The antivenom efficacy against a viper bite without medical treatment for 3 days: a case report.

Snakebites can be deadly, depending on the course of extremely serious hemorrhagic complications in the absence of antivenom, which remains the only specific and effective treatment, if it is introduced in time. We report the case of a young patient of 18 years, bitten by a snake and receiving only tradition care until admission to intensive care 3 days later, with advanced bleeding and inflammation; four vials of FAV-Africa antivenom were administered and resulted in dramatic improvement in his condition. This result confirms the empirical concept that delay in management should under no circumstances exclude the administration of antivenom.

Refeeding syndrome: a forgotten and potentially lethal entity.

Refeeding syndrome (RS) is defined as the fluid, electrolyte, metabolic, and clinical disturbances that occur after nutrition of patients who have been undernourished or fasting for a prolonged period. This syndrome has been recognized for several decades but is most often overlooked and underdiagnosed by health professionals. The authors report a RS in a patient subjected to prolonged fasting after being kidnapped by a criminal gang. Refeeding resulted in severe hypophosphatemia, neurological impairments, and hematologic disorders. The patient died due to septic shock with multiple organ failure secondary to aspiration pneumonia. In this case, the failure to recognize RS was decisive in the fatal outcome. Professionals must be aware of this disease to prevent and treat it properly.

[Pneumomediastinum: an aspect of pulmonary barotrauma during mechanical ventilation of acute respiratory distress syndrome]. / Le pneumomédiastin : un aspect du barotraumatisme pulmonaire au cours de la ventilation mécanique du syndrome de détresse respiratoire aiguë

Mechanical ventilation is a fundamental treatment of acute respiratory distress syndrome (ARDS). Despite compliance with the recommendations of protective mechanical ventilation, it can results in serious complications including the pulmonary barotrauma. This is often manifested by a pneumothorax. This observation describes an unusual aspect of barotrauma which is pneumomediastinum. The authors also point out the role of chest imaging in the management of mechanical ventilation during ARDS.

[Association of ischemic and hemorrhagic cerebral stroke due to severe envenomation by the Sahara horned viper (Cerastes cerastes)]. / Association de lésions cérébrales thrombotiques et hémorragiques lors d'une envenimation grave par la vipère à cornes du Sahara (Cerastes cerastes).

Viper envenomation can cause complex disorders of hemostasis. These disorders usually lead to hemorrhagic syndrome. The occurrence of thrombosis is exceptional. This case report describes a severe envenomation by the Saharan horned viper (Cerastes cerastes), complicated by unusual brain injuries: hemorrhagic and ischemic stroke. The physiopathologic link between this serious toxic coagulopathy and the multitude of toxins in the venom of Cerastes cerastes is highlighted.

[Paraspecificity of antivenins: example of severe envenomation by the Sahara horned viper (Cerastes cerastes) treated with non-specific antivenin]. / La paraspécificité des antivenins: exemple d'une envenimation grave par la vipère à cornes du Sahara (Cerastes cerastes) traitée par un antivenin polyvalent non spécifique.

Snake bites are a major public health problem in Morocco. Both morbidity and mortality of ophidian envenomation remain very high in this country. Antivenin immunotherapy, the only etiological treatment of this envenomation, is often unavailable in local hospitals. Moreover, when available, antivenins are not necessarily suitable for local ophidian species. This case report describes severe poisoning caused by a Sahara horned viper (Cerastes cerastes) in southern Morocco. In the absence of specific immunotherapy, FAV-Afrique®, a polyvalent antivenom serum, was administered. The favorable outcome suggests that this serum is paraspecific against the Sahara horned viper. The paraspecificity of antivenin immunotherapy could be a solution to ophidian envenomation in the absence of an antivenin adapted to local snake species.

[Effect of a single intramuscular dose of dexamethasone on pain after circumcision. A randomized controlled study]. / Effet d'une dose unique intramusculaire de déxaméthasone sur la douleur après circoncision. Étude randomisée contrôlée.

OBJECTIVE: To assess the effect of a preoperative single dose of dexamethasone associated with penile block on pain after circumcision. STUDY DESIGN: Prospective randomized controlled study. PATIENTS AND METHODS: Forty male children aged 2 to 5 years, scheduled for circumcision under general anaesthesia, combined with penile block, were randomized into two groups. The dexamethasone group received dexamethasone 0.4 mg/kg preoperatively. The control group received the same volume of normal saline. Data compared between two groups were: postoperative pain assessed by the Objective Pain Scale collected in the recovery room, at 8 and 24 hours postoperatively (h0, h8 and h24), time to first analgesic request and the quality of sleep on the first postoperative night. RESULTS: Pain scores at h0 were similar between the two groups. The dexamethasone group showed significantly lower pain scores at h8 [0 (0-1) vs. 2 (0-3); P=0.04] and h24 [0 (0-0) vs. 0 (0-1); P=0.02]. The time to first analgesic administration was also significantly delayed in the dexamethasone group compared to the control group (240 vs 180 min; P=0.035). The quality of sleep was also better in children in the dexamethasone group (P=0.018). CONCLUSION: This study showed that the combination of a preoperative single dose of dexamethasone 0.4 mg/kg with penile block significantly improves the quality of analgesia after circumcision.

