[Acute meningoencephalitis revealing a Behçet's disease]. / Méningoencéphalite aiguë révélatrice d'une maladie de Behçet.

We report a 69-year-old man admitted in intensive care unit for aseptic meningoencephalitis. Initially, suspicion of an infectious etiology led to introduce an anti-infectious treatment. Behçet's disease was diagnosed during hospitalization incited to screen for noninfectious etiologies. A high dose steroid therapy was rapidly effective. The diagnosis of neuro-Behçet's disease was entertained.

[Organization of an operational site. Comparison of the durations of intervention planned and real]. / Organisation d'un site opératoire. Comparaison des durées d'intervention prévues et réelles.

OBJECTIVE: To improve planning of our operational site by comparing the durations of intervention scheduled by the surgeons and the real durations of occupation of room of intervention, surgical procedure and surgical operation. STUDY DESIGN: Prospective study carried out of December 8, 2003 to February 27, 2004. PATIENTS AND METHODS: Anaesthetic and surgical times of the interventions of visceral and gynaecological surgery were raised. From these data several durations were calculated like the duration of occupation of the room of intervention, surgical procedure and surgical operation. These durations were compared with the durations envisaged by the surgeons to carry out the planning of the operational activity. RESULTS: Two hundred and ten interventions were studied. The analysis showed that there was a significant difference between the duration planned and the real duration of occupation of the room of intervention 45 minutes [5-125] (p<0.0001). The duration planned corresponded with duration of surgical operation, duration which did not take into account anaesthetic induction and surgical installation. CONCLUSIONS: The effectiveness of the planning of an operational site depends on the exactness of the durations scheduled, which are used for its realization. It is significant that all the actors of the operating theatre suite use the durations closest to reality.

[A rare aetiology of acute respiratory distress syndrome in adult: leptospirosis]. / Une étiologie rare de syndrome de détresse respiratoire aiguë de l'adulte: la leptospirose.

We report the case of an 18-year-old man with pulmonary leptospirosis presenting as an atypical pneumonia with alveolar haemorrhage, without icterus. Has he developed ARDS the patient was admitted in intensive care unit. This patient was contaminated when swimming in a lake. The purpose of this article is to remind doctors that in patient presenting atypical pneumopathy with haemoptysis, the pulmonary leptospirosis should be considered.

[Acute neurotoxic organophosphate poisoning: insecticides and chemical weapons]. / Intoxications aiguës par neurotoxiques organophosphorés: insecticides et armes chimiques.

OBJECTIVE: To review clinical and therapeutic bases of an organophosphate poisoning, either with insecticide or nerve agent. DATA SOURCES: References were obtained from computerized bibliographic research (Medline), from personal data (academic memoir, documents under approbation of the National Defense Office), from Internet's data. DATA SYNTHESIS: Generally, organophosphate poisoning occurs during accidental exposure with agricultural insecticide or suicide. The effects of organophosphate compounds are due to the inhibition of the enzyme acetylcholinesterase. The intoxication symptoms can be divided into muscarine-like, nicotine-like effects, effects on the central nervous system and symptoms related to the dysfunction of the neuromuscular junction. The interest of biological acetylcholinesterase's measuring is minimal because it is weakly specific or sensitive. The immediate severity is due to hypoxia. Respiratory failure results from the lack of central drive inflated with excessive bronchial secretions, bronchospasm and respiratory muscles paralysis. The secondary complications are early myopathies whose gravity is correlated with the decrease of acetylcholinesterases, or later neuropathies induced by a different mechanism. Beside the symptomatic measures, atropine is the specific anticholinergic treatment. When promptly used, oximes can regenerate cholinesterases. The attempted effects of the treatment are mouth dryness, pupilar dilatation and flushing of the skin. Nerve agents are lethal toxics which have a short onset time and produce severe neurological pathology. In a terrorist incident, it is as important to identify rapidly the toxic agent and provide emergency decontamination as to manage medical care. An effective response must be multidisciplinary, involving clinicians, toxicologists, Emergency Medical Service and public's health personnel.

[Hypothermia in traumatology]. / Hypothermie en traumatologie.

Basing on the experience of the Chamonix hospital team which managed in six years 89 cases of hypothermia in trauma patients, this article reviewed the literature concerning the association hypothermia-trauma. Shock is a major triggering factor. The deleterious effects of hypothermia on the outcome is due to inadequate cardiorespiratory adaptation to shock and to increased bleeding. Although a few articles reported a beneficial effect of hypothermia in head trauma, further studies are required to assess the value of deliberate hypothermia in such patients. Restoration of a satisfactory haemodynamic activity is a priority and most often requires surgery. The rewarming manoeuvres should be initiated early and always be preventive. They are active, internal and rapid in case of haemodynamic instability and when the central temperature is below 32 degrees C. It can be more progressive and less invasive in other cases. During recovery from anaesthesia the patient must be closely monitored. In spite of a possible protecting effect, hypothermia remains an aggravating factor in traumatology and must therefore be either prevented or amended.

