[Meningitis after spinal anesthesia]. / Méningites après rachianesthésie.

BACKGROUND: Meningitis is a rare complication after spinal anesthesia. aim: We report 4 cases of meningitis occurred after spinal anesthesia. OBSERVATIONS: These meningitis were diagnosed during tow months and with 3 different operators. The first symptoms appeared 4 to 6 hours after surgery and were represented especially by headaches and fever. Cyto-chimic analysis of cerebrospinal fluid (CSF) indicates bacterial meningitis but soluble antigens and culture were negative. Evolution was favorable in all cases under or without antibiotics. The exactly cause of these meningitis remained unknown and an insufficient asepsis was the principle risk factor found in all cases. CONCLUSION: Prevention of this risk consists on hygienic rules and perfect skin disinfection.

[Evaluation of a protocol of spinal anesthesia for cesarean section in a Tunisian maternity unit: hemodynamic repercussions and risk factors for hypotension]. / Evaluation d'un protocole de rachianesthésie pour césarienne dans une maternité Tunisienne : Répercussions hémodynamiques et facteurs de risque d'hypotension.

AIM: To evaluate hemodynamic repercussion of a protocol of spinal anesthesia (SA) for cesarean and release the predictive factors of maternal arterial hypotension post spinal anesthesia. METHODS: We included parturients proposed for Cesarean under SA. They were not included the women of statute ASA > II, preeclamptics, eclamptics and/or having counter-indications of SA. We excluded the cases where there were technical difficulties at the time of the realization of SA, a failure or a complication of this SA. We injected 10 Mg of bupivacaïne 0.5% isobar, 10 µg of fentanyl and 100 µg of morphine. The data were collected before the realization of SA (anthropometric parameters; antecedents; basic systolic and diastolic blood pressures (BSBP and DSBP) and basic heart rate (BHR)) and after SA (systolic and diastolic blood pressure (SBP and DBP), heart rate (HR); occurred or not of a sympathetic block (falls of the SBP of more than 20% of its basic value or a SBP<90 mm Hg); the time of installation of the sympathetic block and the duration of hypotension. RESULTS: The full number of parturients included was 1016 among whom 16 were excluded. Only 1000 parturients finished the study and were divided into 2 groups (group 1: 500 emergency cesarean and group 2: 500 elective cesarean). The incidence of the sympathetic block was of 44.2% as a whole and this block was significantly more frequent in group 2 (p=0.0001). There was a significant relation between the incidence of a sympathetic block and the advanced age of the parturient (p=0.0001), the important weight (p=0.047), high ASA statute (p=0.0001), the presence of hypertension (p=0.0001), diabetes (p=0.001) or cesarean (p=0.00015) in the antecedents and the low BSBP (p=0.015). CONCLUSION: In spite of the beneficial effect of the reduction in the amounts of local anesthetic in the SA, the sympathetic block remains frequent after SA for Cesarean. Thus, it is essential to detect the high risk women of occurred of sympathetic block after SA, and to propose strategies of prevention, monitoring and management for this population.

[The prophylaxis of the thromboembolic disease in the head trauma]. / Thromboprophylaxie des traumatises crâniens.

BACKGROUND: The prophylaxis of the thromboembolic disease in the severe head trauma remains a controversy. AIM: In this study, we are interested to the determination of under groups of patients for whom the advantages of the prophylaxis of the thromboembolic disease (TED) are higher than its disadvantages. METHODS: We proceeded to a retrospective study based on patient medical records ranging from March 2003 until March 2004, enrolling 56 consecutive patients. The data collected related to the age, the gender, past medical history, the type of trauma, results of the initial CT scan, the treatment, appearance or not of the thromboembolic disease and its prophylaxis therapy. RESULTS: The average age was of 36 ± 19 years. 76.8% did not have significant past medical history. All the patients profited from an elastic compression stocking. The LMWH were used among 15 patients victim of severe head trauma associated with other injuries and 72 hours after stabilization of hemorrhagic attacks. A thromboembolic disease diagnosis was based clinical or biological assumptions. Among 56 patients, 4 of them showed a TED with an incidence of 7.1 including 3 DVT and one case of pulmonary embolism. The 4 patients sustain severe multiple trauma; 3 of them received an early anti-coagulation therapy. In the group of patients with TED, the OMEGA scores and IGS are high; all of them are multiple traumatized patients with shock requiring a blood transfusion in 75 of the cases. Only the blood transfusion is correlated at the risk of TED, statistically established. CONCLUSION: The risk to develop a thromboembolic complication in the traumatic patients with head injury is high particularly in case of associated muscleskeletal injuries. Elastic compression technique is not always effective but considered as an interesting alternative to the pharmacological prevention of thrombosis. The use of the anticoagulants therapy must be careful. It is contra-indicated in case of cerebral haemorrhage in progress and must be considered upon individual case of each patient.

