[Difficult intubation: should follow the recommendations]. / Intubation difficile: il faut suivre les recommandations.

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.

[Surgery of aortic regurgitation with reduced left ventricular function]. / Chirurgie de l'insuffisance aortique avec dysfonction ventriculaire gauche.

BACKGROUND: Aortic valve replacement improves clinical symptoms and left ventricular systolic function in patients with chronic aortic regurgitation despite a higher surgical risk. The objective of this study is to determine if left ventricular function will be normalized after surgery. PATIENTS AND METHOD: This retrospective study included 40 patients (nine females and 31 males) with chronic aortic regurgitation and left ventricular systolic dysfunction who were evaluated by echocardiography Doppler. Were included patients with left ventricular ejection fraction less or equal to 45%. Ages ranged from 18 to 77 years (mean = 46.4 ± 12.6 years). Preoperatively, six patients (15%) were asymptomatic, ten (25%) were in NYHA II, half (50%) in NYHA III and four (10%) in NYHA IV. The mean preoperative ejection fraction (EF) was 36.2 ± 2%. The mean end systolic and diastolic dimensions were 61.7 ± 8.5 mm and 78.9 ± 9.7 mm respectively. Aortic regurgitation was quantified grade III in sixteen patients (40%) and grade IV in twenty-four (60%). RESULTS: Thirty-seven patients underwent aortic valve replacement and three Bentall operations. Hospital mortality was 7.5% (3/40). The mean follow-up period was 69.7 months. All survivor patients were investigated. Out of these, five were lost and 32 were controlled. Symptomatic improvement was noted in most of the survivors. Sixty percent (24/40) were severely symptomatic before and only 6.25% (2/32) during follow-up. The ejection fraction increased significantly after surgery (36.2 ± 2% in preoperative period vs. 55.2 ± 10% in postoperative period, P < 0.02). Left ventricular diameters decreased significantly also. Survival rates were 3-year 94%, 5-year 91% and 7-year 89%. CONCLUSION: Despite reduced left ventricular systolic function, aortic valve replacement in chronic aortic regurgitation was associated with acceptable operative risk. Surgery improves functional status, symptoms and ejection fraction in most patients.

[Systemic candidiasis in medical intensive care unit: analysis of risk factors and the contribution of colonization index]. / Les candidoses systémiques en réanimation médicale : analyse des facteurs de risque et intérêt de l'index de colonisation.

OBJECTIVES: Description of the epidemiological and clinical characteristics of the patients introducing risk factors of invasive candidiasis. Analysis of risk factors for candidiasis invasive and evaluation of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in medical intensive care. PATIENTS AND METHODS: Prospective observational study (October 2007 to October 2009). The selected patients present risk factors of system IC candidiasis with an infectious syndrome or clinical signs suggestive of Candida infection and hospitalized more than 48 hours in medical intensive care unit. Pittet's colonization index was calculated at admission and then once a week added to a blood culture. Patients were classified according to level of evidence of Candida infection and the degree of colonization (CI<0.5, CI ≥ 0.5). RESULTS: The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male prevalence. Neurological disease was the most frequent pathology in admission (48%). The most common risk factors were broad-spectrum antibiotics and foreign material. In the various mycology IC specimens, Candida albicans was the most frequent, followed by C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients, and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and specificity was 93% and 48% respectively. CONCLUSION: CI has the advantage to provide a quantified data of the patient's situation in relation to the colonization. But, it isn't helpful with patients having an invasive candidiasis in medical intensive care unit.

[Results of coronary artery bypass grafting with left ventricular dysfunction (comparison of off-pump versus on-pump)]. / Résultats du pontage coronaire en cas de dysfonction ventriculaire gauche (comparaison du cœur battant et de la CEC).

