Removal of airway foreign body using flexible bronchoscopy in children.

BACKGROUND: Flexible bronchoscopy is mainly used to diagnose airway foreign bodies (AFBs). Due to advances in pediatric anesthesia, many teams have considered the extraction of AFBs by flexible bronchoscopy. We aimed to assess the success of flexible bronchoscopy in AFB removal in children. PATIENTS AND METHODS: We analyzed retrospectively the data of children admitted for AFB aspiration in the Pediatric Respiratory Diseases Department B of Abderrahmane Mami Hospital in Tunisia between January 2012 and December 2022. AFB removal was performed by flexible bronchoscopy through the use of a laryngeal mask airway (LMA) or intubation. RESULTS: Of the 105 children included, AFB was removed by flexible bronchoscopy in 99 children (94.3 %). The mean age of the children was 32 months (9-150 months) with a sex ratio of 2:3. The foreign body was organic in 67 % of cases. Overall, 37 children underwent rigid bronchoscopy first (35.2 %). Flexible bronchoscopy was performed through the LMA in 77 cases (73 %) and after intubation in the other cases. Thoracic surgery was needed in two cases (1.9 %). Four infants expectorated the AFB after the procedure (3.8 %). Only two children developed laryngeal edema with transient oxygen desaturation. CONCLUSION: AFB removal using a flexible bronchoscope is an efficient and safe procedure when performed by an experienced team. The recent use of LMA has facilitated the use of a larger bronchofiberscope and the insertion of multiple tools that can reach distal airways.

Left sleeve pneumonectomy for a rare lung tumor: A case report.

INTRODUCTION AND IMPORTANCE: Primary adenoid cystic carcinoma (ACC) of the lung is extremely rare. This tumor can be asymptomatic or have non characteristics symptoms, and the diagnosis is often late. The treatment of choice is surgery when it's possible. CASE PRESENTATION: We herein report the case of a young patient with ACC of the left main bronchus. He had dyspnea and chest pain for 6 months. Complete atelectasis of the left lung was found on the chest x-ray. Bronchoscopy showed a tumor obstructing the LMB and invading the carina. The CT scan revealed a 5 cm tumor obstructing the left main bronchus (LMB) with extension to the carina and thoracic trachea. The extension assessment was without abnormalities. The treatment was surgical. A left carinal pneumonectomy by double lateral thoracotomy was performed. The postoperative results were satisfactory. There was no recurrence with a follow-up of 2 years. CLINICAL DISCUSSION: The therapeutic management of ACC is essentially based on surgical resection, which should be as radical as possible. However, complete resection is often difficult given the infiltrating nature of the tumor. CONCLUSION: Sleeve pneumonectomy with carinal resection is a curative option for patients with ACC of the main bronchi and carina that require expertise of the surgeons.

Oxygen delivery monitoring under cardiopulmonary bypass : what implication on postoperative morbidity and mortality ?

INTRODUCTION: The standard control parameters of cardiopulmonary bypass (CPB) currently used in Tunisia are replaced in Western countries by the concept of "goal-directed-perfusion" requiring oxygen delivery (DO2) minimum at 270ml / min / m2. AIM: In this study, we explored the association between the DO2 and the postoperative morbidity and mortality. METHODS: This is a cross-sectional and retrospective observational study including a series of 50 patients operated on for myocardial revascularization under CPB. RESULTS: We noticed a significant correlation between starting DO2i and Creatinine clearance at day 0, Δcreate (day 1-day 0) and ventilation time. There was also a significant correlation between discharge DO2i and daytime urine output, ventilation time, hospital stay and in-hospital mortality. Through a univariable study, we compared the classic parameters of perfusion monitoring during CPB in addition to the starting DO2i with the different postoperative results. It was noted that the starting DO2i figures below the threshold of 270ml / min / m² were significantly correlated with the duration of administration of catecholamines postoperatively, with prolonged ventilation, with the variation in serum creatinine postoperatively and with in-hospital mortality. CONCLUSION: DO2 is a monitoring tool that has proven its advantages for monitoring under CPB.

Surgical management of a simultaneous aortic valve replacement and pneumonectomy.

