[Epidemiologic and prognostic aspects of nosocomial bacteremia in the intensive care unit]. / Aspect epidemiologique et pronostic des bacteriemies nosocomiales en reanimation.

The nosocomial bacteremia (NB) are frequent and associated to a high mortality and morbidity with extension of stay in the intensive care unit (ICU). The aim of this study is to evaluate epidemiological aspect and prognosis of NB. It is a retrospective study about 872 patients hospitalized in our unit during 2 years. The diagnosis of the NB is based on two positive hemocultures with 24 hours of interval in the patients who are hospitalized more than 48 hours. The incidence of the bacteremia represents 6.6% (n = 58). The portal of entry is noticed in 55% of the cases (n = 32). The most frequent origin is respiratory infection 24% (n = 14), whereas bacteremia after catheter colonization represents 3.4% (n = 2). Gram Positive cocci were incriminated in more than 53% of the cases (n = 39). Staphylococcus aureus was the first causal germ (n = 28) whereas the Pseudomonas is the most frequent of the gram negative bacilli that represent 41% of the isolate germs (n = 31). The sensitibility of this germ to ceftazidim and imipenen was respectively 18% and 19%. The rate of the resistant Staphylococcus to meticilline was 38%. The whole mortality represented 28% (n = 16) that 7% (n = 14) of the cases were directly in relationship with the septic shock. Among prognostic factors evaluated, only septic shock and multivisceral failures are correlated to mortality. NB mortality is not negligible in ICU. Staphylococcus and Pseudomonas are the most frequent germs. Limitation of invasive acts, rigorous antibiotherapy management and observance of hygienic measures will significantly reduce incidence of NB.

[Post-traumatic carotid-cavernous fistula]. / Fistules carotido-caverneuses post-traumatiques.

The authors report three cases of carotid-cavernous fistula occurring after severe cranio facial trauma. The diagnosis has been suspected on the association of a pulsatil exophtalmia and systolo-diastolic murmur, and confirmed by arteriography. Embolization was successful in two patients, the third one died from neurologic complication before embolization. The carotid cavernous fistula is a rare but severe complication of a craniofacial trauma. The functional (blindness) and vital prognosis (subarachnoid and intracerebral haemorrage). Treatment by interventional neuroadiology has considerably improved the outcome.

[Stab wound of the spinal cord complicated by meningitis and subarachnoid fistula]. / Plaie vertébro-médullaire par arme blanche compliquée de méningite et de fistule du liquide céphalorachidien.

We describe a case of penetrating spinal cord injuries in an 20-year-old man after stab wound attack. The outcome was complicated with subarachnoid fistula and meningitis. The diagnosis and management of these complications are discussed.

The effect of oral etilefrine premedication on the incidence of hypotension during spinal anaesthesia.

This study was designed to determine the efficacy of oral etilefrine in preventing hypotension induced by spinal anaesthesia. Forty patients, ASA grade I or II, aged 23-60 years, scheduled for orthopaedic surgery involving the lower extremity under spinal anaesthesia were studied. The patients were randomly allocated to one of two groups; the etilefrine group (n = 20) received oral etilefrine 15 mg (30 drops), 60 min before the subarachnoid block, and the control group (n = 20) received no etilefrine. Patients were given 0.5% isobaric bupivacaine intrathecally. Hypotension was defined as a 30% decrease from base-line for systolic arterial pressure and mean arterial pressure or systolic value <90 mmHg, and was treated with intravenous boluses of etilefrine 2 mg. The overall incidence of spinal anaesthesia induced hypotension was 25%, ranging from 20% in the etilefrine group to 30% in the control group. The fall in systolic arterial pressure and mean arterial pressure was significantly greater in the control group than in the etilefrine group (P < 0.05). The patients in the etilefrine group received less etilefrine supplement than those in control group and no subject in the etilefrine group required repeat etilefrine doses, while in the control group five patients received multiple etilefrine doses (P < 0.05). The mean heart rate remained fairly stable throughout the study periods. We conclude that oral etilefrine, given 60 min before surgery, reduces the fall in blood pressure during spinal anaesthesia.

[Cervical extradural hematoma revealing hemophilia]. / Hématome extra-dural cervical révélateur d'une hémophilie.

BACKGROUND: Neurological hemorrhagic complications are unusual in hemophiliacs. Extradural hematoma is an exception, particularly at the cervical level. Less than 10 cases have been reported in the literature. We report a new case which was the inaugural sign of hemophilia A. CASE REPORT: Moderate hemophilia A was revealed by post-traumatic cervical extradural hematoma in a 12-year-old boy. Pain in the cervical spine and progressive tetraplegia led to the diagnosis, confirmed by cervical CT scan. The dissonance between the injury and the minor trauma led to hemostasis exploration which revealed factor VIII at 3%. After prompt correction of the deficiency, total laminectomy allow removal of the hematoma. The neurological course was satisfactory. CONCLUSION: We stress the specific character of this association and the previously unreported mode of hemophilia disclosure. CT scan and MRI facilitate diagnosis allowing satisfactory course after emergency decompressive laminectomy.