BACKGROUND: The aim of this study was to compare the results of myocardial revascularisation with or without cardiopulmonary bypass in patients with impaired left ventricular function. PATIENTS AND METHODS: Five hundred and sixteen consecutive patients who underwent coronary artery bypass grafting from January 2000 through December 2007 were analyzed retrospectively. One hundred and eight cases had a left ventricular EF (ejection fraction) of 45% or less. Of these patients, 78 underwent conventional coronary artery bypass (CCABG) and 30 underwent off-pump procedure (OCABG). The CCABG group received 300IU/kg of heparin while the OCABG received 100IU/kg. The off-pump coronary surgery was carried out using a tissue stabilizer Octopus II. Different pre-, per- and postoperative variables were evaluated among both groups. Statistical analysis was performed by SPSS 11.5. The variables were compared between these two groups using univariate analysis (Chi(2) test, Fisher's test exact) for qualitative variable and (Student's t test, Mann-Whitney's test) for quantitative variable. RESULTS: Patients profiles and risk factors were similar among both groups except for age (CCABG: 57.8±9.2 year vs OCABG: 52±9.9 year; P=0.004) and left ventricular EF (CCABG: 37.4±6.3% vs OCABG: 34±7.8%; P=0.02). The number of grafts performed per patient was significantly more among patients who underwent extracorporeal circulation (CCABG: 2.53±0.7 graft/patient vs OCABG: 1.77±0.8 graft/patient; P<0.0001). The hospital mortality was more among CCABG group 9% vs 3.3% in OCABG but the difference was not significant (P=0.3). However, the operative time and the operative room stay were long in CCABG (252±61min vs 175±38min; P<0.0001 - 389±70min vs 298±54min; P<0.0001). The ventilation time was also long in CCABG (32.3±67hour vs 10.4±5.9hour; P=0.15). There was more postoperative myocardial infarction in CCABG (P=0.008), but the EF increased and was better in CCABG. CONCLUSION: Off-pump coronary artery bypass surgery provides satisfactory operative results for most patients with reduced left ventricular function. Prospective and randomly study will be necessary before concluding.

[Medication errors in anesthesia: a Moroccan university hospitals survey]. / Erreurs médicamenteuses en anesthésie : enquête prospective au niveau des CHU Marocains.

INTRODUCTION: Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco. MATERIAL AND METHODS: After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner's statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity. RESULTS: During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline. CONCLUSION: Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice.

[Impaired consciousness associated with a hysterical conversion after obstetrical epidural analgesia: a case report with literature review]. / Troubles de la conscience liés à une conversion hystérique après une analgésie péridurale obstétricale : un cas clinique avec revue de la littérature.

The occurrence of impaired consciousness after epidural analgesia is an alarming situation that requires urgent diagnostic and therapeutic approach. Various causes may be responsible for such a state. Hysterical conversion remains an outstanding issue. Through a clinical case of a hysterical conversion and a literature review the authors draw attention to the difficulty of diagnosing this entity after epidural analgesia.

[Peripheral intravenous access in the operating room: characteristics and predictors of difficulty]. / Accès veineux périphériques au bloc opératoire : caractéristiques et facteurs prédictifs de difficulté

PURPOSE: To investigate of predictor's factors of difficult venous access device in the operating room in elective surgery. METHODS: In a prospective study in central operating room, were included all patients scheduled for a surgical or diagnostic intervention. Were excluded all patients admitted with functional venous access. For each, were recorded patient's demographic characteristics (age, gender, ASA class, BMI), history (chemotherapy, prolonged ICU stay, hospitalization for more than five days), data from the clinical examination (presence of skin lesions, arteriovenous fistulas, burns, neurological deficits) and the type of operator (trainee, nurse, resident, senior). The difficulty was judged on the number of attempts required for successful venous access. Puncture was considered easier for a number of attempts to one to two and difficult if the number of attempts was greater than two. Predictor's factors were identified after univariate and multivariate analysis. RESULTS: During one year (March 2008 to February 2009), form returns in 1500 were met, 1325 were usable. Venous catheterization was successful in 50.9% at the first attempt in 24.2% of patients at the second attempt and after three attempts in 18% of patients. Only 6.8% of patients required more than three attempts. A central venous catheter was required in seven patients. In multivariate analysis, chemotherapy (OR=4.54, 95% CI [2.92 to 7.03]; P<0.001), a nurse in training (OR=2.27, 95% CI [1.40 to 3.63]; P=0.001), a resident in training (OR=2.14, 95% CI [1.29 to 3.58]; P=0.003) and the presence of burns (OR=3.59, 95% CI [2.44 to 5.27]; P<0.001) were identified as independent predictors of difficulty of peripheral venous access. DISCUSSION: The optimization of venous access devices in the operating room through the search for predictors of difficulty.

[Unilateral bronchospasm during general anesthesia]. / Le bronchospasme unilatéral lors d'une anesthésie générale.

