Restenosis after balloon angioplasty for cerebral vasospasm.

Transluminal balloon dilatation for symptomatic vasospasm after subarachnoid hemorrhage is effective, and clinical studies have shown that it achieves long-lasting dilatation of spastic cerebral arteries. Delayed arterial renarrowing has not been reported. Here we report the case of a 58-year-old woman who presented asymptomatic and permanent restenosis after angioplasty for cerebral vasospasm.

Effects of acetylcysteine and ischaemic preconditioning on muscular function and postoperative pain after orthopaedic surgery using a pneumatic tourniquet.

BACKGROUND AND OBJECTIVE: The use of a pneumatic tourniquet can induce muscular and neurological complications in the operated limb. The genesis of these injuries could involve an ischaemia/reperfusion phenomenon and a compression under the cuff. We evaluated effects of an antioxidant, acetylcysteine and ischaemic preconditioning on the rhabdomyolysis and postoperative pain following a knee ligamentoplasty using a pneumatic tourniquet. METHODS: We included 31 patients scheduled for a knee ligamentoplasty randomly assigned in three groups (control, acetylcysteine 1200 mg the day before and 600 mg at the operative day, ischaemic preconditioning). RESULTS: There was a moderate rise in myoglobin and creatinine phosphokinase with no significant difference between the three groups. The muscular functional parameters were similar in all the groups. However, the morphine consumption within the first 48 h was smaller in the treatment groups (0.22 +/- 0.31 mg kg-1 and 0.22 +/- 0.23 mg kg-1 in the preconditioning and antioxidant groups, respectively) than in the control group (0.47 +/- 0.33 mg kg-1, P <0.05). CONCLUSIONS: Acetylcysteine and ischaemic preconditioning do not decrease the extent of rhabdomyolysis related to the use of a pneumatic tourniquet and do not improve the postoperative muscle recovery. On the other hand, they allow a significant reduction in the postoperative morphine consumption.

Improvement of surgical antibiotic prophylaxis: a prospective evaluation of personalized antibiotic kits.

This prospective study compared personalized surgical antibiotic prophylaxis kits (SAPKs) with freely prescribed antibiotics. SAPKs use significantly enhanced national guidelines on surgical antibiotic prophylaxis application (82% vs 41%, P < 0.001), and result in limited errors in terms of antibiotic choice (3% vs 28%, P < 0.001), timing of administration (12% vs 24%, P = 0.003) and prophylaxis duration (1.5% vs 22%, P < 0.001), thereby demonstrating their effectiveness.

[Face necrotizing fasciitis following spinocellular epithelioma excision]. / Fasciite nécrosante de la face après exérèse d'un épithélioma spinocellulaire.

Necrotizing fasciitis is a bacterial dermo-hypodermitis with superficial aponevrosis necrosis due to Streptococcus pyogenes. Head and neck region are some rare localization of this infection especially after surgery. We report herein a case of a face necrotizing fasciitis following minor face surgery. A 86 year-old Caucasian male without any antecedents, nor treatment, has been operated for a fronthead spinocellular epithelioma under local anesthesia. Twelve hours later, a severe pain localized to the face occurred, with sleeplessness, followed up with a face orbitary oedema and fever. Twenty-four hours later, an intravenous antibiotherapy was therefore started and surgical treatment was performed as soon as the diagnosis of necrotizing fasciitis was considered. An important inflammatory oedema was noticed, associated to a large necrotic softening of the face, the eyelid and the neck sub-cutaneous tissues. Then, the patient has been transferred in intensive care unit because multi-organ failure clinical and biological signs occurred. Pre-operatory bacteriological samples culture identified Streptococcus pyogenes. Repeated surgical explorations and debridement (excision, cleaning, draining and bandages recovery) were performed daily as needed until all the necrotic tissue was all eradicated. The antibiotherapy was prescribed to totalised 15 days. Our report underlines the importance of an early recognition of the diagnosis of soft tissue infection, because early surgical treatment has a better prognosis and antibiotic treatment alone is inefficient for the recovery. Alert is delivered by the local signs quickly followed up by skin changes. Anti-inflammatory therapy must be avoid in case of any soft tissue infection sign: they may increase the lesions, hide alarm signs and delay surgical treatment.

[Secondary Streptococcus pyogenes peritonitis following necrotizing fasciitis]. / Péritonite à Streptococcus pyogenes et fasciite nécrosante.

We report the case of a 66-year-old woman with diabetes mellitus and disseminated lupus treated with immunosupressive drug. She was admitted for an inflammatory oedema of the right lower limb associated to diffuse abdominal pain and vomiting. The occurrence of septic shock with multiple organ failure and surgical abdominal picture led us to perform urgent laparotomy without taking in account the evolutive signs of cutaneous lesions i.e. purpuric elements and haemorrhagic phlycthena. The abdominal cavity exploration showed peritonitis without digestive tracts perforation. The patient died few hours after surgical procedure. All bacteriological samples i.e. peritoneal effusion, blood cultures and phlycthena liquid were positive for Streptocoque pyogenes (group A) and peritonitis was considered to be related to haematogen diffusion from rapid course necrotizing fasciitis.

