Blast pulmonaire primaire chez le brûlé. a propos d'un cas et revue de la littérature.

Blasts can cause specific lesions requiring specialized care. After an explosion, primary blast injury (due to the shock wave), secondary blast injury (due to shrapnel) or tertiary blast injury (due to the victim being displaced by the blast) can occur. Secondary and tertiary blasts are much more frequent than primary blasts and can lead to polytrauma. Burns occur in 5% of cases and are termed quaternary blast lesions, which include lesions not due to the above-mentioned mechanisms. Care of secondary and tertiary blasts does not differ to that for any polytrauma. Primary pulmonary blast worsens the prognosis of more serious patients, but seldom requires specific care. Knowledge of both pathophysiologic and injury characteristics would allow better care of seriously burned-blasted patients. We report a case of primary pulmonary blast in a burn patient.

[Awake intubation using Pentax Airway Scope as an alternative to awake fiberoptic intubation in management of anticipated difficult tracheal intubation in major burn patients]. / Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d'intubation difficile prévue du brûlé grave.

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.

Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines.

BACKGROUND AND OBJECTIVE: To produce up-to-date clinical practice guidelines on the prevention of venous thromboembolism in surgery and obstetrics. METHODS: A Steering Committee defined the scope of the topic, the questions to be answered, and the assessment criteria. Eight multidisciplinary working groups (total of 70 experts) performed a critical appraisal of the literature in the following disciplines: pharmacology of antithrombotic agents, orthopaedics; general surgery (gastrointestinal (GI) and varicose vein surgery); urology; gynaecology and obstetrics; thoracic, cardiac and vascular surgery; surgery of the head, neck and spine; and surgery of burns patients. The resultant reports and guidelines were submitted for comment and completion of the Appraisal of Guidelines Research & Evaluation questionnaire to a total of 150 peer reviewers, before producing definite guidelines. RESULTS: The report answers the following questions for each type of surgery: (i) What is the venous thromboembolism incidence according to clinical and/or paraclinical criteria in the absence of prophylaxis? (with stratification of venous thromboembolism risk into low, moderate and high categories); (ii) What is the efficacy and safety of the prophylactic measures used? (iii) When should prophylaxis be introduced and how long should it last? (iv) Does ambulatory surgery affect efficacy and safety of prophylaxis? CONCLUSIONS: Apart from answering the above questions, the guidelines provide a summary table for each discipline. This table stratifies types of surgery into the three risk categories, specifies the recommended prophylaxis for venous thromboembolism (pharmacological and/or mechanical) and grades each recommendation. In addition, whenever appropriate, the recommended prophylaxis is adjusted to low- and high-risk patients.

Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis.

OBJECTIVE: Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. DESIGN: Multicentric prospective randomized study. PATIENTS: 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. INTERVENTIONS: Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. MEASUREMENTS AND RESULTS: We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686-2.048). Glycemia on day 4 and gamma-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. CONCLUSIONS: In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

[Venous thromboprophylaxis in burn patient]. / Prévention de la maladie thromboembolique veineuse chez le brûlé.

Few studies deal with thromboembolic complications in burn patients. The review of the literature and current practice in burn centres point out low, average and high-risk patients, according to the characteristics of the burns wounds. In case of average risk, low molecular weight heparin prophylaxis is suggested. In high risk patients, low molecular weight heparin therapy or continuous intravenous heparin are recommended. This prevention should be continued until the recovery of a normal mobility and complete resolution of inflammation.

[Cultured epidermis for the treatment of severe burns. A 2-year study (18 patients)]. / Les cultures d'épiderme pour le traitement des grands brûlés. Etude sur deux ans (18 patients).

