Severe amlodipine intoxication treated by hyperinsulinemia euglycemia therapy.

The objective of this study was to report a use of hyperinsulinemia euglycemia therapy in severe amlodipine intoxication. Intoxication with 420 mg of amlodipine caused severe hypotension in a 20-year-old female patient. The patient was initially treated with fluids, calcium gluconate, and epinephrine without effect. She was then given hyperinsulinemia euglycemia therapy. We observed a rise in blood pressure (BP) approximately 30 min after insulin was given and the BP was subsequently responsive to epinephrine. The patient was weaned from pressors 5 h after insulin therapy. The trachea was extubated 24 h after ingesting amlodipine, and the patient was transferred for psychiatric treatment 3 days later. This possible positive inotropic effect of insulin therapy in patients with calcium channel blocker intoxication supports previous findings. It is suggested that hyperinsulinemia euglycemia therapy may be considered as a first-line therapy in amlodipine intoxication.

[Effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section]. / Effet d'une infiltration sous-cutanée de ropivacaïne 0,75 % sur l'analgésie postopératoire après césarienne.

OBJECTIVE: Evaluate the effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section in the first 24h. PATIENTS AND METHODS: A prospective randomized double blind study was realized during three months in Auxerre Hospital. All ASA 1-2 patients presenting for elective caesarean section under spinal anesthesia were enrolled in the study. Drug addicts and patients with chronic pain were excluded from the study. The patients were randomly divided into two groups to receive skin infiltration 20 ml of ropivacaine 0,75% (Gr R) or skin infiltration of 20 ml of 0,9% saline solution. All patients received systematically propacetamol 1g per six hours and ketoprofen 50mg per six hours. Intravenous morphine titration was delivered to patients with a simple numerical scale greater or equal to three (SNS> or =3). Postoperative pain (SNS), morphine consumption and adverse reactions were compared. RESULTS: From July to September 2005, 42 patients were enrolled in the study. The SNS was lower in the Gr R. Total morphine consumption was reduced in the Gr R. The incidence of the adverse effects were higher in the Gr P. One case of parietal haematoma was detected in the Gr P, the evolution of which was favorable. DISCUSSION AND CONCLUSION: Skin infiltration of ropivacaine 0,75% is a simple technique able to reduce postoperative pain score and morphine consumption after caesarean section.

[Prevention of myoclonus after etomidate using a priming dose]. / Prévention des myoclonies induites par l'étomidate en utilisant une priming dose.

OBJECTIVE: To investigate the influence of pretreatment with a low dose of etomidate (priming dose) on the incidence of etomidate-induced myoclonus. STUDY DESIGN: Prospective randomized double-blind study. METHODS: Forty six patients ASA physical status I - II, scheduled for abdominal elective surgery, were allocated randomly to receive either pre-treatment 0.03 mg/kg of etomidate (priming group) or placebo (control group). Sixty-seconds after the pre-treatment was injected, anesthesia was induced with etomidate 0.3 mg/kg and 60 seconds later induction was completed with fentanyl (3 microg/kg) and vecuronium (0.1 mg/kg). The occurrence and intensity of myoclonus were graded clinically by a blinded observer as: 0=no myoclonus, 1=mild myoclonus, 2=moderate myoclonus and 3=severe myoclonus. STATISTICAL ANALYSIS: Fisher test exact for qualitative variable and Student t-test for quantitative variables. RESULTS: Demographic data and the average dose of etomidate used during the induction were similar in the 2 groups (0.29+/-0.032 mg/kg in the priming group and 0.30+/-0.029 mg/kg in the control group). Twenty patients (87%) in the control group experienced myoclonic movements whereas only 6 patients (26%) in the control group had such movements (P<0,001). CONCLUSION: Pretreatment with etomidate (0.03 mg/kg), given 60 seconds before induction of anesthesia, is effective at reducing etomidate-induced myoclonus, without related side-effect.

[Postoperative meningitis caused by an unusual etiological agent: Salmonella enteritidis]. / Salmonella enteritidis: une cause inhabituelle de méningite post-opératoire.

Salmonella intracranial infections are unusual in adults, and particularly after neurosurgical procedures. We report a case of post-operative meningitis owing to Salmonella enteritidis. A 72-year-old man with type 2 diabetes was admitted to our unit for postoperative evaluation and management after neoplasic intracranial surgery. On the third day of admission, the patient developed infectious signs and diagnosis of postoperative meningitis was evoked. The cultivation of cerebrospinal fluid revealed Salmonella enteritidis which was also identified in several blood cultures. The treatment consisted of third-generation cephalosporin and quinolone to which Salmonella enteritidis was susceptible. However, the clinical course was poor and the patient died on day 8. This case demonstrates that postoperative meningitis can be caused by an unusual agent like Salmonella enteritidis.

