[ gangrene diabetic of the lower limb: epidemiology and factors of choice of the best anesthetic technique]

Objective: The identification of the epidemiological characteristics as well as the comparison of the anesthetic techniques of the patients presenting a gangrene of the foot diabetic [general anesthesia versus locoregional anesthesia]

Material and method: Descriptive, retrospective study spread over the year 2013 and realized in the operating block of the emergencies of the military hospital of Rabat. The criteria of inclusion were an age of more than 18 years, and an amputation at the level of the lower limb further to a gangrene evolving in a context of known or inaugural diabetes. The incomplete files were excluded. Various epidemiological, clinical, biological and therapeutic parameters were collected. The various used anesthetic techniques were compared in term of modifications perioperative hémodynamiques, speed to reduce the hyperglycemia, arisen post-operative short-term complication, appeal in the analgesia operating comment as well as the total duration of intervention

Results: During year 2013, 118 patients were listed among which 109 only included. The average age of the patients was 58.3 +/- 11 years old [extremes: 25-86 years] among which 81.6% were male [40 men, 9 women]. The gangrene was localized at the level of a foot [61.5%], of a toe [34.9%], by a leg [2.7%] or of a thigh [0.9%]. The biological characteristics of the patients in the admission were characterized by a hyperleucocytose, hyponatremia, a light acidose and a renal insufficiency. The quantity of the perfused solution in preoperative was 250 +/- 132 mL with administration of an initial bolus of 10 UI of fast insulin. The antibiotic treatment was with amoxicillin/clavulanic acid [66.7%], of cefazolin [22.8%], of amoxicilline/clavulanic acid + metronidazol [6.3%] and of metronidazol only [4.2%]. The used anesthetic techniques were a plexique block [62.2%], a spinal anesthesia [24.7%], a local anesthetic [8.5%] and a general anesthesia [4.6%]. These various techniques were compared in term of modifications perioperative hémodynamiques, speed to reduce the hyperglycemia, arisen post-operative short-term complication, appeal in the analgesia operating comment as well as the total duration of intervention. The quantity of the perfusd solution it peropératoire was 775 +/- 409 mL. The premedication was made by the midazolam. The hemodynamic variations were important in the group spinal anesthesia and local anesthetic. The reduction of hyperglycemia as well as the duration of intervention were more important in the group general anesthesia. The post-operative consequences were marked by the arisen of a hemorrhagic shock at three sick [3.3%] and with a toxic shock at a sick person [1.1%]. Our study showed the advantage to realize plexique blocks compared with the other anesthetic techniques

Conclusion: Our therapeutic protocol which consists of an adapted hydro electrolytic resuscitation e metabolic preoperative and favors plexiques blocks allowed to reduce the incidence of the hemodynamics peroperative variations and the post-operative complications but would require to have patients' more important staff and to be compared with other similar studies

[Critical analysis of the prescription of the assay of troponine Ic]

The roponine Ic is a good tool diagnosis and forecast in the assumption of responsibility of cardiac ischemic pathologies. Its requirement in the mergency department often exceeds the framework of the international recommendations. Our objective of this work is to evaluate the practices concerning the regulation of the proportioning of TnIc. This is a study that was conducted over a period of one month from 01/04/ 2009 to 30/04/2009. Sixty-six patient who benificie of a regulation of the proportioning of the TnIc. On the whole, 130 proportionings were carried out, with the method of the first proportioning to the admission, then a second 6 to 9 hours after, in the event of negativity of the first. The reasons for admission having led to the regulation of proportioning are: thoracic pain [63%], dyspnea [18,4%], disorders of conscience [7.8%], epigastric pains [6.8%], dysarythmy [4%]. The number of pathological results of TnIc according to the symptoms of calls is of 20 cases for the thoracic pains, 3 for dyspnea, 4 for the disorders of conscience. The number of pathologicalresults of TnIc according to diagnosed pathology is of 17 per 27 cases of SCA,6 per 15 case of cardiac failure, 2 per 7 cases of ischemic heart disease, 1 per 18 cases of atypical thoracic pains and 1 per 9 cases of acute edema of the lungs. This study confirms that the proportioning of TnIc is required ill-advisedly in a large number of cases considering the percentage of pathological results [20,8%]. This proportioning as that of any biological marker is only one help with the diagnosis. These results suggests that a better control of the use of TnIc, is essential on the part of the prescribers