Combined heart surgery and lung resection remains a controversial issue. The treatment of two major conditions in the same operative time may be attempted in certain cases. We report the case of a 68-year-old man who presented for dyspnea on exertion. The chest computerized tomography scan showed an infiltrating tumor which involved the right interlobar artery. A pneumonectomy was indicated and the preoperative echocardiography detected a calcified aortic valve with severe stenosis and significant pressure gradient. The patient had combined pneumonectomy and aortic valve replacement through median sternotomy and was discharged 18 days after surgery. Cardiac valve replacement is feasible in conjunction with pulmonary resection. However morbidity is increased in case of associated pneumonectomy.

The emergent use of Cardiopulmonary bypass and extracorporeal membrane oxygenator in a child with sickle cell disease.

The use of Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenator (ECMO) in patients suffering from Sickle cell disease (SCD) needs specific precautions. Whereas, no consensual protocols have been established to clarify therapeutic management. CASE REPORT A 7-year-old boy was admitted to the hospital for surgery of advanced endocarditis.  Major dyspnea, hemodynamic distress and fever were noted on physical examination. Biological tests exploring anaemia revealed Haemoglobin (Hb) S levels of 39.1%. Echocardiography showed important right heart cavities dilation with multiple aortic vegetations. The child was accepted for emergent surgery. Ten minutes after anesthetic induction, serious hemodynamic distress was established. The patient was put on normothermic CPB when he received four packed red-blood-cell. After surgery, he was placed on ECMO support for 2 days than he succumbed. CONCLUSION Urgent cardiac surgery in patients suffering from SCD poses a major therapeutic dilemma. Multiplying case reports and encouraging prospective studies are necessary to define the right place of cardio-pulmonary assistance in treatment protocols for better management.

[Meningitis after spinal anesthesia]. / Méningites après rachianesthésie.

BACKGROUND: Meningitis is a rare complication after spinal anesthesia. aim: We report 4 cases of meningitis occurred after spinal anesthesia. OBSERVATIONS: These meningitis were diagnosed during tow months and with 3 different operators. The first symptoms appeared 4 to 6 hours after surgery and were represented especially by headaches and fever. Cyto-chimic analysis of cerebrospinal fluid (CSF) indicates bacterial meningitis but soluble antigens and culture were negative. Evolution was favorable in all cases under or without antibiotics. The exactly cause of these meningitis remained unknown and an insufficient asepsis was the principle risk factor found in all cases. CONCLUSION: Prevention of this risk consists on hygienic rules and perfect skin disinfection.

Major pulmonary resections by exclusive VTS. a first in Tunisia.

Although thoracoscopic surgery had been introduced in Tunisia since 1993, there were no anatomical resections performed that way. We report herein the first 3 cases of lobectomy performed by exclusive video-thoracoscopic surgery (VTS). Three female patients presenting with bronchiectasis (2 cases) and cystic adenomatoid malformation (1 case) have underwent a thoracoscopic lobectomy with different outcomes.

[Beating heart coronary artery bypass: 100 cases]. / Pontage coronaire à coeur battant : A propos de 100 cas.

BACKGROUND: Coronary artery revascularization with cardiopulmonary bypass has been reported to carry several risks. AIM: Off-pump coronary artery bypass grafting has been proposed to result in a better outcome. The aim of this study is to assess the effect of off-pump cardiopulmonary bypass. METHODS: In a 7-year period, a total of 100 patients undergoing isolated first-time off-pump coronary artery bypass graft were studied. The mean ejection fractions was 48% and the EUROSCORE mean was 4.9. RESULTS: The average number of grafts was 1.55 per patient. The postoperative outcomes were simple for most patients with little use of inotropes after 24 hours (42%), few cases of atrial fibrillation (9.4%), and transfusion (27.3%). Time to extubation was less than 48 hours in most cases (94.7%) and hospital mortality rate was 10.5%. CONCLUSION: The beating heart bypass surgery allows good immediate results including multi-vessel disease and in patients at high risk.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer?

BACKGROUND: The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. METHODS: From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. RESULTS: 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. CONCLUSION: Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

[Evaluation of a protocol of spinal anesthesia for cesarean section in a Tunisian maternity unit: hemodynamic repercussions and risk factors for hypotension]. / Evaluation d'un protocole de rachianesthésie pour césarienne dans une maternité Tunisienne : Répercussions hémodynamiques et facteurs de risque d'hypotension.