Clinical benefits related to the combination of ketamine with morphine for patient controlled analgesia after major abdominal surgery.

BACKGROUND: combination of ketamine may improve morphine patient controlled analgesia (PCA) but clinical results are still equivocal. AIM: The authors designed a powerful study to evaluate this hypothesis after major abdominal surgery. METHODS: 138 patients undergoing abdominal surgery participated in the randomized double blind study. Patients were allocated to two groups: M-group: morphine 0.5 mg/ml + placebo in PCA and MK-group: morphine 0.5 mg/ml + ketamine 0.5 mg/ml with the same bolus dose and lock out time. The patients were evaluated during 48 hours by visual analog scale (VAS), simplified verbal scale (SVS). Side effects and amount of morphine used were monitored. RESULTS: The two groups are comparable for demographic data and surgery characteristics. From the 24th hour, morphine consumption was significantly lower in the MK-group. At 48 hours after surgery, the amount of morphine received in the MK-group was significantly lower than in the M-group (48 vs 66 mg, p < 0.001). The average value of VAS was lower in the MK-group from the 12th hour at rest and 20th hour during mobilization. SVS was significantly lower for the MK-group after the 12th postoperative hour. The incidence of respiratory depression was higher in the M-group: 4 vs none in the MK-group. The incidence of nausea, vomiting and pruritus was halved in the MK-group (p < 0.04). CONCLUSION: The combination of ketamine with morphine in PCA after major abdominal surgery offers a reduction of the morphine consumption, a reduction of pain scores and a decrease in the incidence of adverse effects.

[Postoperative analgesia after laparoscopic cholecystectomy: comparison of the preoperative administration of celecoxib with paracetamol?]. / Analgesie postoperatoire pour cholecystectomie sous coelioscopie: comparaison de l'administration preoperatoire du celecoxib et du paracetamol.

OBJECTIVE: The goal of this study was to evaluate the preventive analgesic effectiveness of paracetamol and celecoxib in laparoscopic cholecystectomy. METHODS: Randomized prospective study was undertaken, 75 patients of class ASA I and II were included, divided into three groups: P (Paracetamol 1000 mg), C (Celecoxib 200 mg) given orally one hour before induction and group T (without preoperative analgesia). The VAS at rest and effort was noted on arrival in the recovery room then with regular intervals (T(30mn) to T(h24). A morphine titration was carried out during the first 12 postoperative hours. Hemodynamic parameters, Ramsay score and the adverse effects were noted. RESULTS: The three groups were comparable for the demographic data, the duration of anesthesia and peroperative morphine consumption. The evolution of VAS scores shows a significant difference between the groups P and T with the effort of cough at t24h (p = 0.04), and between the groups C and T at postoperative T 4h (p = 0.016). In our study the group C consumed to a significant degree less morphine 5.44 +/- 3.00 Mg against 7.83 +/- 4.00 Mg for the group P (p < 0.03) and 8.04 +/- 3.00 Mg for the group T (p < 0.008). CONCLUSION: The administration of 200 Mg of celecoxib in the preoperative period of a laparoscopic cholecystectomy allows a significant decrease in morphine consumption in the postoperative period and a reduction in the scores of the VAS at rest and at the effort of cough compared to the groups which received only one placebo or paracetamol.

Efficacy of patient controlled epidural analgesia during labor analgesia--a prospective randomized study using 0.1% bupivacaine with fentanyl 2 mg/ml.

BACKGROUND: Epidural analgesia is the most effective for the control of pain during labor but irregularity of analgesia, toxicity of local anesthetics (LA) and driving block are the major limits of the modalities of maintenance. AIM: The purpose of this work was to assess the effectiveness and adverse effects of adaptations offered with Patient Controlled Epidural Analgesia (PCEA). METHODS: 40 mono-foetal parturients were randomized in two groups: 0.1% bupivacaine continuous drip associated to fentanyl 2 lg/mL (CP-group) or same products administrated in PCEA. Evaluation of analgesia, driving and sensory block allows adapting the outputs of drip. RESULTS: Consumption schedule in LA was of 7.5+/-2 mL/h in the CP-group and 3.5+/-1.5 mL/h in PCEA-group (p < 0.05). Consumption accumulated by LA is reduced by 35 % from the very beginning and 43% a 4-th hour (p<0.05). Incidence of the driving block was of 11 cases in CP-group against 4 in PCEA-group per first hour and of 13 cases against 3 per second hour (p<0.001). 50% of clinical obstetric interventions were brought together in the CP-group against 5 % in the PCEA-group (p=0.013). Incidence of side effects is comparable. CONCLUSION: Besides the perfect analgesia, PCEA offers a psychic independence which explains comfort and maternal satisfaction. Accumulation of LA entails a driving block involved in the change of dynamics of the labor. Incidence of clinical obstetric interventions is the major observation of our study.

