V. Minville

Hématome péridural chez une parturiente au décours d'un choc hémorragique

RésuméObjectifĽhématome péridural est une complication exceptionnelle mais grave de ľanesthésie péridurale. Nous rapportons un cas ďhématome péridural en obstétrique, survenu aprèas le retrait accidentel du cathéter péridural en période ďhypocoagulabilité au décours ďun choc hémorragique.Éléments cliniquesUne patiente avait bénéficié ďune anesthésie péridurale pour le travail, aprèas vérification du bilan ďhémostase. Une hémorragie et des troubles importants de ľhémostase (plaquettes: 16 x 10-9·L-1; temps de prothrombine: 85 sec) sont survenus en post-partum. La situation hémodynamique a été rétablie aprèas une anesthésie générale, une transfusion de produits sanguins, un remplissage et une ligature des artèares hypogastriques. Le retrait accidentel du cathéter péridural a été constaté en période ďhypocoagulabilité. La patiente a par la suite présenté un déficit neurologique évoquant une compression médullaire par un hématome péridural. La réalisation ďune imagerie par résonance magnétique a montré la présence ďun hématome péridural étendu de T3 à L5 de caractèare peu compressif, faisant choisir ľoption ďune abstention thérapeutique avec une surveillance clinique et radiologique rapprochée. La patiente n’a pas présenté de séquelles par la suite.ConclusionEn présence ďun hématome péridural, le recours à une chirurgie de décompression médullaire en urgence reste nécessaire dans la majorité des cas. Ľoption ďune surveillance neurologique est de plus en plus décrite comme une autre solution intéressante dans certains cas mais reste mal codifiée.AbstractPurposeEpidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state.Clinical featuresA patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10-9·L-1, thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae.ConclusionIn the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.PURPOSE Epidural hematoma is a rare but serious complication of epidural anesthesia. We report a case of epidural hematoma, occurring in an obstetric patient after the epidural catheter had been withdrawn accidentally after an episode of hemorrhagic shock leading to a hypocoagulable state. CLINICAL FEATURES A patient had the epidural catheter inserted during labour when coagulation was normal. She had a postpartum hemorrhage with alteration of coagulation (platelets 16 x 10(-9) x L(-1), thrombin time: 85 sec. Vital signs returned to normal after a general anesthetic, transfusion of blood products, volume repletion and ligation of hypogastric arteries. It was then noticed that the epidural catheter had been withdrawn inadvertently while the patient was hypocoagulable. The patient then developed neurological signs consistent with spinal cord compression due to an epidural hematoma. A hematoma extending from T3 to L5 was diagnosed by magnetic resonance imaging. Because the cord had minimal compression, no specific action was undertaken, other than clinical and radiological follow-up. There were no long-term sequelae. CONCLUSION In the presence of an epidural hematoma, surgery for emergency cord decompression is usually required. Another option that receives increasing attention is to monitor neurological function, but the indications for this expectant treatment are not well defined.

Contrôle de la température : les moyens d’action en pratique ☆

Mild therapeutic hypothermia can provide neuroprotection in some clinical situations (postanoxic cardiac arrest, neonatal anoxia). Techniques to induce hypothermia are based on thermal exchanges, in particular conduction and convection. There are several external cooling techniques: application of ice packs, cold moistened towel, ice-cold devices, ventilation of cooled air, water- or air-cooled circulating mattresses or devices. These techniques are frequently used because of their reduced cost. Internal cooling techniques are more limited and more expensive: ice-cold perfusion, endovascular catheters, extracorporeal circulation, but they offer more efficiency (high speed to reach and to maintain the temperature target). Drugs can also induce hypothermia, either by decreasing body temperature, e.g. paracetamol and aspirin, or by blocking shivering, e.g. neuromuscular blocking agents, opioids and alpha2-agonist.

Embolie pulmonaire et grossesse

OBJECTIVE Pulmonary embolism remains a leading cause of maternal death in France and in other developed countries. Prevention is well codified, but management remains complex both for diagnosis and therapeutics. The objective of this review was to update the knowledge on diagnosis and treatment of pulmonary embolism during pregnancy. ARTICLE TYPE Review. DATA SOURCE Medline(®) database looking for articles published in English or French between 1965 and 2012, using pulmonary embolism, pregnancy, heparin, thrombolysis and vena cava filter as keywords. Editorials, original articles, reviews and cases reports were selected. DATA SYNTHESIS Pulmonary embolism is one of the leading causes of maternal death in France. Clinical signs and biologic tests are not specific during pregnancy. Doppler ultrasound is helpful for diagnosis and avoids maternal and fetal radiation. Treatment is based on full anticoagulation. Low molecular weight heparin is the treatment of choice. A temporary vena cava filter may be proposed, especially at the end of pregnancy, or when heparin is contraindicated. In case of pulmonary embolism with cardiogenic shock, thrombolysis is an alternative treatment. CONCLUSION Diagnostic approach is first based on the use of ultrasound- Doppler, and frequently on-to computed tomographic pulmonary angiography or ventilation-perfusion lung scanning. The treatment is based on low molecular weight heparin. Others therapeutics, such as thrombolysis or temporary vena cava filter, may be useful in certain circumstances.

