Abdelghafour Elkoundi

Unplanned intensive care unit admission following elective surgical adverse events: Incidence, patient characteristics, preventability, and outcome

Context: Adverse events (AEs) are a persistent and an important reason for Intensive Care Unit (ICU) admission. They lead to death, disability at the time of discharge, unplanned ICU admission (UIA), and prolonged hospital stay. They impose large financial costs on health-care systems. Aims: This study aimed to determine the incidence, patient characteristics, type, preventability, and outcome of UIA following elective surgical AE. Settings and Design: This is a single-center prospective study. Methods: Analysis of 15,372 elective surgical procedures was performed. We defined UIA as an ICU admission that was not anticipated preoperatively but was due to an AE occurring within 5 days after elective surgery. Statistical Analysis: Descriptive analysis using SPSS software version 18 was used for statistical analysis. Results: There were 75 UIA (0.48%) recorded during the 2-year study period. The average age of patients was 54.64 ± 18.02 years. There was no sex predominance, and the majority of our patients had an American Society of Anesthesiologist classes 1 and 2. Nearly 29% of the UIA occurred after abdominal surgery and 22% after a trauma surgery. Regarding the causes of UIA, we observed that 44 UIA (58.7%) were related to surgical AE, 24 (32%) to anesthetic AE, and 7 (9.3%) to postoperative AE caused by care defects. Twenty-three UIA were judged as potentially preventable (30.7%). UIA was associated with negative outcomes, including increased use of ICU-specific interventions and high mortality rate (20%). Conclusions: Our analysis of UIA is a quality control exercise that helps identify high-risk patient groups and patterns of anesthesia or surgical care requiring improvement.

Accident vasculaire cérébral ischémique révélant un syndrome de Fahr

Le syndrome de Fahr est défini par la présence de calcifications intracérébrales bilatérales et symétriques, non artériosclérotiques, localisées aux noyaux gris centraux. La découverte de celles-ci au cours d’un accident cérébrale ischémique constitue un mode de révélation exceptionnelle de cette affection et doit faire pratiquer une étude du métabolisme phosphocalcique avec dosage de la PTH. L’analyse des signes clinico-biologiques et radiologique est à la base du diagnostic. Un traitement antiépileptique au long cours peut favoriser les calcifications au niveau des noyaux gris centraux et induire le syndrome qui reste de bon pronostic. La correction des troubles du métabolisme phosphocalcique amène souvent une amélioration notable.Fahrs syndrome is defined as the presence of bilateral intracerebral, symmetrical, nonarteriosclerotic calcifications involving the basal ganglia. Their detection during stroke is exceptional. Phosphocalcium metabolism should be investigated with human parathyroid hormone (HPH) dosage. Diagnosis is based on the evaluation of clinical and laboratory data as well as on radiological imaging. Long-term antiepileptic treatment can cause basal ganglia calcification resulting in Fahrs syndrome. Prognosis is favorable. The correction of phosphocalcium metabolism usually leads to significant improvement.

Erector spinae plane block for pediatric hip surgery

Surgical repair of the hip is considered an extremely painful procedure. Managing pain in this surgery is challenging even with several available options, each with limitations. Erector spinae plane (ESP) block is a novel technique that has been used in different types of surgery, with promising results. Herein, we describe a case of a successful ESP block for pediatric hip surgery. In the future, ESP block could be an alternative technique for providing effective analgesia.

Nebulized ketamine to avoid mechanical ventilation in a pediatric patient with severe asthma exacerbation

&NA; Asthma is a major cause of morbidity and mortality despite advances in outpatient treatment. Sometimes, children fail to respond to standard treatment and can potentially require mechanical ventilation. We describe a case of a 26‐month‐old girl with a severe asthma exacerbation successfully managed by ketamine administration via nebulization route that permitted to avoid mechanical ventilation. Nebulized ketamine might be a reasonable option to avoid mechanical ventilation in children who fail to respond to standard treatment of severe asthma exacerbation.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient.

Anesthetic management of spontaneous cervical epidural hematoma during pregnancy: a case report

BackgroundSpontaneous spinal epidural hematoma during pregnancy is a quite rare event requiring emergent decompressive surgery in the majority of cases to prevent permanent neurological damage. Therefore, there is little data in the literature regarding anesthetic management of cervical localization during pregnancy. The potential for difficult airway management with the patient under general anesthesia is one of the major concerns that needs to be addressed to prevent further cord compression. Anesthetic management should also include measures to maintain the mean arterial pressure to improve spinal cord perfusion. Furthermore, spine surgery in pregnant patients needs special consideration in terms of positioning and in the postoperative period.Case presentationWe present a case of a 35-year-old white woman at 21 weeks of gestation with a spontaneous cervical epidural hematoma. Fiberoptic bronchoscope-guided nasal intubation was a safe option to ensure a higher rate of successful endotracheal intubation while minimizing the risk of aggravating the injury. Her care posed other multiples challenges that required a multidisciplinary team approach.ConclusionsThe case of our patient serves as a reminder of this rare condition and its implications regarding anesthesia.

