Haemodialysis before emergency surgery in a patient treated with dabigatran.

Novel oral anticoagulants (NOAs) which directly inhibit thrombin (dabigatran) or factor Xa (rivaroxaban and apixaban) have recently been developed. We report the first case of perioperative management of a patient treated with dabigatran requiring haemodialysis before emergency surgery. A 62-yr-old woman visited the emergency department for a left bi-malleolar ankle fracture; she had a past medical history of severe ischaemic cardiomyopathy, alcoholic cirrhosis Child B, and moderate chronic renal insufficiency. The patient was treated with dabigatran for a left ventricular aneurysm with thrombus. Cutaneous manifestation of a voluminous haematoma required emergency surgery. Blood tests revealed dabigatran anticoagulant activity of 123 ng ml(-1) (therapeutic values: 85-200 ng ml(-1)), activated partial thromboplastin time of 63 s, and a prothrombin ratio of 68%, indicating that dabigatran disturbed coagulation. We decided to perform emergency haemodialysis before surgery. After 2 h, the anticoagulant activity of dabigatran was 11 ng ml(-1), allowing surgery. Surgery proceeded without any problems and the postoperative period was unremarkable. This case highlights the difficulties for the anaesthesiologist regarding emergency perioperative management of patients treated with NOAs and confirms the efficacy of haemodialysis in cases of dabigatran treatment. NOAs should be prescribed with caution, especially for patients with renal or hepatic disease, at least as long as no antagonist is available. In cases of deferred operative urgency in haemodynamically stable patients treated with dabigatran, haemodialysis should be considered to reverse dabigatran's anticoagulant effects.

Impact of high-dose norepinephrine during intra-hospital damage control resuscitation of traumatic haemorrhagic shock: A propensity-score analysis.

INTRODUCTION: The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA). METHOD: We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.

Specific elements of thoracic wound management.

Damage control for thoracic trauma combines definitive and temporary surgical gestures specifically adapted to the lesions present. A systematic assessment of all injuries to prioritize the specific lesions and their treatments constitutes the first operative stage. Packing and temporary closure have a place in the care of chest injuries.

Anesthetic activities provided by the French forward surgical team in Abidjan, Ivory Coast: Four-year retrospective analysis.

The aims of this study were to review and quantify the types of anesthetic procedures performed by anesthesiologists assigned to the forward surgical team (FST) deployed in Abidjan, Ivory Coast. The study includes all patients undergoing surgery by the FST from July 2012 through July 2016. The activity was retrospectively analyzed and divided according to demographics, surgical specialties, emergency versus elective surgery, types of anesthetic and post-operative analgesic procedures, and transfusion aspects. Over this period, surgeons performed 1520 operations, 98 % as medical support to the population (MSP). Elective surgery accounted for 96 % of this activity, and emergencies for only 4 %. The main surgical activities were visceral (74 %) and orthopedic (26 %). Anesthetic procedures were general anesthesia for 62 % and locoregional anesthesia in 38 %. Our study showed that the FST contributed to MSP. Anesthetic procedures for MSP required limited resources, standardization of the procedures, and specific skills beyond the original specialties of military anesthesiologists to fulfill the needs of the local population.

Damage control: Concept and implementation.

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

[Global management of patients with ebola viral disease, experience of the Healthcare workers Treatment of Conakry, Guinea]. / Prise en charge globale du patient contaminé par le virus Ebola, expérience du Centre de traitement des soignants de Conakry, Guinée.

The Healthcare Workers Treatment Center of Conakry, Guinea, was inaugurated in january 2015. It is dedicated to the diagnosis and the treatment of healthcare workers with probable or confirmed Ebola viral disease. It is staffed by the french army medical service. The french military team may reconcile their medical practice and the ethno-cultural imperatives to optimise the patient adherence during his hospitalization.

Application of carbohydrate analysis to verify honey authenticity.

Gas chromatography and liquid chromatography have been used simultaneously to analyze sugars in honey. After statistical processing by principal components analysis, additions of exogenous sugars could be detected by the appropriate fingerprints of adulteration. Application to acacia, chestnut and lavender honeys enabled the detection of fraud resulting from 5 to 10% addition of sugar syrups. This method may be considered as a replacement of isotopic analysis, that has some limitations.

Animal welfare and the intensive production of bovine meat.

After a brief review of the legal framework of animal protection applicable to cattle--including Council of Europe and European Union legislation, as well as French law--the main features of husbandry systems used in the intensive husbandry of veal calves and young cattle are analysed. For veal calves, the standards proposed at the European level do not take into account major differences in the age, weight and quality of veal produced by different Member States. In the case of red meat, the production of baby beef in intensive units leads to some behavioural anomalies, which could be remedied within economic restrictions compatible with the interests of producers and consumers.

