[Vasoreactivity changes during extracorporeal circulation: effects of halogenated agents]. / Modifications de la vasoréactivité en CEC : influence des halogénés.

During cardiopulmonary bypass (CPB), endothelium is exposed to multiple disturbances leading to significant vasomotor tone and vascular systemic resistances (VSR) level modifications. Properties of endothelial function on vascular tone were summarized herein. According bibliographic findings, physiological and clinical impacts of respectively halogenated agents and CPB concerning vasomotor tone were reported. Main effects of halogenated agents administered through oxygenator during CPB were also identified. Usually when administered above one MAC, halogenated agents decreased VSR during hypothermic bypass. Once those mechanisms summarized, increase of halogenated agent's effects on VSR during normothermic CPB was postulated. Assuming that decrease of VSR could be deleterious favoring severe vasoplegia event, clinical experience of administration of isoflurane during CPB among more 4000 patients was retrospectively reported. Incidence of severe vasoplegia was established to 9.5 % in the studied population and this result was similar as others. More over predicting factors of severe vasoplegia were the same as previously reported : severity of preoperative clinical status according Euroscore, hemodynamical instability before induction of anesthesia, surgical procedure complexity and CPB duration. Absence of deleterious effects in SVR decrease when administering isoflurane during normothermic CPB was assumed but prospective comparative studies comparing effects of halogenated agents and other anesthetic agents are needed in order to confirm these findings.

Reliability of the HemoCue® hemoglobinometer in critically ill patients: a prospective observational study.

BACKGROUND: The aim of the study was to assess the reliability of hemoglobin measurements made with HemoCue®, compared with those made with the reference method in critically ill patients. METHODS: A prospective observational study was conducted in three adult surgical intensive care units of a university hospital. One hundred and ninety-eight consecutive patients were included, and a total of 1166 hemoglobin concentrations were measured using arterial blood samples in the laboratory (HbLAB) and at bedside (HbHC.art) with a portable hemoglobinometer (HemoCue® Hb201+). Simultaneously, a capillary measurement (HbHC.cap) was performed at bedside using the same device. RESULTS: The mean difference (bias) between HbHC.cap and HbLAB was 0.2 g/dL (95%CI, 0.1;0.3), and limits of agreement were -1.3 g/dL (95%CI, -1.4;-1.2) to 1.7 g/dL (95%CI, 1.6;1.9). The discrepancies between HbHC.cap and HbLAB were greater than 1 g/dL in 30.8% of cases. The bias between HbHC.art and HbLAB was -0.1 g/dL (95% CI, -0.2;0.2), and limits of agreement were slightly better at -1.1 g/dL (95% CI, -1.2;-1.0) and 1.0 g/dL (95% CI, 0.9;1.1). The HemoCue®'s accuracy was not affected by the hospital unit, the puncture site (finger or ear), norepinephrine administration or by hemoglobin levels below 10 g/dL or 8 g/dL. CONCLUSION: Capillary HemoCue® is not sufficiently accurate to make a therapeutic decision such as whether a blood transfusion should be performed. The method's performance was moderately improved by the use of arterial blood.

[Training for adult subclavian venous catheterization: use of real-time echography]. / Apprentissage du cathétérisme de la veine sous-clavière chez l'adulte: apport de l'assistance échographique en temps réel.

OBJECTIVE: To assess the training in adult subclavian venous catheterization of an inexperienced operator, with two different procedures: ultrasound guidance vs anatomic landmark technique. STUDY DESIGN: Prospective, comparative study. PATIENTS AND METHODS: After informed consent, 50 adults were divided in two groups, with an original method of inclusion, designed to assess the training of the operator, which alternated ultrasound guidance (n = 25) and Aubaniac's landmark technique (n = 25). RESULTS: All the catheterizations have been completed. The success rate at first attempt was higher in ultrasound group than in landmark group, without reaching significance (76 vs 56%). Two arterial punctures were reported in landmark group. With ultrasound guidance, there were 21 puncture sites at the external third and 4 at the medial third of the clavicle. Average access time (skin to vein) was 15 +/- 8 seconds in ultrasound group and 63 +/- 78 seconds in landmark group (p < 0.01), with a significant relation between access time and patient rank in landmark group (r2 = 0.42, p < 0.01). CONCLUSION: Ultrasound guidance makes the training in adult subclavian venous catheterization easier, and allows inexperimented operator to be rapidly efficient. The use of ultrasound would decrease the incidence of complications by a real time visualization of anatomical structures, and by a more external approach of the vein than in the Aubaniac's technique.

Spontaneous haemoperitoneum from surreptitious ingestion of a rodenticide.

Superwarfarins have progressively replaced warfarin as rodenticides as they are more potent and have a longer anticoagulant activity. Human exposure may be complicated by spontaneous haemorrhage in various sites. We report the case of a 51-year-old woman who was admitted with spontaneous haemoperitoneum and intramural haematoma along the small intestine. After the evidence of a deficit of vitamin K1-dependent clotting factors (II, VII, IX, X), the patient admitted that she was chronically ingesting difenacoum. She was successfully treated with fresh frozen plasma and vitamin K1. Follow-up was not accepted.