Revue généraleEmbolie pulmonaire et grossessePulmonary embolism and pregnancy

OBJECTIVE Pulmonary embolism remains a leading cause of maternal death in France and in other developed countries. Prevention is well codified, but management remains complex both for diagnosis and therapeutics. The objective of this review was to update the knowledge on diagnosis and treatment of pulmonary embolism during pregnancy. ARTICLE TYPE Review. DATA SOURCE Medline(®) database looking for articles published in English or French between 1965 and 2012, using pulmonary embolism, pregnancy, heparin, thrombolysis and vena cava filter as keywords. Editorials, original articles, reviews and cases reports were selected. DATA SYNTHESIS Pulmonary embolism is one of the leading causes of maternal death in France. Clinical signs and biologic tests are not specific during pregnancy. Doppler ultrasound is helpful for diagnosis and avoids maternal and fetal radiation. Treatment is based on full anticoagulation. Low molecular weight heparin is the treatment of choice. A temporary vena cava filter may be proposed, especially at the end of pregnancy, or when heparin is contraindicated. In case of pulmonary embolism with cardiogenic shock, thrombolysis is an alternative treatment. CONCLUSION Diagnostic approach is first based on the use of ultrasound- Doppler, and frequently on-to computed tomographic pulmonary angiography or ventilation-perfusion lung scanning. The treatment is based on low molecular weight heparin. Others therapeutics, such as thrombolysis or temporary vena cava filter, may be useful in certain circumstances.

The importance of blood platelet lipid signaling in thrombosis and in sepsis

Blood platelets are the first line of defense against hemorrhages and are also strongly involved in the processes of arterial thrombosis, a leading cause of death worldwide. Besides their well-established roles in hemostasis, vascular wall repair and thrombosis, platelets are now recognized as important players in other processes such as inflammation, healing, lymphangiogenesis, neoangiogenesis or cancer. Evidence is accumulating they are key effector cells in immune and inflammatory responses to host infection. To perform their different functions platelets express a wide variety of membrane receptors triggering specific intracellular signaling pathways and largely use lipid signaling systems. Lipid metabolism is highly active in stimulated platelets including the phosphoinositide metabolism with the phospholipase C (PLC) and the phosphoinositide 3-kinase (PI3K) pathways but also other enzymatic systems producing phosphatidic acid, lysophosphatidic acid, platelet activating factor, sphingosine 1-phosphate and a number of eicosanoids. While several of these bioactive lipids regulate intracellular platelet signaling mechanisms others are released by activated platelets acting as autocrine and/or paracrine factors modulating neighboring cells such as endothelial and immune cells. These bioactive lipids have been shown to play important roles in hemostasis and thrombosis but also in vessel integrity and dynamics, inflammation, tissue remodeling and wound healing. In this review, we will discuss some important aspects of platelet lipid signaling in thrombosis and during sepsis that is an important cause of death in intensive care unit. We will particularly focus on the implication of the different isoforms of PI3Ks and on the generation of eicosanoids released by activated platelets.

État des lieux des transmissions médicales en réanimation en Midi-Pyrénées

INTRODUCTION Medical handover is critical for quality of care in ICU. Time assigned to medical handovers can vary across different units, with significant impact on the organization of medical work. We aimed to study the time spent for medical handover in ICU and its variation across academic, general and private hospitals in the area of the South West of France, the Midi-Pyrénées region. METHODS Between August and October 2010, we questioned by phone, 86 physicians issued from 19 different ICUs. This prospective observational study mainly focused on four items: units characteristics, health diaries organization, medical handovers procedures, and self-assessment of satisfaction for medical handover (numeric scale from 0 to 10). RESULTS Eleven general hospital centers, three private hospitals, five university hospitals were concerned by the survey. The mean time spent for medical handover was 59±35 min on monday morning, significantly longer than other days, evening, and to weekend handovers (P<0.001 for all comparisons). When reporting it to the number of ICU bed, the time spent for handover per patient was significantly shorter in private hospital compared to general and academic hospital (P<0.05 for all comparison). CONCLUSION Time spent for medical handover is important, with an approximate total time of 1h 30 min on monday, and 1h the other days. Physician in private hospitals spend less time for medical handovers. This fact should be considered for medical timework organization, especially in academic hospital and in hospital with large ICU.

Dopexamine test in septic shock with hyperlactatemia.