[Lipid peroxidation in aged patients. Influence of an antioxidant combination (vitamin C-vitamin E-rutin)]. / Etude de la lipidoperoxydation chez le malade âgé. Influence d'une association antioxydante (vitamine C - vitamine E - rutine).

Lipoperoxidation has an important role in the normal processes of the cell-life. The induction is produced by oxygen-derived free radicals which attack the membrane phospholipids. Such an attack is modulated by an enzymatic protection system (superoxide dismutase, catalase, glutathione peroxidase, glutathione transferase) and by a non-enzymatic one (vitamin C, vitamin E...). In various pathologic conditions, a dispoise takes place between radical attack and antiradical protection. The place taken by lipoperoxidation in the ageing process seems to be fundamental. We report here the results of a study carried out in aged and sick patients who were given an antioxidant medicamentous combination made from Vitamin C, Vitamin E and Rutin. Our results evidence that such a synergistic combination does modify both enzymatic protection system and lipoperoxidation, this latter showing a decrease under treatment.

[Hyperglycinemia without ketosis. Biochemical and enzymatic study]. / Hyperglycinémie sans cétose. Etude biochimique et enzymatique.

We report a biochemical and enzymatic study of two neonatal cases of non ketotic hyperglycinemia. We report the comparative evolution of glycine level in plasma and CSF during a restrictive diet excluding glycine and serine. The high levels of glycine found in CSF and brain are likely to reflect the brain damage. After autopsy, the glycine synthase activity determination shows a significative partial deficiency in the liver and a total deficiency in the brain. Glycine synthase affinity for glycine is similar for controls and patients and this lead use to think that the deficiency is due to a diminished biosynthesis of the enzyme molecule.

[Neonatal screening of congenital hypothyroidism with TSH measurement in dried blood spots on filter paper. A two years experience (author's transl)]. / Dépistage néonatal de l'hypothyroïdie congenitale par le dosage de la TSH sur tache de sang séché. Expérience de 2 ans dans la région Rhône-Alpes.

Systematic screening for congenital hypothyroidism was started in Lyon in september 1976. This screening was coupled with PKU, using the same dried blood samples on filter paper obtained on the 5th day of life. TSH levels were determined by radioimmunoassay adapted for dried blood samples (Kit Abbott). In 24 months, 56 176 samples were analyzed. The critical level calling for control was successively raised from from 20 to 30, now 40 microUI/ml of serum. A high level of TSH was found in 307 children (0,55%). Pathological deliveries were found in most of these infants (neonatal injury, cesarean, section forceps or ocytocic perfusion, neonatal icterus) and a second or a third measurement showed normal TSH level. Congenital hypothyroidism, was found detected in 18 infants: 12 ectopic gland, 5 athyreosis and 1 dyshormonogenesis. Treatment was begun at a mean age of 38 days (29 to 50 days).

[Neonatal screening for congenital hypothyroidism by measuring TSH in dried blood samples. Two years experience in the method (author's transl)]. / Dépistage néonatal de l'hypothyroïdie congénitale par le dosage de la TSH sur tache de sang séché.

Systematic screening for congenital hypothyroidism was started in Lyon in September 1976. This screening was coupled with PKU screening, using the same dried blood samples in filter paper obtained on the 5 th day of life. TSH levels were determined by radioimmunoassay adapted for dried blood samples (Kit Abbott). In 24 months, 56 176 samples were analyzed. The critical level calling for control was successively raised from 20 to 30 now 40 muUl/ml of serum. A high level of TSH was found in 307 children (0.55 p. 100). Pathological deliveries were found in most of these infants (neonatal injury, cesarean section, forceps or ocytocic perfusion, neonatal icterus) and a second or a third measurement showed normal TSH level. Congenital hypothyroidism, was detected in 18 infants: 12 ectopic gland, 5 athyreosis and 1 dyshormonogenesis. Treatment was begun at a mean age of 38 days (29 to 50 days). Despite a short follow-up the psychomotor development of the infants seems to be normal in all cases but one (one athyreosis with a neonatal injury and a malformative syndrome).

[Collagen and its technological possibilities]. / Le collagène et ses possibilités technologiques.

Collagen enjoys a privileged position as a biomaterial in its cosmetic applications. It exists under different forms and is more particularly able to reticulate. The process which is used allows a modulated reticulation. This means that a collagenous matrix having a varying degree of solubility can be obtained, which can lend itself to different applications. The prilling technique consists in producing microspheres consisting of a more or less reticulated collagenous matrix being able or not to imprison an insoluble or lipophilic active substance having previously been incorporated in the original solution. In this way, it is possible to obtain either strongly reticulated and mechanically resistant microspheres of particles which dissolve when crushed. The cosmetic significance of these new products is connected with the biocompatibility characteristics of the collagenous material and with the characteristics relating to the modulated reticulation of the obtained product.

