[Cerebral air embolism complicating talc pleurodesis: case report]. / Embolie gazeuse cérébrale compliquant une pleurodèse au talc : à propos d'un cas.

Cerebral air embolism is a severe complication which can occur during many invasive medical procedures. Its prognosis depends on early diagnosis and hyperbaric oxygen therapy. We report a case of cerebral air embolism which occurred during a talc pleurodesis within a chest tube, in chest postoperative period. After early and appropriate treatment, we observed a significant functional recovery.

[Severe hyperthermia and neurological disorders following prostaglandin treatment for uterine atonia after caesarean section]. / Hyperthermie sévère et troubles neurologiques après administration de sulprostone dans un contexte d'atonie utérine post-césarienne.

Uterine atony is the most frequent cause of post-partum haemorrhage. In France, the management is based on early administration of oxytocic agents and prostaglandin analogues (sulprostone-Nalador®). We report the case of a 30-year-old woman who presented soon after administration of sulprostone, a severe hyperthermia with neurological disorders. A complete reversibility was observed a few hours after discontinuation of sulprostone administration. Other causes were eliminated by biological and radiological findings.

Prescriptions analysis by clinical pharmacists in the post-operative period: a 4-year prospective study.

BACKGROUND: Clinical pharmacists can help prevent medication errors. However, data are scarce on their role in preventing medication prescription errors in the post-operative period, a high-risk period, as at least two prescribers can intervene, the surgeon and the anesthetist. We aimed to describe and quantify clinical pharmacist' intervention (PIs) during validation of drug prescriptions on a computerized physician order entry system in a post-surgical and post-transplantation ward. We illustrate these interventions, focusing on one clearly identified recurrent problem. METHODS: In a prospective study lasting 4 years, we recorded drug-related problems (DRPs) detected by pharmacists and whether the physician accepted the PI when prescription modification was suggested. RESULTS: Among 7005 orders, 1975 DRPs were detected. The frequency of PIs remained constant throughout the study period, with 921 PIs (47%) accepted, 383 (19%) refused and 671 (34%) not assessable. The most frequent DRP concerned improper administration mode (26%), drug interactions (21%) and overdosage (20%). These resulted in a change in the method of administration (25%), dose adjustment (24%) and drug discontinuation (23%) with 307 drugs being concerned by at least one PI. Paracetamol was involved in 26% of overdosage PIs. Erythromycin as prokinetic agent, presented a recurrent risk of potentially severe drug-drug interactions especially with other QT interval-prolonging drugs. Following an educational seminar targeting this problem, the rate of acceptation of PI concerning this DRP increased. CONCLUSION: Pharmacists detected many prescription errors that may have clinical implications and could be the basis for educational measures.

[Implementation strategy of the HAS French surgical check-list in a university hospital]. / Stratégie de déploiement de la check-list dans un CHU.

The check-list (CL) "Safety in Operating Room" has been introduced in our teaching hospital since 2009, associated to a "Quality and Prevention of Risks" program. This introduction was carried out over two distinct phases. The first one was a pilot start including five OR, allowing us to draw firm recommendations on the best way to perform the introduction, followed by a generalization to the other operating room (OR). The recommendations were the followings: a pilot committee including all the professionals should be constituted before the onset of introduction, a dedicated communication should focus on the actual concerns and benefits, and finally, the person questioning other care givers and filling the form should be clearly identified and supported in the OR. Meanwhile a guide on the utilization of the CL in each surgical speciality was written, and a dedicated manager was in charge of the whole procedure. This experience raised several remarks. This implementation of the CL proved to be a cause of self-interrogation on our medical practices, and the opportunity to improve communication among the professionals of the OR. Indeed, the 10 items of the OR should be thought as the last check before the no-return point, which should be shared by anyone in the OR. If these conditions were fulfilled, the CL could be viewed as an actual improvement of safety in the OR. Otherwise, CL is just a supplementary form.

