechanical ventilation, ICU stay, incidence of pneumonia and mortality in comparison with prolonged intubation (PI) in patients with head injury. METHODS Patients were prospectively included in this study if they met the following criteria: isolated head injury, Glasgow coma scale (GCS) score < or =8 on first and fifth day, with cerebral contusion on CT scan. On the fifth day, randomization was done in two groups: early tracheostomy group (T group, n = 31) and prolonged endotracheal intubation group (I group, n = 31). We evaluated total time of mechanical ventilation, ICU stay, pneumonia incidence and mortality. Complications related to each technique were noted. Analysis of data were performed using Yates and Kruskall Walis tests. p < 0.05 was considered significant. RESULTS The two groups were comparable in term of age, sex, and Simplified Acute Physiologic Score (SAPS). The mean time of mechanical ventilatory support was shorter in T group (14.5 +/- 7.3) versus I group (17.5 +/- 10.6) (p = 0.02). After pneumonia was diagnosed, mechanical ventilatory time was 6 +/- 4.7 days for ET group versus 11.7 +/- 6.7 days for PEI group (p = 0.01). There was no difference in frequency of pneumonia or mortality between the two groups. CONCLUSION In severe head injury early tracheostomy decreases total days of mechanical ventilation or mechanical ventilation time after development of pneumonia.

The incidence of difficult endotracheal intubation (DEI) for patients undergoing thyroidectomy has rarely been studied, and evaluation of factors linked to DEI is limited to a few studies. We undertook this prospective study to investigate the incidence of DEI in the presence of goiter (an enlargement of the thyroid gland) and to evaluate factors linked to DEI. We studied 320 consecutive patients scheduled for thyroidectomy. DEI was evaluated by an intubation difficulty scale. The trachea was intubated by an unassisted anesthesiologist, and the intubation difficulty scale was calculated. A univariate analysis was performed to identify potential factors predicting DEI, followed by a multivariate analysis. DEI was reported in 17 patients. The rate of easy tracheal intubation was 36.9%; the rate for patients who had minor difficulty of intubation was 57.8%. Sex (male), body mass index, Mallampati class, thyromental distance, neck mobility, Cormack grade, cancerous goiter, and tracheal deviation or compression were identified in the univariate analysis as potential DEI risk factors. With multivariate analysis, two criteria were recognized as independent for DEI (Cormack Grade III or IV and cancerous goiter). We conclude that the large goiter is not associated with a more frequent DEI. However, the presence of a cancerous goiter is a major factor for predicting DEI.

Recent study showed that neostigmine (500 microg) by intra-articular produces postoperative analgesia without adverse effect. The author's goal was to determine whether 500 microg of neostigmine added to bupivacaine in axillary plexus block could prolonged postoperative analgesia without increasing the incidence of side effects.Ninety patients scheduled for orthopedic or plastic surgery with axillary plexus block were randomly assigned to one of 3 groups : group 1 (TGr n = 30) received saline solution (1 ml) in the axillary plexus, group 2 (NAGr n = 30) received 500 microg (1 ml) neostigmine in the axillary plexus and group 3.500 microg neostigmine subcutaneously (NSGr n = 30). We evaluated visual analog pain scores (VAS), the consumption of the ketoprofene, nausea and vomiting incidence during the first 24 h. ANOVA, Kruskall Wallis and Fisher tests were used for statistical analysis. A p value of0.05 was considered significant.The VAS score was lower in NAGr (21 +/- 18) vs NSGr (31 +/- 14) and control group TGr (45 +/- 2) (p0.05). The consumption of the ketoprofene is 127 +/- 65 mg in NAGr vs 150 +/- 53 mg in NSGr and 200 +/- 50 mg in group TGr (p = 0.02). Incidence of nausea and vomiting was 3.5% in NAGr vs 6.8% in NSGr and 0% for TGr.Neostigmine combined to a mixture of lidocaine and bupivacaine prolongs postoperative analgesia after axillary plexus block.

