[Evaluation of verification of brain death and coordination with hospital organ procurement at the University Hospital at Lille]. / Evaluation du recensement des morts encéphaliques par la coordination hospitalière de prélèvement au CHU de Lille.

OBJECTIVES: To determine the incidence of brain death (BD) and to evaluate the registration of potential organ donors (PD) by the organ procurement team (OPT). STUDY DESIGN: Two-year prospective audit in the French university hospital of Lille. PATIENTS AND METHODS: All deaths occurring in the intensive care units or the emergency department were studied. If death was consecutive to brain damage, on-site review of medical records and charts was performed. Death cause, presence of criteria for brain death and reference to the OPT were recorded for each death. A medical expert staff evaluated the incidence of and reasons for unsuitability for organ donation. After 12 months of observation, a protocol for "systematic alert of the OPT when brain death is suspected" was broadcast and evaluated during the next 12 months. RESULTS: During the first period, 277 BD occurred and 119 PD were suitable for organ donation. The OPT recorded 80 PD (67.2% of all PD) and 45 multi-organ procurements (MOP) were performed. Physicians opposed two major reasons for not calling OPT: anticipation of a non-validated medical contraindication in 18 cases and approach of the family without the OPT team in 21 cases. After broadcast of the protocol, 110 PD were identified and the OPT was called in 93 cases (84.5% of all PD, p < 0.004 versus first period). Fifty-three MOP were performed. CONCLUSION: The OPT was not called to manage one-third of the PD. The protocol for "systematic alert of the OPT when brain death is suspected" improves the call of the OPT and increases MOP.

Escherichia coli endotoxin reduces cytochrome aa3 redox status in pig skeletal muscle.

OBJECTIVE: To assess the effect of endotoxin on cytochrome aa3 (Caa3) redox status in a controlled blood flow preparation of pig isolated hindlimb, at a constant oxygen delivery (Do2limb) (constant flow period) and during progressive ischemia (decreasing flow period). DESIGN: Randomized, controlled experimental study. SETTING: University hospital experimental laboratory. SUBJECTS: Ten piglets. INTERVENTIONS: Hindlimb blood flow was restricted to the femoral vessels. The arterial femoral blood flow coming from the carotid artery was controlled by a roller occlusive pump. The femoral venous blood flow was returned to the jugular vein. During the first 100 mins, the hindlimb blood flow was maintained at a normal level and then decreased stepwise. Animals were randomized to receive 150 microg/kg endotoxin lipopolysaccharide (LPS; n = 5) or saline (control; n = 5). MEASUREMENTS AND MAIN RESULTS: Hindlimb muscle Caa3 redox status was monitored by near-infrared spectroscopy. Hindlimb Do2limb and oxygen consumption (Vo2limb) were calculated. In the LPS group, a rapid reduction of Caa3 redox status was observed after LPS administration, whereas the hindlimb blood flow remained normal with no change in Do2limb and Vo2limb. A progressive simultaneous decrease in Do2limb and Vo2limb was observed during the decreasing flow period with no further reduction in Caa3 redox status. In the control group, no change was observed in Caa3, Do2limb, or Vo2limb during the constant flow period. During the decreasing flow period, Caa3 redox status was reduced as Do2limb and Vo2limb decreased. CONCLUSION: Our results suggest that endotoxin may induce a reduction of Caa3 redox status independently of Do2 and Vo2.

[Celioscopic treatment of small intestine obstructions]. / Traitement coelioscopique des occlusions du grêle.

We evaluated the reliability and immediate results of celioscopic management of acute small bowel obstruction. From January 1995 to April 1998, 39 patients underwent a primary celioscopic procedure for small bowel obstruction. The most common etiology was post operative adhesions (34 patients). The whole operation could be carried out exclusively by celioscopy in 22 patients (56%). A laparotomy had to be performed in 17 patients due to: impossibility to identify or treat the cause of obstruction, bowel necrosis or intraoperative complication (3 bowel wounds). Post operative complications were: 1 death (not directly related to the surgical procedure), 2 early recurrences of obstruction after exclusive celioscopy, 1 evisceration after laparotomy and 1 small bowel fistula after conversion to laparotomy. Mean hospital stay was 5 days after exclusive celioscopy and 9.5 days after conversion to laparotomy. Celioscopic management of small bowel obstruction is feasible, but it is often difficult and may be hazardous; a careful selection of patients must be made, based on the importance of obstruction and the type of previous abdominal surgery.

-Secondary cerebral stress of systemic origin in children with severe craniocerebral injuries-. / Agressions cérébrales secondaires d'origine systémique chez les enfants traumatisés craniocérébraux graves.