[Patient controlled epidural analgesia: interest in thoracic surgery]. / Interet de l'analgesie peridurale autocontrolee en chirurgie thoracique.

AIM: To compare efficacy of pain control, the consumption of local anaesthetics and opioids as well as the side effects between continuous epidural analgesia, patient controlled analgesia and patient controlled epidural analgesia in thoracic surgery. METHODS: Prospective randomised study included 66 patients who had thoracotomy. Patients were divided into 3 groups, to receive different pain control methods. Group 1 (n=22) received patient control analgesia Group 2 (n=22) received continuous epidural analgesia (Bupivacaine 0,125% + 5 microg/ml of Fentanyl) between 6 and 10 ml/h in order to obtain a T2 level Group 3 (n=22) received patient controlled epidural analgesia (Bupivacaine 0,08% + 3 microg/ml of Fentanyl) 6 ml/h and bolus of 5 ml. RESULTS: There was no difference between the three groups in age, delay of surgical operation and per operative morphine consumption. VAS was less at rest and after cough in patient group with patient controlled epidural analgesia. The difference was less significant in local anaesthetics and opioids consumption in patient with controlled epidural analgesia. CONCLUSION: The benefit of patient controlled epidural analgesia in thoracic surgery is proven by the following analgesic efficiency which allows good respiratory rehabilitation, decreasing the risk of drug toxicity by decreases consumption, weak hemodynamic effects and absence of motor block.

[The end of life, euthanasia, and medical futility]. / Fin de vie, entre orient et occident.

The progress in medicine transformed the issue of death. In fact, the means that can be used to prolong the life or a patient are unlimited nowadays. This infers problems, that as professional health carers, can neither ignore nor take upon oneself. Euthanasia, assisted suicide, non excessive treatment, are totally different acts, nevertheless encounter of such situations led to a confusion harmful to any reflexion. It's imperative to avoid the controversy and find collectively ethical, legal and medical solutions that permit to confront one of the major challenges to progress.

[Septic shock in a Tunisian intensive care unit: mortality and predictive factors. 100 cases]. / Choc septique dans une reanimatio Tunisienne: mortalite et facteurs associes. A propos de 100 cas.

This is a retrospective study, of 100 consecutive patients with septic shock hospitalized in the ICU of Mongi Slim Hospital La Marsa between January 1997 and December 2001. The state of shock was defined according to the criteria established by the American College of Chest physicians in conjunction with the Society of Critical Care Medicine during the consensus conference on sepsis. Our study shows that septic shock affect both sexes in the same way, that it increases with the age and with the existence of underlying diseases. The global mortality was 82%. According to our study o, septic shock mortality in creases with age and with the existence of an underling pathological condition such as high blood pressure. It also increases with the cause of the septic shock. (Pleuro-pulmonary).

[Factors associated to maternal mortality among preeclamptic parturients. About 55 cases]. / Facteurs associees a la mortalite maternelle chez les preeclamptiques: a propos de 55 cas.

Retrospective study about 55 preeclamptic parturients. Data was collected from the medical files of the patients hospitalized during two consecutive years. Admittance of preeclamptic women in the intensive care unit was 6,37 % (55/689). Mortality rate was 11% (6 deaths). Complications associated with the maternal death were renal failure, disseminated intravascular coagulopathy and Hemorrhagic shock after subcupsular liver hematoma. Advanced maternal age is a factor associated to maternal mortality. All these risk factors of death may be avoided if adequate management was performed.

[Pulmonary alveolar proteinosis in two siblings. A case report]. / La protéinose alvéolaire pulmonaire de l'enfant. A propos d'une observation familiale.

Pulmonary alveolar proteinosis (PAP) is a rare disorder in children. This report describes two siblings in whom PAP developed during infancy (three years for the boy and four years two months for the girl). The girl was admitted for chronic respiratory distress. Chest x-ray showed a reticulonodular pattern. Her brother was asymptomatic. The diagnosis of PAP was confirmed by open lung biopsy for the boy and broncho-alveolar lavage for the girl. Therapeutic broncho-alveolar lavages were performed (six for the girl and two for the boy), the girl lost dependence on oxygen therapy. 6 years later, the brother is still asymptomatic. The sister had two episodes of respiratory distress, after two and four years, that required therapeutic lavages. The last therapeutic bronch-oalveolar lavage was performed for the first time by a Tunisian team.

[Malignant hyperthermia]. / L'hyperthermie maligne.

