C. Landy

Complication of intraosseous administration of systemic fibrinolysis for a massive pulmonary embolism with cardiac arrest.

We managed a 53-year-old man for suspected acute respiatory failure. Accessing a peripheral vein was very difficult. efore insertion of venous access, the patient developed ventriclar fibrillation (VF) cardiac arrest. We started cardiopulmonary esuscitation (CPR) with chest compressions. An intraosseous (IO) atheter (EZ-IO®, Vidacare®) was inserted into the proximal tibia. fter 30 min of resuscitation, including injection of adrenaline, e remained in asystole. Echocardiography showed marked right entricular dilatation and a collapsed left ventricle. We susected massive pulmonary embolism (MPE) and gave thrombolysis Acteplase 0.6 mg kg−1). Five minutes later, sinus rhythm was estored. Femoral venous access was inserted and the IO catheter as removed. The patient was treated successfully in the intensive are unit (ICU) for post cardiac arrest syndrome with multi-organ ailure. He had few residual neurological sequelae. A large extensive ecrosis of the anteromedial side of the right leg appeared in the IO nsertion area (Fig. 1) 48 h later. Medical treatment failed, thus surical excision was performed followed by vacuum-assisted closure. fter 5 weeks in the ICU, vacuum therapy was pursued for 3 weeks n the dermatology department with repetitive surgical dressing. lceration persisted on the whole anteromedial side of the right eg with direct exposure of bone. The computed tomography (CT)

Seizures associated with local anaesthetic intoxication

cannot support specific recommendations. The cardiovascular profile of pancuronium suggests that it can produce cardiovascular stimulation possibly by a direct action and an increased release/decreased reuptake of catecholamines at the adrenergic nerve terminals. b-Adrenoreceptors and M2 muscarinic receptors possibly play a significant role in pancuronium-induced cardiac responses. 6 Pancuronium has been found to have a higher potency for interaction with cardiac muscarinic receptors compared with newer neuromuscular blockers. On the other hand, as shown in Supplementary Table S1 of our review, there is sufficient evidence supporting the lack of significant cardiac effects of newer neuromuscular blockers, such as atracurium, cisatracurium, and rocuronium. Based on the above, we consider that pancuronium is probably not the first-choice neuromuscular blocker for patients with arrhythmogenic syndromes (as ARVD), even though serious adverse effects have not been observed in the authors’ clinical practice, or confirmed in relevant clinical reports. In conclusion, pancuronium seems to have a less favourable cardiovascular profile compared with newer neuromuscular blockers according to electrophysiological studies. Regarding neuromuscular blockers and ARVD, relevant literature is inadequate to support specific recommendations. On the other hand, as it is prudent for the physicians always to be on the safe side, we consider that neuromuscular blockers with minimal cardiovascular effects should be preferred over pancuronium in patients who are at risk of arrhythmias, as are patients with ARVD.

Another Use of Continuous Transversus Abdominis Plane (TAP) Block in Trauma Patient: Pelvic Ring Fractures

Dear Editor: We would like to respond to the article published by Allcock et al. ⇓ describing the use of continuous transversus abdominis plane (TAP) block for analgesia in major abdominal surgery in a combat surgical environment. We report the successful use of an unconventional indication of this block in two patients who had painful traumatic pelvic ring fractures. The first patient was admitted to the intensive care unit following motor vehicle accidents with a stable pelvic fracture, left acetabular fracture, and right iliac wing and right ischium fractures. Immobilization was indicated. She had a severe left hip pain, 90/100 on the numerical rating scale (NRS). The NRS is a self-report assessment scale for patients using numbers (0 to 100) in order to rate the intensity of their pain. A multimodal analgesia with paracetamol, nefopam, and intravenous patient-controlled analgesia (PCA) with morphine was started. After morphine was administered (20 mg on 4 hours), the patient experienced drowsiness and bradypnea without demonstrable effective analgesia (NRS = 70/100). A left ultrasound-guided …

