Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study.

Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5 years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.

[Internal jugular venous cannulation: what is the best approach?]. / Cathétérisme veineux jugulaire interne : quelle est la meilleure voie d'abord ?

OBJECTIVES: The aim of this study was to compare two approaches used for internal jugular venous cannulation: the anterior way, described by English et al. and the posterior way, described by Jernigan et al. The primary endpoint was the rate of success. The secondary endpoints were the related adverse events and the difficulty factors. STUDY DESIGN: Prospective, randomized open clinical trial. PATIENTS AND METHODS: The study took place in the vital emergency room, the operating room and the emergency intensive care unit of Ibn Sina University hospital (Rabat, Morocco), between June and September 2010. Hundred and one patients needing a central venous catheter were randomized to undergo one of the two techniques. We compared: demographics, success rates, number of attempts, difficulty factors and adverse events. RESULTS: The success rate was significantly higher in the posterior group (96% versus 68%, P < 0.001), with fewer attempts (1.3 ± 0.7 versus 2.1 ± 1.3; P < 0.001). There were less pneumothorax, (0 versus 6%) and more accidental arterial punctures (34 versus 25.5%) in the posterior group, but the difference wasn't significant. Finally, none of the difficulty factors were correlated to the failure rate. CONCLUSION: This study shows that the posterior approach in internal jugular venous cannulation is more efficient than and as safe as the anterior approach.

[Cardiac complications associated with organophosphate poisoning]. / Complications cardiaques au cours de l'intoxication aux organophosphorés.

INTRODUCTION: The clinical picture of organophosphate poisoning is dominated by respiratory and neurological signs. Cardiac complications are rare, serious and little known by clinicians. OBSERVATION: F.B, 17 years, was addressed intubated, at the emergencies after an organosphorus poisoning. At admission, the patient was comatose with a muscarinic syndrome. Her hemodynamic was stable. Chest radiography and ECG of admission were normal. A gastric washing and a treatment by atropine were quickly started. The toxicological analysis of gastric liquid showed presence of malathion. After 20hours, the patient presented a cardiogenic shock. Chest radiography showed signs of acute pulmonary edema and ECG: a circumferential endocardic ischaemia. In spite of vasopressors and positive inotropic treatment, the patient quickly died. The autopsies revealed multiple necrosis of the heart. DISCUSSION: The cardiac symptoms are caused by many mechanisms often associated. The cardiac attack appears primarily by many electrocardiographic modifications: arrhythmias, disturb of repolarisation, conduction's disorder... On the hemodynamic plan, a circulatory insufficiency is possible. The ventricular arrhythmias, which are not treated by lidocaine or electric cardioversion are treated effectively by injection of isoproterenol and/or ventricular stimulation, and recently by the use of magnesium salts. CONCLUSION: If the clinical picture of the IOP is dominated by neurological and respiratory signs, it is always necessary to remember the possibility of cardiac complications (early or late) whose pronostic is very often bad.

[The post-traumatic pancreatitis: about four cases]. / La pancréatite post-traumatique: à propos de quatre cas.

The post-traumatic pancreatitis is the main reason of mortality in the traumatisms of the pancreas, its concurrence is related to the lesions of the pancreatic channels. It represents only 1% of the pancreatitis. In a descriptive retrospective study, four cases of post-traumatic pancreatitis are described.

[Cerebellum abscess: first demonstration of undiagnosed infective endocarditis in an adult with corrected transposition arteries]. / Abcès du cervelet révélant une greffe oslérienne sur une transposition corrigée des gros vaisseaux chez l'adulte.

Neurological complications occur in approximately 30% of all patients with infective endocarditis and represent a major factor associated with an increased mortality rate. Third of these complications is represented by cerebral embolism, followed by mycotic aneurysm, meningitis or meningoencephalitis. Brain abscesses are rare; their localization to the cerebellum is exceptional. A case of cerebellum abscess occurring in a 34-year-old patient with non-operated corrected transposition of the great arteries is reported. Occurrence of this abscess was the first demonstration of undiagnosed infective endocarditis.

[Haemocholecyst: a rare complication of anticoagulant treatment]. / Hémocholécyste: complication rare du traitement antithrombotique.

We report a case of a 50-year-old woman, taking antivitamin K for double mitro-aortic valvular replacement, having presented a clinical picture of acute cholecystitis with marked hypotension. The radiological and biologic exams showed a deep hypocoagulability, vesicular gallstones, a haemoperitoneum and retroperitoneal haematoma. After correction of biological anomalies, the patient was operated. The gallbladder was distended containing large clots and four stones without any evidence of perforation. One of the gallstones led to cystic duct obstruction. Haemocholecyst is a rare complication of anticoagulant therapy, which may occur in the setting of gallbladder stones. The usual complication was the vesicular perforation. In spite of its rarity, haemocholecyst should be suspected when an anticoagulant treated patient presents symptoms of acute cholecystis with or without haemorrhagic shock.

[Traumatic thrombosis of the inferior vena cava]. / Thrombose post-traumatique de la veine cave inférieure.

Traumatic thrombosis of vena cava is rare. Thrombosis of the inferior vena cava diagnosed by uroscanner after blunt abdominal trauma involving the kidney is reported. The Doppler exam confirmed the floating character of the clot. Three days after the initiation of anticoagulant therapy, the thrombus disappeared without any clinical or radiological signs of pulmonary embolism. Fifteen cases of traumatic thrombosis of the inferior vena cava have been described in the literature. Mechanisms, clinical pictures and the management are discussed.

[Traumatic asphyxia or Perthe's syndrome. Six cas reports]. / Syndrome d'asphyxie traumatique ou syndrome de Perthes. A propos de six cas.

Perthe's syndrome or traumatic asphyxia is a clinical syndrome associating cervicofacial cyanosis, petechia and subconjonctival hemorrhage to neurological symptoms. This syndrome appears after severe and transient compressive blunt chest injury. A Valsalva maneuver is necessary before thoracic compression for the development of this syndrome. The treatment includes rapid chest decompression and cardiopulmonary resuscitation. The prognosis is good but a prolonged thoracic compression could lead to cerebral anoxia and neurological sequelae. We report six cases of Perthe's syndrome most of them resulting from thoracic compression after road traffic accidents. All of them made a good prognosis.

[Tension pneumopericardium: a rare complication after thoracic stab wound]. / La tamponnade gazeuse: une complication rare des plaies thoraciques.

The authors report a case involving a patient with thoracic stab wound. The patient developed tension pneumopericardium with acute cardiac tamponade. The clinical and radiological features of tension pneumopericardium and its treatment are discussed.