Eyelid Chemical Burns: A Multidisciplinary And Challenging Approach.

During second- and third-degree eyelid sulfuric acid burns, many surgeons prefer to wait until primary wound separation occurs before grafting. However, this approach may miss the chance to recover the eyelids and can cause ectropion, resulting in delayed eyeball healing with exposure keratitis. We propose that early eyelid release and grafting makes a significant difference in long-term outcomes and improves eyeball healing. Here, we present the case of a woman who presented second- and third-degree burns of the eyelids secondary to physical domestic assault with acid, who had an early surgical management with a full-thickness skin graft. Ten days after surgery, we found that the graft had survived totally, and the donor site of the right arm had already healed. Eyelids were successfully grafted and the functions of both eyelids were well recovered, allowing complete cover of the eyeball. Two months after surgery, functional and cosmetic results were satisfying, with no postoperative lagophthalmos or difficulties with exposure-related problems. Case reports of eyelid chemical burns are very few. No specific and codified management of eyelid chemical burns was found in the literature search. This case report demonstrated that a multidisciplinary approach led by both ophthalmologists and plastic surgeons must be decided early (<6h) in order to achieve synergistic and coordinated management between the eye and the eyelid. There is a significant improvement in ocular healing with early excision and grafting of eyelids after sulfuric acid burn.

En cas de brûlure du 2ème ou du 3ème degré des paupières par acide sulfurique, de nombreux chirurgiens préfèrent attendre la séparation spontanée de l'escarre avant de greffer. Cette stratégie comporte le risque d'une cicatrisation défectueuse source d'ectropion, d'occlusion incomplète et de kératite. Nous conjecturons qu'une excision-greffe précoce améliore le pronostic à long terme de ce type de brûlure. Nous présentons le cas d'une femme victime d'une agression intra-familiale à l'acide sulfurique, souffrant de brûlure des 2ème et 3ème degrés des paupières traitée par excision-greffe de peau totale précoce. À J10, la greffe était totalement intégrée et le site donneur (bras droit) était cicatrisé. La fonction palpébrale était normale et l'occlusion oculaire complète. Ces bons résultats persistaient à 2 mois, sans lagophtalmie ni défaut d'occlusion, avec un aspect esthétique correct. Les rapports de brûlures chimiques des paupières sont peu fréquents et il nous n'avons pas trouvé de protocole dans la littérature. Ce cas clinique illustre la nécessité d'une analyse précoce (dans les 6h) par ophtalmologiste et plasticien afin de définir une stratégie coordonnée vis à vis du globe oculaire et de la paupière. L'excision-greffe précoce améliore la pronostic oculaire après brûlure par acide sulfurique.

Epidemiology of filamentous fungal infections in burned patients: A French retrospective study.

INTRODUCTION: Filamentous fungal infections (FFI) seem to become more frequent in burn patients, in whom they are usually accepted to cause severe. However published data regarding their incidence and consequences in that context remain scarce. The aim of this study was to evaluate the incidence of mould infections in our burn centre, and to review characteristics and outcomes of patients with such infections. METHODS: This retrospective single-centre study reviews all patients admitted in our centre with acute burns (2000-2011) and positive culture for moulds. Wound infections were defined as follows: fungal wound colonisations (FWC) for positive mycological cultures without signs of wound infection; fungal wound infections (FWI) for positive mycological cultures with local signs of wound infection; disseminated infection (DI) for FWI with a positive blood culture or a positive galactomannan (for aspergillosis) or severe sepsis or secondary organ localisation(s). RESULTS: Among 1849 patients, 31 patients presented a FFI. For 29 patients (93%), positive fungal samples were cutaneous: 20 Aspergillosis ASP (5 FWC, 8 FWI and 7 DI), 9 mucormycosis MMC (3 FWC and 6 FWI) and 3 fusariosis FUS (3 FWI). Two patients presented a catheter colonisation or a pulmonary colonisation (Aspergillus fumigatus). Incidence of FFI was 1.7%. Total body surface area burned, full-thickness burn surface area, Unit Burn Standard, Tobiasen score and SAPS2 (respectively 55% [40-73], 45% [30-63], 180 [129-259], 11 [8-12] and 50 [40-62]) were markedly higher than in burned patients without FFI hospitalised during the same time period. 30% of the patients with burn wound ASP (6/22) died. Mean length of stay was 111±67 days. CONCLUSION: FFI are essentially cutaneous, infrequent and occur in the most severe burned patients. ASP seems to be more serious than other FFI.

[Labour epidural analgesia for a parturient with a factor XI deficiency: an ill-considered challenge or a reasonable risk?]. / Analgésie péridurale obstétricale chez une parturiente atteinte d'un déficit en facteur XI : défi inconsidéré ou risque raisonné ?

The authors report the performance of a labour epidural analgesia in a 26-year-old parturient presenting a moderate factor XI (FXI) deficiency. If haemostasis disorders usually contraindicate an epidural analgesia (with a risk of epidural haematoma), a moderate FXI deficiency is not an absolute contraindication to perform such an epidural analgesia. Desmopressin, sometimes used in surgery to reduce the bleeding, was administered to withdraw the catheter in better haemostasis conditions. No neurological signs were observed.

[Parkes-Weber syndrome and pregnancy: anaesthetic implications]. / Syndrome de Parkes-Weber et grossesse : implications anesthésiques.

We report two deliveries in a patient with a Parkes-Weber syndrome. This parturient had a complex angiodysplasia including a soft tissue hypertrophy of a lower limb, a cutaneous angioma and arteriovenous malformations. The risk of perimedullar arteriovenous malformations was ruled out by angiographic magnetic resonance imaging of the spinal cord. We also describe other aspects of the management, including prepartum cardiovascular assessment, mode of delivery, the use of epidural analgesia and the prevention of haemorrhagia and thromboembolism.

[Glucose variability in intensive care unit]. / La variabilité glycémique en réanimation.

Hyperglycemia is significantly associated with increased mortality in critically ill patients and then, strict control of blood glucose (BG) concentration is important. Lowering of BG levels with intensive insulin therapy (IIT) was recommended in order to improve patient outcomes. But recently, some recent prospective trials failed to confirm the initial data, showing conflicting results (significantly increased mortality with IIT, more hypoglycemic episodes). So there is no consensus about efficiency and safety of IIT. Significant associations between glucose variability and mortality have been confirmed by several recent studies. A difference in variability of BG control could explain why the effect of IIT varied from beneficial to harmful. Managing and decreasing this BG variability could be an important goal of BG control in critically ill patients. Clinicians have to consider definitions, physiopathology and impacts of glucose variability, in order to improve patient outcomes.

[Antibodies against high frequency antigen and total knee replacement]. / Anticorps antipublic et prothèse totale de genou.

We report the perioperative management of a woman expressing an antibody against high frequency red cell antigen (anti-Kel4 antibody anti-kpb) who was scheduled for a total knee replacement. A specific strategy was designed to afford this major orthopedic surgery, considering specially the occurrence of unusual bleeding higher than the average bleeding assessed in our hospital in this indication. The transfusion of incompatible red cells may be responsible for acute hemolytic reaction. An autologous transfusion program, including cryopreservation, erythropoietin and iron support, was provided. Three autologous red cells units were collected before surgery. Compatible homologous red cells units were also available at the French bank for rare blood groups. We report logistical and medical problems that have occurred during the perioperative period.