[Agreement between lung ultrasonography and chest radiography in the intensive care unit]. / Analyse de concordance entre l'échographie pulmonaire et la radiographie thoracique en réanimation.

OBJECTIVE: Because the chest radiograph currently remains the routine choice of imaging for the examination of the chest in the intensive care unit, we compared lung ultrasonography with chest radiography. STUDY DESIGN: Observational prospective study. METHODS: An ultrasound examination and chest radiography were simultaneously ordered in 50 patients whose clinical exam justified a lung exploration. Each exam was interpreted independently by an intensivist. The abnormalities found were classified into interstitial syndrome, alveolar consolidation, and pleural effusion. An agreement analysis was performed between the results of the two techniques. The delay between the order and interpretation of both investigations, and the degree of interobserver agreement were also collected. RESULTS: The kappa agreement between lung ultrasonography and chest radiography was 0.42. In total, 329 total abnormalities were detected, 156 abnormalities were found by both techniques, 31 by radiography alone, and 142 by ultrasonography alone. The interobserver agreement was 0.86. Ultrasonography was performed with a shorter delay (14.8 ± 6.9 min vs 44.2 ± 21.4 min). CONCLUSION: There was only moderate agreement between lung ultrasonography and chest radiography for the diagnosis of interstitial syndrome, alveolar consolidation and pleural effusion in intensive care unit. This result is mainly explained by the higher number of ultrasound abnormalities. With the ability to provide fast diagnosis, good reproducibility and high feasibility, ultrasound scan could represent an alternative exam for chest exploration in intensive care unit.

Time course of liver nitric oxide concentration in early septic shock by cecal ligation and puncture in rats.

An overwhelming nitric oxide (NO) production is a crucial step in the circulatory events as well as in the cellular alterations taking place in septic shock. However, evidences of this role arise from studies assessing the NO production on an intermittent basis precluding any clear evaluation of temporal relationship between NO production and circulatory alterations. We evaluated this relationship by using a NO specific electrode allowing a continuous measurement of NO production. Septic shock was induced by a cecal ligation and puncture (CLP) in a first group of anesthetized rats. After the same CLP, a second group received a selective iNOS inhibitor (L-NIL). Control rats were sham operated or sham operated with L-NIL administration. While NO concentration was measured every 2 min by a NO-sensitive electrode over 7h following CLP, the liver microcirculation was recorded by a laser-Doppler flowmeter. CLP induced a severe septic shock with hypotension occurring at a mean time of 240 min after CLP. At the same time, an increase in liver NO concentration was observed, whereas a decrease in microvascular liver perfusion was noted. In the septic shock group, L-NIL administration induced an increase in arterial pressure whereas the liver NO concentration returned to baseline values. In addition, shock groups experienced an increase in iNOS mRNA. These data showed a close temporal relationship between the increase in liver NO concentration and the microvascular alteration taking place in the early period of septic shock induced by CLP. The iNOS isoform is involved in this NO increase.

[Accidental intravenous injection of potassium chloride: analysis of contributing factors and barriers to risk reduction]. / Injection intraveineuse accidentelle de chlorure de potassium : facteurs contributifs et obstacles à la réduction du risque.

Errors linked to injectable potassium chloride (KCl) have been the cause of deaths which have occurred for many years. Following an accidental direct intravenous injection of KCl of no clinical consequence for the patient, we have analyzed the contributive factors, established an action plan to prevent this risk and finally assessed its impact. Among the causes leading to medication errors, we have identified those linked to the handling of the drugs by nurses, the team, the work conditions, the organization, the institutional context and finally to the drug itself. The risk reduction procedure involved a withdrawal of injectable KCI ampoules from wards, possible in 52% of the care units, a reorganization of storage for the others. The subsequent monitoring of floorstocks revealed that these measures were insufficient and that the risks prevailed due to the presence of KCI ampoules in drawers assigned to other ionic solutions. A study carried out among the medical and nursing personnel revealed that 61.2% of the doctors thought that the risk existed in their ward and 68% of the nurses considered themselves to be exposed to the risk of a medication error. The drug supply chain of our institution, as in numerous others, is not safe. Hospitals are not yet organized adequately to prevent the occurrence of such an error. The comparison with foreign organizations of drug dispensation allows us to think that the improvement and professionalization of the drug supply chain will both be assets in the prevention of such medication errors.

