Obstetric patients in a surgical intensive care unit: prognostic factors and outcome.

The objective of this study was to assess the incidence, prognostic factors and the outcome of obstetric patients admitted in a surgical intensive care unit (SICU) during the ante-partum or postpartum period (within 6 weeks of delivery). Between 1995 and 2002, the patients transferred from the department of obstetrics were retrospectively included into the study. Demographics included: obstetric data, medical and surgical histories, diagnosis, simplified acute physiology score (SAPS II), acute physiology and chronic health evaluation system APACHE II score; and the occurrence of organ failure, therapeutic interventions, length of stay in the SICU and outcome were recorded. During the study period, 364 obstetric patients were admitted to the SICU. Obstetric admissions to the SICU represented 0.6% of all deliveries and the SICU utilisation rate was 14.96%. The main indications for admission were eclampsia (70.6%) and postpartum haemorrhage (16.2%). The overall mortality rate was 16.7% (n = 61). In a logistic regression model, risk factors for death included organ system failure (odds ratio (OR) = 3.95 confidence interval (CI) [1.84 - 8.48], bilirubin >12 mg/l (OR = 1.017 CI [1.00 - 1.03]), and prolonged prothrombin time (OR = 0.97 CI [0.95 - 0.99]). Median length of stay was longer in non- survivors (6.5 +/- 7.3 vs 5.5 +/- 4.6 days). Maternal condition on admission and associated complications are the major determinant of maternal outcome.

[Critical analysis of hemostasis disorders in the course of eclampsia. Report of 106 cases]. / Analyse critique des troubles de l'hémostase au cours de l'éclampsie. A propos de 106 cas.

OBJECTIVE: Study of hemostatic disorders during eclampsia, their risk factors, maternal complications and associated mortality. METHODS: Retrospective study concerning 106 cases of severe eclampsia treated in intensive care between September 1992 and December 96. Patients with or without hemostatic disorders were compared for laboratory findings, maternal complications and mortality. RESULTS: Forty patients had hemostasis disorders as follows: isolated thrombopenia in 19 cases, disseminated intravascular coagulation (DIC) in 5 cases, Hellp syndrome associated to DIC in 7 cases and Hellp syndrome in 9 cases. Hemostasis disorders were associated to maternal advanced age, but not with gestational age or blood pressure in admission or time of convulsions. Complications and mortality associated with hemostasis disorders were more frequent compared to patients without hemostasis disorders. Among the 17 deaths of our series, 10 had hemostasis disorders. CONCLUSION: Hemostasis disorders were prognosis factors in eclampsia requiring systematic laboratory tests at admission and immediate delivery.

[Intermediary syndrome in acute malathion poisoning]. / Syndrome intermédiaire lors d'une intoxication aiguë par le malathion.

BACKGROUND: Acute poisoning by an organophosphorus insecticide is frequently observed in Morocco. We report a case of malathion poisoning complicated by an intermediate syndrome. CASE REPORT: A 42-year-old woman was hospitalized 3 hours after ingestion of 50 g of malathion. Intubation and ventilatory assistance was required due to failing consciousness and bronchial plugging. On day 4, a neurological syndrome suggestive of the intermediary syndrome with diaphragmatic palsy made it necessary to continue ventilatory assistance to day 20. DISCUSSION: The intermediary syndrome occurs 24 to 96 hours after the acute cholinergic phase of organophosphorus poisoning. It consists of an exclusive neuromuscular involvement. The intermediate syndrome is confined to an abnormality of neuromuscular function in specific muscle groups: proximal limb muscles, neck flexors, motor cranial nerves and respiratory muscles, with difficult weaning from respiratory assistance. The intermediary syndrome is quite uncommon. The risk of respiratory failure emphasizes the need for close monitoring in an intensive care setting for at least 96 hours, depending on the intensity of the cholinergic syndrome.

[Postpartum cerebral thrombophlebitis. A case secondary to acquired antithrombin III deficiency]. / Thrombophlébite cérébrale du post-partum. Un cas secondaire à un déficit acquis en antithrombine III.

The cerebral thrombophlebitis is a rare complication of the pregnancy and the postpartum. We report a case of a 21 year-woman presenting a post-partum cerebral thrombophlebitis, secondary to an acquired deficiency of antithrombin III. The clinical symptoms of cerebral thrombophlebitis can be misleading. The angiography and the magnetic resonance imaging permit the diagnosis. The treatment is relied on anticoagulating heparin therapy. This treatment will be adapted in case of coagulation's factors deficiency that must be searched in any thromboembolic accident having an unusual localization.

[Combination of Emla cream and nitrous oxide for venous cannulation in children]. / Association crème Emla et protoxyde d'azote pour l'abord veineux chez l'enfant.

