[Systemic candidiasis in medical intensive care unit: analysis of risk factors and the contribution of colonization index]. / Les candidoses systémiques en réanimation médicale : analyse des facteurs de risque et intérêt de l'index de colonisation.

OBJECTIVES: Description of the epidemiological and clinical characteristics of the patients introducing risk factors of invasive candidiasis. Analysis of risk factors for candidiasis invasive and evaluation of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in medical intensive care. PATIENTS AND METHODS: Prospective observational study (October 2007 to October 2009). The selected patients present risk factors of system IC candidiasis with an infectious syndrome or clinical signs suggestive of Candida infection and hospitalized more than 48 hours in medical intensive care unit. Pittet's colonization index was calculated at admission and then once a week added to a blood culture. Patients were classified according to level of evidence of Candida infection and the degree of colonization (CI<0.5, CI ≥ 0.5). RESULTS: The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male prevalence. Neurological disease was the most frequent pathology in admission (48%). The most common risk factors were broad-spectrum antibiotics and foreign material. In the various mycology IC specimens, Candida albicans was the most frequent, followed by C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients, and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and specificity was 93% and 48% respectively. CONCLUSION: CI has the advantage to provide a quantified data of the patient's situation in relation to the colonization. But, it isn't helpful with patients having an invasive candidiasis in medical intensive care unit.

[Effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section]. / Effet d'une infiltration sous-cutanée de ropivacaïne 0,75 % sur l'analgésie postopératoire après césarienne.

OBJECTIVE: Evaluate the effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section in the first 24h. PATIENTS AND METHODS: A prospective randomized double blind study was realized during three months in Auxerre Hospital. All ASA 1-2 patients presenting for elective caesarean section under spinal anesthesia were enrolled in the study. Drug addicts and patients with chronic pain were excluded from the study. The patients were randomly divided into two groups to receive skin infiltration 20 ml of ropivacaine 0,75% (Gr R) or skin infiltration of 20 ml of 0,9% saline solution. All patients received systematically propacetamol 1g per six hours and ketoprofen 50mg per six hours. Intravenous morphine titration was delivered to patients with a simple numerical scale greater or equal to three (SNS> or =3). Postoperative pain (SNS), morphine consumption and adverse reactions were compared. RESULTS: From July to September 2005, 42 patients were enrolled in the study. The SNS was lower in the Gr R. Total morphine consumption was reduced in the Gr R. The incidence of the adverse effects were higher in the Gr P. One case of parietal haematoma was detected in the Gr P, the evolution of which was favorable. DISCUSSION AND CONCLUSION: Skin infiltration of ropivacaine 0,75% is a simple technique able to reduce postoperative pain score and morphine consumption after caesarean section.

[Prevention of myoclonus after etomidate using a priming dose]. / Prévention des myoclonies induites par l'étomidate en utilisant une priming dose.

OBJECTIVE: To investigate the influence of pretreatment with a low dose of etomidate (priming dose) on the incidence of etomidate-induced myoclonus. STUDY DESIGN: Prospective randomized double-blind study. METHODS: Forty six patients ASA physical status I - II, scheduled for abdominal elective surgery, were allocated randomly to receive either pre-treatment 0.03 mg/kg of etomidate (priming group) or placebo (control group). Sixty-seconds after the pre-treatment was injected, anesthesia was induced with etomidate 0.3 mg/kg and 60 seconds later induction was completed with fentanyl (3 microg/kg) and vecuronium (0.1 mg/kg). The occurrence and intensity of myoclonus were graded clinically by a blinded observer as: 0=no myoclonus, 1=mild myoclonus, 2=moderate myoclonus and 3=severe myoclonus. STATISTICAL ANALYSIS: Fisher test exact for qualitative variable and Student t-test for quantitative variables. RESULTS: Demographic data and the average dose of etomidate used during the induction were similar in the 2 groups (0.29+/-0.032 mg/kg in the priming group and 0.30+/-0.029 mg/kg in the control group). Twenty patients (87%) in the control group experienced myoclonic movements whereas only 6 patients (26%) in the control group had such movements (P<0,001). CONCLUSION: Pretreatment with etomidate (0.03 mg/kg), given 60 seconds before induction of anesthesia, is effective at reducing etomidate-induced myoclonus, without related side-effect.

[Percutaneous catheterization of the deep brachial vein]. / Cathétérisme percutané de la veine humérale profonde.

50 attempts of deep percutaneous antecubital catheterization are reported. A tourniquet was applied to the upper arm and the medial deep brachial vein was punctured in a point immediately medial to the brachial artery, in the antecubital fossa. Venepuncture was successful in 88% of the cases (44 cases), catheterization possible in 72% of the cases (36 cases). The catheter reached the central venous compartment in 60% of the cases (30 cases). The only benign complication was injury to the brachial artery in 6 cases. Mean duration of catheterization was 20 days. This very easy and safe technique can be used when superficial veins are unusable and use of the deep central veins dangerous or impossible.

[Acute acalculous cholecystitis after digestive caustic burn]. / Cholécystite aiguë alithiasique après brûlure caustique digestive.

