[Exertional heat stroke: about 4 cases]

Exertional heat stroke is defined as hyperthermia associated with neurological signs related to intense physical activity performed in a hot environment. This is a medical emergency and life-threatening. In this study, we investigated four cases of exertional heat stroke hospitalized at the military hospital in Tunis [Tunisia] to describe the clinical, therapeutic and preventive characteristics and factors favoring this disease. Four young soldiers, 23 to 44 years older, have developed Exertional heat stroke after Intense and prolonged exercise. Exercises were performed in May and June, in high ambient temperature, high humidity and lack of wind. Three soldiers were in battle dress, a backpack and their weapon. Our four subjects had overweight, were not sufficiently trained and were highly motivated. Insufficient hydration and a diet rich in carbohydrates were noted. Upon hospitalization, patients were febrile and had neurological disorders, neuromuscular disorders, rhabdomyolysis and hemoconcentration. The medical care consisted of a rehydration and oxygen

Risk of mishaps during intrahospital transport of critically ill patients

Background: Mishaps are common during transport and may have major impacts on patients

Aims: The main objectives of our study are: first to determine the incidence of complications during intra hospital transports [IHT] of critically ill patients, and second, to determine their risk factors

Methods: All intra hospital transports for diagnostic and therapeutic purposes of patients consecutively admitted in an 18-bed medical surgical intensive care unit in an university hospital, have been studied prospectively during a period of six months [September 1st 2012 to February 28th 2013]

Results: Of 184 transports observed [164 patients], 85 [46.2%] were associated with mishaps. Eighty two mishaps were patient-related [44.5%].Oxygen desaturation [30 cases], agitation [24 cases] and hemodynamic instability [15 cases] were predominantly. One case of cardiac arrest and 3 cases of accidental extubation were occurred during IHT. Seventy three systems-based mishaps were noted [39.6%]. Emergency transports, mechanical ventilation and positive end-expiratory pressure [PEEP] >/= 6 cmH2O were independent risk factors for a higher rate of mishaps. In our study, complications did not statistically increase ventilator-associated pneumonia

Conclusion: This study confirms that IHT of critically-ill patients still involves considerable risks and mishaps incidence remains high

Myocardial ischemic conditioning: physiological aspects and clinical applications in cardiac surgery

Ischemia-reperfusion is a major determinant of myocardial impairment in patients undergoing cardiac surgery. The main goal of research in cardioprotection is to develop effective techniques to avoid ischemia-reperfusion lesions. Myocardial ischemic conditioning is a powerful endogenous cardioprotective phenomenon. First described in animals in 1986, myocardial ischemic conditioning consists of applying increased tolerance of the myocardium to sustained ischemia by exposing it to brief episodes of ischemia-reperfusion. Several studies have sought to demonstrate its effective cardioprotective action in humans and to understand its underlying mechanisms. Myocardial ischemic conditioning has two forms: ischemic preconditioning [IPC] when the conditioning stimulus is applied before the index ischemia and ischemic postconditioning when the conditioning stimulus is applied after it. The cardioprotective action of ischemic conditioning was reproduced by applying the ischemia-reperfusion stimulus to organs remote from the heart. This non-invasive manner of applying ischemic conditioning has led to its application in clinical settings. Clinical trials for the different forms of ischemic conditioning were mainly developed in cardiac surgery. Many studies suggest that this phenomenon can represent an interesting adjuvant to classical cardioprotection during on-pump cardiac surgery. Ischemic conditioning was also tested in interventional cardiology with interesting results. Finally, advances made in the understanding of mechanisms that underlie the cardioprotective action of ischemic conditioning have paved the way to a new form of myocardial conditioning which is pharmacological conditioning

Lower incidence of hypotension following spinal anesthesia with 6% hydroxyethyl starch preload compared to 9% saline solution in caesarean delivery

Hypotension is a common complication following spinal anesthesia for cesarean delivery. Techniques to prevent hypotension include preloading intravenous fluid. To compare the effect of two preloading regimens: 6% hydroxyethyl starch [HES] and 9‰ saline solution, to prevent hypotension after spinal anesthesia in cesarean delivery. 105 patients undergoing intrathecal anesthesia for elective cesarean delivery were randomized and allocated to receive a preload of 500 ml HES 130/0.4 [HES Group] or a preload of 1500 ml 9‰ saline solution [CR group]. Blood pressure and heart rate were recorded at baseline and after spinal anesthesia [every minute for the first 10 min, every 3 min for the next 10 min, and then every 5 min for the last 20 min]. The primary outcome was to compare the incidence of hypotension [defined as a 20% reduction in systolic arterial pressure from baseline] between the two preloading regimens. Vasopressor requirements [i.v. bolus of 6 mg ephedrine] were also compared. The incidence of hypotension was 87% in the CR group and 69% in the HES group [p= 0.028]. Ephedrine requirement, incidence of nausea, and/or vomiting and neonatal outcome did not significantly differ between the two groups. The incidence of hypotension was lower after preloading of 500 mL of HES 130/0.4 than preloading with 1500 mL of 9‰ saline solution