Malignant hyperthermia is a potentially fatal pharmacogenetic disease triggered by volatile anesthetics and/or succinylcholine. Dysregulation of intracellular calcium homeostasis is the trigger of the acute crisis. Malignant hyperthermia crisis correspond to an hypermetabolic state, which occurred acutely and interesting skeletal muscular cell. Early manifestations grouped tachycardia, tachypnea, masseter spasm, mixed acidosis and raise of the end expiratory CO2 pressure. Hyperthermia is a late sign, rhabdomyolysis is a sign of the severity of the malignant hyperthermia. The successful treatment is based on an early diagnosis, immediately interruption of triggering agents, intravenous administration of Dantrolene in sufficient dosage and starting of adequate symptomatic treatment. Prevention of this complication is based on asking the patient about genetic predisposition to malignant hyperthermia. Confirmation of the susceptibility to malignant hyperthermia can be provided by in vitro contracture test with halothane or caffeine after muscle biopsy.

[Isolated acute renal failure is not associated to an increase in mortality of patients in intensive care units]. / L'insuffisance rénale aiguë isolée n'est pas associée à une surmortalité chez les malades de réanimation.

This study assess the prognostic factors increasing mortality of patients with acute renal failure in intensive care units. The study included 923 patients admitted to the intensive care unit over a period of two years. Acute renal failure was defined by the following criteria, a blood urea concentration of more than 30 mmol/l, a serum creatinine concentration of more than 180 micromol/l or creatinine clearance less than 50 ml/min. Patients were divided into two groups survivors (V) and dead patients (D). 95 patients presented acute renal failure with a mortality rate of 57.9%. There was no difference between the two groups. There was no difference between the two groups. Patients in intensive care units with only acute renal failure doesn't have a worse prognosis, but the association to two or more other organ dysfunction's, mechanical ventilation of more that 12 days, sepsis or Glasgow coma scale less than 8 are predictive of mortality.

[Tracheotomy or prolonged tracheal intubation for long-term ventilation]. / Trachéotomie ou intubation tracheale prolongee en ventilation mécanique prolongee.

130 critically ill patients undergoing long term mechanical ventilation were divided into two groups, tracheotomy versus translaryngeal intubation. There were no difference in demographic characteristics between the two groups. The incidence of chronic obstructive pulmonary disease (COPD) was also higher in T. The tracheotomy was achieved at mean within 14 days after the beginning of mechanical ventilation. The incidence of pneumonia is the same in the two groups (41% for T versus 39% for I). The length of mechanical ventilation is longer in T (25 +/- 12 d versus 12 +/- 4 d). The COPD represent a risk factor for prolonged mechanical ventilation in T (18 days in COPD patients with tracheotomy versus 9 days in non COPD patients). The length of stay in intensive care unit is higher in T (29 +/- 13 d versus 15 +/- 4 d). The 28th day mortality is similar between the two groups. The tracheotomy didn't allow a shorter duration of mechanical ventilation. That's can be explain by the fact that we performed the tracheotomy in a high risk population for pulmonary complications (COPD) and often after a first failure of weaning form mechanical ventilation.

[The obstetrical advantages of epidural analgesia in a trial of labor]. / Les avantages obstetricaux de l'analgesie peridurale au cours de l'épreuve de travail.

Two series of labour trial were compared in a forward-looking study. The first series of 24 parturient women (series I) to whom the labour trial took place under peridural analgesy. The second series of 80 parturient women (series II) to whom the labour trial took place without peridural analgesy. The rate of caesarean section is significantly less important in the series I (33.3% versus 58%) P = 0.37. The average duration of the labour trial is significantly prolonged under peridural analgesy but without bared effects for the newborn children. The authors consider that the peridural analgesy is the method that brings ideal conditions for a real test allowing to eliminate dynamic dystocia and maternal restlessness in order to have an accurate cephalo-pelvic confrontation.

[Mechanical ventilation in intensive care units: indications, modalities and complications. Results of a prospective multicenter survey in Tunisia]. / La Ventilation artificielle en réanimation: indications, conduite pratique et complications. Résultats d'une enquête prospective multicentrique tunisienne.

The survey was performed during the month of March 1998 and concerned 9 ICUs located in teaching hospitals. To be included each ICU had to MV for more than 12 hours were included in the study and had a 28 day follow-up in the ICU or until hospital discharge. Collected parameters were indications of MV, modalities of MV and of weaning, complication and outcome at hospital discharge. Assist-control ventilation was the most used ventilation modality (69.8%). Weaning of MV was performed in 63% of the study patients and was based on a once-a-day attempt of spontaneous breathing through a T-piece (59.5%) and a combination of intermittent mandatory ventilation with pressure support (IMV-PS: 27%) or pressure support alone (11.2%). Mean length of hospital stay was 19.7 +/- 15.9 days of which 11.6 days were spent in the ICU. Fifty nine patients (54%) were alive at discharge form the ICU of whom 4 ultimately died during their hospital stay. MV practice as well as ICU facilities are not homogenous in Tunisia. Recommendations and guidelines should be built in order to standardize MV practice in Tunisia.