Choc hémorragique péri-opératoire au Centre Hospitalier Universitaire Androva, Mahajanga, Madagascar

Introduction : Le choc hypovolémique est une défaillance circulatoire aiguë et critique, mettant rapidement en jeu le pronostic vital. L'objectif de l'étude était de déterminer les aspects épidémio-cliniques et la prise en charge du choc hémorragique periopéraoire au centre hospitalier de Mahajanga. Méthodes : Il s'agit d'une étude rétrospective, descriptive, observationnelle et monocentrique réalisée dans le service de Réanimation Chirurgicale du CHU PZaGa de Mahajanga, sur une période de 52 mois. Les données socio-démographiques, les paramètres cliniques périopératoires, la prise en charge médico-chirurgicale, l'évolution et les retentissements organiques de l'état de choc hémorragique ont été les paramètres étudiés. Résultats : Nous avons collecté 6896 dossiers des patients, dont 70 cas de choc hémorragique ont été recensés (1,02%) pour tout type de chirurgie ; 62 dossiers ont été retenus dans l'étude. La majorité des cas était du genre féminin (87,10%). Les pathologies gynéco-obstétricales étaient la principale source de l'état de choc de (77,4%), dont 59,4% d'hémorragie du post-partum. L'insuffisance rénale aiguë était la principale atteinte viscérale (61%, n=38) suivie de 10% (n=6) des cas des troubles neurologiques. Tous les patients ont bénéficié d'une oxygénothérapie, et d'un remplissage vasculaire par des cristalloïdes et 3,2% ont eu des colloïdes. Les substances vasoactives utilisées étaient l'éphédrine 41,9%, suivie de l'adrénaline 27,4% et de la noradrénaline 17,7%. Vingt-sept virgule quarante pourcent de nos patients étaient décédés, et la cause la plus incriminée était la coagulopathie par défibrination. Conclusion: Les hémorragies obstétricales constituent la première cause de choc hémorragique ; le taux de mortalité reste encore élevé.

Causes de décès en milieu de réanimation polyvalente au Centre Hospitalier Universitaire Analakininina, Madagascar / Causes of death in the intensive care unit Of the Analakininina teaching hospital, Madagascar

Background: Intensive Care Unit unit is taking care the serious patients whose vital prognosis is engaged. Death remains the main fear of those patients who are admitted to intensive care. The main objective of our study was to identify the causes of death in the intensive care unit at the Analakininina teaching hospital, Toamasina, madagascar. Methods: This was a descriptive, retrospective study carried out from January 1, 2019 to June 30, 2019. Results: We had identified 110 cases of death with a high male prevalence and a sex ratio of 1.75. The average age was 48.73 +/- 17.60 years. The main reason for admission was disturbance of consciousness in 63.64% of cases with 24.45% of severe coma. Regarding the causes of death, a total of 25 diagnosis were made. The shock states represented 30% of the causes of death of which 69% were septic, 18% cardiogenic and 15.15% hypovolemic. Next, stroke accounted for 28%, cerebral malaria 7.27% and diabetic coma accounted for 5.45% of causes of death. The average length of hospital stay was 1.91 days. Conclusion: Our study provides a better understanding of the causes of death of patients in the intensive care unit. These data can point towards initiatives to improve the quality of care

Consensual coital vaginal laceration in hypovolaemic shock: A report of two cases

Background:Certain life-threatening complications and morbidities may occur following consensual sexual intercourse which may not be commonly experienced in clinical practice. One of such complications is hypovolaemic shock resulting from profuse bleeding.AbstractMethods:Two cases of vaginal laceration complicated by hypovolaemic shock following consensual sexual intercourse are presented.Results:Both patients had resuscitation with intravenous fluid, blood transfusion and subsequent examination under anaesthesia with repair of laceration in theater. Post-operative recovery period was uneventful and they were both discharged after proper counselling. Conclusion:Bleeding from coital laceration could be life threatening. Prompt treatment should be instituted in such cases

Perspectives on aetiology, pathophysiology and management of shock in African children