[Blood transfusion on battlefield. The Kabul hospital experience]. / Transfusion sanguine en opération extérieure. Expérience à l'hôpital médico-chirurgical de Kaboul.

OBJECTIVES: Blood transfusion is an aspect of medical care on the battlefield. French assets include: red blood cell units (RBCu), lyophilized plasma (PLYO), fresh whole blood (FWB) but neither fresh-frozen plasma (FFP) nor platelets. French transfusion strategy in military operations follows the evolution of knowledge and resources. We describe the characteristics of the transfusion at the military hospital in Kabul. PATIENTS AND METHODS: Retrospective study of records of patients transfused between October 2010 to December 2011 conducted in Kabul from transfusion register. Variables studied were: patient characteristics, biology at admission, type and amount of transfusion products, evolution. RESULTS: One hundred and twenty-six patients were transfused: 49 military (39%) which 22 French soldier (17%), most of time afghan (n=97; 77%), mean age at 24 years old (3-66). Two hundred and seventy-three RBCu from France were transfused and 350 unused were destroyed. Conditions leading to a transfusion were: 76 war wounds (60%), 21 trauma (17%) and 29 other (23%). In the first 24 hours, patients received in mean: two RBCu (0-12), one unit of FWB (0-18) and two PLYO (0-14). PLYO/RBCu ratio was 1/1.6. A massive transfusion (more than 10 RBCu) concerned 9% of patients. Twenty-seven percent of patients received FWB. We note 17 dead people (13.5%). CONCLUSION: The use of the FWB and PLYO in substitution of FFP and platelets can provide cares of high quality in a logistically constrained context while controlling costs.

[Nicardipine induced hypoxia: role of hypoxic pulmonary vasoconstriction]. / Hypoxie sous nicardipine : rôle de la vasoconstriction pulmonaire hypoxique.

Nicardipine is a commonly used anti-hypertensive drug for acute situations. We report the case of a 55-year-old man with hypoxemic pneumonia, who presented a worsening of his hypoxia secondary to the injection of this calcium channel inhibitor (CCI). This side effect was probably caused by inhibition of hypoxic pulmonary vasoconstriction. Effects of CCI on pulmonary vessels are well-known. They don't induce clinically relevant hypoxemia in patients without acute pulmonary pathology. This case report shows that nicardipine can severely worsen haematosis of patients with acute hypoxia. CCI should probably not be used in such patients.

Management of exsanguinating pelvic trauma: Do we still need the radiologist?

BACKGROUND: The hemodynamically unstable pelvic fracture are a diagnostic and therapeutic challenge. The current management is based on the control of pelvic bleeding by combining pelvic ring stabilization and embolization of pelvic arteries. The mortality of these patients, however, exceeds 30%. Recently the preperitoneal packing, based on the hemostatic tamponade of the pelvic cavity has been described. The objective of this study was to evaluate the interest of this new surgical procedure. The effectiveness of the standard algorithm is evaluated by analysis of pelvic injuries in 200 severe trauma treated at the Sainte-Anne Hospital. The results are then compared with literature data on the preperitoneal packing. PATIENTS AND METHODS: The profile injury, management and morbidity and mortality was evaluated in 200 polytrauma. After an initial phase of resuscitation, unstable pelvic fractures were treated with a circumferential belt followed by the application of an external fixator. Arteriography was performed for all patients with persistent hemodynamic instability. RESULTS: The mean injury severity score (ISS) was 31 (4-75). The mean trauma-related injury severity score (TRISS) was 74% (3-99). The proportion of hemodynamically unstable patients was 47%. Fifteen patients (41%) had severe bleeding. The median number of blood transfusion was 10 (4-42); eight patients (22%) underwent embolization. For two patients, reducing the pelvic fracture with an external fixator resulted in permanent hemostasis. Two patients underwent a laparotomy first, for the control of a hemoperitoneum. The mortality rate of the group of patients with hemorrhage was 33% (5/15). DISCUSSION: This high mortality leads to reconsider the place of pelvic embolization as firstline treatment. Some major drawbacks are noted: its effectiveness in treating venous bleeding, availability and duration of the procedure. The preperitoneal packing is a fast and effective surgical alternative. It seems to improve hemodynamic status of patients and significantly reduce the use of embolization and massive transfusion. Embolization is still indicated for patients not responding to surgery. However survival is not significantly improved.