[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)

[Peroperative rhabdomyolysis caused by compression of a kidney-bridge. Value of muscular scintigraphy]. / Rhabdomyolyse peropératoire par compression sur un billot lombaire. Intérêt de la scintigraphie musculaire.

A case is reported of acute renal failure occurring after prolonged abdominal aortic bypass surgery in an overweight 69-year-old male patient. Preoperative serum creatinine concentration was normal. Surgery lasted for 6 h, and infrarenal aortic cross-clamping 2 1/2 h. The patient complained of important lumbar pain immediately after the operation. In the same time, oliguria and acute renal failure also developed (creatinine: 464 mumol.l-1; urea: 13 mmol.l-1). Rhabdomyolysis caused by the kidney-bridge was confirmed by the elevated blood creatine phosphokinase levels (16,000 IU.l-1 on the second postoperative day). A 99 m-Technetium methylene-diphosphonate imaging on the 10th postoperative day exhibited diffuse fixation in the paravertebral lumbar and thoracic muscles, extending from Th8 to L3. The acute renal failure regressed completely after haemodialysis.

[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.

[The physiopathology and medical treatment of acute traumatic occlusion of the popliteal artery. The point of view of the anesthesiologist-resuscitator]. / Physiopathologie et traitement médical de l'occlusion traumatique aiguë de l'artère poplitée. Le point de vue de l'anesthésiste-réanimateur.

The acute occlusion of the popliteal artery involves: 1. A regional disease: muscular ischaemia with an increase of capillary permeability and oedema. The recovery of the circulation brings with it the formation of free radicals. 2. Sometimes, a general and metabolic illness complicates the muscular ischaemia. It associates to varying degrees: hypovolemic shock, metabolic troubles, acute renal failure, disseminated intravascular coagulation, infection. It can compromise the vital prognosis. The reanimation which completes the surgical treatment includes two stages: 1. The prehospital stage when the first imperative is to commit the patient to the vascular surgeon's care as soon as possible and in the best hemodynamic conditions. 2. The hospital stage when the therapeutic objectives are represented by: a) the treatment of hypovolemia; b) the curing of acute renal failure (bicarbonates 2 mmol.kg-1, hypertonic mannitol 1 g.kg-1; c) fight against infection; d) Heparin: 1 to 2 mg.kg-1 (if there is no counterindication); e) hyperbaric oxygen treatment in some situations. Despite the progress of reanimation, the initially intended amputation is subject to discussion in the following circumstances: crushing which in fact accomplishes an amputation, prolonged and complete ischemia lasting more than 10 to 12 hours, severe I.V.D.C., associated serious lesions (cranial traumatism, pelvis crushing).

[Is hemodilution sufficient to avoid homologous blood transfusion in reduction mammaplasties?]. / L'hémodilution est-elle suffisante pour éviter la transfusion homologue au cours des mammoplasties de réduction?

The unpredictability of blood loss during reductive mammoplasties induced the authors to use a blood-sparing technique so as to avoid homologous transfusions. Intentional isovolaemic haemodilution (IIH) was performed in 38 patients. Clinical and biological criteria were used for analyzing the results. In this prospective study, IIH could not prevent the necessity of homologous transfusion for 3 patients, in the early postoperative period. In one of these cases, clotting of blood prevented its utilization. Therefore IIH appears to be an interesting alternative blood-sparing method in patients who cannot benefit easily from preoperative programmed blood auto-donation.

[Surgical treatment of Launois-Bensaude disease. The value of liposuction]. / Le traitement chirurgical de la maladie de Launois-Bensaude. Intérêt de la lipoaspiration.

Launois-Bensaude adenolipomatosis or Madelung's disease was described in 1898. Typically, the lipomatosis affects chronic alcoholic patients with a symmetrical distribution around the neck and occiput. The mass gradually diffuses into the scapular, deltoid, chest wall or abdominal areas. Cosmetic deformity and the difficulty of obtaining clothes, lead patients to seek surgical treatment. This surgical management (only effective treatment) has a severe tendency to haemorrhage and dissection is complicated by infiltrations of neighbouring tissue. Suction curettage lipectomy associated with classical surgical resection were performed in three patients, in different sites. Respective indications for the various techniques are studied in this paper.