Évolution catastrophique d'une électrisation des deux membres supérieurs: désarticulation bilaté-rale des épaules.

The importance of tissue damage secondary to high voltage electrical injury to the limbs often makes the management of this kind of burn very difficult. Repair interventions are sometimes ineffective and amputations are then unavoidable. We report the case of a young patient suffering electrical injury to both upper limbs caused by a high voltage current, whose evolution was dramatically marked by bilateral disarticulation of both shoulders.

[Gas tamponade following intraoperative pneumothorax on a single lung: A case study]. / Tamponnade gazeuse suite à un pneumothorax peropératoire sur poumon unique : à propos d'un cas.

Intraoperative pneumothorax is a rare complication with a high risk of cardiorespiratory arrest by gas tamponade especially on a single lung. We report the case of a female patient aged 53 years who benefited from a left pneumonectomy on pulmonary tuberculosis sequelae. The patient presented early postoperative anemia with a left hemothorax requiring an emergency thoracotomy. In perioperative, the patient had a gas tamponade following a pneumothorax of the remaining lung, and the fate has been avoided by an exsufflation. Intraoperative pneumothorax can occur due to lesions of the tracheobronchial airway, of the brachial plexus, the placement of a central venous catheter or barotrauma. The diagnosis of pneumothorax during unipulmonary ventilation is posed by the sudden onset of hypoxia associated with increased airway pressures and hypercapnia. The immediate life-saving procedure involves fine needle exsufflation before the placement of a chest tube. Prevention involves reducing the risk of barotrauma by infusing patients with low flow volumes and the proper use of positive airway pressure, knowing that despite protective ventilation, barotraumas risk still exists.

[Predictors of prolonged ICU stay following elective adult cardiac surgery: Monocentric retrospective study on 5 and half years]. / Facteurs prédictifs de long séjour en réanimation après chirurgie cardiaque programmée de l'adulte : étude rétrospective monocentrique sur 5 ans et demi.

AIM: The aim of our study was to identify predictors for prolonged ICU stay following elective adult cardiac surgery under cardiopulmonary bypass. PATIENTS AND METHODS: A retrospective study was conducted during 5 years and a half period. Were included, patients age≥18 years old, underwent elective cardiac surgery under cardiopulmonary bypass. Patients who died within 48hours of surgery were excluded. Prolonged ICU stay was defined as stay in the ICU for 48hours or more. RESULTS: During the review period, 610 patients were included. One hundred and sixty-four patients have required a prolonged ICU stay (26.9 %). In multivariate analysis, 5 predictors were identified: ejection fraction<30 % (OR 19.991, IC 95 % [1.382-289.1], P=0.028], pulmonary hypertension (OR 2.293, IC 95 % [1.058-4.973], P=0.036), prolonged ventilation (≥12hours) (OR 4.026, IC 95 % [2.407-6.733], P<0.001). Number of blood units transfused (OR 1.568, IC 95 % [1.073-2.291], and postoperative acute renal failure (OR 2.620, IC 95 % [1.026-6.690], P=0.044]. Prolonged ICU stay is significantly associated with prolonged hospital stay (17 days vs 13 days ; P<0.001) and higher in hospital mortality (22 % vs. 3 %, P<0.001). CONCLUSION: The identification of these patients at risk of prolonged ICU stay is crucial. It will aid to plan prophylactic measures to optimize their support.

[Occult pneumothorax: Does it take drain before elective surgery?]. / Pneumothorax occulte : faut-il drainer avant une intervention chirurgicale programmée ?

Pneumothorax occult is defined by the presence of a non-visible to standard asymptomatic pneumothorax and pulmonary diagnosed only by X-ray computed tomography. The presence of this type of pneumothorax before planned surgery is a rare situation. What to do remains non-consensual. Through two clinic cases and a literature review, the authors discuss the modalities of management of this entity.

[Difficult intubation: should follow the recommendations]. / Intubation difficile: il faut suivre les recommandations.

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.

[A comparison of Airtraq™ laryngoscope and standard direct laryngoscopy in adult patients with immobilized cervical spine]. / Comparaison de l'Airtraq™ et du laryngoscope Macintosh pour l'intubation trachéale chez l'adulte avec stabilisation manuelle en ligne du rachis cervical.

