[Gazeous necrosis of the liver due to hepatic artery thrombosis after liver transplantation]. / Nécrose gazeuse du foie par thrombose de l'artère hépatique après transplantation hépatique.

An emergency liver transplantation was performed in a 22 year-old female for fulminant hepatitis. The donor had had splenectomy with portal vein thrombosis which was diagnosed and removed during portoscopy. Nineteen days later, abdominal pain with shock and hepatic failure occurred. X-rays showed pneumoperitoneum and aeric images in the liver area. Laparotomy disclosed massive liver necrosis with gaz under the Glisson's capsula. The hepatic artery was thrombosed. In spite of emergency retransplantation, the patient died 8 days later, due to systemic aspergillosis. Thrombosis of hepatic artery was particular by the importance of gaz-forming infection, and emphasizes the role of rejection. The discovery of portal thrombosis allows to outline the precautions necessary in case of splenectomized donors. The severeness of aspergillosis is underscored.

[Hypomagnesemia associated with hypocalcemia after undetected parathyroidectomy]. / Hypomagnésémie associée à une hypocalcémie après parathyroïdectomie méconnue.

A case is reported of hypomagnesaemia and hypocalcaemia occurring postoperatively in a 59-year-old man operated on for hypopharyngeal carcinoma which had extended to the upper extremity of the oesophagus. Surgery consisted in total pharyngolaryngectomy, ganglion curage, jejunal transplant, thyroidectomy and tracheostomy. Total parathyroidectomy was not mentioned in the surgical report. Hypocalcaemia was first noticed on the day following the procedure. On the tenth postoperative day, the patient became agitated and had myoclonia and muscle fasciculations. Nystagmus and orthostatic hypotension also occurred. There were no cardiac signs. Treatment with calcium alone was insufficient. These symptoms only disappeared once magnesium sulphate had been added.

[Block of the cervical plexus for the unipolar exclusion of a gastroplasty after bronchial fistula]. / Bloc du plexus cervical pour exclusion unipolaire d'une gastroplastie après fistule bronchique.

A 46 year old man was operated on for an oesophageal carcinoma. Total oesophagectomy and gastroplasty were carried out. Postoperatively, a fistula developed between the gastroplasty and the right main bronchus. This led to respiratory impairment, with pulmonary infection, pleural effusion and hypoxia; the patient could not remain supine. A cervical oesophagostomy was decided on; to carry it out, a cervical plexus block was preferred to a cervical epidural anaesthesia because of the lesser respiratory and haemodynamic effects of the former technique. The procedure was well supported by the patient, and no significant hypoxia was detected by continuous pulse oximetry. Artificial ventilation of this patient was therefore successfully avoided.

[The value of monitoring arterial oxygenation saturation by pulse oximetry in neuroleptanalgesia]. / Intérêt de la surveillance de la saturation artérielle en oxygène par oxymétrie de pouls au cours de la neuroleptanalgésie.

Anaesthesia can induce hypoxaemia. Pulse oximetry gives continuous non invasive monitoring of arterial oxygen saturation. No arterial puncture is needed. Ninety-four patients were monitored by pulse oximetry during neuroleptanalgesia for colonoscopy. Eighteen patients showed desaturation episodes of less than 90%, eight linked to opioid-induced respiratory depression. In all patients, pulse oximetry gave clinicians an immediate awareness of the incident. Treatment was facilitated. Pulse oximetry made anaesthesia safer.

[Direct re-instillation through endotracheal intubation tubes during enteral nutrition for short bowel syndrome]. / Réinstillation directe par connexion de sondes d'intubation endotrachéales lors d'une nutrition entérale pour grêle court.

Case report of a 65-year-old man, operated on for small bowel infarction. Only the initial 40 cm of the jejunum, and the last 10 cm of the ileum were vital and could be kept. The ileo-caecal valve and the colon were not resected. Two stomas were carried out: a left-sided jejunostomy, and a right-sided ileostomy. Enteral nutrition was attempted, but jejunal outflow increased. It was therefore decided to attempt re-instillation of jejunal juices directly to the ileum using two 33 CH endotracheal tubes connected with soft chest drain tubing. A bag was placed over the jejunal tube to collect any leakage. Semi-elemental enteral nutrition could then be successfully carried out, and parenteral feeding stopped. With this simple appliance, the patient was able to lead as normal a life as possible. After 42 days of such feeding, the patient had only lost 2 kg in body weight, and intestinal continuity was re-established.

[Delayed low back pain after spinal anesthesia]. / Lombalgies retardées après rachianesthésie.

