Annales Francaises D Anesthesie Et De Reanimation最新文献

In nasal and sinus surgery, the anaesthetist must share the operating field with the surgeon and take into account some patients’ specific pathologies. Bleeding must be avoided by different means but the accurate gesture of the surgeon, added to the properties of the new anaesthetic drugs, may reduce the risk of this functional surgery.

Introduction

Hemorrhagic shock is an emergency, which may benefit from a medicalized prehospital care. Our goal was to survey the means available in the 370 French prehospital medicalized emergency services (SMUR) for hemorrhagic situations.

Methods

Multicenter descriptive observational study by email then phone with all the 370 French SMUR leaders. The questionnaire was created by investigators of the project through a Delphi method, and was about service protocols concerning hemorrhagic patient care, hemorrhagic parameters measure equipment available, intravenous solutes and drugs as well as various medical devices useful or perceived to be useful to support prehospital hemorrhagic shock. The results are expressed in numbers and percentages.

Results

The overall response rate was 48% (n = 178). Protocols were established in between 43% (n = 76) and 47% (n = 83) according to etiology, measuring devices were available in 5% (n = 9) of the Smur for hemostasis up to 89% (n = 158) for hemoglobin measurement. Available intravenous solutes were mainly isotonic salty serum (95%, n = 169), hydroxylethylstarch (83%, n = 148) and Ringer lactate (73%, n = 130). Tranexamic acid was available in 84 (47%) Smur. The teams had access to erythrocytes concentrates, fresh frozen plasma and platelets in 84% (n = 150), 44% (n = 79) and 23% (n = 41) respectively. Eighty-one (46%) Smur had tourniquets and 127 (71%) anti-shock trousers. Finally, 57 (32%) had a pelvic restraint belt.

Conclusion

There is a great disparity in the means available in the French Smur for the support of prehospitalization bleeding. The majority the Smur physicians can transfuse in a prehospital setting. On the other hand, a minority of teams can actively warm patients, employ tranexamic acid or use pelvic restraint belts.

Drug reaction with eosinophilia ans systemic symptoms (DRESS) is a severe medication-induced adverse reaction, which can threaten patient's life. Clinical symptoms and organ failures present wide variability. Furthermore, the latency period is long, so that diagnosis could be a real challenge in the intensive care unit. We report the case of a woman developing a DRESS after neurosurgery complicated by a nosocomial infection.

We report the case of an 8-year-old sickle cell anemia child admitted for acute respiratory failure complicating acute chest syndrome. Because of threatening respiratory failure, tracheal intubation was performed immediately after ICU admission. The patient met the criteria for ARDS with a PaO₂/FiO₂ ratio of 94 mmHg. An exchange transfusion was performed immediately after admission. HbS fraction failed from 69 % to 30 %. Fluid resuscitation with crystalloids and continuous norepinephrine infusion was needed because of arterial hypotension. Due to persistent severe hypoxemia with PaO₂/FiO₂ ratio below 100, the patient was placed in prone positioning 16 hours after admission, for a total duration of 14 hours. A second 12-hour session of prone positioning was performed 41 h after admission and PaO₂/FiO₂ ratio reached 300 mmHg after. Treatment also included transfusion of two red-cell pack on day 1 and 2 after admission in order to maintain hemoglobin level above 8 g/dL, and a daily folic acid supplementation. The control of hyperthermia was achieved by a systematic parenteral administration of paracetamol. Cefotaxime and erythromycine were continued until day 7 despite the negative results of all bacteriological samples. The outcome was favorable from day 3 and the patient met the criteria for extubation on day 5. A first attempt of extubation was performed on day 5, but re-intubation was required because of laryngeal edema. Steroids were given for 48 h and the patient was successfully extubated on day 7. She was discharged from the ICU on day 8, and from the hospital on day 12. We discuss the various treatments available for the management of acute chest syndrome and their actual relevance in acute respiratory distress syndrome in the absence of strong evidence-based guidelines in pediatric ARDS.

The diagnosis of perioperative vertebral artery dissection can be difficult because of non-specific clinical signs. We report a case revealed by a tegmento-thalamic stroke after an abdominal second surgical look. The interest of this observation is related to a particular evolution in two steps separated by a 2-month-interval and an intercurrent cervical manipulation. After the second anesthesia, neck pain associated with a third cranial nerve palsy and a supranuclear ophtalmoplegia revealed a tegmento-thalamic ischemic stroke due to vertebral artery dissection. We discuss here the different factors possibly involved in the pathophysiology of postoperative vertebral artery dissection: positioning, cervical manipulation, subclavian central venous access and cisplatin toxicity. Vertebral artery dissection should be discussed in case of postoperative neck pain, especially with non-typical symptomatology.