[Peribulbar anesthesia: comparing 1% ropivacaine and a mixture of 0.5% bupivacaine--2% lidocaine]. / L'anesthésie péribulbaire: étude comparative entre la ropivacaïne 1% et l'association bupivacaïne 0,5%--lidocaïne 2%

PURPOSE: To compare the efficacy of 1% ropivacaine with a mixture of 0.5% bupivacaine and 2% lidocaine in peribulbar anesthesia for elective cataract surgery. MATERIAL AND METHODS: Prospective double-blinded study, enrolling 100 patients randomly assigned to two different groups. Group 1 received 9 ml of 1% ropivacaine and group 2 received 4.5 ml of 0.5% bupivacaine and 4.5 ml of 2% lidocaine. Both groups received 1 ml of hyaluronidase to reach a total volume of 10 ml. RESULTS AND CONCLUSION: No difference between the groups was noted during the study regarding not only onset time, but also the duration of anesthesia and perioperative analgesia. A greater incidence of pain on injection was significantly reported in group 2 (p<0.001). Patients in group 1 had less need for top-up injection and showed better ocular akinesia (p<0.01).

[Percutaneous catheterization of the deep brachial vein]. / Cathétérisme percutané de la veine humérale profonde.

50 attempts of deep percutaneous antecubital catheterization are reported. A tourniquet was applied to the upper arm and the medial deep brachial vein was punctured in a point immediately medial to the brachial artery, in the antecubital fossa. Venepuncture was successful in 88% of the cases (44 cases), catheterization possible in 72% of the cases (36 cases). The catheter reached the central venous compartment in 60% of the cases (30 cases). The only benign complication was injury to the brachial artery in 6 cases. Mean duration of catheterization was 20 days. This very easy and safe technique can be used when superficial veins are unusable and use of the deep central veins dangerous or impossible.

[Acute acalculous cholecystitis after digestive caustic burn]. / Cholécystite aiguë alithiasique après brûlure caustique digestive.

A case is reported of acute acalculous cholecystitis in a patient who suffered a digestive burn treated by total parenteral nutrition. Pain in the right upper abdominal quadrant and fever occurred 26 days after the start of parenteral nutrition and 24 h after abruptly resuming oral feeding. Ultrasonography showed a distended gall-bladder with a thickened wall and the formation of sludge. Cholecystectomy was followed by a complete recovery. The part played by each of the corrosive burn, the total parenteral nutrition and the abrupt resumption of oral feeding in the pathogenesis of this complication is reviewed.

[Thrombosis of the superior vena cava in Behcet's disease. Apropos of a case associated with chylothorax]. / Les thromboses de la veine cave supérieure au cours de la maladie de Behcet. A propos d'un cas associé à un chylothorax.

The authors report a case of superior vena cava thrombosis associated to a chylothorax during Behcet's disease. This thrombosis was revealed during an evolutive phase by dyspnea and a superior vena cava syndrome. Its course was favourable under a medical treatment associating: pleural drainage, parenteral feeding, corticotherapy and heparin therapy. Then the authors review the bibliography and recall the frequency, pathogenesis, clinic and treatment of this unusual complication of the Touraine's aphthosis. Such a complication appears paradoxically to present a favourable course.

[Peri-bulbar anesthesia for cataract surgery]. / Anesthésie péribulbaire pour chirurgie de la cataracte.

Ninety-five peribulbar blocks for cataract extraction with intraocular lens implantation were performed by an anaesthetist over a period of 6 months. The quality of the block was assessed by the ophthalmologist and the anaesthetist. No dangerous local or systemic complications were observed. Peribulbar anaesthesia is increasingly preferred to retrobulbar block on account of its easiness and safety.

[Efficiency of bupivacaine wound subfasciale infiltration in reduction of postoperative pain after inguinal hernia surgery]. / Efficacité de l'infiltration cicatricielle subfasciale par la bupivacaïne dans la réduction de la douleur postopératoire des hernies inguinales.

INTRODUCTION: The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique. METHODS: This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed. RESULTS: Concerning demographic parameters, ASA class and secondary effects, we didn't find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain. DISCUSSION: Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.

[Not Available]. / Prise en Charge du Syndrome de Lyell ou Necrolyse Epidermique Toxique.