Stercoral colitis mimicking appendicitis

BackgroundStercoral colitis is an inflammatory process involving the colonic wall related to fecal impaction. This rare condition is associated with high morbidity-mortality.FindingsWe report a case of a 78-year-old woman with a history of dementia under clozapine who presented a clinical and sonographic presentation of acute appendicitis. The worsening of her clinical condition prompted us to review our diagnosis and modify our approach using the CT scan which was consistent with stercoral colitis. This report concerns an atypical presentation of this condition.ConclusionsThe present case highlights the ability of severe forms of fecal impaction to precipitate very rare and life-threatening complications like stercoral colitis. It also points the importance of including stercoral colitis in the differential diagnosis of acute appendicitis in altered patients under anticholenergic drugs and the critical role of the CT scan as a crucial radiologic adjunct.

Gitelman syndrome: a rare life-threatening case of hypokalemic paralysis mimicking Guillain–Barré syndrome during pregnancy and review of the literature

In rare cases, patients with Gitelman syndrome may present with hypokalemic paralysis mimicking Guillain–Barré syndrome. The severity of resultant symptoms may be life‐threatening. Controversial drugs such as aldactone, amiloride, and eplerenone should be used in this situation despite the lack of safety data.

Use of sugammadex in parotid surgery: a case report

BackgroundParotid surgery is a common ear, nose, and throat procedure. Facial nerve paralysis is the main feared complication following this surgery. To avoid this paralysis, intraoperative facial nerve monitoring is often used, but neuromuscular blocking agents interfere with this technique. Therefore, the neuromuscular blocking agent used should have a short duration of muscle relaxation. With the discovery of sugammadex, a steroidal neuromuscular blocking agent has acquired the potential to be used in place of succinylcholine.Case presentationA 41-year-old African woman was scheduled for a parotidectomy at our hospital. Rocuronium-induced neuromuscular block was reversed intraoperatively with sugammadex to facilitate identification of facial nerve function. The facial nerve was identified without incident, and surgical conditions were good for the removal of the tumor. During postoperative follow-up, no evidence of residual paralysis has been noted.ConclusionsIn parotid surgery, the use of sugammadex allows free use of a steroidal neuromuscular blocking agent for intubation and thus intraoperative facial nerve monitoring can be done safely.

Perioperative visual loss following transurethral resection surgery: not always a transurethral resection syndrome.

To the Editor, Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder, the diagnosis of which is based on clinical and abnormal neuroimaging findings. The visual loss associated with PRES may be difficult to distinguish from similar findings in transurethral resection (TUR) syndrome, resulting in diagnostic delay. We focus here on the differential diagnosis and investigation required to distinguish between these conditions. Written informed consent was obtained from the patient to publish this report. A 67-yr-old man (height 170 cm, weight 78 kg) with a history of untreated hypertension and benign prostatic hypertrophy underwent TUR of the prostate under spinal anesthesia. Preoperative serum electrolytes and blood count were normal. In the operating room, his blood pressure (BP) was 135/85 mmHg, and heart rate (HR) was 68 beats min. Spinal anesthesia was administered with 12 mg of hyperbaric bupivacaine (0.5%) and 25 lg fentanyl at the L3-4 level. The patient was placed in the lithotomy position, and the BP increased to 160/85 mmHg. Transurethral resection proceeded using monopolar electrocautery and 1.5% glycine irrigation solution. Forty minutes into the procedure, the patient reported the acute onset of bilateral blindness. Apart from the visual loss, he was conscious and had no other neurological deficits. His BP was 210/140 mmHg, HR 90 beats min, and SpO2 100%. The total amount of irrigation fluid absorbed was not recorded. We suspected TUR syndrome, so the surgery was stopped and the patient transferred to the intensive care unit. His serum sodium was 119 mEq L, and calculated serum osmolality was 245 mmol L. Other conditions, such as retinal ischemia and ischemic optic neuropathy, were excluded because of a normal fundoscopic examination and the bilateral involvement. Symptoms suggestive of cerebral edema (e.g., preserved light perception; dilated, non-reactive pupils) were present. A computed tomography scan of the head was obtained and was negative for structural neurologic injury. An intravenous infusion of 3% saline solution at a rate of 0.5 mL kg hr was started with furosemide 20 mg. His blood pressure dropped to 145/95 mmHg and remained slightly above the normal range (150/90 to 170/95 mmHg) without further therapy. Forty-eight hours later, his vision loss persisted despite normalization of serum sodium (136 mmol L). Glycine and their metabolites (glyoxylic, oxalic acid) are major inhibitory neurotransmitters in both the retina and the central nervous system. Considering that the halflife of glycine is 85 min, this mechanism seemed unlikely to be the cause of persistent visual loss. Ammonia, another metabolite of glycine, can impair vision, but the patient’s serum levels were not elevated (50 lg dL). A psychiatric assessment ruled out a conversion disorder. With other causes eliminated, we considered the diagnosis of PRES. This syndrome is characterized by headache, altered mental function, seizures, and visual disturbances. An acute increase in blood pressure is regarded as the main risk factor for PRES. Hypertension causes temporary impairment of autoregulation of the cerebral vasculature, leading to breakdown of the bloodbrain barrier, vasogenic edema, and endothelial A. Elkoundi, MD (&) M. Bensghir, PhD M. Meziane, MD C. Haimeur, PhD Department of Anesthesiology and Intensive Care, Military Hospital Med V of Rabat, Faculty of Medicine and Pharmacy of Rabat, University Souissi-Med V, Rabat, Morocco e-mail: abd.el.koundi@gmail.com