[Combined lumbar plexus-sciatic nerve block in the emergency surgery for pertrochanteric fracture: an alternative technique in patients at high risk of anaesthetic complications]. / Bibloc lombaire et sciatique plexique pour la chirurgie urgente des fractures pertrochantériennes: une technique alternative chez les patients à haut risque anesthésique.

INTRODUCTION: emergency surgery for pertrochanteric femoral fractures (PFF) in patients at high risk of anaesthetic complications is a real challenge for surgeons due to the increased intraoperative risk. We report our experience with combined lumbar plexus-sciatic nerve block as an alternative anesthetic technique for these fractures. METHODS: we conducted a three-year descriptive, single-center, cross-sectional study including patients with a history of recent pertrochanteric femoral fractures (PFF) at high risk anaesthetic complications. Combined lumbar plexus-sciatic nerve block was performed using the common neurostimulation technique. A mixture of 20ml of lidocaine 2% and bupivacaine 0.5% (50/50) was injected into each block. The primary endpoint was the effectiveness of lumbar plexus-sciatic nerve block assessed through the rates from anesthesia-related failures defined as need for conversion into general anaesthesia (GA). The secondary endpoints were: 1) anesthetic technique, 2) intraoperative hemodynamic, respiratory and neurological impairment, and 3) outcomes and potential postoperative complications. RESULTS: the study included 30 patients. The average age of patients was 74 ± 10 years. The average admission time in the Department of Emergency Surgery was 12(5-36) hours. The average duration of the procedure was 15.20 ± 3.45 minutes. No conversion into GA was necessary. There were no statistically significant differences between the various recorded intraoperative hemodynamic and respiratory parameters (MAP, HR, SpO2) (p > 0,05). Surgical procedure duration was 46 ± 5 minutes. Surgical satisfaction was 9.7 ± 0.1. The first post-operative analgesic treatment was started after 8(1-24) hours. All patients had complete sensorimotor recovery. CONCLUSION: combined lumbar plexus-sciatic nerve block is an anesthetic alternative for urgent PFF surgery in patients at high risk of anaesthetic complications: reduced operative delays, anesthetic efficiency, hemodynamic and intraoperative respiratory stability, absence of complications due to other anesthetic techniques, rapid admission to recovery room, and good postoperative analgesia.

Unusual localization of bleeding under acenocoumarol: Spinal subdural hematoma.

BACKGROUND: The spinal subdural hematoma (SSH) is an extremely rare entity which represents only 4.1% of all spinal hematomas. It needs accurate diagnosis and rapid intervention because of the major neurological risk induced by spinal compression. Several etiologies have been reported: anticoagulant treatments, haematological disorders, arterio-venous malformation, repeated attempts at lumbar punctures and tumors. We report the case of an 82-year-old patient under acenocoumarol for atrial fibrillation who presented with paraplegia secondary to SSH. CASE REPORT: An 82-year-old patient with a history of ischemic heart disease and atrial fibrillation under acenocoumarol was admitted to emergency department with sudden onset of paraplegia and intense back pain associated with urinary incontinence and anal sphincter disorder. On examination his lower limb power was MRC grade 0 out of 5 in all ranges of movement bilaterally and a complete bilateral anesthesia reaching the T12 dermatome was noted. Biological test results showed an International Normalized Ratio at 10. Magnetic resonance imaging revealed a posteriorly located spinal hematoma at T12 level, measuring 36 mm with spinal cord compression. After correction of hemostasis disorders the patient was admitted to the operating room for a T11-L1 laminectomy with evacuation of the subdural hematoma. Muscle power showed a gradual improvement in the lower limbs estimated at 3/5 with regression of sphincter disorders but unfortunately a sequellar sensory impairment persisted. CONCLUSION: SSH is a rare situation of acenocoumarol bleeding incident, it should be evoked in any patient treated by this molecule with signs of spinal cord compression.

[Asystole during surgery to manage small intestine cancer: are we dealing with anaphylaxis or carcinoid crisis]. / Asystolie au cours d'une chirurgie pour tumeur de l'intestin grêle: anaphylaxie ou crise carcinoïde.

Cardiac arrest in the operating room is a life-threatening event with multiple causes. We report the case of a 53-year old female patient with no particular past medical history scheduled for surgery to manage small intestine cancer. Twenty minutes after anesthetic induction the patient had asystole rapidly reversible after resuscitation measures. The association of face rash with chest rash gave rise to suspicion of late anaphylactic reaction. Rapid patient recovery allowed to resume surgical procedure. Tumor manipulation immediately caused a second severe bradycardia rapidly reversible after the administration of 0.5 mg atropine. Skin rush at the level of the face and the chest occurred again. This second complication immediately gave rise to suspicion of carcinoid crisis. Sandostatine was then administered. No other complication occurred, the patient spent 24 hours in the Intensive Care Unit receiving sandostatine infusion. Urinary 5-HIAA values were very high and histological examination of the surgical specimen confirmed carcinoid tumor. This study aims to highlight the rarity of this entity and the importance of suspecting carcinoid crisis in patients with intraoperative complications during anesthesia for small intestine tumor surgery.

[Epilepsy revealing chorea-acanthocytosis: about a case]. / Epilepsie révélant une chorée-acanthocytose: à propos d'un cas.

Chorea-acanthocytosis (ChAc) is an extremely rare autosomal recessive disorder caused by mutations in the VSP13A gene on chromosome 9q21. It is characterized by neurological symptoms, psychiatric manifestations and multisystem involvement resulting in myopathy, axonal neuropathy and presence of spiculated red blood cells or acanthocytes. Rarely, epilepsy may be the early symptom in these patients. This can lead to serious delays in diagnosis. We here report the case of a patient with this disease who had seizures several years before the onset of typical manifestations.

[Pancreatic encephalopathy: about 2 cases and review of the literature]. / Encéphalopathie pancréatique: à propos de deux cas.

Pancreatic encephalopathy (PE) is a rare complication of acute pancreatitis. Our study reports 2 cases of patients with pancreatic encephalopathy, hospitalized and treated in the Intensive Care Unit of the Military Hospital of Instruction Mohammed V, Rabat. Patient age ranged between 43 and 54 years, our 2 cases involved a woman and a man. The pathophysiologic process of EP is still not well understood, many assumptions have been described in the literature; some authors have suggested that lipase and phospholipase A2 are involved in the pathological process of PE. Other factors including infections, fluid and electrolyte disturbances, hypoxemia and perturbations in blood glucose can be triggers. The diagnosis of pancreatic encephalopathy is easy to establish, clinical symptoms usually include confusion, amazement and psychomotor agitation, sometimes associated with neurological damages such as convulsions, headache, transient hemiparesis, dysarthria, difficulties in verbal expression and amnesia. Paraclinical tests, including brain MRI and electroencephalogram allow a definitive diagnosis. Treatment is primarily symptomatic aiming to fight against factors favoring the onset of neurologic signs using resuscitative measures based on severity of the situation. The prognosis depends on the severity of acute pancreatitis and its complications. In our study data are broadly comparable to those currently published by the majority of authors.