OBJECTIVE To evaluate the 6 hours haemodynamic effects of dopexamine (DPX) infusion in septic shock patients with persistent hyperlactatemia treated with high dose of norepinephrine (NE). STUDY DESIGN Preliminary, prospective, uncontrolled study. PATIENTS Twenty-one septic shock with NE>0.5 μg/kg/min, venous mixed oxygen saturation (ScvO(2)/SvO(2))>70%, cardiac index (CI)>3.5 l/min/m(2) and lactate>3 mmol/l. INTERVENTIONS Infusion of DPX at 0.5 μg/kg/min. After 6 hours, patients were classified as DPX-responders or DPX-non-responders according to the presence or not of a decrease ≥20% in lactatemia. MEASUREMENT DPX-responders and DPX-non-responders were compared with MAP, CI, central venous pressure (CVP), heart rate (HR) before infusion of DPX (h0), 30 minutes (h0.5) and 6 hours later (h6); and with NE infusion rate at h0 and h6. RESULTS Eleven (52%) patients were DPX-responders and 10 (48%) DPX-non-responders. At H0.5, DPX-responders increased MAP more than DPX-non-responders (+21% versus +7%, P=0.01) with no change in CI, CVP and HR in both groups. At h0.5, an increase in MAP higher than 14%, compared to h0, could predict lactate clearance at h6 (sensitivity 91%, specificity 90%). From h0 to h6, increase in MAP (80±7 versus 70±8 mmHg, P<0.01) in DPX-responders allowed reduction in NE infusion (from 1.6±0.3 to 0.4±0.3 μg/kg/min, P<0.01); 28-day mortality was lower in DPX-responders than in DPX-non-responders (7 versus 90%, P<0.01). CONCLUSION This study suggests that DPX did induce a decrease in lactatemia in 52% of septic shock, that could be predict by an increase in MAP (>14% within 30 minutes). Controlled studies are needed to confirm those preliminary results.

Le propofol pour réaliser une rachianesthésie en position latérale chez les victimes d’une fracture du fémur

ObjectifLe but de cette étude était d’évaluer la faisabilité et l’efficacité du propofol avant la mobilisation en décubitus latéral chez les patients âgés, victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une rachianesthésie.MéthodeUne étude prospective et descriptive a été réalisée chez 79 patients consécutifs de plus de 75 ans ayant une fracture de l’extrémité supérieure du fémur. Le propofol (0,5 mg·kg−1) était injecté au départ. Si la perte de conscience n’était pas obtenue (score de Ramsay ≤ 3/6), d’autres injections de 0,25 mg·kg−1) étaient administrées jusqu’à l’obtention d’un score de Ramsay de 4 ou 5. Ensuite, le patient était placé en décubitus latéral, le membre fracturé vers le haut. l’efficacité du propofol a été évaluée sur la grimace, ainsi que sur le souvenir d’une douleur à la mobilisation. Les données hémodynamiques et la saturation en oxygène étaient aussi notées.RésultatsUne seule injection de propofol a été nécessaire chez 43 patients, deux injections chez 34 patients et trois injections chez deux patients. Aucune grimace n’a été remarquée dans cette étude, et aucun patient n’a eu le souvenir d’une douleur lors de la mobilisation. Aucune désaturation (SpO2 < 92%), ni chute de tension (diminution de la pression artérielle systolique d’au moins 30%) n’a été observée.ConclusionLe propofol est un moyen simple et efficace d’assurer un confort pendant la mobilisation des patients âgés victimes d’une fracture de l’extrémité supérieure du fémur, pour la réalisation d’une anesthésie médullaire.AbstractPurposeThe aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic.MethodsIn this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg·kg−1, was administered. If loss of consciousness was not obtained (Ramsay score ≤ 3/6), then additional doses of 0.25 mg.kg−1 were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected.ResultsForty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO2 < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed.ConclusionPropofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.PURPOSE The aim of this study was to assess the feasibility and efficacy of propofol before positioning elderly patients with a femoral neck fracture in the lateral decubitus position, to perform a spinal anesthetic. METHODS In this prospective and descriptive study, 79 consecutive patients, > 75 yr old, with a femoral neck fracture were included. Propofol, 0.5 mg x kg(-1), was administered. If loss of consciousness was not obtained (Ramsay score < or = 3/6), then additional doses of 0.25 mg x kg(-1) were given until a Ramsay score of 4 or 5 was attained. Then, the patient was turned to the lateral decubitus position, the fractured side up. The efficacy of propofol was assessed by observing a grimace during positioning and asking the patients if they had recall of pain. Hemodynamic data and oxygen saturation were collected. RESULTS Forty-three patients required a single injection, 34 required two injections and only two patients required three injections. No grimace and no recall of pain were recorded during the study. There was no desaturation (SpO(2) < 92 %), and hypotension, defined as a systolic blood pressure decrease > 30% from baseline, was observed. CONCLUSION Propofol is a simple and efficacious means of providing comfort while positioning elderly patients with a femoral head fracture before performing spinal anesthesia.