Paediatric shock is still a common emergency of public health importance with an estimated 400,000­500,000 reported cases annually. Mortality due to paediatric shock has varied over the years. Data in 1980s show that mortality rates due to septic shock in children were over 50%; but by the end of the year 2000 data indicated that though a marked decline in mortality rates had been achieved, it had stagnated at about 20%. Descriptions of paediatric shock reveal the lack of a common definition and there are important gaps in evidence-based management in different settings. In well-resourced healthcare systems with well-functioning intensive care facilities, the widespread implementation of shock management guidelines based on the Paediatric Advanced Life Support and European Paediatric Advanced Life Support courses have reduced mortality. In resource limited settings with diverse infectious causative agents, the Emergency Triage Assessment and Treatment (ETAT) approach is more pragmatic, but its impact remains circumscribed to centres where ETAT has been implemented and sustained. Advocacy for common management pathways irrespective of underlying cause have been suggested. However, in sub Saharan Africa, the diversity of underlying causative organisms and patient phenotypes may limit a single approach to shock management.Data from a large fluid trial (the FEAST trial) in East Africa have provided vital insight to shock management. In this trial febrile children with clinical features of impaired perfusion were studied. Rapid infusion of fluid boluses, irrespective of whether the fluid was colloid or crystalloid, when compared to maintenance fluids alone had an increased risk of mortality at 48 h. All study participants were promptly managed for underlying conditions and comorbidity such as malaria, bacteraemia, severe anaemia, meningitis, pneumonia, convulsions, hypoglycaemia and others. The overall low mortality in the trial suggests the potential contribution of ETAT, the improved standard of care and supportive treatment across the subgroups in the trial. Strengthening systems that enable rapid identification of shock, prompt treatment of children with correct antimicrobials and supportive care such as oxygen administration and blood transfusion may contribute to better survival outcomes in resources limited settings

Elevated International Normalised Ratios Correlate with Severity of Injury and Outcome

Background. Haemorrhagic shock is the leading cause of preventable early deaths from trauma. Acute coagulopathy on admission to a trauma unit is associated with worse outcomes. The relationship of haemorrhage to early mortality remains consistent regardless of mechanism of injury. Haemorrhage and haemorrhagic shock are increasingly amenable to interventions that result in reductions in morbidity and mortality.Objectives. To assess the prevalence of coagulopathy in patients admitted to the level 1 trauma unit at Inkosi Albert Luthuli Central Hospital; Durban; South Africa; and correlate it with in-hospital mortality.Methods. A retrospective analysis of the first 1 000 patients admitted to the trauma unit during the years 2007 - 2011 was performed. The admission international normalised ratios (INRs) were correlated with Injury Severity Scores (ISSs) and in-hospital mortality. A multivariable Poisson model with robust standard errors was used to assess the relationship between coagulopathy and mortality after adjustment for the confounding influence of age and gender. The data were analysed using the R statistics program. Results.Of the 1 000 patients; 752 were male. There were 261 admissions directly from the scene and 739 inter-hospital transfers (non scene). The mean INRs among survivors for all; scene and non-scene patients were 1.33; 1.30 and 1.34; respectively; and those among non-survivors 1.92; 2.01 and 1.88; respectively (p0.001). The overall prevalence of coagulopathy was 48.7%; 46.9% in scene patients and 49.2% in non-scene patients. The mortality rate of scene patients with abnormal INR levels was 41.1% (adjusted relative risk (aRR) 3.59; 95% confidence interval (CI) 2.11 - 6.44; p0.001) v. 25.1% for non-scene patients (aRR 1.67; 95% CI 1.15 - 2.05; p

The acute inflammatory response in trauma / hemorrhage and traumatic brain injury: current state and emerging prospects

Traumatic injury/hemorrhagic shock (T/HS) elicits an acute inflammatory response that may result in death. Inflammation describes a coordinated series of molecular; cellular; tissue; organ; and systemic responses that drive the pathology of various diseases including T/HS and traumatic brain injury (TBI). Inflammation is a finely tuned; dynamic; highly-regulated process that is not inherently detrimental; but rather required for immune surveillance; optimal post-injury tissue repair; and regeneration. The inflammatory response is driven by cytokines and chemokines and is partially propagated by damaged tissue-derived products (Damage-associated Molecular Patterns; DAMP's). DAMPs perpetuate inflammation through the release of pro-inflammatory cytokines; but may also inhibit anti-inflammatory cytokines. Various animal models of T/HS in mice; rats; pigs; dogs; and non-human primates have been utilized in an attempt to move from bench to bedside. Novel approaches; including those from the field of systems biology; may yield therapeutic breakthroughs in T/HS and TBI in the near future. Key words: Trauma; Hemorrhagic Shock; Taumatic Brain Injury; Inflammation; Systems Biology