Ultrasound does not shorten the duration of procedure but provides a faster sensory and motor block onset in comparison to nerve stimulator in infraclavicular brachial plexus block / 대한마취과학회지

BACKGROUND: Infraclaviculr Brachial plexus (ICBP) block is useful for upper extremity surgery. The aim of this study was to compare the ultrasound (US) technique with the nerve stimulation (NS) technique in their success rates and times to perform ICBP block. METHODS: 60 patients undergoing surgery of the upper limb were randomly allocated into two groups (n = 30 per group). Group 1; US, and Group 2; NS. Procedure time (including time for initial ultrasound examination), the success rate and the onset time of sensory and motor blockade were assessed. RESULTS: The time needed to perform the ICBP block is similar in both groups (220 seconds +/- 130 in US group versus 281 +/- 134 seconds in NS group; P = 0.74). The success rate of all the nerve blocks in the US group was 100%. The success rate in the NS group was 73.3%, 76.7%, 76.7% and 100% for radial, ulnar, medial, and musculocutaneous nerve, respectively. A significantly faster onset of sensory block for the radial, ulnar, median, musculocutaneous, and the four nerves considered together were observed. The onset of motor block for the radial, ulnar, and medial nerves was faster in the US group. However, the onset of motor block for the musculocutaneous nerve and the four nerves considered together was comparable between the two groups. CONCLUSIONS: The ultrasound-guided infraclavicular brachial plexus block is a significantly efficacious method with faster onset but similar procedure time compared to the nerve stimulation technique.

[Effects of 15 mcg intrathecal clonidine added to bupivacaine and sufentanil for labor analgesia]

For the combined spinal epidural analgesia for labour, 30 mcg of subarachnoid clonidine has proved its effectiveness to extend the analgesia, but increased severe hemodynamic effects. To assess the effectiveness and the safety of 15 mcg intra thecal clonidine for labour analgesia. Four months, prospective, randomised, simple blind Study, including ASA I or II women, with mono foetal pregnancy. Patients were randomised in 2 groups: SB Group received intra thecal isobaric bupivacaine 2.5 mg and sufentanil 5 mcg and SBC Group received 15 mcg clonidine added to the same doses of bupivaca‹ne and sufentanil. Epidural analgesia was used when VAS is more than 30. Studied parameters were: delay of installation, duration of analgesia, VAS score, hemodynamic parameters and the incidence of maternal and neonatal side effects. Sixty pregnant women were included [27 in SBC Group and 33 in SB group]. The duration of initial analgesia was significantly longer in the SBC group [145 +/- 43 min] compared with the SB group [98 +/- 28 min]. The delay of analgesia, sensory level and motor block level were similar. There was neither significant increase of the low incidence of blood pressure nor of the ephedrine consumption. The abnormalities of fetal heart rate, the mode of delivery and the incidence of side effects were also similar. The addition of 15 mcg intra thecal clonidine to the bupivacaine and the sufentanil during combined spinal epidural analgesia for obstetrical labour results in extended significantly duration of analgesia without increasing side effects

Transcranial Doppler and cerebral tomodensitometry scan in the predictivity of intracranial hypertension

To compare transcranial Doppler ultrasonography [TCD] and cerebral tomodensitometry [CT], in the predictivity of intracranial hypertension [ICH]. Sixteen patients, with a median age of 47 years, under continuous monitoring of intracranial pressure [ICP] were included in a double blinded prospective study. Each time a CT was performed the left and right middle cerebral arteries were insonated. With TCD, ICH is noted if the worst mean blood flow diastolic velocity was less than 25 cm/s, associated with a pulsatility index value larger than 1.2. Cerebral tomodensitometry was analysed and the ICH noted if one or more of the following radiographic signs was present [disappearance of sulci, effacement of ventricles, reduction of the white-grey matter differentiation, basal cistern compression, hydrocephalus and midline shift higher to 5 mm]. The median initial Glasgow Coma Score was 8 +/- 3. Intracranial pressure monitoring was undertaken in the following situations: 10 severe head injury, 4 strokes and 2 cerebral tumours. A total of 30 CT were carried out. Fourteen patients presented at least one episode of ICH. During episodes of ICH, TCD correlated with ICP in 64% of the cases, whereas CT correlated with ICP in 68% of the cases. In the absence of ICH the correlation of TCD and ICP decreased to 37.5%. In 4 cases of ICH, data of CT were not in favour of ICH while TCD correlated with ICP. Associating TCD and CT allows to detect ICH in 86% of cases vs. 68% only with CT [p=0.15] and vs. 64% only with TCD [p=0.08]. Transcranial Doppler ultrasonogrpahy is equivalent to CT in the predictivity of an ICH. This predictability is better in cases of ICH [ICP > 20 mmHg]. Associating TCD to CT allows to recover the majority of the cases of ICH not detected by CT alone

