Dermal regeneration template for deep hand burns: clinical utility for both early grafting and reconstructive surgery.

Adequate acute treatment of the deeply burned hand and any subsequent reconstructive procedures may be hampered by the lack of sufficient suitable graft material and the risks of donor site morbidity and scarring. This investigation was designed to determine the feasibility of treating deep hand burns using a dermal regeneration template. Patients with deep hand burns underwent either acute treatment or reconstructive procedures with Integra dermal regeneration template. Wound sites were first grafted with the dermal regeneration template, and then 2-3 weeks later after neodermis formation the silicone layer of the Integra was removed and a very thin split-thickness epidermal autograft placed. Acute grafting was performed on 15 hands in 11 patients and reconstructive surgery on 14 hands in 11 patients. Median follow-up was 12 months. Integra take was 100% on all treated hands. After acute grafting the wound site skin was flexible and supple and did not adhere to the deeper layers, thus permitting free articular and functional movement. Cosmetic results of acute surgery were judged satisfactory by both patients and surgeons. After reconstructive procedures, significant improvements were achieved in cosmetic status, based on Vancouver Scar Scale (p=0.0002), and in three measures of function, namely, thumb opposition score (p=0.0005), fingertip-to-palm distance (p=0.0039) and prehensile score (p=0.0039). Favourable cosmetic and functional outcomes were consistently attained using a synthetic dermal regeneration template for treatment of deep hand burns either by acute grafting or reconstructive surgery.

[Integra, a new surgical alternative for the treatment of massive burns. Clinical evaluation of acute and reconstructive surgery: 39 cases]. / Intégra, une nouvelle alternative chirurgicale pour le traitement des grands brûlés. Evaluation clinique en chirurgie aiguë et réparatrice: à propos de 39 cas.

Early excision and prompt coverage in severely burned patients are the best way to lessen morbidity and improve survival. Repair of full-thickness burns requires replacement of both dermal and epidermal components of skin and treatment with split thickness autografts replaces both of them. But healthy skin is not sufficient in extensive burns. Alternative to split thickness skin grafts have been studied by several groups including epidermis, dermis or a complete replacement comprising epidermis and dermis. Because of the difficulties in homografts supplying, a new way was use to replace the dermis. In 1981, Yannas and Burke were the first to develop such a matrix. Intégra is available in France since 1997 and was used in our service for the treatment of both acute and reconstructive surgery for burned patients. Twenty patients were treated for acute surgery. Nineteen patients were treated for reconstructive surgery of burn scar contractures. Fifty-one grafts of Intégra were performed. Long-term final results seem to show that Intégra improve cosmetical and functional results and is a new surgical alternative for the treatment of burns in the acute phase as well as in late surgery of deformities.

Percutaneous tracheostomy by forceps dilation: report of 162 cases.

A prospective, observational clinical study evaluated the safety of percutaneous single-step dilatational tracheostomy over a 43-month period. One hundred and sixty-two patients were deemed suitable for the procedure. The mean duration of tracheal intubation prior to tracheostomy was 6 days. The mean duration of the procedure was 9.3 min. Intra-operative complications occurred in 27 patients (16.6%), most of which were minor technical difficulties without morbidity. Postoperative complications, some of which were associated with morbidity, occurred in 16 patients. There were two deaths secondary to premature decannulation, one case of severe bleeding and five pneumothoraces. Long-term complications were assessed in 81 patients; there were four tracheal stenoses requiring surgery or laser therapy and seven patients with granulation tissue at the stoma site which did not require treatment. Forceps dilatational percutaneous tracheostomy appeared to be a convenient bedside procedure. However, complications do occur and further studies should address late sequellae, such as tracheal stenosis.

[Acute Streptococcus salivarius meningitis after spinal anesthesia]. / Méningite aiguë à Streptococcus salivarius après rachianesthésie.

The case of a 50-year-old woman who experienced an acute Streptococcus salivarius meningitis after a spinal anaesthesia for hysteroscopy is reported. The contamination of the cerebrospinal fluid may occur from a puncture during a bacteriaemia. Contamination from the patient's skin and from the upper airway's flora of the operator seems to be a more plausible cause. Spinal anaesthesia is contra-indicated in the febrile patient. Asepsis is essential during spinal puncture, including wearing a surgical face mask.

[Severe form of familial migraine with coma]. / Forme grave de migraine familiale avec coma.

The authors report the case of a 43-year-old man experiencing a migraine attack with coma requiring a treatment in an intensive care unit for 9 days. The probable triggering cause as a cerebral arteriography.

[Combination of propofol-ketamine-vecuronium for total intravenous anesthesia under hazardous conditions]. / Association propofol-kétamine-vécuronium pour l'anesthésie totalement intraveineuse en situation difficile.

A total intravenous technique using propofol, ketamine and vecuronium was successfully used on 29 patients treated for elective surgery at the UNPROFOR French Medical Group (Sarajevo, Bosnia Herzegovina). Operative conditions were satisfactory for the surgeons. Recovery was fast and emergence reactions very limited. No hypoxaemia was observed during the immediate postoperative period. The use of a propofol/ketamine/vecuronium combination is possible in field anaesthesia especially when opiates and inhalational agents are not available.

[Hyperammonemia encephalopathy after ureterosigmoidostomy]. / Encéphalopathie hyperammoniémique après urétérosigmoïdostomie.

Ureterosigmoidostomy (USS) for bladder cancer is an attractive surgical technique for the improved quality of life provided to the patient, notably from a preserved body image. Complications, however, can jeopardize this result. We report the case of a woman who developed an hyperammonemic encephalopathy after USS "Mainz pouch II". We discuss the indication of a liver needle biopsy before USS when hepatic functions are abnormal and we stress the importance of regular "rectal exonerations" during the day.