Convulsions after normal dose of lidocaine: a probable drug interaction

Convulsions after normal dose of lidocaine: a probable drug interaction Editor—The case reports by Satsumae and colleagues and Pasquier and colleagues have addressed the question of sensitivity to local anaesthetics (LAs) with toxicity occurring at low plasma levels. We recently encountered a similar problem in a 74-yr-old woman (ASA II, 60 kg) who presented with generalized myoclonic movement after a brachial plexus block for radius fracture. Her medical history included dyslipidaemia treated with a statin, arterial hypertension with a hypertrophic cardiomyopathy treated using angiotensin-converting enzyme inhibitors, and atrial fibrillation treated with flecainide. We performed a brachial plexus block using ultrasound for surgery on the radius. After a negative aspiration test, lidocaine 300 mg with epinephrine was injected with repeated negative aspiration and under visual control. The radial nerve was not completely blocked and a further injection was done at the wrist with lidocaine 80 mg with epinephrine again with negative aspiration and ultrasound control. Thus, a total dose of lidocaine with epinephrine 380 mg was injected. After 15 min, the patient presented with general myoclonic movements. A venous blood sample drawn during the myoclonic movements showed a non-toxic lidocaine concentration of 4.2 mg litre. The flecainide plasma concentration at that time was 180 mg ml. The patient had no neurological disease, and blood glucose was normal. She was treated with 200 ml of Intralipid 20%. Surgery was possible after 30 min. CT scan and EEG recorded 2 weeks later were normal. It is generally accepted that toxic effects from lidocaine occur in a conscious subject at a plasma concentration exceeding 5 mg ml. For regional blocks, plasma concentrations are typically 3–5 mg ml, with toxic levels 6–10 mg ml. Our case describes seizures after a brachial plexus block with a normal dose of LA. Toxicity is still possible within clinical plasma concentration limits, without intravascular placement of the needle and injection using divided doses and frequent aspiration. A possible explanation is that the needle tip might have been placed within a small vein, so that the negative pressure aspiration resulted in apposition of the vessel wall against the needle. However, the 15 min delay between injection and the onset of symptoms is too long for direct i.v. injection. Therefore, seizures may occur after LAs absorption. A few case reports described toxicity of LA associated with a small dose. 2 The authors of one of these cases suggested that some patients may have a low tolerance to LA or that the threshold of toxicity varies with factors such as medication, hypercarbia, electrolytes abnormalities, and carnitine deficiency. In our case, the patient did not have electrolyte abnormalities or carnitine deficiency. We initially suspected low tolerance to the LA, but the patient was treated with flecainide. Flecainide is a type Ic anti-arrhythmic agent used for the treatment of supraventricular arrhythmias. It has a relatively narrow therapeutic window. Side-effects such as dizziness and visual disturbances, including diplopia, are not uncommon. However, severe neurological complications are rare. There are only four published case reports of serious flecainide-induced nervous toxicity, generalized seizures, and cerebello-myoclonic syndrome. It has been noted that plasma levels of above 700–1000 mg ml are associated with increased likelihood of adverse events. Lidocaine is an amide LA which is a class 1B anti-arrhythmic drug affecting nerve axon sodium channels, thus preventing depolarization. In our case, both flecainide and lidocaine were within their therapeutic range. An interaction with this anti-arrhythmic agent could potentially explain the LA toxicity observed and care may be needed with this combination of drugs.

Treatment of a life-threatening laryngeal bradykinin angio-oedema precipitated by dipeptidylpeptidase-4 inhibitor and angiotensin-I converting enzyme inhibitor with prothrombin complex concentrates

(etomidate 20 mg, fentanyl 150 mg, and suc-cinylcholine 75 mg). Once in the operating theatre, TEM study was performed at the beginning of surgery. The fibTEM MCF was 9 mm, and fibrinogen at the same time was 3.19 g litre 21 ; i.v. fibrinogen 30 mg kg 21 and tranexamic acid 25 mg kg 21 were given. Fetal extraction was performed with evacuation of a retroplacental haematoma affecting 30–40% of placental surface. During surgery, bleeding was estimated at about 1500 ml, and Ringers lactate 1500 ml was given. At the end of surgery, the patient was transferred to post-anaesthesia care unit (PACU) and discharged after 12 h, without symptoms or new episodes of bleedings. In the PACU, she received 1000 ml of Ringers lactate and one unit of packed red blood cells (PRBCs) as the haemoglobin was 7.2 g dl 21. Four hours after arrival in the PACU, the plasma fibrinogen level was 3.28 g litre 21 and fibTEM MCF reached 18 mm, while immediately before discharge, fibrino-gen plasma level was 3.31 g litre 21 and fibTEM MCF 21 mm. I.V. infusion of hydroxyethyl starch 130/0.4 (6%) may be accompanied by a marked overestimation of fibrinogen concentration measured according to the Clauss method. 5 It also appears to impair clot formation. 6 This impairment is accompanied by an increase in transfusion requirements resulting in a decline in MCF. 6 This effect lasts approximately for up to 2 h, 7 can be reversed with i.v. fibrinogen, and seems to be due to interference with formation of fibrin mesh. 6 Overestimation of fibrinogen concentration and interference with formation of fibrin mesh would explain the initial finding of a lower fibTEM MCF than expected, with a fibrino-genaemia of 3.19 g litre 21. 4 Meanwhile, both the treatment and disappearance of the effects of hydroxyethyl starch would explain the progressive increase in fibTEM MCF in spite of stable fibrinogen levels. In conclusion, hydroxyethyl starch 130/0.4 (6%) seems to be a friend to haemodynamics and a foe for haemostasis. 1 Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose tranex-amic acid reduces blood loss in postpartum haemorrhage. Crit Care 2011; 15: R117 2 Cortet M, Deneux-Tharaux C, Dupont C, et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. 4 Huissoud C, Carrabin N, Audibert F, …

