[Intravenous ketoprofen for severe lithium-induced polyuria]. / Traitement par kétoprofène intraveineux d'une polyurie sévère survenue au cours d'une intoxication au lithium.

INTRODUCTION: Although lithium has a narrow therapeutic range, it is widely used in psychiatry because of its antipsychotic and antidepressant properties. During long-term treatment, the onset of nephrogenic diabetes insipidus is common, but few cases of severe hypotonic polyuria, which would be an aggravating factor, have been reported. Appropriate treatment in such cases is an open question. CASE: We report a case of acute lithium poisoning in a 42-year-old man, due to chronic lithium treatment (plasma lithium=2.6 mmol/L). This patient, admitted to our intensive care unit, presented neurological disorders complicated by the early emergence of severe nephrogenic diabetes insipidus. After perfusion of hypotonic solution and intravenous treatment with ketoprofen (100 mg x 3/24 h), the polyuria improved rapidly. COMMENTS: The beneficial action of nonsteroidal antiinflammatory drugs lies in their capacity to inhibit prostaglandin synthesis. Lithium causes excess production of prostaglandins, which decrease the ability of kidneys to reabsorb free water. Some publications report indomethacin to be effective in this case. Because it is available only in oral or rectal forms, however, its effect may be delayed. Our case suggests that intravenous ketoprofen, with its rapid onset of action, is effective in the treatment of severe lithium-induced nephrogenic diabetes insipidus. Rehydration must be strictly monitored because of the risk of renal failure connected with nonsteroidal antiinflammatory drugs.

[Invasive infections by Streptococcus pyogenes]. / Infection fulminante à Streptococcus pyogenes chez l'adulte.

Invasive infections by Streptococcus pyogenes continually increase both in France and in others industrialized countries. Because of the seriousness, the rapidity of the evolution and the epidemic potentialities, guidelines for managing these infections are requested by the Superior Council of Public Hygiene of France. The authors report herein a case of an adult stricken down by a violent evolution due to Streptococcus pyogenes. They point up how diagnosis, treatment and prophylaxis for family circle are difficult.

[Restlessness in intensive care unit: think to the nicotinic withdrawal syndrome]. / Agitation en réanimation: penser au syndrome de sevrage nicotinique.

We report a case of tobacco-addicted woman who has been hospitalized in intensive care unit. During mechanical ventilation, management of sedation was difficult, when she was awake, we observed restlessness associated with failure of the mechanical ventilation weaning. The improvement of restlessness and mechanical ventilation were obtained when we set a transdermal nicotine patch. This observation suggests that the nicotine withdrawal syndrome is an unrecognized cause of restlessness and that the transdermal nicotine patch should be a diagnosis means which is safe, cheap and easy to use.

[Guidelines on difficult intubation in anesthesia: evaluation of 2 information diffusion methods]. / Les recommandations dans l'intubation difficile en anesthésie: évaluation de deux modalités d'information.

BACKGROUND: In 1996, experts from the Société Française d'Anesthésie et de Réanimation published guidelines about difficult intubation. We aimed to assess the effectiveness of two diffusion methods of these guidelines, media versus direct mailing plus media diffusion, and the relation between reading of the guidelines and practice behavior and training willingness. METHODS: Data were collected in two different samples of 300 anesthetists from three regions for pre and post-intervention surveys (E1 and E2 samples). Half of the anesthetists from E2, randomly chosen, received a direct mailing of the guidelines (E2a sample). The remaining constituted the E2b sample. Three assessment criteria were used, two concerning practice behavior and one training willingness. Relationship between these criteria and diffusion methods and reading was tested using logistic regression. RESULTS: The response rates were respectively 91%, 80% and 78% in the E1, E2a and E2b samples. The socio-professional features were not statistically different between the three samples. There was no relationship between the criteria and the diffusion methods. The direct mailing did not increase the reading rate (81% and 82% respectively in the E2a and E2b samples). The rate of anesthetists who routinely screened for predictive signs of difficult intubation (one of the practice criteria) was higher in E2a than in E2b (28% and 12% respectively). In the multivariate analysis, the difference only appeared among the sub-group of anesthetists who did not receive the direct mailing. The private practice was associated with a lower rate of routine screening. CONCLUSION: No impact of the diffusion methods on practice behavior and training willingness was found. Reading was inconstantly associated with practice behavior.

[Procedures use by French anesthetists in cases of difficult intubation and the impact of a conference of experts]. / Procédures utilisées par les anesthésistes-réanimateurs français en cas d'intubation difficile et impact de la conférence d'experts.

OBJECTIVE: To analyse the management of difficult intubation (DI) by French anaesthetists and the impact of the French experts' conference (EC) on this topic. STUDY DESIGN: Prospective, comparative, before/after study by questionnaire carried out in Aquitaine, Provence-Alpes-Côte d'Azur and Alsace-Lorraine. MATERIAL AND METHODS: A questionnaire on demographical data, detection of DI, management techniques and desiderata for continuing education on DI, was sent three months before the publication of the EC to 100 randomly selected anaesthetists, in each region (group PRE). Three months after the diffusion of the EC, the questionnaire completed by a survey on the impact of the EC was sent to 100 other randomly selected anaesthetists in each region (group POST). In the latter group, anaesthetists who considered the EC were compared to those who did not. RESULTS: The participation rate was 91% for the group PRE and 79% for the group POST respectively. Both groups were not significantly different for age, gender, position and seniority. Most used techniques that included blind nasal intubation (84%), intubation through laryngeal mask (82%), and intubation with fibrescope (53%). Demands for additional training were for translaryngeal ventilation (68%), intubation with fibrescope (64%), retrograde intubation (52%), and intubation through a laryngeal mask (46%). The EC was known by 71% of anaesthetists. In this group, the EC improved the assessment rate of the three recommended predictive criteria for DI from 12 to 28% (P < 0.02), but neither the management policy, nor the desiderata for additional training. CONCLUSION: Currently, the search of predictive indicators for DI is not systematically applied. The EC has only slightly modified the practice patterns. The need for additional training is important.

[Value of the monitoring of curarisation during prolonged mivacurium induced neuromuscular block]. / Intérêt du monitorage de la curarisation lors d'un bloc neuromusculaire prolongé par mivacurium.

A case of neuromuscular blockade of about 200 min of duration, in a 9-year-old boy from mivacurium 0.15 mg.kg-1 is reported. The diagnosis was delayed, after onset of the first signs of recovery, due to the lack of monitoring of neuromuscular transmission. The neuromuscular blockade was reversed with neostigmine 0.04 mg.kg-1. Complete reversal required fifty minutes. The presence of an abnormal genetic variant of pseudocholinesterases was demonstrated by the measurements of pseudocholinesterase activity and dibucaine number. The importance of monitoring of neuromuscular transmission for diagnosis and treatment of mivacurium-induced neuromuscular blockade is underlined.