INTRODUCTION: Airtraq laryngoscope is a new and single use device for endotracheal intubation. Few studies showed the superiority of the Airtraq comparing to Macintosh laryngoscope in the setting of difficult intubation. STUDY DESIGN: To compare the performance of these two laryngoscopes by simulating a situation of reduced mobility of the cervical spine by applying the Manual in-line stablization (MILS) maneuver. PATIENTS AND METHODS: After obtaining the approval of the ethic committee, we realized a prospective single blind randomized study. During a 6-month period, 120 consenting patients scheduled for ORL or ophthalmologic surgery were included. They all had general anesthesia and orotracheal intubation. These patients were randomly and equally divided in two groups (n=60), depending on the type of the laryngoscope used (Airtraq or Macintosh). Were excluded from the study the patients with history or criteria predicting difficult intubation. Each patient was intubated by one of the five experimented anesthetists selected for this work. The principle judgment criteria were: i) the time taken for the orotracheal intubation and ii) the intubation difficulty score (IDS). The secondary judgment criterion was the hemodynamic modifications after the endotracheal intubation. RESULTS: Demographic and upper airway track variables were comparable between the two groups. There was no case of failure of intubation in this serie. Nonetheless, all the patients of the Airtaq group were intubated from the first attempt, whereas half of the patients of the Macintosh group were intubated after the third attempt. Comparing to the Macintosh, the Airtraq reduces the time taken for the orotracheal intubation (14±1s vs 19±3s, P=0.01), the necessity of additional maneuver to facilitate the intubation, and the intubation difficulty score (0.7±0.3 vs 3.8±1, P<0.001). Orotracheal intubation using the Airtraq laryngoscope caused less hemodynamic stimulation than using the Macintosh. CONCLUSION: Our study showed the usefulness of the Airtraq laryngoscope for endotracheal intubation for patients presenting conditions of difficult intubation such as reduced mobility of the cervical spine.

[Systemic candidiasis in medical intensive care unit: analysis of risk factors and the contribution of colonization index]. / Les candidoses systémiques en réanimation médicale : analyse des facteurs de risque et intérêt de l'index de colonisation.

OBJECTIVES: Description of the epidemiological and clinical characteristics of the patients introducing risk factors of invasive candidiasis. Analysis of risk factors for candidiasis invasive and evaluation of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in medical intensive care. PATIENTS AND METHODS: Prospective observational study (October 2007 to October 2009). The selected patients present risk factors of system IC candidiasis with an infectious syndrome or clinical signs suggestive of Candida infection and hospitalized more than 48 hours in medical intensive care unit. Pittet's colonization index was calculated at admission and then once a week added to a blood culture. Patients were classified according to level of evidence of Candida infection and the degree of colonization (CI<0.5, CI ≥ 0.5). RESULTS: The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male prevalence. Neurological disease was the most frequent pathology in admission (48%). The most common risk factors were broad-spectrum antibiotics and foreign material. In the various mycology IC specimens, Candida albicans was the most frequent, followed by C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients, and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and specificity was 93% and 48% respectively. CONCLUSION: CI has the advantage to provide a quantified data of the patient's situation in relation to the colonization. But, it isn't helpful with patients having an invasive candidiasis in medical intensive care unit.

[Medication errors in anesthesia: a Moroccan university hospitals survey]. / Erreurs médicamenteuses en anesthésie : enquête prospective au niveau des CHU Marocains.

INTRODUCTION: Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco. MATERIAL AND METHODS: After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner's statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity. RESULTS: During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline. CONCLUSION: Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice.

[Impaired consciousness associated with a hysterical conversion after obstetrical epidural analgesia: a case report with literature review]. / Troubles de la conscience liés à une conversion hystérique après une analgésie péridurale obstétricale : un cas clinique avec revue de la littérature.

The occurrence of impaired consciousness after epidural analgesia is an alarming situation that requires urgent diagnostic and therapeutic approach. Various causes may be responsible for such a state. Hysterical conversion remains an outstanding issue. Through a clinical case of a hysterical conversion and a literature review the authors draw attention to the difficulty of diagnosing this entity after epidural analgesia.

[Peripheral intravenous access in the operating room: characteristics and predictors of difficulty]. / Accès veineux périphériques au bloc opératoire : caractéristiques et facteurs prédictifs de difficulté