Abcès compliquant un cathéter sciatique poplité

Nous avons lu avec intérêt l’article publié par Delfosse et al., [1] décrivant deux cas de complications infectieuses suite à la pose d’un cathéter périnerveux fémoral pour l’analgésie postopératoire. Nous décrivons un cas de complication infectieuse suite à la pose d’un cathéter périnerveux sciatique poplité. Le patient de 27 ans dont nous rapportons l’histoire, n’avait pas d’antécédent particulier et bénéficiait du traitement chirurgical d’un hallux valgus. L’anesthésie reposait sur la mise en place d’un cathéter sciatique au creux poplité permettant la chirurgie et l’analgésie postopératoire. Une préparation cutanée en quatre temps était réalisée : détersion à la povidone iodée moussante, rinçage, séchage, antisepsie par povidone iodée alcoolique. L’opérateur était revêtu d’une blouse et de gants stériles. Il portait un calot et un masque chirurgical. Le patient était en décubitus ventral. Un champage chirurgical de la zone de ponction était réalisé. Un cathéter avec filtre incorporé Plexolong 19G* 50 mm de marque Pajunk était mis en place à l’aide d’un neurostimulateur. Une seule ponction était nécessaire sans douleur, ni paresthésies. Vingt millilitres de ropivacaı̈ne 7,5 mg/mL était injecté. Un pansement occlusif transparent type Opsite 1 était appliqué afin de protéger le cathéter. En postopératoire, une administration continue de 8 mL/h de ropivacaı̈ne 2 mg/mL était réalisée. Suite à la survenue d’une douleur au niveau du point de ponction, le cathéter était retiré à j3. À j4, le patient était apyrétique, mais se plaignait de douleurs spontanées du creux poplité irradiant vers la fesse sans collection ni adénopathie inguinale à la palpation. L’examen révélait une zone ponctiforme blanchâtre au niveau du point de ponction entourée d’une zone inflammatoire de 2 * 3 cm de diamètre. On ne retrouvait aucun déficit sentivo-moteur. La CRP était à 9 mg/mL, les globules blancs à 13 420/mm avec des polynucléaires neutrophiles à 11 045/mm. L’échographie montrait un œdème sous-cutané sans collection. Le point de ponction était écouvillonné. Une

Use of a Fogarty catheter after tracheobronchial inhalation of a bead

Summary We describe a case of tracheobronchial inhalation of a bead by a five-year-old girl in Djibouti. The bead was extracted using a Fogarty balloon catheter passed through the rigid bronchoscope without complication. This kind of accident is not exceptional and we discuss the management of such cases with limited diagnostic tools and therapeutic environments.

Interest of ketamine for the management of a large foreign body in the trachea

1 Hamilton ND, Hegarty M, Calder A et al. Does topical lidocaine before tracheal intubation attenuate airway responses in children? An observational audit. Pediatr Anesth 2012; 22: 345–350. 2 Orliaguet GA, Gall O, Savoldelli GL et al. Case scenario: perianesthetic management of laryngospasm in children. Anesthesiology 2012; 116: 458–471. 3 Mamie C, Habre W, Delhumeau C et al. Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Pediatr Anesth 2004; 14: 218–224. 4 von Ungern-Sternberg BS, Boda K, Chambers NA et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376: 773– 783. 5 Xue FS, Li BW, Zhang GS et al. The Influence of surgical sites on early postoperative hypoxemia in adults undergoing elective surgery. Anesth Analg 1999; 88: 213–219. 6 Xue FS, An G, Tong SY et al. Influence of surgical technique on early postoperative hypoxaemia in children undergoing elective palatoplasty. Br J Anaesth 1998; 80: 447–451. 7 Morris IR. Pharmacologic aids to intubation and the rapid sequence induction. Emerg Med Clin North Am 1988; 6: 753–768. 8 Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med 2002; 27: 180–192.