[Antimicrobial prophylaxis in surgical procedures: assessment of the guidelines application and validation of antibiotic prophylaxis kits]. / Antibioprophylaxie chirurgicale: évaluation de l'application des recommandations et validation des kits d'antibioprophylaxie.

INTRODUCTION: Surgical wounds infections represent a major cause of morbidity and are at the origin of an increase in the postoperative mortality rate. Those infections represent in France one-fourth of the nosocomial infections. Combine with the elementary hygiene rules and the surgical "good practices", antimicrobial prophylaxis with antibiotics is an essential tool for the reduction of the surgical wound infections rate. In the French hospitals, antimicrobial prophylaxis represents one-third of the antibiotic prescriptions. The rules for the application of surgical prophylaxis are based on current guidelines for antibiotic prophylaxis, however, guidelines are not totally respected. MATERIALS AND METHODS: Study 1: assessment of the guidelines application (practical audit) of the antibiotic antimicrobial prophylaxis in surgery, and of their impact on the established prescriptions: three audits were realized with four years interval (1994, 1998 and 2002), in order to estimate the evolution in the application of the current guidelines, which indirectly estimate the evolution of the guidelines impact. Study 2: assessment of the use of an antibiotic kit through a prospective comparative study of two groups: exposed patients vs non-exposed patients. Nominatives kits contained the recommended antibiotics with recommended posology and the instructions for each surgical procedure. RESULTS: Study 1: this study showed a significant increase in the antibiotics prescription volume since 1994 (+23%). After a temporary increase from 1994 to 1998, the conformity of the effective prescriptions with the current guidelines for the indication to realize or not to realize an antibiotic surgical prophylaxis decreases of 7% between 1998 and 2002. Nevertheless, we noticed an overall improvement in the guidelines application for the modalities of the antimicrobial prophylaxis when it was prescribed in a valid indication. Persistent weak points were in 2002 the antibiotic molecule choice (error rate of 25%), the duration of prescription (rate of abnormal prolonged antibiotic prophylaxis of 19%), and the timing of administration (error rate of 31%). Study 2: antibiotic kits have permitted to increase the accordance of the antimicrobial prophylaxis prescriptions with the guidelines. Antibiotic prophylaxis was in total agreement with guidelines for 82% of exposed patients vs 41 for non-exposed patients. Choice of the antibiotic molecule, timing of administration and duration of prescription were the parameters particularly well rectified by this new antibiotic prophylaxis technical. CONCLUSION: In this study, guidelines diffusion seems to be an essential but also an insufficient point for the improvement of the quality prescriptions in surgical antimicrobial prophylaxis. The "day by day" nominative antibiotic prophylaxis deliverance in the shape of a << ready to use >> antibiotic kit went with an increase in the respect of the recommendations, by correcting in a significant way the persistent weak points identified during the first part of our study. The antibiotic prescriptions control is an imperative goal in individual health (the patient himself), but also in public health (the community). This radical change in habits is listed in a policy of antimicrobial agent prescription improvement (best efficacy with less cost).

[Rapid sequence intubation in emergency: is there any place for fentanyl?]. / Induction à séquence rapide en urgence: quelle est la place du fentanyl?

OBJECTIVES: Rapid sequence intubation (RSI) with the association of etomidate and succinylcholine is the French "Gold standard" for urgent "full stomach" endotracheal intubations. The aim of this study is to assess the fentanyl as a co-induction agent to take over the sedation between the RSI and the keeping of sedation, which is a critical period in which harmful neuro-vegetatives events, and awakening signs are frequently seen. STUDY DESIGN: Randomized, double blind controlled prospective study, after acceptation by the local ethical committee. PATIENTS AND METHODS: Three groups of patients undergoing RSI in the intensive care unit and by the out-of-hospital medical team were compared: group A patients received fentanyl 3 micrograms kg-1 during RSI, before paralysis was induced. Group B patients received the same dose of fentanyl immediately after endotracheal intubation. Group C patients did not received fentanyl (control group). Outcome measures were awakening signs arrival (respiratory movements, eyes opening, spontaneous limb movements), Ramsay score assessment, and haemody namics. Attempt at intubation and vomiting incident were also measured. Discrete data were compared by chi-2 analysis, continuous data were compared with two-way analysis of variance. A p value < 0.05 was the significant threshold. RESULTS: Thirty-six patients were enrolled and completed the study. All the included patients presented awakening signs. The use of fentanyl did not prevent the recourse of other sedative medications. Ten minutes after endotracheal intubation, significant differences has been noticed for the awakening signs arrival between fentanyl groups (A: 42% and B: 36%) and control group (C: 77%). The Ramsay score evolution follows the same variation. All the patients were intubated on the first attempt, there was no vomiting incident noticed. CONCLUSION: The use of fentanyl, as a co-induction agent with etomidate and succinylcholine during RSI, allows a significant delay of the awakening signs arrival and attenuate the neurovegetative response during the minutes after endotracheal intubation after RSI, without deleterious haemodynamic effects.