PURPOSE: To investigate of predictor's factors of difficult venous access device in the operating room in elective surgery. METHODS: In a prospective study in central operating room, were included all patients scheduled for a surgical or diagnostic intervention. Were excluded all patients admitted with functional venous access. For each, were recorded patient's demographic characteristics (age, gender, ASA class, BMI), history (chemotherapy, prolonged ICU stay, hospitalization for more than five days), data from the clinical examination (presence of skin lesions, arteriovenous fistulas, burns, neurological deficits) and the type of operator (trainee, nurse, resident, senior). The difficulty was judged on the number of attempts required for successful venous access. Puncture was considered easier for a number of attempts to one to two and difficult if the number of attempts was greater than two. Predictor's factors were identified after univariate and multivariate analysis. RESULTS: During one year (March 2008 to February 2009), form returns in 1500 were met, 1325 were usable. Venous catheterization was successful in 50.9% at the first attempt in 24.2% of patients at the second attempt and after three attempts in 18% of patients. Only 6.8% of patients required more than three attempts. A central venous catheter was required in seven patients. In multivariate analysis, chemotherapy (OR=4.54, 95% CI [2.92 to 7.03]; P<0.001), a nurse in training (OR=2.27, 95% CI [1.40 to 3.63]; P=0.001), a resident in training (OR=2.14, 95% CI [1.29 to 3.58]; P=0.003) and the presence of burns (OR=3.59, 95% CI [2.44 to 5.27]; P<0.001) were identified as independent predictors of difficulty of peripheral venous access. DISCUSSION: The optimization of venous access devices in the operating room through the search for predictors of difficulty.

[Unilateral bronchospasm during general anesthesia]. / Le bronchospasme unilatéral lors d'une anesthésie générale.

We report a case of unilateral bronchospasm encountered following an induction of anesthesia of healthy young man with no significant past medical or surgical history. The differential diagnosis and management are discussed. Unilateral bronchospasm was probably caused by topical lidocaine injected with a Laryngojet injector at the vocal cords.

[Acute respiratory distress syndrome secondary to influenza A (H1N1) infection: a report of a case]. / Le syndrome de détresse respiratoire aiguë secondaire à une infection par le virus de la grippe A (H1N1) : à propos d'un cas.

Through a clinical case of acute respiratory distress syndrome after infection with influenza virus H1N1 and a review of the literature the authors discuss treatment options, prognostic factors and the problems raised in support this pathology in Moroccan center.

[Efficiency of bupivacaine wound subfasciale infiltration in reduction of postoperative pain after inguinal hernia surgery]. / Efficacité de l'infiltration cicatricielle subfasciale par la bupivacaïne dans la réduction de la douleur postopératoire des hernies inguinales.

INTRODUCTION: The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique. METHODS: This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed. RESULTS: Concerning demographic parameters, ASA class and secondary effects, we didn't find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain. DISCUSSION: Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.

Influence of cranial morphology on the location of chronic subdural haematoma.

BACKGROUND: The purpose of the present study was to evaluate the relationship between cranial morphology and location of a chronic subdural haematoma (CSDH) in patients with and without intracranial vault asymmetry. METHOD: The study was conducted in 110 consecutive adult patients who underwent surgery for CSDH. The relationship between the following variables and CSDH was studied: sex, age, past medical history, history of trauma, interval between head injury and symptoms, clinical presentation, location of the CSDH, symmetry of the frontal and occipital intracranial vault on the CT scan and/or MR images, surgical treatment and outcome. Throughout the analysis, p < 0.05 was considered statistically significant. FINDINGS: The frontal cranial vault was symmetrical in 48 patients (43.6%) and asymmetrical in 62 patients (56.4%). CSDH was more commonly bilateral in patients with a symmetrical frontal cranial vault than those with an asymmetrical shape (41.7% vs 17.7% and this difference is statistically significant (p = 0.01). In 62 patients with an asymmetric frontal skull vault, the CSDH was bilateral in 11 patients. In the remaining 51 patients, the CSDH was located on the same side of the most curved frontal convexity in 34 patients and on the side of the less curved frontal convexity in 17 patients. The occipital cranial vault was symmetrical in 44 patients (40%) and asymmetrical in 66 patients (60%). CSDH was more commonly bilateral in patients with a symmetrical occipital cranial vault than those with an asymmetrical one (40.9% vs 19.7%) and this difference was also statistically significant (p = 0.019). In 66 patients with an asymmetric occipital skull vault, the CSDH was bilateral in 13 patients. In the remaining 53 patients, the CSDH located on the same side of the most curved occipital convexity in 39 patients and on the side of the less curved occipital convexity in 14 patients. CONCLUSIONS: Frontal and occipital intracranial vault morphology provides valuable information about location of CSDH. Bilateral CSDH is common in patients with symmetrical frontal and occipital cranial vault. In asymmetrical cranium, CSDH usually locates on the same side of the most curved frontal or occipital convexity. Identification of this relationship can be very useful to elucidate the origin and the pathogenesis of CSDH.