Heparin-associated thrombocytopenia syndrome: an underestimated etiology of adrenal hemorrhage.

A 74-year-old man developed bilateral arterial thrombosis of the lower limbs related to heparin-associated thrombocytopenia syndrome (HATS). On day 4 after thrombectomy of both limbs, abdominal pain, fever, hypotension, abdominal tenderness appeared. Acute acalculous cholecystitis was suspected and cholecystectomy was carried out although the gallbladder was not imflamed. Later on, hyponatremia in addition to the aforesaid signs suggested the diagnosis of adrenal insufficiency. Diagnosis was confirmed by low cortisol and aldosterone plasma concentration and by CT scan, which showen two enlarged adrenal glands. HATS might explain two unexpected facts: occurrence of adrenal hemorrhage during heparin therapy with coagulation tests within the therapeutic range and paradoxical thrombosis in the central vein of adrenal gland. HATS must be regarded as one cause of adrenal hemorrhage necrosis.

[Phentolamine in treatment of acute left ventricular insufficiancies]. / La phentolamine dans le traitement des insuffisances ventriculaires gauches aiguës

Phentolamine (Regitine) at the dose of 0.3 mg/mn behaves as an arterial and, above all venous, vasodilatator agent, resulting in a marked and early lowering of the pulmonary pressures in acute oedema of the lung and in cardiac asthma. It was used alone in 47 attacks of acute severe left ventricular failure with very favourable results in 43 cases, as proved by the rapid improvement of the haemodynamic status and of the aicd-base balance. Under strict observation, tolerance has been excellent. This therapeutic method seems of great interest in the cases of acute pulmonary oedema with a maintained blood pressure level, and in the forms with severe arterial hypertension which might tolerate larger doses.

[Cardiac surgery in aged patients; immediate and medium-term results in 100 patients over 75 years of age]. / Chirurgie cardiaque chez les patients âgés; résultats immédiats et à moyen terme chez 100 patients âgés de 75 ans et plus.

With improved operative technique and postoperative care, progressively older patients are being referred for cardiac surgery. One hundred out of 633 patients operated between September 1990 and December 1992, were over 75 years of age (Group I). These patients were compared with the last 100 patients under 75 years of age (Group II). Both groups were operated by the same surgical team with the same anaesthetic, cardiopulmonary bypass and myocardial protection techniques. The average age of the groups was 79.5 +/- 3.1 and 62.1 +/- 9.2 years, respectively. The procedures performed were: myocardial revascularisation (Group I, 28 cases; Group II, 59 cases), aortic valve surgery alone or associated with coronary bypass (56 and 22 cases respectively), and mitral valve surgery alone or associated with another procedure (11 and 12 cases). There were no significant differences between the two groups with respect to true low output state, the duration of mechanical ventilation and of intensive care and hospital stay. On the other hand, there were significant differences in: the number of blood transfusions (44 cases versus 20, p < 0.001), the occurrence of atrial fibrillation (52 cases versus 29, p < 0.001) and neuropsychiatric disturbances (27 cases versus 5, p < 0.0001). There were no cases of mediastinitis in either group. The hospital mortality was 6% in Group I and 5% in Group II (NS). The medium-term mortality after an interval of 5 to 32 months in the over 75 age group was 7 cases, including 4 cases of cerebrovascular accident. An enquiry was performed in the 87 survivors of Group I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Retrograde cerebral perfusion for replacement of the aortic arch. Apropos of a case]. / Perfusion cérébrale rétrograde pour remplacement de la crosse aortique. A propos d'un cas.

The authors report a case of cerebral protection with retrograde cerebral perfusion during aortic arch surgery. The duration of retrograde cerebral perfusion and the favorable neurological outcome seem to confirm the promising results of this technique developed in Japan.

[Acute pancreatitis: prognostic value of early x-ray computed tomography coupled with Ranson's criteria and its role in surveillance of the course]. / Pancréatites aiguës: valeur pronostique de la tomodensitométrie précoce couplée aux critères de Ranson et son rôle dans la surveillance de l'évolution.

