Efficacy of a premedication with melatonin during cataract surgery under peribulbar block: a prospective randomized double-blinded study.

INTRODUCTION: Cataract is a ubiquitous pathology. Its prevalence increases with age. Nowadays, cataract surgery is increasingly performed on an outpatient basis under locoregional anesthesia. In this context, sedation-analgesia is essential but not without risks. AIM: To evaluate the effectiveness of premedication with melatonin on intraoperative sedation-analgesia. METHODS: This is a prospective randomized double-blind study including patients proposed for scheduled cataract surgery by phacoemulsification under peribulbar anesthetic block. The participants will be randomized into two groups: group (M) will receive 05 tablets of melatonin (10mg sublingual) and group (P) will receive 05 tablets of Sucralose sublingually. Perioperative sedation-analgesia will be evaluated by the Ramsey score, the bisectral index, the simple verbal scale (EVS) and by the perioperative consumption of midazolam and alfentanyl. Secondary endpoints will be the degree of preoperative anxiety (Amsterdam Preoperative, Anxiety and Information Scale), the perioperative tonus of the eyeball, intraoperative nicardepine consumption and patients and surgeons satisfaction. A value of p <0.05 will be considered statistically significant. EXPECTED RESULTS: The administration of melatonin as a premedication for scheduled cataract surgery will allow a better quality of intraoperative sedationanalgesia, a reduction in the doses consumed of midazolam and alfentanyl, improves surgical conditions, leads to a decrease in ocular tone, and optimizes surgical safety conditions for the patient.

Risk factors of conversion in laparoscopic cholecystectomies for lithiasic acute cholecystitis. Results of a monocentric study and review of the literature.

INTRODUCTION: Nowadays, laparoscopic cholecystectomy has become the gold standard in the management of lithiasic acute cholecystitis. However, the rate of conversion to laparotomy remains considerable, greater than that of uncomplicated lithiasis. Some factors, related to the patient, the disease or the surgeon, are associated with a high risk of conversion. AIM: To identify the factors associated with a significant risk of conversion in laparoscopic cholecystectomy for acute cholecystitis. METHODS: Between January 2011 and December 2015, all patients operated on for acute cholecystitis at the Department of General and Digestive Surgery of Farhat Hached University Hospital of Sousse - Tunisia were divided into two groups: A for the laparoscopic approach and B for conversion. We compared the two groups. RESULTS: The conversion rate was 21.9% (43 patients). At the end of this work, we found that the conversion rate was significantly increased for males (p = 0.044), ulcerative disease (p = 0.004), smokers (p = 0.007), ASA score = II (p = 0.005), abdominal guarding (p = 0.001), fever (p = 0.001), perivesicular effusion on ultrasound (p = 0.041), ultrasound Murphy's sign (p = 0.023), delayed cholecystectomy (p = 0.038), perivascular adhesions (p <10-3) and gangrenous cholecystitis (p = 0.009). CONCLUSION: The conversion is sometimes badly perceived by the surgeon. However, it should in no way be considered a failure, but rather a change of strategy to ensure patient safety. Conversion should not be delayed, especially as risk factors have been identified.

[Transfusion strategy for patients with severe postpartum hemorrhage: a retrospective study of 47 cases]. / Stratégie transfusionnelle des hémorragies graves du post-partum: étude rétrospective à propos de 47 cas.

INTRODUCTION: Postpartum haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It requires a multidisciplinary approach. Transfusion strategy is essential, playing a key role in maternal prognosis. This study aims to determine FFP/RBC ratio (plasma frais congelé/concentrés de globules rouges; fresh frozen plasma/red blood cells) during the treatment of serious postpartum haemorrhages. METHODS: We conducted a retrospective study at a Maternity Referral Center (level III) in eastern Tunisia over a period of 4 years (2009-2012). All parturients admitted due to severe postpartum bleeding requiring transfusion of more than 4 Units of RBC during the first 3 hours or of more than 10 Units of RBC during the first 24 hours of treatment were included in the study. RESULTS: 47 parturients were enrolled in our study. The diagnosis of PPH was made on the basis of vaginal bleeding in 28 cases and following cesarean section in 19 cases. Preoperative hemoglobin level was of 6.3 g/dl. Transfusion ratio (FFP/RBC) was 1/0.7. CONCLUSION: During tratment transfusion ratio was greater than that indicated in the existing guidelines stating an early and massive administration of FFP with a FFP/RBC ratio ranging between 1/2 and 1/1. Fibrinogen (Fbg) and tranexamic acid should be administered as early as possible. The use of recombinant activated factor VII (rFVIIa) should remain the ultimate treatment option.

New pharmacologic therapies for acute heart failure.

Given the limitations of high-dose diuretics and vasodilators and the increasing literature showing that inotropes, regardless of the dose used, have a detrimental effect on mortality, a variety of new agents are under investigation for the treatment of pulmonary and systemic congestion and restoration of cardiac output in the setting of acute heart failure syndromes. The new therapeutic approach is based on two goals: short-term improvement in symptoms together with long-term improvement of cardiac function. This review describes new agents that are in preclinical and in clinical phases with realistic prospects: anti-endothelin, natriuretic peptides, istaroxime, levosimendan, myosin activators, and vasopressin antagonists. Those new therapeutic strategies aim to act at the cellular level to improve vessel and heart functions, with minimal side effects, together with improved sodium and water balance.