The nosocomial bacteremia (NB) are frequent and associated to a high mortality and morbidity with extension of stay in the intensive care unit (ICU). The aim of this study is to evaluate epidemiological aspect and prognosis of NB. It is a retrospective study about 872 patients hospitalized in our unit during 2 years. The diagnosis of the NB is based on two positive hemocultures with 24 hours of interval in the patients who are hospitalized more than 48 hours. The incidence of the bacteremia represents 6.6% (n = 58). The portal of entry is noticed in 55% of the cases (n = 32). The most frequent origin is respiratory infection 24% (n = 14), whereas bacteremia after catheter colonization represents 3.4% (n = 2). Gram Positive cocci were incriminated in more than 53% of the cases (n = 39). Staphylococcus aureus was the first causal germ (n = 28) whereas the Pseudomonas is the most frequent of the gram negative bacilli that represent 41% of the isolate germs (n = 31). The sensitibility of this germ to ceftazidim and imipenen was respectively 18% and 19%. The rate of the resistant Staphylococcus to meticilline was 38%. The whole mortality represented 28% (n = 16) that 7% (n = 14) of the cases were directly in relationship with the septic shock. Among prognostic factors evaluated, only septic shock and multivisceral failures are correlated to mortality. NB mortality is not negligible in ICU. Staphylococcus and Pseudomonas are the most frequent germs. Limitation of invasive acts, rigorous antibiotherapy management and observance of hygienic measures will significantly reduce incidence of NB.

Evaluate the effect of the addition of clonidine to lidocaine on postoperative pain after intravenous regional anaesthesia.Double blind prospective study.Forty-five patients were randomly allocated to two groups: group 1 (n = 25) receiving 3 mg.kg-1 of lidocaine 0.5% added to saline and group 2 (n = 20) receiving 3 mg.kg-1 of lidocaine 0.5% added to clonidine (150 micrograms). Postoperative analgesia was assessed using a visual analogue pain score (VAPS) and the time to first analgesic request. The incidence of side effects after tourniquet release was noted. Analysis of variance, Kruskall Wallis and chi 2 tests were used for statistical analysis. A p-value of0.05 was considered significant.Age, ASA class, duration and type of surgery, tourniquet time and sensory block duration were comparable for the two groups. The time to first antalgic request after deflation of tourniquet was similar in the two groups (38 +/- 15 min versus 44 +/- 19 min), while VAPS score was lower (p0.05) in the clonidine group (5.2 versus 6.8). The incidence of side effects was comparable in the two groups.The addition of clonidine (150 micrograms) to lidocaine for intravenous regional anaesthesia improved postoperative analgesia but in a limited and short-lasting manner.

Neurological hemorrhagic complications are unusual in hemophiliacs. Extradural hematoma is an exception, particularly at the cervical level. Less than 10 cases have been reported in the literature. We report a new case which was the inaugural sign of hemophilia A.Moderate hemophilia A was revealed by post-traumatic cervical extradural hematoma in a 12-year-old boy. Pain in the cervical spine and progressive tetraplegia led to the diagnosis, confirmed by cervical CT scan. The dissonance between the injury and the minor trauma led to hemostasis exploration which revealed factor VIII at 3%. After prompt correction of the deficiency, total laminectomy allow removal of the hematoma. The neurological course was satisfactory.We stress the specific character of this association and the previously unreported mode of hemophilia disclosure. CT scan and MRI facilitate diagnosis allowing satisfactory course after emergency decompressive laminectomy.

We report two cases of tetraplegia caused by cervical stab wounds. In the first one, in a 34-year-old patient, the injury caused an immediate tetraplegia from cervical spine section and had a rapid lethal outcome. The second case occurred in a 30-year-old woman, who experienced a progressive tetraplegia associated with a Brown-Séquard syndrome from an oedema of the bulbo-spinal junction. Three months later, the motor recovery was satisfactory, however a thermo-algesic hemi-anaesthesia still persisted after the 6th month.