Effect of intra and postoperative magnesium sulphate infusion on postoperative pain

Evaluate the effect of intra and postoperative magnesium sulphate infusion on postoperative pain in abdominal surgery. Prospective double-blind randomized controlled study. Forty eight patients were randomly allocated to receive in the induction of anaesthesia, intraoperatively and six hours postoperatively either magnesium sulphate M Group [bolus 50mg/kg and 0.5g/h] or placebo [P Group]. Patients were given a dose of morphine [0.l mg/kg] IV, 45min before the end of surgery. Sedation, pain scores, cumulative morphine consumption and adverse effects were recorded up to 24 hours postoperatively. The duration of anaesthesia was similar in both groups. The time of the first demand of morphine was significantly longer in M Group then in P Group, respectively [18 +/- 5min vs 7 +/- lmin, p = 0.03]. Morphine consumption was significantly higher in control group than M group on the first postoperative day [52 +/- 4mg vs 30 +/- 3mg, p = 0.0002]. Pain scores were significantly lower in M group than in P group. Serum magnesium concentration was significantly higher in the M group. The frequency of side effects was similar in the two groups. The results of the study support magnesium sulphate as useful adjuvant for postoperative analgesia in abdominal surgery

Spinal anesthesia for endoscopic urological surgery- low dose vs. varying doses of hyperbaric bupivacaine

The aim of this study is to compare the efficiency of low dose vs. varying doses of hyperbaric bupivacaine in spinal anesthesia for endoscopic urological procedures. Sixty consecutive patients were studied in a randomized prospective manner. They received either of 5 [Gr I], 7.5 [Gr II] or 10 mg [Gr III] of hyperbaric bupivacaine 0.5% combined with 25 micro g of fentanyl, through a 25-gauge W hitacre spinal needle placed in the L3-L4 interspace. Characteristics of sensory and motor block, dose of ephedrine required, secondary effects, the patients, and the surgeons, satisfaction, were noted. The maximum number of blocked segments was 14 +/- 1 [Gr I], 15 +/- 2 [Gr II] and 16 +/- 2 [Gr III]. Time to T12 regression was significantly shorter for Gr I [53 +/- 13 min] than for Gr II [69 +/- 20 min] or Gr III [94 +/- 14 min]. Bromage 3 block was not found in Gr I compared to 4 patients in Gr II and 15 patients in Gr III. The duration of motor block was shorter in Gr 1[51 +/- 18 min] than in Gr II [86 +/- 19 min] and in Gr III [138 +/- 21 min]. Ephedrine was used for 16 patients in Gr III [9.8 +/- 12.2 mg], 5 patients in Gr II [3.7 +/- 7.8 mg] and 2 patients in Gr I [0.5 +/- 1.5 mg]. The difference is statistically significant between Gr III and the other groups. These results suggest that the use of a low dose of bupivacaine [5 mg] added to fentanyl [25 micro g] for endoscopic urological surgery, resulted in short-acting sensory block, without motor block and a lower incidence of cardiovascular side effects, as compared to either of 7.5 or 10 mg bupivacaine with 25 micro g fentanyl

[Successful use of levosimendan in a patient with cardiogenic shock complicating acute myocardial infarction]

Levosimendan is a new inodilator that improves cardiac contractility by sensitizing troponin C to calcium. This drug has proved to be effective in treating advanced congestive heart failure but has not been evaluated in cardiogenic shock. We present the case of a 54-year-old male patient treated successfully with levosimendan for cardiogenic shock following acute myocardial infarction. Treatment with dobulamine, revascularisation and intra-aortic balloon conterpulsation had first failed to improve his hemodynamic variables. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by an increase in cardiac index and mixed venous oxygen saturation. Left ventricular ejection fraction improved from 25% to 47%. Infusion of levosimendan can be used in cardiogenic shock without side effects and to improve hemodynamics and left ventricular function