Anaesthesia and intensive care management of face transplantation.

The face-grafting techniques are innovative and highly complex, requiring well-defined organization of all the teams involved. Subsequent to the first report in France in 2005, there have been 17 facial allograft transplantations performed worldwide. We describe anaesthesia and postoperative management, and the problems encountered, during the course of seven facial composite tissue grafts performed between 2007 and 2011 in our hospital. The reasons for transplantation were ballistic trauma in four patients, extensive neurofibromatosis in two patients, and severe burns in one patient. Anaesthesia for this long procedure involves advanced planning for airway management, vascular access, technique of anaesthesia, and fluid management. Preparation and grafting phases were highly haemorrhagic (>one blood volume), requiring massive transfusion. Median (range) volumes given for packed red cell (PRC) and fresh-frozen plasma (FFP) were 64.2 ml kg(-1) (35.5-227.5) and 46.2 ml kg(-1) (6.3-173.7), respectively. Blood loss quantification was difficult because of diffuse bleeding to the drapes. The management of patients with neurofibromatosis or burns involving the whole face was more difficult and haemorrhagic than the patients with lower face transplantation. Average surgical duration was 19.1 h (15-28 h). Postoperative severe graft oedema was present in most patients. Most patients encountered complications in ICU, such as renal insufficiency, acute respiratory distress syndrome, and jugular thrombosis. Opportunistic bacterial infections were a feature during the postoperative period in these highly immunosuppressed patients.

[Right hemiplegia and spatial neglect with apraxia and agraphia without aphasia in a right-handed patient]. / Hémiplégie droite et négligence avec apraxie et agraphie sans aphasie chez une patiente droitière.

A 65 year-old right-handed woman was admitted after the sudden onset of a right dense hemiplegia. C.T. showed a large left infarction in the middle cerebral artery territory. There was a slight anosognosia and neglect of the right space without confusion. She had aprosodia but no aphasia. On the other hand, there was a severe apraxia and all the components of Gerstmann's syndrome were present. This suggests an unusual sattering of hemispheric functional dominances.

[Severe suicides: short- and long-term outcome. Assessment of their quality of life]. / Les suicidés graves: leur devenir à court et à long terme. Appréciation de leur qualité de vie.

From January 1977 to December 1982, 160 patients (10 to 55 years old) were admitted in a traumatic Intensive Care Unit after serious attempted suicides. Hospital mortality rate was about 34%. A questionnaire was sent to alive patients in 1983 (median delay between attempted suicide and questionnaire: 3.5 years); 68 were alive in 1983, 46 answered to questionnaire, 3 were died (two according to a new suicide); 32 could not be found; 85% of contacted patients answered (they were comparable in age, sex and means used in their suicide attempts, to the others). One patient about two must be rehospitalised one or more times. One patient about two must be always take drugs; 85% worked. Over 50% of the patients considered they had returned to their former way of life but 50% presented increased difficulty to work, and 25% said that they had no sequelae. Any of these 46 patients had made an other attempt suicide.