A case is reported of acute acalculous cholecystitis in a patient who suffered a digestive burn treated by total parenteral nutrition. Pain in the right upper abdominal quadrant and fever occurred 26 days after the start of parenteral nutrition and 24 h after abruptly resuming oral feeding. Ultrasonography showed a distended gall-bladder with a thickened wall and the formation of sludge. Cholecystectomy was followed by a complete recovery. The part played by each of the corrosive burn, the total parenteral nutrition and the abrupt resumption of oral feeding in the pathogenesis of this complication is reviewed.

[Thrombosis of the superior vena cava in Behcet's disease. Apropos of a case associated with chylothorax]. / Les thromboses de la veine cave supérieure au cours de la maladie de Behcet. A propos d'un cas associé à un chylothorax.

The authors report a case of superior vena cava thrombosis associated to a chylothorax during Behcet's disease. This thrombosis was revealed during an evolutive phase by dyspnea and a superior vena cava syndrome. Its course was favourable under a medical treatment associating: pleural drainage, parenteral feeding, corticotherapy and heparin therapy. Then the authors review the bibliography and recall the frequency, pathogenesis, clinic and treatment of this unusual complication of the Touraine's aphthosis. Such a complication appears paradoxically to present a favourable course.

[Duodenal tuberculosis associated with lymph node tuberculosis (apropos of a surgical case)]. / Tuberculose duodénale associée à une tuberculose ganglionnaire (à propos d'un cas chirurgical).

The authors report a case of duodenum tuberculosis associated to a lymph gland tuberculosis. Diagnosis has been made possible only with an exploratory laparotomy justified by an almost total duodenum stenosis. They review the different aspects (pathogenic, anatomopathologic, clinical, radiological, therapeutic) of a disease non frequent but not exceptional, especially in the african countries.

[Unusual complication of noninvasive ventilation: The œsogastric pneumatosis associated with a subcutaneous emphysema]. / Complication inhabituelle de la ventilation non invasive : la pneumatose œsogastrique associée à un emphysème sous-cutané

The non-invasive ventilation (NIV) is a technique of ventilator support to avoid endotracheal intubation and its potential complications. However, it has some complications that are usually harmless to type of erythema and/or cutaneous ulcerations, mouth or nose dryness, conjunctival irritation and rarely lesions of barotrauma, volotrauma or gastric insufflation with nausea and vomiting. We report the case of a patient who had an unusual complication of NIV: sub mucosa gastro-esophageal pneumatosis associated with subcutaneous emphysema occurring on the second day after one hepatectomy which was settled but complicated with a postoperative pulmonary aspiration syndrome.

[Endocarditis complicated by an aneurysm of the superior mesenteric artery]. / Endocardite infectieuse compliquée d'un anévrysme de l'artère mésentérique supérieure.

Infective endocarditis (IE) is a rare, polymorphic disease in children. Mycotic aneurysm is a rare condition that complicates about 2.5 to 10% of cases of endocarditis. It is responsible for significant morbidity and mortality [1,2]. Mycotic aneurysms are often asymptomatic, physical examination is poor, but the diagnosis should be considered with the triad including fever, abdominal pain, and abdominal mass beating. Abdominal ultrasound and computed tomography are the most useful for the identification of the aneurysmal mass. However, angiography is an interesting addition to confirm the diagnosis and implement a treatment procedure [3]. The treatment of SMA aneurysms is largely surgical. IE treatment is based on antibiotic therapy combined with surgical repair. We report the case of a 15-year-old patient, first operated for an SMA aneurysm complicating the course of IE, who secondarily underwent mitral valve repair. We review the epidemiology, diagnosis, and care principles of mycotic aneurysms of the SMA.

[Paraspecificity of antivenins: example of severe envenomation by the Sahara horned viper (Cerastes cerastes) treated with non-specific antivenin]. / La paraspécificité des antivenins: exemple d'une envenimation grave par la vipère à cornes du Sahara (Cerastes cerastes) traitée par un antivenin polyvalent non spécifique.

Snake bites are a major public health problem in Morocco. Both morbidity and mortality of ophidian envenomation remain very high in this country. Antivenin immunotherapy, the only etiological treatment of this envenomation, is often unavailable in local hospitals. Moreover, when available, antivenins are not necessarily suitable for local ophidian species. This case report describes severe poisoning caused by a Sahara horned viper (Cerastes cerastes) in southern Morocco. In the absence of specific immunotherapy, FAV-Afrique®, a polyvalent antivenom serum, was administered. The favorable outcome suggests that this serum is paraspecific against the Sahara horned viper. The paraspecificity of antivenin immunotherapy could be a solution to ophidian envenomation in the absence of an antivenin adapted to local snake species.

[Not Available]. / Prise en charge d'un afflux massif de brûles lors d'une situation de catastrophe par incendie au Maroc.