Diabetic neuropathy and peri operative period in general surgery: about 164 cases

The objective of our study is to evaluate the morbidity of diabetic neuropathy, during peri operative time in a general surgery unit. This retrospective study was conducted between January 2002 and December 2004 in the Military Hospital Mohamed V in Rabat. All diabetic patients with a diabetic neuropathy and who had surgery were included [164 upon 516 diabetic patients]; mean age is 54.6 +/- 10.2 years and type 1 diabetes was present in 56% of the cases. The diagnosis of diabetic neuropathy was based on a careful clinical examination. A distal and symmetrical neuropathy was found in 91% of the cases; a proximal and symmetrical neuropathy in 10% and a diabetic foot in 68%. In these patients, neuropathy was associated to hypertension [29%], to renal insufficiency [9%] and to cardiac disease 4%. Diabetic neuropathy was significantly associated to a higher hospitalization duration [p<0.05] and to a higher postoperative incidence of infection

Infection in diabetic patient in emergency

This retrospective study was conducted to evaluate the place of infection in diabetic ketoacidosis in an emergency unit. It included 214 patients who were admitted for ketoacidosis and in whom an infection was identified. The infection was present in almost all patients and it seemed to be the direct cause of decompensation in 41%. The diagnosis was made on the clinical signs and the biological evaluation. On the 112 urinalysis performed, 45 were positive and on the 43 hemocultures, 9 were positive. An empirical antibiotherapy was started on admission in 88 cases. Thirty four patients had a severe sepsis of whom 21 developed a septic shock and 13 [6%] were transferred to the Intensive Care Unit; 4 patients died [1.9%]. We found a strong correlation between the initial presence of infection and the occurrence of at least one organ dysfunction [p=0.0001]

[Incidence and risk factors of nosocomial infections in gravelly traumatised patients]

To evaluate the incidence and the risk factors of the nosocomial infections [NT] in gravelly traumatized patients. It is a retrospective study of 6 months concerning a cohort of patients admitted in resuscitation department for a grave traumatism [ISS >/= 15]. The risk factors of NI were studied in univariate and multivariate analyses. The study included 55 patients [54 men and 1 woman], the average age was 36 +/- 13 years, the ISS of 19.3 +/- 3. The incidence of NI was 49%, the pulmonary localization was most frequent [81%]. The variables related to occurrence of NI in the gravelly traumatized patients were a low GCS [p<0.001], an associated cranial traumatism [p = 0.004], high scores of gravity: IGS II [p = 0.04], APACHE 11[0.01] and ISS [p = 0.006], the recourse [p = 0.001] and the duration of artificial ventilation [p<0.0001]. The logistic regression retained two independent variables: the low GCS [OR: 3.9; IC95% = 1.6 - 88; p = 0.011. In this work the incidence of NI in of a gravelly traumatized patients was high [49%], it was dominated by the pulmonary localization. The low GCS and the duration of artificial ventilation were independent risk factors

[Cerebral toxoplasmosis revealing a neuro-Aids]

Cerebral infection to toxoplasmosis is an opportunist infection. Its radiological aspect is not specific. It concernes male patient of 38 years old, treated from Crohn disease since three months, who was presented by infectious intracranial hypertension syndrome, symptomatic treatment was prescribed. In front his clinical aggravation, a multiple intracranial MRI was done, which showed a miliary encephalitis. Tubercolous origin was thought of and the patient received an anti-tubercolous treatment. Secondary, stereotaxic biopsy and biological study showed an advanced stage of toxoplasmosis infection reveals to a neuro-Aids. Through this observation, the authors paid an attention to think always in the eventuality of neuro-Aids in front of cases of miliary encephalitis