AIM OF THE STUDY: For fifteen years, Edouard Herriot Burn Center has been using cultured epidermis provided by an hospital Laboratory. This means of production results in great freedom for their application compared with the centers who have to buy the cultured epidermis. In order to evaluate our clinical results, a two-year study has been performed. MATERIAL AND METHODS: Eighteen patients suffering acute burns were concerned. The average burned area was 68% of the total body surface (range 49 to 88). The average age was 31.6 years, ranging from 1 to 58, including two children. Even autologous or allogenic epidermis was used. In our series cultured epidermis was grafted according four different strategies. It was the preparation of the wound bed by skin allografts, the association of widely meshed auto-graft with cultured epidermis, the stimulation of the healing of extensive deep second degree burns with allogenic epidermis, and the coverage of skin auto-graft donor sites. RESULTS: Two patients died. For the survivors, the average hospital stay was 60 days (range 22 to 90), and on average 70 days over 70% TBSA burns. Cultured epidermis allowed the definitive coverage of 17% of the total body surface of the patients. This study supports the importance of a careful preparation of the patient for the engraftment of cultured epidermis. CONCLUSION: In our opinion, in spite of the difficulties of handling of cultured epidermis, they represent a precious means of coverage for the rapid and definitive healing of extensive burns over 70% TBSA.

Time course of oxidative stress after major burns.

OBJECTIVE: To evaluate oxidative stress resulting from major burns in humans. DESIGN: Prospective clinical study with control group. SETTING: Mechanically ventilated adult patients admitted with more than 30% total burn surface area. PATIENTS AND PARTICIPANTS: 20 patients with a mean body surface burned area of 54%. MEASUREMENTS AND RESULTS: The oxidative stress evaluation was based on measurements of trace elements, vitamins, antioxidant enzymatic activity and end-products of lipid peroxidation. During the first 5 days after injury burn patients exhibit a decrease in selenium and antioxidant vitamins (C, beta-carotene, lycopene) and an increase in lipid peroxidation products (TBARS). CONCLUSION: Our results suggest that major burn is associated with oxidative stress during the 5 days after the initial injury, as demonstrated by a simultaneous decrease in antioxidant vitamins and a large increase in TBARS.

Advantages of using a bank of allogenic keratinocytes for the rapid coverage of extensive and deep second-degree burns.

In 1975, serial subculture of human keratinocytes was first described. Clinical application of this discovery was made possible after the preparation of these cells into epithelial sheets. In 1981, the earliest application of cultured autologous epithelia was made for the treatment of extensive third-degree burns. Although the most important advantage is the large surface area obtained from a relatively small biopsy of healthy skin from the patient, a disadvantage is the delay, which is too long, especially for the treatment of extensive deep burns. This delay leads to denutrition and infection of the burn wounds, which in turn risks the life of the patient and jeopardizes the engraftment of the cultures. More recently, allogenic cultured epidermis, obtained more quickly from donor skin, has been described in the treatment of leg ulcers, repair of skin donor site harvested for split thickness autograft, dermatological diseases and in second-degree burns, although limited to certain areas. In this last case, grafted cells act by stimulation of epithelialisation from the adnexal appendages. To be able rapidly to treat patients suffering extensive and deep second-degree burns, a bank of allogenic keratinocytes has been created, with due attention to safety and security. The paper demonstrates the advantages of using allogenic keratinocytes in the first phase of treatment of a 97% deep second-degree burn patient awaiting autologous cultured keratinocytes. The time required for complete healing achieved using such a strategy is compared with the results obtained after treatment using autologous sheets of two patients burnt on 80% and 82% of their total body area. The treatment of these two latter patients is relatively long and complicated by potentially lethal problems. In the 97% burnt patient, however, the clinical course is shorter and without complication. Moreover, autologous and allogenic cultured epithelia give good aesthetic results, without the mesh aspect obtained with a split-thickness autograft, and also without the discomfort for the patient of removing a sample of skin. Deep second-degree burns are an application of choice for the cultured epithelia, as the presence of the dermis avoids retractions responsible for functional complications usually observed in third-degree burns where dermis is absent. Because of the safety of the bank of allogenic keratinocytes, the treatment of extensive and deep second-degree burns has become safer and faster, with better functional and aesthetic results.

Widely meshed autograft associated with cultured autologous epithelium for the treatment of major burns in children: report of 12 cases.