AIM: To evaluate hemodynamic repercussion of a protocol of spinal anesthesia (SA) for cesarean and release the predictive factors of maternal arterial hypotension post spinal anesthesia. METHODS: We included parturients proposed for Cesarean under SA. They were not included the women of statute ASA > II, preeclamptics, eclamptics and/or having counter-indications of SA. We excluded the cases where there were technical difficulties at the time of the realization of SA, a failure or a complication of this SA. We injected 10 Mg of bupivacaïne 0.5% isobar, 10 µg of fentanyl and 100 µg of morphine. The data were collected before the realization of SA (anthropometric parameters; antecedents; basic systolic and diastolic blood pressures (BSBP and DSBP) and basic heart rate (BHR)) and after SA (systolic and diastolic blood pressure (SBP and DBP), heart rate (HR); occurred or not of a sympathetic block (falls of the SBP of more than 20% of its basic value or a SBP<90 mm Hg); the time of installation of the sympathetic block and the duration of hypotension. RESULTS: The full number of parturients included was 1016 among whom 16 were excluded. Only 1000 parturients finished the study and were divided into 2 groups (group 1: 500 emergency cesarean and group 2: 500 elective cesarean). The incidence of the sympathetic block was of 44.2% as a whole and this block was significantly more frequent in group 2 (p=0.0001). There was a significant relation between the incidence of a sympathetic block and the advanced age of the parturient (p=0.0001), the important weight (p=0.047), high ASA statute (p=0.0001), the presence of hypertension (p=0.0001), diabetes (p=0.001) or cesarean (p=0.00015) in the antecedents and the low BSBP (p=0.015). CONCLUSION: In spite of the beneficial effect of the reduction in the amounts of local anesthetic in the SA, the sympathetic block remains frequent after SA for Cesarean. Thus, it is essential to detect the high risk women of occurred of sympathetic block after SA, and to propose strategies of prevention, monitoring and management for this population.

[N-acetylcysteine in septic shock]. / La N-acétylcysteine dans le choc septique.

AIM: To focus on the various studies evaluating the effects of Nacetylcysteine in septic shock METHODS: Main references obtained from the medical database Medline using the keywords: N-acetylcysteine; septic shock, free radicals. RESULTS: Septic shock remains the leading cause of mortality in intensive care units. The progressive knowledge of the pathophysiology of septic shock, underline the production of free radicals and their cellular and microcirculatory effects. The Nacetylcysteine used mainly in paracetamol poisoning, has properties to control free radicals. The explosion of free radicals in septic shock has led to multiple studies assessing the role of N-acetylcysteine as an anti radical, and for its anti inflammatory action. CONCLUSION: NAC seems to play an important role in septic shock to control free radicals and the inflammatory response. But these results remain contradictory. Some larger and more standardized studies should allow to evaluate the actual effects of NAC in septic shock.

[Iatrogenic gas embolism after use of hydrogen peroxide in the treatment of lung hydatid cyst: a report of 2 cases]. / Embolie gazeuse iatrogène après utilisation de peroxyde d'hydrogène dans le traitement du kyste hydatique du poumon: a propos de deux cas.

BACKGROUND: Echinococcus disease is endemic in our country. Surgical resection of the hydatid cyst with the use of a protoscolicidal solution in the operative field remains the standard treatment. The degradation of hydrogen peroxide results in considerable amounts of gaseous oxygen witch has proven protoscolicidal properties. This gas can enter the circulation and determine severe embolism. AIM: We report two cases of severe oxygen embolism with neurological signs during surgical treatment of thoracic hydatid cysts. CASES REPORT: We report 2 cases of embolic events with neurological signs. The first, during a pleural cleaning with hydrogen peroxide after cystectomy of a pulmonary hydatic cyst at the right upper lobe. The second case, after a pleural washing during the treatment of hepatitic hydatidosis complicated by a ruptured cyst in the thorax. CONCLUSION: The most important diagnostic criterion is the patient's history, because the clinical suspicion of embolism is based on the initial neurologic or cardio-respiratory symptoms and the direct relation between these symptoms and the use of hydrogen peroxide and imposes appropriate treatment before further examination including brain imaging. The treatment with hyperbaric oxygen is the first line treatment, thus, transfer to a hyperbaric oxygen facility should be accomplished without delay. The possibility of such serious complication leads us to use hydrogen peroxide with great care or to use other protoscolicidal solutions.

Reduction of bupivacaine dose in spinal anaesthesia for caesarean section may improve maternal satisfaction by reducing incidence of low blood pressure episodes.