[Black oesophagus, a rare event in intensive care unit]. / L'oesophage noir, une complication exceptionnelle du patient de réanimation.

We report a new case of acute necrotizing oesophagitis, diagnosing on a patient hospitalised in intensive care unit. This pathology is still a rare event; the definition excludes patients with a history of recent caustic ingestion. Oesophageal necrosis can be diagnosed at endoscopy by the presence of black necroting appearing oesophagus. Contrary to the caustic oesophagitis whose treatment is often surgical, treatment of the acute necrotizing oesophagitis is primarily medical. The prognosis for patients who develop acute necrotizing oesophagitis is generally poor, even if one can hope for the cure without after-effect of it.

[Severe accidental hypothermia]. / Hypothermie majeure accidentelle.

Two cases of severe accidental hypothermia (core temperature below 25 degrees C) are reported. Both occurred in an urban area during the same winter period. Both patients had the same age and similar clinical symptoms. In the first patient, the EEG, the echocardiography and the blood gases were in favour of a good tolerance of hypothermia, which led to choice a non aggressive rewarming method. The latter included the rewarming of inhaled gas mixture as well as i.v. fluids and gastro-intestinal lavage fluid. The outcome was uneventful. In the second patient, the visceral and biological consequences were more important (pH: 6.80, blood glucose concentration: 1.48 mmol.L-1, major coagulation disorders). Therefore a rapid rewarming via a cardiopulmonary bypass was preferred. The patient died from a prolonged shock with disseminated intravascular coagulation. The use of cardiopulmonary bypass which is essential in case of cardiac arrest rhythm, is controversial in case of severe hypothermia with a still beating heart.

[Severe pneumococcal meningitis and ceftriaxone allergy]. / Méningite grave à pneumocoque et allergie à la ceftriaxone.

We report the case of a 51-year-old man with an allergy to amoxicillin/acid clavulanique who presented with Streptococcus pneumoniae meningitis. Initial treatment consisted of an association of antibiotics including ceftriaxone. Six days after treatment was initiated the patient developed skin reaction and the diagnosis of allergy to ceftriaxone was established by the dosage of specific IgE. Typically Streptococcus pneumoniae meningitis is treated with vancomycin and a third-generation cephalosporin. This association had to be modified because cross allergy to cephalosporins could have developed in this patient who had previously reacted to penicillins.

[Continuous infusion of vancomycin in post-neurosurgical staphylococcal meningitis in adults]. / Vancomycine en perfusion continue dans les méningites à staphylocoques post-neurochirurgicales de l'adulte.

Eight adult patients with post-surgery meningitis caused by methicillin-resistant staphylococci were treated with continuous intravenous infusion of vancomycin in mean doses of 50 mg/kg/day. This treatment, which lasted 3 to 6 weeks, was well tolerated by the kidneys and resulted in cure in all cases; its effect on the ear was not evaluated. Stable concentrations of 4 to 7 mg/l in cerebrospinal fluid were obtained after the 48th hour of treatment.

[Endotracheal intubation under propofol with or without vecuronium]. / Intubation endotrachéale sous propofol avec ou sans vécuronium.

OBJECTIVE: In order to test the hypothesis that under the association propofol-alfentanil-IV lidocaine the trachea could be intubated easily without an additional muscle relaxant, this study compared the intubation conditions when this association was combined or not with vecuronium. STUDY DESIGN: Randomized comparative trial. PATIENTS: The study included 152 young adults classified as ASA physical class I and Mallampati presentation grade 1, randomly allocated either into Vecu+ group or Vécu0 group, depending on whether vecuronium was co-administered or not. METHODS: All patients received midazolam 0.05 mg.kg-1 i.v., one minute before induction. Those of group Vecu0 were given successively within two minutes: alfentanil 0.03 mg.kg-1, lidocaine 1.5 mg.kg-1 i.v. and propofol 2.5 mg.kg-1. Patients of group Vecu+ received similar doses of alfentanil and propofol as well as vecuronium 0.08 mg.kg-1. The endotracheal tube was inserted one minute after induction in the patients of Vecu0 group, and after three minutes in those of the Vecu+ group. During intubation, scores of mouth opening, glottis opening and coughing were established, in order to assess intubation conditions. RESULTS: Similar convenient intubating conditions were obtained in both groups (in 97% of patients in Vecu+ group vs 95% of those in Vecu0 group). In the latter, the glottis opening was less pronounced. CONCLUSIONS: In young healthy adults, without anaesthetic risk (emergency, full stomach) and without foreseen difficult intubation, the endotracheal tube can be inserted in convenient conditions without a muscle relaxant, under the association propofol-alfentanil-lidocaine iv.

[Acute interstitial nephritis. Role of ceftazidime]. / Néphrite interstitielle aiguë: rôle de la ceftazidime.