[E-learning in medicine: appraisal and perspectives. Example of an educational website about echocardiography in anaesthesia, intensive care and emergencies: www.echorea.org]. / Le e-learning en médecine: état des lieux et perspectives. Exemple d'un site Internet d'enseignement appliqué à l'échocardiographie en anesthésie, réanimation et urgences : www.echorea.org.

Internet is a mode of quick and more and more easily approachable communication. Its use as support of education allows an enrichment of the master-pupil relation by its availability, its interactivity and the multiplicity of its means. Medicine benefits particularly from these new means of virtual companionship. This review offers to characterize means and constraints of the use of Internet in medical education, and to illustrate these purposes by an example of site created for the teaching of ultrasound use in anaesthesia, intensive care and emergency.

Post-operative pressure lability and cardiac baroreflex in normotensive patients as a function of age.

BACKGROUND: Pressure lability may be linked to the loss of the cardiac baroreflex. The reduction of the sensitivity of the cardiac baroreflex has not been delineated in the post-operative period according to age in normotensive patients. This study addresses pressure lability and slope of the cardiac baroreflex as a function of age. METHODS: Patients were allocated to the following three groups: young (20-39 years, n=7), middle aged (40-59 years, n=7) and elderly (60-79 years, n=6), and studied before minor intra-abdominal surgery under CO(2) peritoneal insufflation and nitrous oxide-isoflurane-sufentanil anesthesia, up to 24 h after extubation. An electrocardiogram and non-invasive beat-by-beat pressure monitoring (Finapres) allowed offline calculation of the sensitivity of the cardiac baroreflex ('sequence' technique) and standard deviation (SD) of heart rate (HR; HR variability) and systolic blood pressure (SBP; pressure lability). RESULTS: Before anesthesia, (a) an inverse relationship was observed between the slope of the cardiac baroreflex and age and (b) a trend (P<0.09) existed between the slope of the cardiac baroreflex and pressure lability, irrespective of age. During the early post-operative period, young patients returned to their baseline slope of the cardiac baroreflex; no inverse relationship between increased SD of SBP and decreased SD of RR interval was observed. Middle-aged and elderly patients displayed a depressed slope of the cardiac baroreflex both before and after anesthesia. CONCLUSION: At variance with the pre-operative period, no simple inverse relationship was observed between increased pressure lability and depressed HR variability in young patients during the early post-operative period.

[Increased troponin I level in a Duchenne muscular dystrophy patient with normal coronarography]. / Elévation de troponine I à coronarographie normale chez un patient porteur d'une myopathie de Duchenne.

Duchenne muscular dystrophy (DMD) is a neuromuscular disease characterized by a progressive skeletal muscular weakness. As the respiratory care of such patients has been dramatically improved during the past few years, the DMD associated cardiomyopathy is becoming a new concern. We report a clinical case of a Troponin I level increase with normal coronarography occurring after an acute episode of respiratory failure. This report suggests the sensitivity of cardiomyocytes to hypoxemia in DMD patients.

Unusual sinus arrhythmia.

A juxtaposition of long and short RR intervals was observed in 2 hypertensive patients recovering from major surgery under spontaneous ventilation. Sinus rhythm was ascertained throughout the recording. These oscillations could not be linked one-to-one to ventilatory cycles.

[Misplacement of a central femoral catheter in the urinary conduit of a renal transplant]. / Migration extravasculaire d'un cathéter veineux fémoral dans les cavités excrétrices d'un rein transplanté.

