Mohammed Meziane

Accès veineux périphériques au bloc opératoire : caractéristiques et facteurs prédictifs de difficulté

PURPOSE To investigate of predictors 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 patients 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. Predictors 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.

Utilisation d'un vidéolaryncoscope pour une intubation difficile en chirurgie thoracique

Enfin, l’administration d’épinéphrine par voie sous-cutanée a prévenu une éventuelle hypotension orthostatique consécutive à la sympathoplégie due à la péridurale et au fait que, dans les avions des compagnies low-cost, le voyageur est en position assise stricte sans possibilité d’inclinaison du fauteuil. En outre, les seules personnes qui accompagnaient la patiente, son conjoint et sa fille, n’avaient aucune connaissance médicale ou paramédicale.

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.

Moyamoya disease in a Moroccan baby: a case report

BackgroundA stroke in a baby is uncommon, recent studies suggested that their incidence is rising. Moyamoya disease is one of the leading causes of stroke in babies. This condition is mostly described in Japan. In Morocco, moyamoya disease has rarely been reported and a few cases were published. We report a rare Moroccan case of a 23-month-old baby boy who presented with left-sided hemiparesis and was diagnosed as having moyamoya disease.Case presentationA 23-month-old full-term Moroccan baby boy born to a non-consanguineous couple was referred to our hospital with the complaint of sudden onset left-sided hemiparesis. On neurological examination, there were no signs of meningeal irritation, his gait was hemiplegic, tone was decreased over left side, power was 2/5 over left upper and lower limb, and deep tendon reflexes were exaggerated. Preliminary neuroimaging suggested an arterial ischemic process. Clinical and laboratory evaluation excluded hematologic, metabolic, and vasculitic causes. Cerebral angiography confirmed the diagnosis of moyamoya disease. Our patient was treated with acetylsalicylic acid 5 mg/kg per day and referred to follow-up with pediatric neurosurgeon. Cerebral revascularization surgery using encephaloduroarteriosynangiosis was performed. At 8-month follow-up, his hemiparesis had improved and no further ischemic events had occurred.ConclusionThis case highlights the importance of considering moyamoya disease to be one of the classic etiologies of acute ischemic strokes in children from North Africa. It also emphasizes the rare presentation among the African population and the use of neurovascular imaging techniques to facilitate diagnosis of moyamoya disease.

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.

Refractory collapse and severe burn: Think about acute adrenal insufficiency

Introduction: Adrenal insufficiency (AI) is a rare endocrine disorder, which can in its acute form be life‐threatening in case of late diagnosis or treatment. The stress during a thermal burn can easily decompensate the AI. We report the case of an acute adrenal insufficiency (AAI) discovered following a refractory collapse occurred after a severe thermal burn. Case presentation: A 60‐year‐old woman was accidentally burned to the lower limbs by hot water. Total burn surface area was 36 %. The patient had local care and dressings, vascular filling, and analgesics. Four hours later, she became dyspneic, and presented tachycardia associated with collapse at 60/40 mmHg. Suspecting a hypovolemic origin, we performed a solid fluid replacement with colloids. However, hemodynamic stability was not achieved and motivated a continuous injection of norepinephrine. Despite high doses, immediate evolution was marked by a persistent precarious hemodynamic state. AAI was suspected, and a substitutive hormonotherapy was started. The clinical condition progressively improved and catecholamines were quickly stopped. Conclusion: AAI is a vital emergency. The large burn is a possible cause of the AI decompensation. This diagnosis must be kept in mind when the hemodynamic status remains unstable despite an adequate vascular treatment.

Embarrure suite à l’utilisation de la têtière de Mayfield chez l’adulte: à propos d’un cas et revue de la littérature

Many neurosurgical procedures involve the use of a pin-type headrest to immobilize the patients head. We report the case of depressed skull fracture in an adult patient secondary to the use of Mayfield headrest. The diagnosis was based on postoperative CT scan of the brain following surgical resection of medulloblastoma. Several factors seem to increase the risk of complications due to Mayfield headrest use. Preventive measures are outlined in our literature review.

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

Anesthesia for endoscopic retrograde cholangiopancreatography: target-controlled infusion versus standard volatile anesthesia

Background Endoscopic retrograde cholangiopancreatography (ERCP) is a technique used both for diagnosis and for the treatment of biliary and pancreatic diseases. ERCP has some anesthetic implications and specific complications. The primary outcome aim was to compare two protocols in terms of time of extubation. We also compared anesthetic protocols in terms of hemodynamic and respiratory instability, antispasmodics needs, endoscopist satisfaction, and recovery room stay. Methods Patients were randomized into two groups standard anesthesia group (Gr: SA) in whom induction was done by propofol, fentanyl and cisatracurium and maintenance was done by a mixture of oxygen, nitrousoxide (50%:50%) and sevoflurane; and intravenous anesthesia group to target concentration (Gr: TCI) in whom induction and maintenance of anesthesia were done with propofol with a target 0.5-2 μg/mL, and remifentanil with a target of 0.75-2 ng/mL. Results 90 patients were included. Extubation time was shorter in Gr: TCI, 15±2.6 vs. 27.4±7.1 min in Gr: SA (P<0.001). The incidence of hypotension was higher in GrL: SA (P=0.009). Satisfaction was better in Gr: TCI (P=0.003). Antispasmodic need was higher in Gr: SA (P=0.023). Six patients in Gr: SA group had desaturation in post-anesthesia care unit (PACU) versus one patient from Gr: TCI (P=0.049). Patients in Gr: TCI had shorter PACU stay 40.2±7.3 vs. 58.7±12.4 min (P<0.001). Conclusion The use of TCI mode allows better optimization of general anesthesia technique during ERCP.