A 50-year-old man had an inguinal hernia repair under spinal anaesthesia with bupivacaine. On the 2nd postoperative day, he complained of backache and paresis at the posterior part of the lower extremities, well relieved by non-steroidal anti-inflammatory drugs. On the 6th postoperative day, he came back to hospital, because of low back pain associated with a heavy feet sensation. The hypothesis of a neurological complication of the spinal anaesthesia was considered. The interview of the patient revealed a history of lumbar disk disease, not reported during the preoperative visit. After an in depth clinical examination, two causes seemed possible: subarachnoid haematoma and lumbar disk protusion. Against the first diagnosis were the initial clinical signs. However, in many cases, objective neurological deficit arise too late to allow efficient neurosurgical treatment. Thus, a MRI examination was performed which is non invasive in comparison with a computed tomography myelogram. In our patient, it did not detect a true lumbar disk protusion, but a simple degenerative disease of the L5-S1 disk. In suppressing the lumbar lordosis, spinal anaesthesia probably allowed a distension of spinal capsules and tendons, responsible for the troubles.

[Infectious complications after surgery of esophageal pathology. Apropos of 60 cases]. / Complications infectieuses après chirurgie pour pathologie oesophagienne. A propos de soixante cas.

Infections after oesophageal surgery are studied on sixty patients who received perioperatively two antibiotics (cefoxitin and amikacin). Postoperative infection rate is 62% (pneumopathies: 27%, leakage of cervical anastomoses: 17%). Different parameters which can induce postoperative infection are analyzed. The only significative data are the duration of total parenteral nutrition and of intensive care stay. The commonest isolated organisms are gram negative bacilli (61%) and streptococci (30%). Yeasts infections are frequent, and significantly correlated with antibiotic treatment duration.

[Locoregional analgesia in palliative care: a 4-year survey]. / Analgésie locorégionale en soins palliatifs : bilan de quatre années d'utilisation.

UNLABELLED: It could append that patient pain relief in palliative care is not achieved despite the use of opioids and the multimodal approach. Therefore, regional techniques are used in the palliative care unit of the Limoges University Hospital since four years. PATIENTS AND METHODS: From October 2006 to September 2010, every patient under regional technique was followed with a specific form. The items collected were demographic characteristics, underlying disease, and associated treatments. The efficacy of regional techniques on pain was scored. RESULTS: Sixty-three patients, 39 males and 24 females, mean age 59 years, were treated by 104 regional procedures. There were 49 neuroaxial analgesia (40 spinal and nine epidural), 39 peripheral nerve blocks including 25 iliofascial blocks and 16 blocks for nerves of the scalp, face and neck. In 67.5% of the cases, the regional techniques provided adequate pain relief. For 24% of the cases, the results were uncompleted. Regional techniques were unsuccessful in 8.5%. CONCLUSION: Despite this underperformance in terms of pain control, a multicenter study is ongoing to evaluate the improvement of quality of life induced by the regional techniques.

[About safety parameters for patient-controlled analgesia (PCA) devices]. / À propos des paramètres de sécurité des pompes d'analgésie contrôlée par le patient (PCA).

During the course of preparation of an opioid prescription, the nurse in charge became aware that the patient-controlled analgesia (PCA) syringe driver did not permit programming for the delivery as required: a maximum bolus number (Bmax) was indicated but only a maximum cumulative dose (Dcmax) could be programmed. The prescription dose criteria were consistent with the guidelines of the French societies of palliative care, anesthesiology, and reanimation (Société française d'accompagnement et de soins palliatifs [Sfap] and Société française d'anesthésie réanimation [Sfar]). A Dcmax dose simulation was programmed and used in order to test this problem. This highlighted the following four defects: bolus delivery is not controlled, leading to potential overdose. When Dcmax is reached, the continuous flow stops, triggering an end dose failure and a new programming step is needed to restart infusion, increasing the risk of programming errors. Human intervention is required to stop the alarm, identify and solve the problem. Finally, Dcmax leads to random dose delivery in place of the predictability of dose delivery expected for opioid administration. On the other hand, Bmax is a limited dose, administered only as a bolus and regulated by the lockout interval. When the Bmax dose is reached, no alarm is triggered, the basal flow continues, but no additional doses can be delivered. Bmax and Dcmax systems are not interchangeable. No comparative study between Bmax and Dcmax could be found, and Sfap and Sfar guidelines are not precise and did not take into consideration the safety aspects of dose delivery however some facts tend to prefer that Bmax. Most of the syringe driver devices are configured for the Dcmax, but not all of them, and the physician is often forced to use the parameter of the available device restricting the choice between Bmax and Dcmax. This is not justified, whether by scientific evidence, industrial, manufacturing or commercial standards. It becomes only a technical option that does not promote standardization of dose delivery and compromises the main safety feature of PCA.