[Asphyxiating intra-alveolar hemorrhage: a rare form of fat embolism syndrome]. / Hémorragie intra-alvéolaire asphyxiante: forme rare du syndrome d'embolie graisseuse.

We report a case of a 23-year-old patient admitted for a right femur fracture resulting from a traffic accident. An intra-alveolar haemorrhage occurred 48 hours later, with asphyxia anaemia, haematic bronchial aspirations, and bilateral alveolar opacities at chest X-ray. This symptomatology was associated with fever, sub-conjunctival petechiae, major hypocholesterolemia, deterioration of renal function, and cholestasis. All these features suggested a fat embolism. Other possible aetiologies were discarded because of normal cardiovascular and immunologic systems and absence of infection. The outcome under symptomatic treatment was satisfactory within 15 days. The occurrence of intra-alveolar haemorrhage in post-traumatic fat embolism is a rare event caused by pulmonary capillary obstruction by fat emboli.

[Acute obstructive renal insufficiency and pregnancy. Apropos of a case]. / Insuffisance rénale aiguë obstructive et grossesse. A propos d'un cas.

Acute renal failure caused by obstruction by the gravid uterus is a rare complication of pregnancy. We report a case of obstructive acute renal failure in a patient at 28 weeks of gestation. Serum creatinine was 65 mg/l. Ultrasound examination showed a solitary right kidney. The course was marked by premature delivery. Renal function spontaneously returned to normal. This case suggests that acute obstructive uropathy should be considered to be a physiological phenomenon, especially on the right side.

[Paraplegia after cardiac arrest]. / Paraplégie après arrêt cardiaque.

We report a case of a permanent flaccid paraplegia, with a sensory loss at T12 level, not associated with cerebral damage, subsequent to a cardiac arrest of 15 minutes duration, in a 67-year-old patient, undergoing haemorragic surgery for gangrenous purulent cholecystitis. Besides cardiovascular collapse and subsequent circulatory arrest, possible favouring factors include anatomical anomalies in the territory of anterior spinal artery, surgical posture with hyperlordosis generating venous stasis, emergency haemostatic maneuvers with compression of the arterial territory providing spinal blood supply. Spinal cord lesions are probably more frequent than expected, as the often associated cerebral anoxic encephalopathy impedes their recognition. Only a systematic anatomopathological examination of the spinal cord, in patients who died after a cardiac arrest, would provide the accurate incidence of spinal complications.

[Acute phostoxin poisoning]. / Intoxication aiguë au phostoxin.

Phostoxin is a mixture of aluminium phosphide and ammonium carbonate. When exposed to water, it releases phosphorus hydrogen (PH3), a highly-poisonous gas. In Morocco, death rate from suicide due to self-administration of phostoxin pills is high. Clinical signs include abrupt digestive and nervous disorders. Pulmonary oedema or cardiogenic shock dominate early prognosis. Liver and renal damage is secondary. Prevention requires both legal constraints and regulation of sales.

[Neurologic manifestations of fat embolism]. / Manifestations neurologiques de l'embolie graisseuse.

Neurologic manifestations are usual and variable during post-traumatic fat embolism. The pathogenesis of these lesions continues to be a source of considerable controversy. Thirteen cases of post-traumatic fat embolism with neurologic signs were treated in a surgical intensive care unit. All patients had impaired consciousness. Focal neurologic disorders were reported in 5 cases [hemiplegia (2), tetraplegia (2), aphasia (1)]. The aspects on brain CT scan seemed to be related to ischemic lesions (1 case), appeared normal in ten cases, or revealed post-traumatic hemorrhagic lesions (2 cases). The outcome at 2-4 weeks was spontaneously good, with complete resolution, without neurologic sequellae, in 11/13 patients. Two deaths were related to brain trauma severity (one case) and nosocomial pneumonia (one case).

[Prevention of nosocomial urinary tract infection: vesical catheter versus Penilex]. / Prévention de l'infection urinaire nosocomiale: sondage vésical versus Pénilex.

Nosocomial urinary tract infection is the most frequent nosocomial infection in many care units. Its main risk factor is the presence of a bladder catheter. Prevention is based upon the enforcement of hygiene recommendations which are not always carefully applied everywhere. We report a prospective study concerning 328 patients divided into two gropus. Group I patients (n = 161) had an indwelling bladder catheter. Group II patients (n = 167) had an external urinary drainage by Penilex. The incidence of nosocomial urinary infection was 2.4% in group II versus 26.7% in group I. Thus preventive efficacy of Penilex use appears to be well demonstrated.

[Severe hemobilia of cholecystic origin]. / Hémobilie grave d'origine vésiculaire.

The authors report a case of severe hematobilia originating in the gall bladder itself ans associated with a cholecysto-colic fistula. They review the different etiologies of hematobilia and stress the major value of selective arteriography of the coeliac trunk and possible pitfalls in this condition. This case highlights the rare complications of cholelithiasis (hematobilia and cholecyto-colic fistula) and the severity of blood spoliation. Therapy is reviewed as a function of the lesion causing hematobilia.