Fifty nine patients suffering from a first attack of acute pancreatitis were investigated during the first ten days of illness with computerized tomography (CT scan) and biological signs of Ranson. The prognostic value of the combination of these two classes of signs was evaluated. The grading of initial CT scan findings was accorded to the Ranson and Balthazar classification. In addition, the authors evaluated the presence and extent of necrosis and studied phlegmonous extrapancreatic spread. A high risk group of patients was determined: grade C, D, E, with at least three prognostic signs. Twelve of these high risk patients with grade D and E had a glandular necrosis as detected on initial contrast enhanced CT scan. This was an important prognostic value sign (sensibility 100 percent; specificity 92 percent) as all morbidity was 100 percent compared with 8.5 percent among the 47 other patients who did not exhibit this CT sign; mortality was 25 percent compared with 0 percent among the other patients. Phlegmonous extrapancreatic spread in three or more areas also influenced the prognostic but to a lesser extent (sensibility 100 percent; specificity 62 percent). Forty-four patients among the fifty-nine had a morphologic follow-up of the course of lesions by repeated CT scan. Local complications occurred only in patients at high risk: 9 pancreatic abscesses (20.4 percent) and 6 pseudocysts (15 percent). One-third of the twenty-one grade D and E patients had spontaneous resorption of the phlegmonous extrapancreatic areas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pharmacokinetics of paracetamol in the cerebrospinal fluid in the elderly]. / Pharmacocinétique du paracétamol dans le liquide céphalorachidien de sujets âgés.

We investigated acetaminophen pharmacokinetics in CSF in twelve operated arteritics patients with continuous spinal anesthesia. Nine men and three women aged 77 +/- 7 years and weighing 66 +/- 15 kg entered in the study after expressing verbal informed consent. They received intravenously a single dose of acetominophen (equivalent to 1 g). Fifteen minutes to six hours after the intravenous injection, blood and CSF samples were withdrawn every thirty minutes, except during the second to the third hour were it was every fifteen minutes. Acetaminophen concentrations in blood and in CSF were assayed by HPLC. Acetaminophen was detected in the earliest samples (1.32 +/- 1.32 micrograms.ml-1) and then increased up to 8.16 +/- 3.04 micrograms.ml-1 at 186 +/- 56 minutes. From 135th to 345th minute, acetaminophen concentration in CSF stay at about 6 micrograms.ml-1, which is the duration of its maximal analgesic central effect.

[Hematoma of the adrenal glands and heparin]. / Hématomes des surrénales et héparine.

The diagnosis of adrenal haemorrhage complicating heparin therapy is often delayed, despite computed tomography (CT). Moreover, its pathogenesis is not clear. Adrenal haemorrhages are often seen in cases where there is no unduly excessive anticoagulation, and can be accompanied by a paradoxical thrombosis of the central adrenal vein. Symptoms usually occur within the first 8 to 12 days after starting heparin. The difficulty in establishing the diagnosis stems from the fact that symptoms are rather nonspecific: abdominal pain and backache, nausea, vomiting, lethargy, weakness, hypotension, hyperpyrexia. To confirm the diagnosis, both hormonal proof of adrenal failure and anatomic evidence of haemorrhage must be found. Early CT scans may show the haemorrhage. Several possible causes have been put forward to account for these adrenal haemorrhages. The degree of anticoagulation did not seem to be a prerequisite, 30 to 50% of patients showing no evidence of other bleeding or coagulation tests outside the therapeutic range. Capillary fragility of old age might be a factor. Stress would seem to be an important factor predisposing to adrenal haemorrhage. Many authors consider the paradoxical central vein thrombosis as a result of the haemorrhage rather than its cause, whereas other conclude the opposite. Unfortunately, to date coagulation studies are often incomplete; platelet counts were missing in most reports published before 1985. Since that date, a heparin induced thrombosis-thrombocytopaenia syndrome (HITTS), in which thrombosis may occur in any vascular bed, has been recognized with increasing frequency. Nine cases of adrenal haemorrhage associated with HITTS have been reported. It seems highly likely that a proportion of cases of heparin-related adrenal destruction are due to HITTS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Final arrest of a pacemaker after use of electrocautery]. / Arrêt définitif d'un stimulateur cardiaque après utilisation du bistouri électrique.