Lettre à la rédactionAbcès compliquant un cathéter sciatique poplitéComplication of a continuous popliteal sciatic nerve block

Nous avons lu avec intérêt l’article publié par Delfosse et al., [1] décrivant deux cas de complications infectieuses suite à la pose d’un cathéter périnerveux fémoral pour l’analgésie postopératoire. Nous décrivons un cas de complication infectieuse suite à la pose d’un cathéter périnerveux sciatique poplité. Le patient de 27 ans dont nous rapportons l’histoire, n’avait pas d’antécédent particulier et bénéficiait du traitement chirurgical d’un hallux valgus. L’anesthésie reposait sur la mise en place d’un cathéter sciatique au creux poplité permettant la chirurgie et l’analgésie postopératoire. Une préparation cutanée en quatre temps était réalisée : détersion à la povidone iodée moussante, rinçage, séchage, antisepsie par povidone iodée alcoolique. L’opérateur était revêtu d’une blouse et de gants stériles. Il portait un calot et un masque chirurgical. Le patient était en décubitus ventral. Un champage chirurgical de la zone de ponction était réalisé. Un cathéter avec filtre incorporé Plexolong 19G* 50 mm de marque Pajunk était mis en place à l’aide d’un neurostimulateur. Une seule ponction était nécessaire sans douleur, ni paresthésies. Vingt millilitres de ropivacaı̈ne 7,5 mg/mL était injecté. Un pansement occlusif transparent type Opsite 1 était appliqué afin de protéger le cathéter. En postopératoire, une administration continue de 8 mL/h de ropivacaı̈ne 2 mg/mL était réalisée. Suite à la survenue d’une douleur au niveau du point de ponction, le cathéter était retiré à j3. À j4, le patient était apyrétique, mais se plaignait de douleurs spontanées du creux poplité irradiant vers la fesse sans collection ni adénopathie inguinale à la palpation. L’examen révélait une zone ponctiforme blanchâtre au niveau du point de ponction entourée d’une zone inflammatoire de 2 * 3 cm de diamètre. On ne retrouvait aucun déficit sentivo-moteur. La CRP était à 9 mg/mL, les globules blancs à 13 420/mm avec des polynucléaires neutrophiles à 11 045/mm. L’échographie montrait un œdème sous-cutané sans collection. Le point de ponction était écouvillonné. Une

Feasibility of a thoraco-abdominal CT with injection of iodinated contrast agent on sternal intraosseous catheter in an emergency department.

Fig. 1. Intraosseous trocar in sternal position. Opacification of the anterior thoracic venous system: axial section. Intraosseous device can replace intravenous access in emergency. In this letter, we report the first case of intraosseous injection of iodinated contrast agent on a Jamshidi (Cardinal Healt) trocar in the sternum of a 61-year-old man admitted to our emergency department for severe sepsis. This patient was known to the hospital, because he underwent a right hepatectomy (2 months) and colonic adenoma surgery for the treatment of liver metastases one year ago. On arrival, the patient was agitated and confused, with respiratory distress (88% saturation under high concentration oxygen mask). Blood pressure was 110/70 mmHg, and as the establishment of a peripheral vein was difficult, a Jamshidi (Cardinal Healt) trocar was inserted into the sternum. This catheter permitted the start of resuscitation: volume expansion, induction of anesthesia (rocuronium, etomidate), and tracheal intubation. Maintenance of sedation (midazolam and sufentanil) and pursuit of resuscitation were executed in the peripheral vein (18-gauge left arm). A thoracic and abdominal computed tomography was decided. However, when transferring, the patient’s hemodynamic situation deteriorated. A continuous infusion of norepinephrine on the peripheral vein was set up, not allowing the bolus injection of iodinated contrast agent. No other peripheral veins were readily accessible. The necessity of diagnosis led to the use of Jamshidi catheter for this injection. A total of 130 mL of ioversol (Omnipaque 350 mL/mL) was injected at 3 mL/s for a total administration time of 45 seconds on the injection system (Stelland Injection System, Medrad-France, 94623 Rungis). The CT scan was performed on an Optima CT 660 (General Electric healthcare Technology) using a collimation of 64 1.25 mm, with an increment of 1.25 mm and pitch of 1375. Reconstructions were performed in axial plane at 1.25 mm,