OBJECTIVE: To assess incidence of secondary brain insults of systemic origin (SBISOs) such as arterial hypotension, hypoxaemia, hypercarbia, and anaemia in severely head injured children; to assess their impact on mortality and morbidity in the short- and long-term. STUDY DESIGN: Prospective, open study covering a 24-month period. PATIENTS: Seventy-one children, under 15 years of age, admitted to a trauma centre for severe brain injury. METHOD: Analysis of SBISOs and outcome. RESULTS: Twenty-five children were admitted with SBISOs. The mortality rate was 37%. After hospitalization, 84% of the children with SBISOs vs 46% without SBISOs had severe disability (Glasgow outcome score = 1, 2 and 3). After 1 year, 20 out of the 45 children still alive were contacted. One of the four with SBISOs communicated a bad recovery. Fifteen children without SBISOs presented good recovery: GOS = 4-5, paediatric overall performance category (POPC scale) = 1-2. CONCLUSION: Hypotension was associated with significant increase in mortality (x 3.6) in children with severe head injury. The consequences were worse when anaemia was associated.

[Brachial plexus anesthesia via an axillary route for emergency surgery: comparison of three approach methods]. / Anesthésie du plexus brachial par voie axillaire pour chirurgie urgente: comparaison de trois méthodes d'approche.

OBJECTIVES: To compare three techniques of brachial plexus blockade for emergency surgery of the upper limb. STUDY DESIGN: Prospective, randomised study. PATIENTS: One hundred eleven patients admitted to an emergency surgical service, randomly assigned to three groups. METHODS: The patients were given 2% lidocaine with epinephrine 20 mL and 0.5% bupivacaine 20 mL. The three groups were as follows: brachial plexus block using a peripheral nerve stimulator (group St, n = 38); transarterial brachial plexus blockade with injection of 2/3 of the anaesthetic in back of and 1/3 in front of the artery (group TAP, n = 36); transarterial brachial plexus blockade with one single injection in back of the artery (group TP, n = 37). The success rate, time required to perform the technique, latency of analgesia, quality of motor blockade, and adverse effects were compared between the three groups. Analysis of variance was used to compare quantitative data and chi 2 test were used for qualitative data. RESULTS: Rates of success varied between 65 and 75%. Success rates, latency of analgesia and quality of motor blockade were not significantly different between groups. Time to perform the technique was longer when using a nerve stimulator. CONCLUSION: As these three techniques for brachial plexus block in emergency surgery are comparable, no one can be recommended instead of the others.

[Benzodiazepine withdrawal presenting as pseudo-surgical abdominal pain]. / Sevrage en benzodiazépines révélé par un syndrome douloureux abdominal pseudochirurgical.

A 39-year-old patient was admitted to the emergency department for acute abdominal pain. Physical examination showed a peritoneal syndrome. However, CT-scan, Doppler and blood analysis were unremarkable. As the patient had a history of auto-medication with benzodiazepines at high doses, a withdrawal syndrome was considered. An intravenous administration of 3 mg of midazolam determined the relief of all symptoms in a few minutes.

[Malignant hyperthermia and appendicular sepsis. Can they be differentiated during surgical procedure?]. / Hyperthermie maligne et état infectieux d'origine appendiculaire. Peut-on les différencier en cours d'intervention?

OBJECTIVE: To assess the possibility to differentiate clinically intraoperative malignant hyperthermia (MH) and sepsis. STUDY DESIGN: Comparative retrospective study of clinical cases. PATIENTS: Sixteen patients operated on for acute appendicitis and developing clinical signs of MH confirmed or not by in vitro caffeine halothane contracture tests (IVCT). METHOD: To isolate the patients' characteristics with regard to the diagnosis of sepsis and MH crisis. To compare both groups of clinical features with results of IVCT. RESULTS: The diagnosis of MH sensitivity has been excluded in ten hyperthermic patients and confirmed in four others with IVCT. No correlation was existing between the importance of perioperative sepsis, MH features and IVTC results. CONCLUSIONS: This study confirmed the difficulty to differentiate clinically MH and sepsis during surgery. Considering the severe outcome of MH crisis, it is recommended to start the specific therapy even in case of appendicular sepsis.

[Cardiac herniation and sub-herniation. Complication of intrapericardial pneumonectomy]. / Luxation et subluxation cardiaques. Complications des pneumonectomies intrapéricardiques.

Two cases are reported of cardiac herniation complicating intrapericardial pneumonectomy in the early postoperative period. Both patients had a radical pneumonectomy for right-sided bronchial carcinoma invading, in one patient, the carina and the superior vena cava. The pericardial defect, made necessary by the surgical procedure, had not been closed in either patient. About two hours after the end of surgery, both patients, lying supine, developed a state of shock, with tachycardia and arterial hypotension. The diagnosis of cardiac herniation was made in both cases on the chest film. Placing the patient on his left side was only partly efficient in one patient, slowing the heart rate from 160 b.min-1 to 120 b.min-1 and increasing the systolic blood pressure (from 60 mmHg to 80 mmHg). Both patients therefore required to be operated on again. In one patient, the heart had completely herniated through the pericardial defect, and had turned to the right side about the vena caval axis; in the other patient, partly improved by being turned to his left, the heart had returned to its normal position. The pericardial defects were closed in both cases with a strip of dura mater previously treated with 2 (ethyl-mercurithiol-5-benzoxazol) carboxylic acid. The immediate postoperative course was uneventful. Unexpected symptoms and sign occurring in the early postoperative period after intrapericardial pneumonectomy must imperatively lead to carrying out a chest X-ray.