A case is reported of irreversible damage being caused to a permanent programmable pacemaker by electrocautery used in the epigastric region. The pacemaker was rapidly replaced, and the patient had no adverse effects of this accident. The use of monopolar electrocautery in patients who have one of the new generation of programmable pacemakers is very dangerous. Bipolar forceps can reduce the level of interference between electrocautery units and pacemaker electrodes. With programmable pacemakers, the generator instruction manual should be consulted before surgery, as placing a magnet on the generator may not necessarily convert it to the asynchronous mode. When the use of electrocautery is unavoidable, external cardiac pacing electrodes should be placed on the patient, with an external cardiac pacemaker ready.

[Repeated convulsions after abrupt benzodiazepine withdrawal]. / Convulsions itératives après sevrage brutal en benzodiazépines.

Benzodiazepines are widely used and well-known for their safety; serious complications may, nevertheless, occur in the particular case of an abrupt withdrawal, which is quite common after general anaesthesia. The case reported emphasizes the seriousness of the syndrome : after vascular surgery the patient presented with repeated epileptic seizures and a short lasting cardiac arrest. The patient used to absorb large quantities of benzodiazepines, without medical prescription. The convulsions stopped after the benzodiazepine had been taken again. The exact mechanism of the withdrawal syndrome remains hypothetical. There are numerous risk factors which increase the probability and seriousness of the withdrawal symptoms. The prevention of withdrawal accidents depends on the physician, and especially the anesthetist, knowing the patient's drug intake. This shows yet again the importance of the preanaesthetic visit.

[Indications for the use of magnesium in anesthesia and intensive care]. / Indications du magnésium en anesthésie-réanimation.

Magnesium (Mg), a cofactor in numerous enzymatic reactions, is often ignored by clinicians, as the symptomatology of Mg depletion is not specific and usually associated with that of the cause of the depletion. Furthermore, the plasma Mg concentration (0.8 to 1.1 mmol.L-1) is only equivalent to one percent of the total body content. A Mg deficit may exist while plasma Mg concentration is normal. Therefore other techniques for Mg assessment, such as the repletion test, as well as red blood cell and lymphocyte concentrations have been used. A renewed interest for Mg occurred as numerous studies have shown the therapeutic efficiency of Mg and as the mechanisms of its haemodynamic effects have been recognized. Mg regulates Na-K-ATPase activity, K channels activity and, most of all, it is a natural calcium channel blocking agent. These properties explain its important place in electrophysiology of myocardial cells and the effects on the tension of smooth muscles, resulting in a vasodilation and a bronchodilation respectively. The antagonistic effect of Mg on calcium decreases the presynaptic release of acetylcholine at the neuromuscular junction and the release of epinephrine at the peripheral sympathetic nerves and the adrenals. Mg potentiates the effect of non-depolarizing muscle relaxants. A Mg deficiency occurs often in ICU patients, in alcoholics and during use of diuretics. Simultaneous administration of Mg is often required for treatment of potassium deficiency. Mg has an anti-arrhythmic effect towards digoxin-mediated dysrhythmias and torsades de pointes, and can be efficient in other arrhythmias. Systematic use of Mg seems to decrease mortality of acute myocardial infarction and is justified during cardiac surgery, often associated with hypomagnesemia, because of vasodilation of coronary arteries and in order to prevent occurrence of arrhythmias. Mg, because of its calcium channel blocking properties and as it lowers the release of epinephrine, is indicated for surgery of pheochromocytoma. In eclamptic and pre-eclamptic patients, the use of Mg is valuable, but not as an anti-epileptic agent. Other clinical uses of Mg have been proposed, but they are either anecdotal or of uncertain efficiency.

[Iloprost (Ilomedine) and extracorporeal circulation with conventional heparinization in a patient with heparin-induced thrombocytopenia]. / Iloprost (Ilomédine) et circulation extracorporelle avec héparinisation conventionnelle chez un patient ayant une thrombopénie à l'héparine.