A 22-year-old man treated with ceftazidime-amikacine for a Pseudomonas aeruginosa pneumonia, experienced two days later allergic symptoms, acute renal failure and urinary sediment abnormalities. The renal biopsy showed an acute interstitial nephritis. Basophils stimulation test was positive for ceftazidime. Early diagnosis and discontinuation of the suspected agent is essential to allow rapid and complete recovery of renal function.

[Diagnosis of ventilator-associated pneumonia: a prospective comparison of the telescoping plugged catheter with the endotracheal aspirate]. / Diagnostic non invasif des pneumopathies nosocomiales acquises sous ventilation mécanique: comparaison entre le prélèvement distal protégé et l'aspiration endotrachéale.

OBJECTIVE: Quantitative culture of endotracheal aspirates (EA) is widely accepted for the diagnosis of ventilator-associated pneumonia (VAP). The aim of the study was to compare the diagnostic accuracy of the EA with the blinded plugged telescoping catheter (PTC) in patients suspected of VAP. STUDY DESIGN: Prospective non-randomised observational study. PATIENTS AND METHODS: 31 patients suspected of having VAP underwent 46 bronchial samplings. An EA and a blinded PTC were performed successively in each case; the PTC result was taken as the reference standard. The EA and PTC cultures were defined positive if the result of bacterial cultures yielding were > or = 10(5) cfu.mL-1 and > or = 10(3) cfu.mL-1 respectively. RESULTS: The diagnosis of VAP could be established in 19 cases when PTC was taking as gold test. The overall agreement between the two techniques was 76%. EA had a sensitivity of 89.5%, a specificity of 66.7%, a negative predictive value of 90% and a positive predictive value of 65.4%. CONCLUSION: EA is a good diagnostic test when a non-invasive test has been chosen. The diagnosis of VAP could be excluded in 90% of cases when the EA cultures yielding were < 10(5) cfu.mL-1. His low specificity could drive in an over treatment of bronchopulmonar bacterial colonization. The accuracy of the EA compares well with that of the TPC for the diagnostic of VAP.

[Cardiac arrest at induction of a patient with thyrotoxicosis. Have you thought of anaphylaxis?]. / Arrêt cardiaque à l'induction d'un patient en thyrotoxicose. Avez-vous pensé à l'anaphylaxie ?

We report the occurrence of cardiac arrest shortly after the anaesthetic induction for thyroidectomy in a patient with decompensated thyrotoxicosis associated with taking amiodarone. After investigation, it was revealed that the cardiac arrest was linked to an anaphylactic reaction to suxamethonium. This accident, unrelated to hyperthyroidism, reminds us of the relative frequency and severity of anaphylactic reactions related to curare. This event, in the context of severe cardiac insufficiency, due to an amiodarone-associated thyrotoxicosis, is described here for the first time. Its diagnosis requires to remain consistent. Its support must be in compliance with the recommendations of learned societies of anaesthesia.

Pharmacokinetic analysis of pralidoxime after its intramuscular injection alone or in combination with atropine-avizafone in healthy volunteers.

BACKGROUND AND PURPOSE: Treatment of organophosphate poisoning with pralidoxime needs to be improved. Here we have studied the pharmacokinetics of pralidoxime after its intramuscular injection alone or in combination with avizafone and atropine using an auto-injector device. EXPERIMENTAL APPROACH: The study was conducted in an open, randomized, single-dose, two-way, cross-over design. At each period, each subject received either intramuscular injections of pralidoxime (700 mg), or two injections of the combination: pralidoxime (350 mg), atropine (2 mg), avizafone (20 mg). Pralidoxime concentrations were quantified using a validated LC/MS-MS method. Two approaches were used to analyse these data: (i) a non-compartmental approach; and (ii) a compartmental modelling approach. KEY RESULTS: The injection of pralidoxime combination with atropine and avizafone provided a higher pralidoxime maximal concentration than that obtained after the injection of pralidoxime alone (out of bioequivalence range), while pralidoxime AUC values were equivalent. Pralidoxime concentrations reached their maximal value earlier after the injection of the combination. According to Akaike and to goodness of fit criteria, the best model describing the pharmacokinetics of pralidoxime was a two-compartment with a zero-order absorption model. When avizafone and atropine were injected with pralidoxime, the best model describing pralidoxime pharmacokinetics becomes a two-compartment with a first-order absorption model. CONCLUSIONS AND IMPLICATIONS: The two approaches, non-compartmental and compartmental, showed that the administration of avizafone and atropine with pralidoxime results in a faster absorption into the general circulation and higher maximal concentrations, compared with the administration of pralidoxime alone.

[Obstetrical epidural analgesia during labour: one dural puncture, repeated postural headaches, three blood patches ]. / Analgésie péridurale obstétricale pour le travail: une brèche dure-mérienne, des céphalées posturales, trois blood patchs

We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.