OBJECTIVE: To assess the efficacy of an combination of Emla cream and N2O for venous cannulation in children. STUDY DESIGN: Prospective, randomized, double blind trial. PATIENTS: The study included 75 unpremedicated children, aged 3 months to 5 years, ASA physical class I and II, undergoing an elective surgical procedure, randomized into three groups. METHODS: In group I and III, children received Emla cream one hour before entering the theatre. In group II, children received a placebo. Children of group I and III also inhaled 50 vol% nitrous oxide in oxygen and those of groupe II 100 vol% oxygen, 3 min prior and during venous cannulation. A blinded observer recorded the following items: pain assessment with CHEOPS scoring, conditions of venous puncture and behaviour of children. Heart rate, blood pressure and oxygen saturation were assessed at three timepoints: before, 3 min after facial mask application and following venous cannulation. RESULTS: There were non significant differences between the three groups for the conditions of venous cannulation. The CHEOPS score was better in group I (7[4-11]), compared to group II (10[6-13]; P < 0.01) and to group III (9[6-12]; P < 0.01). CONCLUSION: Emla cream combined with nitrous oxide is effective for venous cannulation in providing satisfactory analgesia and in controlling anxiety elicited by the vision of needle.

[Fatal hepatitis in a young child: probable role of halothane]. / Hépatite fatale chez un jeune enfant: rôle probable de l'halothane.

A 3-year-old boy, who underwent multiple anaesthetics including halothane in a short period of time, developed 3 days after the last operation abdominal pain, jaundice and fever. Laboratory tests showed hepatic failure, with cytolysis, cholestasis and eosinophilia. Tests for hepatitis A, B, C, CMV and EBV were negative. No other causes of postoperative jaundice were identified. Despite symptomatic treatment, the child died 5 days after the last anaesthetic. Post mortem liver biopsy showed massive hepatic necrosis. The authors discuss factors increasing the risk for halothane-hepatitis, especially multiple exposures.

Lidocaine-clonidine retrobulbar block for cataract surgery in the elderly.

BACKGROUND AND OBJECTIVES: Clonidine, an alpha-2-adrenoreceptor agonist, has been shown to decrease intraocular pressure (IOP) and to have some analgesic and sedative effects when it is used in premedication for ophthalmic surgery. This study was designed to investigate the efficacy of lidocaine-clonidine retrobulbar block for cataract surgery with respect to its effect on IOP, analgesic action, and sedative effects. METHODS: Sixty elderly patients (ASA status I and II) were allocated randomly to receive in a prospective double-blind manner retrobulbar block for cataract surgery. Group I (n = 30) received 3-4 mL of 2% lidocaine with 1 mL saline, while group 2 (n = 30), received 3-4 mL of 2% lidocaine with clonidine 2 micrograms/kg. RESULTS: A large decrease in intraocular pressure from 13.5 +/- 4.6 to 7.7 +/- 3.7 mm Hg (P < .01) and a small but significant reduction of both systolic and diastolic blood pressure were observed 20 minutes alter the retrobulbar block in patients receiving clonidine, while no changes occurred in the control group. The median duration of analgesia and akinesia was greater in the lidocaine-clonidine group (241 +/- 88 minutes and 80 +/- 20 minutes, respectively) as compared with the lidocaine group (128 +/- 24 minutes and 70 +/- 20 minutes, respectively) (P < .01, P < .05). Sedation scores were greater in group 2 from the 10-minute point (P < .01). CONCLUSIONS: Addition of clonidine to lidocaine for retrobulbar block causes a decrease in intraocular pressure, a sedative effect, and an increased duration of analgesia and akinesia, with relatively stable hemodynamic parameters.

[Does oral ondansetron reduce the incidence of nausea and vomiting after surgery for strabismus in children?]. / L'ondansétron oral réduit-il l'incidence des nausées et vomissements après chirurgie du strabisme chez l'enfant?

OBJECTIVE: To compare the efficacy of oral ondansetron with oral metoclopramide for the prevention of postoperative vomiting and nausea in children undergoing strabismus surgery. STUDY DESIGN: Prospective, randomized, double-blind trial. PATIENTS: Thirty children of physical class 1, age 9 +/- 4 years, scheduled for strabismus surgery, were randomized into two groups (ondansetron and metoclopramide). METHODS: In the ondansetron group, the children received the first oral dose of ondansetron (4 mg) 1 hour before induction of anaesthesia and the other doses 8 and 16 hours later. In the metoclopramide group, children received metoclopramide (5 mg) in the same conditions. Anaesthesia was induced with thiopentone, vecuronium and fentanyl and maintained with halothane and N2O/O2. Patients were evaluated by an independent observer for nausea and emesis in recovery room (0-2 h) and on the ward. The adverse effects of oral ondansetron and metoclopramide were assessed. RESULTS: There were non-significant differences between the two groups for incidence of nausea and vomiting (40% and 53% in ondansetron group versus 33 and 60% in metoclopramide group, respectively. CONCLUSION: Unlike intravenous ondansetron, oral ondansetron is not superior to metoclopramide for the prevention of nausea and vomiting caused by strabismus surgery in children.