We report a case of unilateral bronchospasm encountered following an induction of anesthesia of healthy young man with no significant past medical or surgical history. The differential diagnosis and management are discussed. Unilateral bronchospasm was probably caused by topical lidocaine injected with a Laryngojet injector at the vocal cords.

[Acute respiratory distress syndrome secondary to influenza A (H1N1) infection: a report of a case]. / Le syndrome de détresse respiratoire aiguë secondaire à une infection par le virus de la grippe A (H1N1) : à propos d'un cas.

Through a clinical case of acute respiratory distress syndrome after infection with influenza virus H1N1 and a review of the literature the authors discuss treatment options, prognostic factors and the problems raised in support this pathology in Moroccan center.

Difficult intubation in a parturient with syringomyelia and Arnold-Chiari malformation: Use of Airtraq laryngoscope.

Anesthetic technique in parturient with syringomyelia and Arnold-Chiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq™ laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and Arnold-Chiari type I malformation.

[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.

[Efficiency of bupivacaine wound subfasciale infiltration in reduction of postoperative pain after inguinal hernia surgery]. / Efficacité de l'infiltration cicatricielle subfasciale par la bupivacaïne dans la réduction de la douleur postopératoire des hernies inguinales.

INTRODUCTION: The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique. METHODS: This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed. RESULTS: Concerning demographic parameters, ASA class and secondary effects, we didn't find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain. DISCUSSION: Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.

[Invasive aspergillosis of the cavum associated with candidal meningitis]. / Aspergillose invasive du cavum associée à une méningite à Candida albicans.

Aspergillus fumigatus is a resistant filamentous fungus, common in the environment and pathogenic for human. The most common sites of primary aspergillosis are the maxillary sinus and lungs. Intracranial location is rare and may develop after hematogenous dissemination or contiguity. The invasive pseudotumoral form usually concerns immunodepressed patients. Invasive aspergillosis of the cavum is rare and its diagnosis is difficult. This infection can be fatal because of endocranial involvement and permeabilization of the blood-brain barrier, facilitating other neuromeningeal mycotic infections. We report the case of a 70-year-old diabetic and hypertensive female patient having presented with an invasive aspergillosis of the cavum and endocranial involvement complicated by Candida meningitis.

Results of a public awareness campaign in Morocco regarding the sun's deleterious effects.

OBJECTIVE: To investigate knowledge of the various sun radiation-related risks and awareness of photoprotection measures using a sample of the Moroccan population. METHODS: An investigation of prevalence, which was administered while a public awareness campaign on the sun's harmful effects, organized by the department of dermatology of Ibn Sina's hospital in Rabat, was running. The collection of the data was made on the basis of a questionnaire that was filled by the team of the doctors of the department. The logistic regression allowed to identify the explanatory factors for the prevalent knowledge and behaviours related to the subject in hand. RESULTS: Four hundred eleven subjects were included in the survey. The subjects' average age was 40 +/- 10 years. Eighty-four per cent were female. The analysis of the total score of knowledge related to the sunrays' deleterious effects demonstrated low levels of knowledge among 160 participants (38.9%). Females were clearly more knowledgeable than the opposite sex (P = 0.003) and also those having a higher educational level (P = 0.006) scored high. The use of sunscreens was recognized by 52.8% of the patients and was associated with female gender and higher educational level. CONCLUSION: Our study reports the results of the first public awareness campaign on the sun's deleterious effects on the Moroccan population, inclusive and relevant to all ages. Awareness of the sun's radiation-related risks in a country as sunny as ours is low, whereas different measures of photoprotection are rather well known. Messages adapted to the characteristics of our population are a necessity.

[Takayashu and pregnancy]. / Takayashu et grossesse.

Takayashu arteritis is a chronic inflammatory disease of the large arteries, usually affecting the aorta and its large branches and the pulmonary arteries, with a higher incidence during the childbearing years. We report the case of a 33-year-old patient, primigravida with Takayashu arteritis diagnosed three years ago. At 37 weeks of gestation, she was admitted for a pre-eclampsia and a left ventricular insufficiency. Elective caesarean section under general anesthesia after joint decision between the attending obstetrician and the medical and anesthetic consultants, and allowed the extraction of a hypotrophic baby. The association of pregnancy with Takayashu's arteritis is almost always uneventful. It is associated with high values of maternal blood pressure and severe intra-uterine growth retardation.