BACKGROUND: Spinal anaesthesia for caesarean section exposes to high incidence of arterial hypotension which can result in maternal and neonatal morbidity. We hypothesized that the reduction of this dose from 10 mg to 7.5 mg would minimize hypotension without altering pain relief. METHODS: In this double-blind prospective study, 80 ASA1 women scheduled for elective caesarean section were randomized into two groups A and B receiving respectively 10 and 7.5 mg of isobaric bupivacaine both with 25 microg of fentanyl and 100 microg of morphine in spinal anaesthesia. Intravenous ephedrine was administered for each episode of hypotension. We recorded sensory and motor block, intraoperative pain, nausea and vomiting. In postanaesthesia care unit, sensory and motor recoveries were measured and maternal satisfaction rate was assessed. RESULTS: In group A, a larger dose of ephedrine was needed (32 +/- 23 vs 19 +/- 16 mg; p = 0.004). Incidence of sensory block above T4 (52 vs 10%; p < 0.001), nausea (52 vs 22%; p = 0.005) and vomiting (25 vs 8%; p = 0.03) were all higher than in group B. Arterial hypotension was less frequent in group B (68 vs 88%; p = 0.03). The time required for recovery to T10 sensory level and motor regression were shorter than in group A (p < 0.001) and the satisfaction rate was higher than in group A (excellent and good in 90% vs 67%; p = 0.03). There was no difference in pain relief. CONCLUSION: A dose of 7.5 mg of isobaric bupivacaine reduced incidence of hypotension, nausea and vomiting and improved patient satisfaction.

Combined use of crystalloid preload and low dose spinal anesthesia for preventing hypotension in spinal anesthesia for cesarean delivery: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: Spinal anaesthesia for caesarean section is commonly associated with hypotension and crystalloid preload is widely recommended. Low-dose spinal appears to cause less hypotension. The aim of this study was to investigate whether the combined use of crystalloid preload and low dose spinal anaesthesia might further reduce the rates of hypotension. METHODS: Sixty-two patients were randomly assigned to two groups: crystalloid preload anaesthesia (P): received a rapid infusion of 20 mL/kg lactated Ringer's solution (LR), and no preload anaesthesia (N). The incidence of hypotension and the amount of ephedrine used to treat it were compared. Spinal anaesthesia was performed with 0.5% isobaric bupivacaine 7.5 mg and fentanyl 10 microg and morphine 100 microg. RESULTS: The incidence of hypotension was similar in the P and N groups. Same doses of ephedrine were required to treat hypotension in the two groups. CONCLUSION: Crystalloid preload combined with low-dose spinal anaesthesia do not reduce the incidence of hypotension nor its severity.

[The prophylaxis of the thromboembolic disease in the head trauma]. / Thromboprophylaxie des traumatises crâniens.

BACKGROUND: The prophylaxis of the thromboembolic disease in the severe head trauma remains a controversy. AIM: In this study, we are interested to the determination of under groups of patients for whom the advantages of the prophylaxis of the thromboembolic disease (TED) are higher than its disadvantages. METHODS: We proceeded to a retrospective study based on patient medical records ranging from March 2003 until March 2004, enrolling 56 consecutive patients. The data collected related to the age, the gender, past medical history, the type of trauma, results of the initial CT scan, the treatment, appearance or not of the thromboembolic disease and its prophylaxis therapy. RESULTS: The average age was of 36 ± 19 years. 76.8% did not have significant past medical history. All the patients profited from an elastic compression stocking. The LMWH were used among 15 patients victim of severe head trauma associated with other injuries and 72 hours after stabilization of hemorrhagic attacks. A thromboembolic disease diagnosis was based clinical or biological assumptions. Among 56 patients, 4 of them showed a TED with an incidence of 7.1 including 3 DVT and one case of pulmonary embolism. The 4 patients sustain severe multiple trauma; 3 of them received an early anti-coagulation therapy. In the group of patients with TED, the OMEGA scores and IGS are high; all of them are multiple traumatized patients with shock requiring a blood transfusion in 75 of the cases. Only the blood transfusion is correlated at the risk of TED, statistically established. CONCLUSION: The risk to develop a thromboembolic complication in the traumatic patients with head injury is high particularly in case of associated muscleskeletal injuries. Elastic compression technique is not always effective but considered as an interesting alternative to the pharmacological prevention of thrombosis. The use of the anticoagulants therapy must be careful. It is contra-indicated in case of cerebral haemorrhage in progress and must be considered upon individual case of each patient.