A 73-year-old female patient was admitted for myocardial infarction. Conventional treatment with heparin was started, intraaortic balloon assistance was required for several days, together with heparin. The platelet counts decreased progressively, from 288 G.l-1 on admission to 41 G.l-1 on the 16th day, despite the use of low molecular weight heparin. The in vitro heparin platelet aggregation test remained positive. This aggregation ended on adding iloprost, an analogue of prostacyclin, to the platelet culture bath. A coronary aortic bypass graft was required. An infusion of iloprost was started just after induction of anaesthesia. The initial dose of 0.5 ng.kg-1 x min-1 was gradually increased to 20 ng.kg-1 x min-1. Heparin (400 IU.kg-1) was thereafter added. To maintain a mean blood pressure of a least 50 mmHg, an infusion of up to 10 micrograms.kg-1 x min-1 of phenylephrine was given. As it was insufficient, an infusion of up to 1 microgram.kg-1 x min-1 noradrenaline was required. The iloprost infusion was gradually stopped 15 min before the end of CPB, together with that of noradrenaline. Platelet aggregation tests were positive after protamine had been given, whereas they had been negative during the infusion of iloprost. There was no abnormal postoperative bleeding. An infusion of 2 ng.kg-1 x min-1 was started at the sixth postoperative hour for 48 h, until the coumarin-like agent had started taking its effects. It is concluded that iloprost might be useful for carrying out cardiac surgery in patients with heparin-induced thrombocytopaenia.

[Value of fiberoptic bronchoscope in children with epiglottitis]. / Intérêt de l'utilisation du bronchoscope à tube souple en cas d'épiglottite chez l'enfant.

Acute epiglottitis is an infectious disease causing a severe respiratory distress. Any attempt to move the child in the horizontal position or to examine his throat can result in cardiac arrest. Diagnosis, endotracheal intubation as well as decision making of the optimal time for extubation are greatly facilitated by the use of a fiberoptic bronchoscope. The device is a paediatric model (external diameter 3.6 mm with an operating channel). It is inserted through the nare in the child in the sitting position. Oxygen is delivered through a nasal tube. The examination is performed under local anaesthesia (lidocaine 0.5%). Midazolam is sometimes added via the rectal or i.v. route. The clinical signs are monitored as well as the heart rate and SpO2. The diagnosis of epiglottitis as it is visual, is very easy and rapid once the epiglottis is observed through the fibreoptic bronchoscope. The advantage of the examination under fibreoptic bronchoscope is to allow visualization without aggression or stimulation of the pharyngolaryngeal structures and without modification of the child's position. Endotracheal intubation, which is always required, is facilitated as the child is breathing spontaneously. The expiratory flow blows bubbles of saliva, which guide the bronchoscope to the glottis. When the internal diameter of the endotracheal tube is larger than 4 mm, the bronchoscope is used as a guide. When it is less than 4 mm. the bronchoscope is inserted in the trachea with a guide wire slipped in the operating channel; the bronchoscope, but not the wire is withdrawn and the endotracheal tube is inserted over the guide wire.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemical submission]. / Soumission chimique.

INTRODUCTION: The clinical submission syndrome is well known by the general population, but too frequently ignored by physicians. OBSERVATION: A 23 year-old woman was drugged by a third person wishing to sexually abuse of her. The diagnosis was proved biologically after the judicial enquiry. COMMENTS: The diagnosis of clinical submission is difficult to make because of the frequent delays in emergency consultations and the difficulties in biological assays, since the doses of drugs administered are often very low and infra-therapeutic. Over a period of one year, we evoked the diagnosis four times and it was confirmed only once. It sometimes leads to diagnostic peregrinations. Close cooperation between the physicians and the police is required so that a judicial enquiry can be rapidly set-up.

[Traumatic infarction of the right ventricle caused by coronary dissection]. / Infarctus traumatique du ventricule droit secondaire à une dissection coronaire.