Le syndrome de Lyell ou nécrolyse épidermique toxique (NET) est une pathologie très grave des dermatoses bulleuses d'étiologie médicamenteuse. Il se caractérise par une nécrose aiguë de l'épiderme sur toute la hauteur du corps muqueux. L'aspect clinique de la NET est celui d'une brûlure étendue du deuxième degré profond. A ce tableau s'associent constamment des lésions muqueuses et une atteinte multiviscérale qui aggrave le pronostic. Nous rapportons deux cas de NET qui illustrent l'importance d'une prise en charge précoce et multidisciplinaire de ces patients atteints au sein d'un service de réanimation des brûlés, dont les fondements reposent sur l'asepsie rigoureuse, l'apport hydroélectrolytique et nutritionnel, la prévention de l'infection et son traitement par une antibiothérapie adaptée, et un nursing et des soins locaux. L'efficacité supposée des immunoglobulines intraveineuses ne repose que sur des cas isolés et il n'y a pas encore d'études randomisées.

[Effect of ephedrine on the intubation conditions using rocuronium versus succinylcholine]. / Effet de l'éphédrine sur les conditions d'intubation après bloc neuromusculaire par le rocuronium versus succinylcholine.

OBJECTIVE: The goal of this study was to determine if ephedrine could improve intubating conditions when it is administered before the muscle relaxant (rocuronium and succinylcholine). PATIENTS AND METHODS: In this prospective randomized double-blind study, 80 patients ASA I- II, scheduled for elective surgery, were allocated randomly to receive: succinylcholine 1mg/kg+ephedrine 70 microg/kg (Group I, n=20); rocuronium 0.6 mg/kg+ephedrine 70 microg/kg (Group II, n=20); succinylcholine 1mg/kg+0.9% saline (Group III, n=20); rocuronium 0.6 mg/kg+0.9% saline (Group IV, n=20). Induction of anaesthesia started with administration of the first syringe containing either ephedrine or saline, then 30s later propofol 2.5mg/kg and fentanyl 3 microg/kg, were administered followed by the contents of the second syringe containing either rocuronium or succinylcholine. Thirty seconds after injection of the muscle relaxant, another blinded staff anaesthetist performed intubation of the patient. Intubating conditions were evaluated according to criteria's of the conference of Copenhagen. Heart rate, systolic blood pressure and diastolic were also noted. Kruskall-Wallis test for non-parametric variable and Student t test for quantitative variables were used for statistical analysis. RESULTS: There was no significant difference between the groups concerning age, sex, BMI and ASA status. Pretreatment by ephedrine improved significantly (p<0.0001) intubating conditions after succinylcholine and rocuronium. CONCLUSION: Use of ephedrine 30 seconds before induction with propofol, fentanyl followed by rocuronium or succinylcholine provides faster good conditions of intubation.

[Transfusion-related acute lung injury. A case report]. / Cedème pulmonaire lésionnel post-transfusionnel. A propos d'un cas.

A transfusion-related acute lung injury (Trali) is a noncardiogenic lung oedema occurring within six hours following the infusion of a blood component. It is a under-recognized transfusional accident, for which the aetiology and physiopathology are still controversial, evoking immunological or nonimmunological mechanisms which do not seem sufficient per se to cause this accident. A predisposing condition, associated with leucostasis in pulmonary vessels, is required. The pulmonary lesion is due to the activation of neutrophils in contact with endothelial cells of lung micro-capillary vessels. We report a case of Trali following the transfusion of the first red blood cells unit to a 26-year-old young woman.

[Timing of tracheostomy and outcome of patients requiring mechanical ventilation]. / Délai de la trachéotomie et devenir des patients sous ventilation mécanique.

OBJECTIVES: To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV). STUDY DESIGN: Retrospective clinical study in a twelve beds intensive care unit (ICU). PATIENTS AND METHODS: From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups. RESULTS: During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10+/-3 vs 17+/-5 days, P<0.001), length of MV (21+/-19 vs 29+/-17 days, P=0.02) and length of stay in ICU (33+/-22 vs 42+/-18 days, P=0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P=0, 13), weaning from MV (50 vs 36%, P=0.19), and mortality rates between the 2 groups (38 vs 54%, P=0.15). CONCLUSION: This study demonstrated that early tracheostomy (< or =7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.

[Iatrogenic oesophageal perforation following an imprevisible difficult tracheal intubation]. / Perforation iatrogène de l'oesophage suite à une intubation trachéale difficile imprévisible.

The authors report a case of oesophageal perforation after difficult tracheal intubation. Interest of an early diagnosis and management of such complication are discussed.