[Lung contusion in the multiple trauma patient]. / Contusion pulmonaire chez le polytraumatisé.

The main management's characteristics of the pulmonary contusion in the trauma patients are explained. From possible alveolocapillary membrane's injuries, with consideration of worsening evolution (ARDS, nosocomial infection, MOF), main points of discussion are circulation and mechanical ventilation. For the most severely injured, invasive monitoring is necessary, including the oxygenation parameters we now can dispose of. Quantification of extravascular lung water is an original and valuable tool to determine the time course and amount of pulmonary oedema. There is no ideal mode of ventilation but the basic ventilatory patterns must be adjusted; a target is the reduction of time requirement for ventilatory support.

[Prolonged neuromuscular block after administration of mivacurium caused by plasma psueudocholinesterase deficiency]. / Curarisation prolongée après mivacurium par déficit en pseudocholinestérases plasmatiques.

Mivacurium is a new neuromuscular blocking agent with a short acting time of about 30 min, due to a fast hydrolysis by pseudocholinesterases. This metabolism carries a risk for prolonged neuromuscular block in case of an acquired or congenital pseudocholinesterase deficiency. We report the case of a 75-year-old woman who experienced a neuromuscular block prolonged for 10 h after a single dose of 0.35 mg.kg-1 of mivacurium, because of a major pseudocholinesterase (1800 UI.L-1, normal value: 5400-13200 UI.L-1). The likely cause was a congenital deficiency by a homozygote genetic mutation, as usual causes of an acquired deficiency had been eliminated.

[Trans-sacral caudal anesthesia in ambulatory practice in infants. Our experience]. / Anesthésie caudale transsacrée en pratique ambulatoire chez l'enfant. Notre expérience.

Sacral epidural block (S2 S3 intervertebral space, P. Busoni's method) is as safe and easy as caudal block. 11 children ASA 1 undergoing ambulatory surgery are studied (inguinal herniorrhaphy, undescended testis). Bupivacaine 0.25%, 0.5 ml.kg-1 is unsatisfactory, but anaesthesia is excellent with 0.8 ml.kg-1.

[Use of Cell Saver 4 in traumatology. Apropos of 9 cases]. / Utilisation du Cell Saver 4 en traumatologie. A propos de 9 observations.

During a recent seven mouth period of time, patients with intrathoracic and intraabdominal injury had recovery of shed blood utilizing a Haemonetics Cell Saver. Blood is suctioned from the surgical field or with tube thoracostomy. Autotransfusion is sufficient for four patients; five others patients need blood transfusion, for intraoperative or postoperative hemorrhage. However, the decrease of transfusion requirement is evident, and autotransfusion is equivalent to 8.6 concentrated red cells units for each patient, as 2.6 homologous bank blood concentrated red cell units. The difficulties are nurse training, and cost (to be compared with homologous bank blood cost); but autotransfusion with Haemonetics Cell Saver 4 is sizeable part of transfusion therapy of acute trauma.

[Value of prolonged epidural analgesia in thoracic surgery]. / Intérêt de l'analgésie péridurale prolongée en chirurgie thoracique.

The use of high thoracic epidurals for post-thoracotomy pain relief in 156 patients is reviewed. Analgesia was maintained with a continuous infusion of a local anaesthetic, bupivacaïne 0.5% 40 ml, mixed with a narcotic, fentanyl 10 ml (perfusion rate between 3 and 7 ml/h). There was successful analgesia in 92%, with efficient ventilation, effective cough, no respiratory distress and only 8 cases of fibroaspiration. Only two significant respiratory complications occurred, due to incorrect management of the peridural route: the analgesic mixture was too concentrated and was injected by bolus instead of by continuous infusion. Other complications occurred, 8 cases of nausea or pruritus, 4 hallucinations, 10 cases of urinary retention lasting more than 24 h, 14 superior limb palsies and 22 Horner's oculopapillary syndrome. All of these complications were minor, easy to manage, and resolved after stopping peridural infusion. In conclusion, peridural analgesia is highly effective and improves the atmosphere in post-thoracotomy wards.

[Peridural anesthesia in thoraco-abdominal surgery. Propofol-methohexital comparison for complementary anesthesia]. / Anesthésie péridurale en chirurgie thoraco-abdominale. Comparaison propofol-méthohexital pour narcose de complément.

Two groups of 20 patients scheduled for major abdominal surgery or thoracic surgery received analgesia by thoracic peridural route: 850 and 837 micrograms.kg-1 of bupivacaine, plus 4.30 and 4.20 micrograms.kg-1 of fentanyl. Anaesthesia was induced and maintained with either infusion of propofol 0.2% or infusion of methohexital 0.1% and patients were intubated and ventilated. The quality of induction was good in the two groups (3.48 mg.kg-1 in 4 min with propofol and 2.76 mg.kg-1 in 5 min with methohexital). But only 4 of propofol group needed vecuronium for intubation; they were 19 in the other group. Maintenance was extremely smooth with propofol (0.088 mg.kg-1.min-1) in 18 cases. In contrast, poor anaesthetic control was obtained with 14 methohexital patients and had to be abandoned. Hemodynamic data show fc, Pa and Ppa decreased with propofol but increased with methohexital in response to laryngoscopy and intubation. In this study, the onset of 5 sinusal bradycardias was noted with propofol. Two of them were severe 39 and 38 b.min-1 with major decrease of LVSWI to 32.45 and 24.47 g.mm-2. The role of hypovolemia (Bainbridge reflex) or vagomimetic effect of propofol is discussed. Nevertheless, this study shows that propofol given by infusion can better achieve adequate anaesthesia than methohexital.