This is a retrospective study of the combination of widely meshed autograft and autologous cultured keratinocytes. We used this method faced with the lack of allogenic skin, as an alternate to the Cuono method. Twelve children suffering extensive burn injury (deep burns of 60%+/-16 of the total body surface) underwent this grafting procedure. The surgical treatment consisted of an early surgical excision, with an immediate coverage by autografts as much as possible. When cultured epithelium was available, a large mesh autograft was applied and covered with cultured epidermis sheets during the same operative procedure. The rate of take was of 84% (+/- 12). No secondary graft loss was observed. This means of coverage appeared reliable and resistant. On average, this method allowed the epidermization of 30% (+/-9) of the total body surface of the children. The average hospital stay of the children was 64+/-20 days. All the children recovered to lead a normal life. The school delay after rehabilitation is one year. This technique is an alternative to Cuono's method when allografts are missing. The combination of autograft and autologous cultured epidermis sheets appeared more effective than one of these techniques applied alone, as if the suggested coupling induced a synergy.

Myocardial effects of isoflurane in healthy infants and small children. Assessment by continuous oesophageal aortic blood flow echo-Doppler.

BACKGROUND: In paediatric healthy patients and in real peroperative conditions, the cardiovascular effects of isoflurane have been poorly described. METHODS: We have evaluated the myocardial effects of 1% end-expired concentration (EEC) of isoflurane in 25 healthy infants or small children undergoing superficial surgical therapy for small burns with a continuous aortic blood flow echo-Doppler device. Aortic blood flow (ABF) was measured with a small oesophageal probe specially designed for infants. The aortic flowmeter was connected with satellite devices to visualize the haemodynamic profile variations during the isoflurane inhalation period. RESULTS: Isoflurane significantly decreased ABF and increased pre-ejection period/left ventricular ejection time (PEP/LVET), when compared with control values previously recorded 5 min after induction with halothane-fentanyl and atracurium (respectively, 80 +/- 7%, mean +/- SD; P < 0.001 and 111 +/- 11%; P = 0.017, 5 min after EEC of isoflurane reached 1%, then respectively, 75 +/- 12%; P < 0.001 and 119 +/- 16%; P < 0.001, at the end of the isoflurane inhalation period). These variations reversed to a great extent when isoflurane was switched off (97 +/- 17% for ABF; P = 0.08 and 105 +/- 12% for PEP/LVET; P = 0.75). Among the usual parameters, 1% EEC of isoflurane caused no significant changes in heart rate, moderately decreased mean arterial pressure (successively, 88 +/- 12%; P = 0.045 and 87 +/- 19%; P = 0.049), but belatedly decreased end-tidal CO2 pressure (87 +/- 11% at the end of the inhalation period (P < 0.001) which persisted 5 min after isoflurane was turned off (90 +/- 11%; P < 0.001)). CONCLUSIONS: These findings suggest that isoflurane can transiently depress cardiac function in healthy infants.

Comparison of the myocardial effects of desflurane and isoflurane in healthy patients: assessment by continuous oesophageal aortic blood flow echo-Doppler.

Experimentally, desflurane causes a moderate positive inotropic effect and a transient increase in arterial pressure with rapid increases in concentration compared with isoflurane. We used a continuous oesophageal aortic blood flow echo Doppler device to study the myocardial effects of equi-anaesthetic concentrations of isoflurane and desflurane in 32 healthy patients undergoing superficial surgery. After induction of anaesthesia with midazolam, etomidate and fentanyl general anaesthesia was maintained in 16 patients with 0.6% end-expired concentration of isoflurane and in 16 patients with 3% end expired concentration of desflurane. Isoflurane induced a rapid decrease in aortic blood flow (ABF) which remained almost stable whereas desflurane induced an early, moderate and transient increase in ABF (1 min after introduction of the halogenated agent, mean ABF was 107 (SD 3)% in the desflurane group vs 95 (9)% in isoflurane group compared with control values before introduction of the inhalation agent; P = 0.005), followed by a marked secondary decrease in ABF. The maximal decrease in ABF reached 71 (15)% of its initial value in the desflurane group compared with 80 (14)% in the isoflurane group (ns). Neither agent caused significant changes in other variables except for PE'CO2 which decreased in both groups. Continuous ABF echo-Doppler monitoring demonstrated an early transient positive inotropic effect of desflurane.