Phostoxin is a mixture of aluminium phosphide and ammonium carbonate. When exposed to water, it releases phosphorus hydrogen (PH3), a highly-poisonous gas. In Morocco, death rate from suicide due to self-administration of phostoxin pills is high. Clinical signs include abrupt digestive and nervous disorders. Pulmonary oedema or cardiogenic shock dominate early prognosis. Liver and renal damage is secondary. Prevention requires both legal constraints and regulation of sales.

Sixty cases of severe eclampsia were treated in an intensive care unit between January 1989 and September 1993. Mean age was 26, and 70% of patients were primipara. The pregnancy has been unsupervised in almost all cases. All had visceral lesions and/or hematologic problems and there was impaired conscious level in 9 cases out of 10. Medical treatment involved the control of seizures and of hypertension. Cesarean section was performed in 34 cases. The maternal death rate was 23.3%. Our experience indicates that mortality depends upon visceral lesions (cerebral, disseminated intravascular coagulation, acute pulmonary edema, Hellp syndrome). Better awareness of severity factors in preeclampsia improves both maternal and fetal prognosis by precisely indicating the best time for fetal extraction.

Neurologic manifestations are usual and variable during post-traumatic fat embolism. The pathogenesis of these lesions continues to be a source of considerable controversy. Thirteen cases of post-traumatic fat embolism with neurologic signs were treated in a surgical intensive care unit. All patients had impaired consciousness. Focal neurologic disorders were reported in 5 cases [hemiplegia (2), tetraplegia (2), aphasia (1)]. The aspects on brain CT scan seemed to be related to ischemic lesions (1 case), appeared normal in ten cases, or revealed post-traumatic hemorrhagic lesions (2 cases). The outcome at 2-4 weeks was spontaneously good, with complete resolution, without neurologic sequellae, in 11/13 patients. Two deaths were related to brain trauma severity (one case) and nosocomial pneumonia (one case).

The authors report a case of pre-eclamptic toxemia, characterised by extensive cortical, sub-cortical and vertebro-basilar neurological lesions. The appearance of these lesions and their course were suggestive of the role played by toxemic vasculitis and vasospasm.

A case of polyradiculoneuritis, resembling Guillain-Barre syndrome, was reported during the sixth month of a first gestation. The patient was seventeen years old and also had toxaemia of pregnancy. The interaction between polyradiculoneuritis and pregnancy is slight and carries little risk of prematurity. Plasma exchange procedures can be used in pregnant women and the results of this treatment are similar to those in patients presenting with polyradiculoneuritis alone.

This is a report of two cases of tetraplegia complicating fat embolism after fracture of long bones. In the first case, a 26 year-old male sustained fractures of femur and tibia. One day after admission, the patient became comatose (Glasgow coma score = 6) with dyspnaea and petechiae present on the anterior chest wall. In second case, a 22 year-old man with a fracture of tibia and humerus, suffered two days after admission from similar signs of fat embolism (dyspnaea, Glasgow score coma = 6, petechiae). A tetraplegia occurred after 7 days in the first patient and 6 days in the second. No lesions were visible on brain CT scan. Magnetic resonance imaging showed relative high-intensity areas on T2 weighted views. The outcome at three weeks was favourable, without neurologic sequelae.

Many brain complications occur during eclampsia with various degree of gravity. The pathogenesis of these lesions continues to be a source of considerable controversy. Five cases of eclampsia with severe neurologic manifestations were treated in our surgical intensive care unit. The CT image appeared to be related to haemorrhagic lesions (3 cases) and ischaemic lesions (2 cases). The clinical course was favourable, often reversible, in cases with oedema and ischaemia maternal prognosis was poor in the case with haemorrhage.

Nosocomial urinary tract infection is the most frequent nosocomial infection in many care units. Its main risk factor is the presence of a bladder catheter. Prevention is based upon the enforcement of hygiene recommendations which are not always carefully applied everywhere. We report a prospective study concerning 328 patients divided into two gropus. Group I patients (n = 161) had an indwelling bladder catheter. Group II patients (n = 167) had an external urinary drainage by Penilex. The incidence of nosocomial urinary infection was 2.4% in group II versus 26.7% in group I. Thus preventive efficacy of Penilex use appears to be well demonstrated.