A case is reported of a 47 year-old man who suffered from a right ventricular myocardial infarct which occurred as a result of right coronary arterial dissection after non-penetrating anteroposterior chest compression. The patient was admitted with right heart failure and a central venous pressure of 17 cm H2O. The ST segment in leads V1 to V3 (V2: 7mm) was significantly elevated. Echocardiography showed dilatation of both right atrium and ventricle, with a deviated septum. Emergency cardiac angiography confirmed a hypokinetic right ventricle, with no other abnormal finding. Coronary angiography, performed 24 h after admission, revealed a dissection of the second part of the right coronary artery, with a normal left coronary system which reperfused that part of the right coronary arterial territory located beyond the dissection. The ST segment elevation stopped at the 10th hour. Initially, the patient's condition worsened. Thereafter, he slowly improved under treatment (5.5 micrograms.kg-1.min-1 dobutamine, and fluids so as to maintain a pulmonary wedged pressure of about 15 mmHg). As post-traumatic myocardial infarction is rare, the diagnostic and therapeutic strategies are discussed.

[Heparin-induced thrombocytopenia complicated by hematoma of the adrenal glands and acute adrenal insufficiency]. / Thrombopénies à l'héparine compliquées d'hématome des surrénales et d'insuffisance surrénalienne aiguë.

Three cases of acute adrenal haemorrhage complicating heparin induced thrombocytopaenia are described. The patients were 2 men and 1 woman, respectively 62, 74 and 76-year old. They all had orthopaedic problems requiring a treatment by subcutaneous calcium heparinate. Thrombocytopaenia occurred 7 to 10 days after the beginning of treatment, with a progressive return to normal of platelet count on stopping heparin. A syndrome suggestive of adrenal failure appeared on the 10 th to 12 th day consisting of abdominal pain, hyperpyrexia, arterial hypotension, asthenia, altered consciousness. Adrenal hormone levels were decreased. Abdominal scanography demonstrated adrenal haemorrhage in 2 patients. The third patient died before further investigations could be carried out. Hormonal replacement therapy brought things back to normal. Six other similar cases have already been published. The heparin induced thrombocytopaenia probably explains the two paradoxes of adrenal haemorrhage complicating heparin therapy: its occurrence in the absence of excessive anticoagulation, and adrenal venous thrombosis. The presence of abdominal pain, fever, collapse, or hyponatraemia with heparin induced thrombocytopaenia should suggest a possible adrenal haemorrhage. Adrenal CT scans should be carried out rapidly, so that hormone treatment can be initiated without delay.

[Early diagnosis of traumatic extra-pericardial luxation of the heart. Value of tomodensitometry. Apropos of a case]. / Diagnostic précoce de la luxation extrapéricardique du coeur d'origine traumatique. Intérêt de la tomodensitométrie. A propos d'un cas.

Heart luxation is a rare complication of chest trauma. The rupture of pericardium must be diagnosed as soon as possible, particularly before prolonged orthopaedic surgery for multitrauma, as a cardiac arrest may occur during anaesthesia. This report underlines the difficulties of diagnosis in a 40-year-old patient with head trauma, chest trauma and multiple fractures. The diagnosis was suspected on unstable blood pressure and left lung atelectasis. The computed tomography showed herniation of the left ventricle. Emergency thoracotomy showed the left rupture of pericardium with complete left heart dislocation. Orthopaedic operation was carried out three days later. Computed tomography in multitrauma patients, seems to be decisive for early diagnosis of heart luxation. Emergency thoracotomy is essential.

[Value of transcranial Doppler ultrasonography in the management of severe head injuries]. / Intérêt du doppler transcrânien dans la prise en charge des traumatisés crâniens graves.

Transcranial doppler ultrasonography (TCD) is a non invasive technique for the assessment of cerebral blood flow (CBF). The aim of this prospective study was to evaluate the benefit of TCD for the monitoring of major head trauma patients. Therefore 10 of such patients, aged 17 to 37 years, had a TCD at admission and subsequently at least twice a day. Following data were measured simultaneously at the site of the right and the left middle cerebral arteries: the systolic (SV), diastolic (DV) and mean (MV) blood velocity, the resistance index (RI) of Pourcelot (RI = SV-DV/SV) and the pulsatility index (PI) of Gosling (PI = SV-DV/MV). Simultaneously, the mean intracranial pressure (ICP) obtained with a subarachnoid probe, the PaCO2 and the mean arterial pressure (Pa) were measured. The cerebral perfusion pressure (CPP) was calculated with the formula: CPP = Pa-ICP. A total of 132 measures were analysed. There was a linear relation between RI and CPP (r = 0.566; p < 0.001), between RI and ICP (r = 0.822; p < 0.001), as well as between PI and CPP (r = 0.563; p < 0.001) and between PI and ICP (r = 0.837; p < 0.001). In the opposite there was no statistically significant relation between ICP and MV (r = 0.18) nor between CPP and MV (r = 0.23). However, a MV over 100 cm.s-1 was regularly associated with a ICP over 60 mmHg. The close correlation between RI, PI and ICP allows to use RI or PI to estimate ICP.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of intranasal nifedipine during clamping of the abdominal aorta]. / Effets hémodynamiques de la nifédipine utilisée par voie nasale au cours du clampage de l'aorte abdominale.

