[Technical constraints in rapid vascular fluid replacement]. / Contraintes techniques du remplissage vasculaire rapide.

Rapid fluid infusion remains the cornerstone for therapy of hypovolaemic shock. The principal limitations of flow rate are governed by the four variables of Poiseuille's law: tube internal diameter and length, viscosity of the fluid passing through the tube, and the pressure gradient between the two ends of the tube. Conventional transfusion systems, with wide bore tubing (up to 5.0 mm internal diameter), large bore cannulas (8.5 French introducer catheters), high pressure (up to 300 mmHg) and diluted blood, can result in a maximum flow rate of about 1,000 ml.min-1 (for crystalloid solutions). Specific apparatus for rapid infusion can increase this to 1,500 ml.min-1 (Rapid Infusion System, Haemonetics). Dry-heat warming devices and microfiltration, to remove microaggregates and prevent non haemolytic febrile transfusion reactions, seem necessary when carrying out rapid transfusions. However, the use of microaggregate filters could be avoided by the routine production of leukocyte-poor red blood cell concentrates.

[Latex allergy: diagnostic pitfalls]. / Allergie au latex: pièges diagnostiques.

A 44-year-old woman, native of Martinique, with a history of multiple allergies and severe asthma, sustained an unexplained cardiovascular collapse during surgery under general anaesthesia. The patient recovered normally. Postoperatively, neither additional explorations were undertaken nor informations given to the patient. Later on she had to undergo cholecystectomy. Data obtained from preanaesthetic assessment (history, analysis of medical files) were in favour of a past intraoperative allergic accident. Allergological tests confirmed a latex allergy. This case substantiates the importance of a careful preanaesthetic consideration of patient's history and the value of a systematic allergologic exploration after an unexplained intraoperative event compatible with an anaphylactoid reaction. All such events should be clearly explained and a written document handed to the patient.

[Early management of severe brain injuries]. / Prise en charge initiale d'un traumatisme cranien grave.

Severe head injury (Glasgow Coma Score less than or equal to 7) is associated with high mortality and morbidity which can be improved by early energetic therapy. Such patients must be picked up by prehospital/EMS service with three aims: controlling ventilation, controlling haemodynamics, avoiding any increased intracranial pressure. After initial neurological assessment, management involves endotracheal intubation, mechanical ventilation following benzodiazepine sedation, early compensation of hypovolemia avoiding any overloading, analgesia for painful injuries; according to the clinical status other pharmacological agents can be used. At admission to emergency unit, intensive care must be continued while X-rays and CT-scan are achieved. Imperative indications of transport to neuro-intensive care unit are discussed for hospitals without a neuro-surgeon.

Lateral approach to laparoscopic repair of left diaphragmatic ruptures.

Video-assisted repairs of traumatic diaphragmatic ruptures have been described where thoracoscopy or laparoscopy in the supine position were used. This study aims to validate a new lateral laparoscopic approach for left diaphragmatic repairs. Six consecutive patients were operated on for left diaphragmatic rupture using a lateral approach (Gagner's position). A series of 362 consecutive patients presenting with abdominal or thoracic trauma with or without diaphragmatic rupture over a 2-year period were reviewed retrospectively. Contraindications for immediate or delayed lateral laparoscopic approach were studied. The lateral approach provided complete visibility of the subdiaphragmatic space, easy reduction of herniated organs, easy thoracic inspection and cleaning, the use of low peritoneal pressure, full range of instrumental motion, and rapid diaphragmatic repair. No operative mortality or morbidity was noted. Altogether, 14% to 50% of the patients with diaphragmatic ruptures were candidates for immediate lateral laparoscopic repair. Associated spleen injury in 50% of the cases was the main contraindication. The lateral laparoscopic approach provides better exposure of the diaphragm on the left side and facilitates the diaphragmatic repair especially with a large herniation. Immediate repair is possible in selected cases (14-50%). There is no contraindication in case of delayed diagnosis.