Burn injuries are most commonly encountered during natural disasters or disasters related to human activity (accidental fires in public places, in time of war, or in terrorist attacks). The care and triage of a large number of burn patients is a difficult problem, which requires adequate planning and emergency preparedness in anticipation of such crises. The training and readiness of doctors and paramedics is of utmost importance. The challenges are many: burn treatment requires a large and qualified staff; evacuations should be prioritized according to the severity of the burn and associated injuries; stocks (especially in topical anti-infective and crystalloid) should be sufficient and appropriate; and hospital services in a military training hospital Mohammed V such as there is in Rabat must be able to be quickly adapted to accommodate and isolate these particular patients. The hypothesis of a fire disaster with a mass influx of burn patients at this hospital should leave no room for improvisation, or else the prompt and accurate prognosis of the patients could be severely hindered.

[Acute negative pressure pulmonary edema: illustration from a unusual clinical case following a postoperative recurrent laryngeal nerve palsy]. / L'œdème aigu du poumon à pression négative : illustration à partir d'un cas clinique inhabituel compliquant une paralysie récurrentielle postopératoire.

Acute postoperative negative pressure pulmonary edema (NPPE) is a respiratory complication due to upper airway obstruction occurring most commonly in the postoperative period. Pathophysiologically, NPPE is explained by the abrupt generation of highly negative intrathoracic pressure that lead to fluid transudation from the pulmonary capillaries. This observation reports an unusual case of a young patient who has undergone total thyroidectomy for multinodular goiter. The postoperative period was marked by the occurrence of bilateral recurrent laryngeal nerve palsy that was complicated by a NPPE. The outcome was favorable after mechanical ventilation with reversal of NPPE and recovery of the recurrent laryngeal nerve function. This article stresses the importance of prevention of recurrent nerve palsy during thyroid surgery. It also highlights a little known respiratory complication: the NPPE. Understanding the pathophysiology of NPPE, rapid diagnosis and appropriate therapeutic measures could prevent its potential lethal consequences.

[Impaired consciousness associated with a hysterical conversion after obstetrical epidural analgesia: a case report with literature review]. / Troubles de la conscience liés à une conversion hystérique après une analgésie péridurale obstétricale : un cas clinique avec revue de la littérature.

The occurrence of impaired consciousness after epidural analgesia is an alarming situation that requires urgent diagnostic and therapeutic approach. Various causes may be responsible for such a state. Hysterical conversion remains an outstanding issue. Through a clinical case of a hysterical conversion and a literature review the authors draw attention to the difficulty of diagnosing this entity after epidural analgesia.

[Acute respiratory distress syndrome secondary to influenza A (H1N1) infection: a report of a case]. / Le syndrome de détresse respiratoire aiguë secondaire à une infection par le virus de la grippe A (H1N1) : à propos d'un cas.

Through a clinical case of acute respiratory distress syndrome after infection with influenza virus H1N1 and a review of the literature the authors discuss treatment options, prognostic factors and the problems raised in support this pathology in Moroccan center.

[Unilateral bronchospasm during general anesthesia]. / Le bronchospasme unilatéral lors d'une anesthésie générale.

We report a case of unilateral bronchospasm encountered following an induction of anesthesia of healthy young man with no significant past medical or surgical history. The differential diagnosis and management are discussed. Unilateral bronchospasm was probably caused by topical lidocaine injected with a Laryngojet injector at the vocal cords.

[Medication errors in anesthesia: a Moroccan university hospitals survey]. / Erreurs médicamenteuses en anesthésie : enquête prospective au niveau des CHU Marocains.

INTRODUCTION: Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco. MATERIAL AND METHODS: After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner's statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity. RESULTS: During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline. CONCLUSION: Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice.

[Peripheral intravenous access in the operating room: characteristics and predictors of difficulty]. / Accès veineux périphériques au bloc opératoire : caractéristiques et facteurs prédictifs de difficulté

PURPOSE: To investigate of predictor's factors of difficult venous access device in the operating room in elective surgery. METHODS: In a prospective study in central operating room, were included all patients scheduled for a surgical or diagnostic intervention. Were excluded all patients admitted with functional venous access. For each, were recorded patient's demographic characteristics (age, gender, ASA class, BMI), history (chemotherapy, prolonged ICU stay, hospitalization for more than five days), data from the clinical examination (presence of skin lesions, arteriovenous fistulas, burns, neurological deficits) and the type of operator (trainee, nurse, resident, senior). The difficulty was judged on the number of attempts required for successful venous access. Puncture was considered easier for a number of attempts to one to two and difficult if the number of attempts was greater than two. Predictor's factors were identified after univariate and multivariate analysis. RESULTS: During one year (March 2008 to February 2009), form returns in 1500 were met, 1325 were usable. Venous catheterization was successful in 50.9% at the first attempt in 24.2% of patients at the second attempt and after three attempts in 18% of patients. Only 6.8% of patients required more than three attempts. A central venous catheter was required in seven patients. In multivariate analysis, chemotherapy (OR=4.54, 95% CI [2.92 to 7.03]; P<0.001), a nurse in training (OR=2.27, 95% CI [1.40 to 3.63]; P=0.001), a resident in training (OR=2.14, 95% CI [1.29 to 3.58]; P=0.003) and the presence of burns (OR=3.59, 95% CI [2.44 to 5.27]; P<0.001) were identified as independent predictors of difficulty of peripheral venous access. DISCUSSION: The optimization of venous access devices in the operating room through the search for predictors of difficulty.