[Tension pneumocephalus after surgical treatment of a bilateral chronic subdural hematoma: a banal and serious complication]. / Pneumocéphalie compressive après traitement chirurgical d'un hématome sous-dural chronique bilatéral: une complication banale et sérieuse.

The occurrence of postoperative pneumocephalus is a common event and is often trivial. When the intracranial air volume is significant, it creates intracranial hypertension causing tension pneumocephalus. This case report describes the occurrence of tension pneumocephalus after surgical drainage of bilateral chronic subdural hematoma. The pneumocephalus was responsible for severe postoperative neurological deterioration. The attending physicians should be aware of the possibility of occurrence of such complication. Treatment and prevention of pneumocephalus should also be well known by the medical staff.

[Acute negative pressure pulmonary edema: illustration from a unusual clinical case following a postoperative recurrent laryngeal nerve palsy]. / L'œdème aigu du poumon à pression négative : illustration à partir d'un cas clinique inhabituel compliquant une paralysie récurrentielle postopératoire.

Acute postoperative negative pressure pulmonary edema (NPPE) is a respiratory complication due to upper airway obstruction occurring most commonly in the postoperative period. Pathophysiologically, NPPE is explained by the abrupt generation of highly negative intrathoracic pressure that lead to fluid transudation from the pulmonary capillaries. This observation reports an unusual case of a young patient who has undergone total thyroidectomy for multinodular goiter. The postoperative period was marked by the occurrence of bilateral recurrent laryngeal nerve palsy that was complicated by a NPPE. The outcome was favorable after mechanical ventilation with reversal of NPPE and recovery of the recurrent laryngeal nerve function. This article stresses the importance of prevention of recurrent nerve palsy during thyroid surgery. It also highlights a little known respiratory complication: the NPPE. Understanding the pathophysiology of NPPE, rapid diagnosis and appropriate therapeutic measures could prevent its potential lethal consequences.

[Chickenpox: a cause of acute respiratory distress syndrome to bear in mind]. / La varicelle: une étiologie de syndrome de détresse respiratoire aiguë à ne pas méconnaître.

The authors report a case of chickenpox (varicella) in an adult, complicated by acute respiratory distress syndrome and resulting in death.

Effect of the addition of rocuronium to local anesthetics for peribulbar block.

To test the hypothesis that rocuronium added to a mixture of local anaesthetics could improve akinesia in Peribulbar Block (PB) we designed this prospective, randomized, double-blinded study. Sixty ASA physical status I and II patients presenting for cataract surgery (manual extracapsular lens extraction) under PB were included. Patients were randomized to 2 groups: rocuronium group (n = 30) received PB with a local anesthetic mixture (Lidocaine 2% + Bupivacaine 0.5%) to which was added 0.06 mg/Kg of rocuronium and control group (n = 30) received PB with the same mixture to which was added saline. Akinesia was assessed with a 12-point scale at 2, 5 and 10 minutes after injection (each of the four rectus muscles and each lid was scored from 0 to 2; 0 = total akinesia, 1 = partial akinesia, 2 = no akinesia). The need for supplementary injection, adverse effects and complications were also recorded. Rocuronium group demonstrated significantly better akinesia scores than control group at 2, 5 and 10 minutes post PB (p < 0.05). Supplementary injection was necessary in 4 patients (13%) in rocuronium group versus 12 patients (40%) in control group (p = 0.039). No significant complications were recorded. Rocuronium added to a mixture of local anaesthetics at a dose of 0.06 mg/Kg improved the quality of akinesia in PB and reduced the need for supplementary injections.

[Central venous catheter-related bacteraemia: prospective study in a Moroccan medical intensive care unit]. / Bactériémies liées aux cathéters veineux centraux : étude prospective dans une unité de réanimation médicale marocaine.

OBJECTIVE: to determine the incidence of catheter-related bacteremia (CRB) in a Moroccan medical intensive care unit, the microbiological profile of this infection and risk factors associated with its occurrence. STUDY DESIGN: Prospective observational study. METHODS: over a period of 8 months, patients who required central venous catheter (CVC) placement for a duration greater than 48 h were included in the study. The CRB has been defined by the criteria of the SRLF Consensus Conference. The proportions of colonization and CRB were expressed as incidence density (ID). Risk factors for colonization were studied in univariate analysis. RESULTS: one hundred and two CVC were inserted in 70 patients. The average age was 54 ± 20 years with an APACHE II of 28 ± 10. The ID of colonization and CRB were respectively 34 for 1000 days of CVC use and 8 for 1000 days of CVC use. The isolated microorganisms were Gram-negative bacilli in 73 %, Gram-positive cocci in 22 % and finally yeast in 5 %. A prolonged duration of catheterization and the absence of systemic antibiotic therapy before catheterization were the main risk factors for colonization. CONCLUSION: the incidence of CRB was high. These results impose a reflection of the care team to improve protocols for prevention of such nosocomial infections.

[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.

[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.