The haemodynamic changes due to cross-clamping of the abdominal aorta below the renal arteries were studied in ten patients. Anaesthesia was induced with thiopentone and maintained with fentanyl and vecuronium and inhalation of 60% nitrous oxide in oxygen. At the fifth minute, clamping increased mean arterial pressure (Pa) by 11%, systemic vascular resistance (Rsa) by 26% and decreased cardiac output (CO) by 20%. Nifedipine was administered intranasally at this time. Heart rate remained unchanged; mean pulmonary arterial and mean pulmonary wedge pressures were slightly decreased. Pa and Rsa fell to significantly lower levels between the fifth and fifteenth minutes (24 and 43% respectively). Although CO increased by 28%, this was not significant. The administration of intranasal nifedipine during anaesthesia was well tolerated. This study demonstrated that intranasal nifedipine prevented adverse haemodynamic effects of cross-clamping of the aorta below the renal arteries.

[Determination of thresholds of external cardiac pacing during anesthesia]. / Détermination des seuils de stimulation cardiaque externe pendant l'anesthésie.

The efficacy of transcutaneous pacing was studied in 33 patients during general anaesthesia. The temporary pacing was effective in all cases. Stimulation thresholds ranged from 85 to 150 mA (mean : 110 +/- 17). In all 33 patients, external pacing was effective in producing a pulse without significantly reducing arterial pressure. Stimulation thresholds were only influenced by electrode position; age, weight, thoracic diameter and cardiothoracic ratio did not have any effect on them. No adverse effects of transcutaneous pacing were recorded. Transcutaneous pacing can be an alternative to transvenous right ventricular endocardiac pacing in the operating room in some circumstances.

[Propofol in urological endoscopy in elderly patients. Comparison with methohexital]. / Le propofol en endoscopie urologique chez le sujet âgé. Comparaison avec le méthohexital.

Twenty patients undergoing cystoscopy (group A) and forty patients undergoing transurethral resection (group B), aged more than 65 years, were anaesthetized. Duration of anaesthesia was less than 15 min for cystoscopy, and more than 30 min for transurethral resection. No premedication was given. The patients were ASA I or ASA II. Group A patients were allocated randomly to receive either 1.5 mg . kg-1 propofol (n = 10) or 2 mg . kg-1 methohexitone (n = 10) for induction of anaesthesia. Anaesthesia was maintained using incremental doses of propofol or methohexitone and 60% N2O with a face-mask. Forty group B patients undergoing transurethral resection were randomly assigned to four equal groups (PB: propofol 1.5 mg . kg-1; MB: methohexitone 2 mg . kg-1; PF: propofol and 1.5 micrograms . kg-1 fentanyl; PFV: propofol, 2 micrograms . kg-1 fentanyl and 0.1 mg . kg-1 vecuronium). Suxamethonium (1 mg . kg-1; groups PB, MB and PF) and vecuronium (0.1 mg . kg-1; group PFV) were given to facilitate endotracheal intubation. Anaesthesia was maintained by infusion of propofol or methohexitone, using a calibrated pump started immediately after intubation. Ventilation was controlled only in group PFV. Induction with 1.5 mg . kg-1 propofol resulted in stopping counting after 62 s and loss of the eye-lash reflex after 84 s versus 47 and 67 s respectively with methohexitone. The anaesthesist's assessment was favourable for cystoscopy with propofol and methohexitone; recovery times were similar for the two drugs in cystoscopy lasting less than 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)