[Fatal hepatic necrosis during treatment with sodium valproate]. / Nécrose hépatique mortelle au cours d'un traitement par le valproate de sodium.

The authors report a case of fatal hepatic failure in a 19-year old young man suffering from absence seizures and treated for two months with valproic acid (VPA). The duration of VPA therapy before onset of clinical manifestations was four weeks. The prodromal symptoms were weakness, anorexia, and vomiting, then in a few weeks occurred a jaundice and an hepatic encephalopathy leading to death. Among laboratory findings disturbance of liver tests and particularly depressed levels of clotting factors were observed. The histologic study of the liver showed an extended centrolobular necrosis associated with fatty change and fibrosis. The mechanism of this hepatic failure remains unknown. The seriousness of this complication necessitates to respect any contraindications.

[Thrombosis of the right atrium disclosed by severe pulmonary embolism]. / Thrombose de l'oreillette droite révélée par une embolie pulmonaire grave.

The case of a thrombosis of the right auricle, revealed by severe pulmonary embolism in a 56-year-old patient without significant medical history is reported. He was admitted to the ICU with a haemorrhagic cerebrovascular accident. The course was characterized by the occurrence of a venous thrombosis of the right lower limb confirmed by phlebography. The treatment with a platelet antiaggregating agent was effective and the patient left hospital two weeks later. He was re-admitted after 2 months with a clinical picture of massive embolism including polypnea, tachycardia and haemoptysis. The diagnosis was confirmed by pulmonary angiography (Miller index > 65%) and echocardiography showed a floating thrombus in the right auricle with dilated right cavities. The phlebocavography displayed an extensive thrombosis in the left lower limb up to femoral, iliac and cava inferior veins. The patient was treated with heparin (500 IU.kg-1.d-1) and later with antivitamine K. The course was favourable. This is a rare case of extensive thrombosis, completely regressive with a treatment including only heparin.

[Block of spermatic cord in surgery of the testis]. / Bloc du cordon spermatique en chirurgie testiculaire.

This study analyses 25 cases of spermatic cord blockade for scrotal surgery (hydrocele, spermatocele, tumor of epididymis). The spermatic cord was infiltrated, after identification of the pubic tubercle, with a mean total dose of 17 +/- 3 ml of a 2% lidocaine solution not containing adrenaline. The scrotal skin was infiltrated separately at the site of incision. Analgesia was excellent in 22 patients. The duration of analgesia was 82 +/- 33 min. No adverse effects occurred. It is concluded that the blockade of the spermatic cord is a convenient anaesthesia technique for testicular surgery.

[Preventive treatment of hemodynamic disorders during conventional spinal anesthesia]. / Traitement préventif des perturbations hémodynamiques au cours de la rachianesthésie conventionannelle.

The prevention of blood pressure fall during a conventional spinal anaesthesia effected with 20 mg (4 ml) of isobaric 0.5 p. 100 bupivacaine relies on the use of vascular filling and/or a vasoconstrictor. A randomized prospective study was performed to evaluate the comparative efficacy of these two treatments. 148 patients were included and divided into three groups. Group I (n = 50): 2.5 mg IV bolus of etilefrine followed by continuous infusion (0.35 mg.kg-1.h-1). Group II (n = 50): 30 ml.kg-1 infusion of saline isotonic solution for 90 min, with infusion rate according to blood pressure. Group III (n = 48) did not receive any preventive treatment. A blood pressure fall of more than 30% of the initial value was observed in 59 patients: 18% of the etilefrine group, 28% of the saline infusion group, 54% of the control group. This peculiar frequency of hypotension in the control group emphasizes the need of a preventive treatment. Haemodynamic changes were fewer and less important in the etilefrine group compared with the saline infusion group. No failure and a better tolerance in the vasoconstrictor group were also to be noticed. These clinical data suggest that etilefrine could meet satisfactorily the therapeutic requirements.

[Postoperative rhabdomyolysis following surgery of a pheochromocytoma]. / Rhabdomyolyse postopératoire après chirurgie du phéochromocytome.

The authors reports one case of post operative rhabdomyolysis after surgery of pheochromocytomas. The diagnosis of rhabdomyolysis suspected on acute renal failure was confirmed on the increase of CPK and myoglobin blood levels. The findings on physical examination were normal. In this particular case, the operative position seems not implicated in the genesis of this rhabdomyolysis. Nevertheless, the long duration of surgery (4 h) is the major factor encountered in this pathology. Evolution was satisfactory after three haemodialysis sessions.