Accidental dural puncture: combination of prophylactic methods to avoid post-dural puncture headache.

Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effective treatment of PDPH. Prophylactic BP has shown its efficacy to prevent PDPH; nevertheless, this method may be insufficient. We report an ADP case before induction of labor in a 28-year-old parturient. To avoid PDPH, an intrathecal catheter was immediately inserted after ADP and an epidural catheter was also inserted at the interspace above. Catheters were kept in place for more than 24hours. A prophylactic BP was performed immediately after removal of the intrathecal catheter. The patient did not experience any headache. This combination of treatments (intrathecal catheter insertion+prophylactic BP) may be a good alternative approach to prevent PDPH, even if it has to be warranted by other clinical studies.

Arrêt cardiorespiratoire par embolie gazeuse à partir d’une voie veineuse périphérique

Au redacteur en chef, Si les risques l’embolie gazeuse a partie d’une voie veineuse centrale sont bien documentes, ceux imputables aux voies veineuses peripheriques semblent moins frequents. Nous rapportons le cas d’un arret cardiorespiratoire cause fort probablement par une embolie provenant d’un catheter veineux peripherique. Un homme de 18 ans etait hospitalise pour prise en charge chirurgicale d’une osteite tibiale compliquant une fracture ouverte. En postoperatoire, malgre une evolution favorable, une voie veineuse peripherique de calibre 18G au pli du coude etait maintenue. Au troisieme jour apres la chirurgie, souhaitant s’habiller, le patient deconnecta lui-meme le raccord de la tubulure de sa voie veineuse puis leva les bras a la verticale pour enfiler un vetement tout en realisant une profonde inspiration. Aussitot, il s’est plaint a sa famille, presente dans la chambre, d’un malaise, accompagne d’une baisse de l’acuite visuelle, puis il a perdu connaissance. L’anesthesiste arriva en quelques minutes et retrouva un patient en coma peu reactif (score de Glasgow = 5), haletant et sans pouls ni tension arterielle. Une reanimation cardiorespiratoire a ete rapidement debutee (ventilation et massage cardiaque externe), permettant une reprise rapide de l’activite cardiaque et respiratoire accompagne de breves convulsions intermittentes. Le catheter a ete occlus. Le patient a ete intube apres une induction a sequence rapide, et ventile. Le diagnostic d’embolie gazeuse a ete suspecte suite a l’interrogatoire de la famille et tenant compte du fait que le catheter n’etait pas raccorde a la tubulure. La tomographie cerebrale, l’angiographie thoracique, l’echocardiographie transthoracique et les prelevements biologiques realises peu apres l’evenement etaient tous normaux. Devant un contexte clinique fort evocateur et l’absence d’autres etiologies possibles, le diagnostic d’arret cardiorespiratoire par embolie gazeuse a ete retenu. Le patient a beneficie d’une seance d’oxygenotherapie hyperbare, puis a ete transfere a l’unite de soins intensifs, ou l’evolution a ete rapidement favorable. Il a ete extube 48 h apres l’arret cardiaque. L’examen clinique apres une semaine etait normal. L’embolie gazeuse est une pathologie rare, aux consequences souvent lourdes en l’absence de traitement specifique, dont l’etiologie est aujourd’hui le plus souvent iatrogene. Les causes medicales les plus incriminees sont la ponction des gros troncs veineux (veines sous clavieres et jugulaires). Les rares cas publies rapportent la survenue d’embolie gazeuse chez de jeunes enfants, essentiellement apres perfusion sur une tubulure mal purgee. Un cas d’embolie gazeuse au cours d’une perfusion intra osseuse chez un enfant a ete rapporte. A ce jour, aucun cas a partir d’une voie veineuse peripherique n’a ete decrit chez l’adulte. L’embolie gazeuse veineuse passive (par aspiration), comme ce fut probablement le cas ici, se produit a travers l’orifice d’un catheter quand l’air, a pression atmospherique, est en contact avec une veine ou regne une pression inferieure, donc negative. Dans notre observation, le gradient de pression etait majore par la position de la veine au dessus du plan de l’oreillette droite quand le malade a leve les bras : a plus de 25 cm de l’oreillette droite, la tension veineuse est alors d’environ -25 cm H2O, et par la baisse de pression intrathoracique concomitante (donc de la tension veineuse centrale) induite par une grande inspiration. Les examens complementaires biologiques et d’imagerie sont souvent peu sensibles et ont surtout l’interet d’eliminer d’autres M. Ponchet, MD C. Chassery, MD V. Minville, MD (&) CHU Toulouse Rangueil, Universite Paul Sabatier, Toulouse, France e-mail: minville.v@chu-toulouse.fr