Femoral vein catheterization is often carried out during resuscitation and in critical care units. Thrombosis and infections are the most current reported complications. Catheter malpositions have been reported. We described the inadvertent cannulation of the urinary tractus in a patient with a right iliac renal transplant.

[Amniotic fluid embolism: successful evolution course of isolated disseminated intravascular coagulation and early biological diagnosis]. / Embolie de liquide amniotique : évolution favorable d'une CIVD isolée et diagnostic biologique précoce.

Amniotic embolism is a sudden, unexpected and devastating complication of pregnancy. The diagnosis is usually made on the basis of clinical presentation after excluding differential diagnosis or at autopsy in the event of death of the parturient. We need to develop simple, non-invasive, sensitive tests for a reliable and early diagnosis. We report the case of a 34-year-old woman, who presented soon after delivery, an isolated disseminated intravascular coagulation with severe haemorrhage, an haemostatic hysterectomy was required. A 3370 g child was delivered by caesarean section. The patient survived without sequelae. The diagnosis of amniotic embolism was established by the presence of amniotic cells in the maternal central venous blood as well as in the bronchoalveolar fluid.

Effects of increased intra-abdominal pressure on central circulation.

BACKGROUND: In an experimental model we investigated the effects of a gradual increase in intra-abdominal pressure (IAP) on the central circulation. METHODS: Seven pigs were anaesthetized, mechanically ventilated and instrumented. IAP was gradually increased by 5 mm Hg up to 30 mm Hg by abdominal banding in normovolaemic animals, and then they were made hypovolaemic after blood withdrawal. Right atrial pressure (RAP) and left ventricular end-diastolic pressure (LVEDP) at each step and aortic, femoral and inferior vena cava blood flows were measured. Left ventricular end-diastolic area (LVEDA) was determined using epicardial echocardiography. RESULTS: Cardiac output maintained at mild IAP was reduced to 76 (24)% of the initial value at 30 mm Hg IAP [mean (sd)] in normovolaemic animals, and 72 (22)% (P<0.001) in hypovolaemic animals. In normovolaemic animals the LVEDA and LVEDP were significantly increased at an IAP of 10 and 15 mm Hg by 26 (24)% and 38 (23)%, respectively. At these IAP values, the difference between the RAP and IAP was positive. When this gradient became negative, that is beyond 15 mm Hg in normovolaemia and for all IAP values in hypovolaemic animals, the LVEDA declined, reaching 78 (16)% and 62 (22)% (P<0.05) of the initial values in normovolaemic and hypovolaemic groups at the highest IAP value. CONCLUSIONS: These results showed that a gradual increase in IAP led to a redistribution of abdominal blood volume towards the thoracic compartment, at IAP lower than 15 mm Hg in normovolaemia, and at its expense at higher values of IAP. In hypovolaemia there was no thoracic compartment gain. Whereas the absolute or transmural RAPs were not informative of the direction of this blood shift, an RAP greater than IAP was associated with an intrathoracic compartment gain.

Nitric oxide and liver microcirculation during autoregulation and haemorrhagic shock in rabbit model.

BACKGROUND: Direct evidence of nitric oxide (NO) involvement in the regulation of hepatic microcirculation is not yet available under physiological conditions nor in haemorrhagic shock. METHODS: A laser Doppler flowmetry was used to measure liver perfusion index and a specific NO-sensitive electrode was inserted into liver parenchyma of anaesthetized rabbits. Hepatic autoregulation during moderate hypovolaemia {mean arterial pressure at 50 mm Hg without liver perfusion alteration; blood withdrawal 17.7 (4.2) ml [mean (SD)]} or haemorrhagic shock [mean arterial pressure at 20 mm Hg associated with liver perfusion impairment and lactic acidosis; blood withdrawal 56.0 (6.8) ml] were investigated over 60 min and were followed by a rapid infusion of the shed blood. Involvement of NO synthases was evaluated using a non-specific inhibitor, NAPNA (Nomega-nitro-L-arginine P-nitro-anilide). RESULTS: In the autoregulation group, a decrease [30.0 (4.0) mm Hg] of mean arterial pressure did not alter liver perfusion index, whereas the liver NO concentration increased and reached a plateau [125 (10)%; compared with baseline; P<0.05]. This NO concentration was reduced to zero by the administration of NO synthase inhibitor. Haemorrhagic shock led to a rapid decrease in liver perfusion index [60 (7)%; compared with baseline; P<0.05] before an immediate and continuous increase in NO concentration [250 (50)%; compared with baseline; P<0.05]. Infusion of NO inhibitor before haemorrhagic shock reduced the NO concentration to zero and hepatic perfusion by 60 (8)% (P<0.05) of the baseline. Mean arterial pressure increased simultaneously. In these animals, during haemorrhage, a continuous increase in NO concentration still occurred and liver perfusion slightly increased. In all groups but NAPNA+haemorrhagic shock, blood replacement induced recovery of baseline values. CONCLUSIONS: NO plays a physiological role in the liver microcirculation during autoregulation. Its production is enzyme-dependent. Conversely, haemorrhagic shock induces a rapid increase in hepatic NO that is at least partially enzyme-independent.

[Amniotic fluid embolism: a review]. / Embolie de liquide amniotique: mise au point.

Amniotic fluid embolism occurs rarely but is a leading cause of maternal mortality. It is a difficult and somewhat intangible diagnosis that warrants a high index of suspicion by physicians. AFE is an unpredictable, unpreventable, and, for the most part, an untreatable obstetric emergency. Management of this condition includes prompt recognition of the signs and symptoms, aggressive resuscitation efforts, and supportive therapy. Any delays in diagnosis and treatment can result in increased maternal and/or foetal impairment or death. Whereas once the invariable outcome of AFE was death of the mother, today the prognosis is somewhat brighter thanks to increased awareness of the syndrome and advances in intensive care medicine. No laboratory test is specific to attest the diagnosis and autopsy must to be realised in case of maternal death. Although non-specific, the diagnosis of AFE could be supported by the observation of amniotic fluid in the central venous blood as well as in the bronchoalveolar fluid. This easy and quick test will be helpful in decision-making. Prompt and aggressive supportive treatment is required to lessen an otherwise dismal outcome, which may include death and permanent disability. This article provides an account of the protean clinical features, pathogenesis, and principles involved in treatment.

Spontaneous baroreflex cardiac sensitivity in end-stage liver disease: effect of liver transplantation.

BACKGROUND AND OBJECTIVE: End-stage liver disease is associated with an imbalance in the autonomic nervous system. The purpose of this study was to estimate the effect of liver transplantation on this imbalance. METHOD: The study involved 10 patients undergoing liver transplantation and 9 patients without liver impairment undergoing liver surgery. The spontaneous baroreflex sensitivity was measured before and 1 month after surgery for the liver surgery group; before and 1, 3, 6, 12 and 18 months after orthotopic liver transplantation. RESULTS: The spontaneous baroreflex slope of patients with end-stage liver disease was decreased before liver transplantation compared to the liver surgery group (3.9 +/- 2.5 ms mmHg(-1) vs. 9.9 +/- 5.0 ms mmHg(-1), P = 0.002). The mean slope was significantly increased at 12 and 18 months compared to the pre-transplantation value (3.9 +/- 2.5 ms mmHg(-1) vs. 8.1 +/- 6.6 ms mmHg(-1) and 7.4 +/- 4.8 ms mmHg(-1), respectively; P = 0.042). Nevertheless, further analysis of individual data showed that only four patients exhibited a marked increase in their baroreflex slope 12 months after the liver transplantation whereas it remained decreased in the six others. CONCLUSIONS: These results confirm that the baroreflex sensitivity is depressed in end-stage liver disease in line with an autonomic nervous system imbalance. The liver transplantation reverses this disturbance only in some patients.