In the early stage of major burns, is there a correlation between survival, interleukin-6 levels and oxygen delivery and consumption?

The correlation between haemodynamic and oxymetric parameters, and circulating cytokines has been little studied for the early phase of extensive burns. The aim of this prospective study was to evaluate survival, looking at variations in cardiac index (CI), oxygen delivery (DO2I) and consumption (VO2I) indexed to the body surface area (BSA), and circulating interleukin-6 (IL6) levels in the acute stage of major burns. Over a 12-month period, all patients admitted within 6 h of extensive thermal injury with total burn surface area (TBSA) of over 60 per cent, necessitating standardized resuscitation and mechanical ventilation, were included. Routine intensive care monitoring, including pulmonary and femoral artery catheters, was set up. During the first 3 days post-injury haemodynamic and oxymetric profiles were recorded every 6 h. Circulating IL6 samples were taken within 6 h of admission, then daily (at 24, 48 and 72 h). A comparison of the results in survivors (S) and non-survivors (NS) at those previously determined times was made. Ten consecutive patients were studied. Six patients survived (Age = 33 +/- 10 years; TBSA = 76 +/- 11 per cent) and four died (Age = 40 +/- 14 years; TBSA = 77 +/- 13 per cent). Similar initial hypovolemic profiles were found in both groups. From 24 h, a hyperdynamic status was observed which increased until 72 h. This hyperkinetic evolution was more marked in the survivors (CI: 4.6 +/- 2.0 for NS and 6.9 +/- 1.51 min-1 m-2 for S; SVRI: 2125 +/- 1288 for NS and 918 +/- 232 dyne s cm-5 m2 for S at 72 h). DO2I and VO2I were always higher in the survivors. DO2I and VO2I increased from admission to 72 h in the survivors whereas a significant drop in DO2I and VO2I occurred in the non-survivors at 48 h (DO2I:536 +/- 222 for NS and 1228 +/- 268 ml min-1 m-2 for S; VO2I:120 +/- 50 for NS and 251 +/- 56 ml min-1 m-2 for S (P < 0.01)). Plasma IL6 revealed abnormal values with consistent peaks at 24-48 h in the survivors (respectively 17,411 +/- 24,542 and 10,746 +/- 11,802 pg ml-1) and only moderate peaks in the non-survivors (865 +/- 652 and 912 +/- 485 pg ml-1). Finally, CI, DO2I, VO2I and circulating IL6 were always higher, and SVRI lower, in the survivors than in the non-survivors. The ability to increase DO2 and to optimize VO2 during the 'turning point' of 48 h seems to improve the prognosis of critically burned patients: the role of IL6 in this systemic inflammatory response is discussed.

Assessment of 2 preventive antibiotic protocols in burned patients: retrospective and comparitive study between Fort de France (Martinique, FWI) and Lyon (France) - abstract

In a retrospective study, we performed two preventive antibiotic policies in 60 severly burned patients. All patients with a Burn Surface Area (BSA) of > 40 percent received ceftazidime-amikacin in Fort de France and piperacillin-netilmicin in Lyon. In Fort de France, 20 percent of patients developed septic shock with a mortality rate of 67 percent. Gram negative bacilli were always responsible for septic shock, of which 50 percent were resistant to initial antibiotics. In Fort de France, the bacteriological ecology in the burn centre showed less methicillin-resistant Staphylococcus aureus (MRSA) than the hospital (p < 0.05) and the same sensitivity for Pseudomonas aeruginosa. In Lyon, 37 percent of burn patients had septic shock with a mortality rate of 82 percent. In 91 percent, responsible isolates were multiresistant to initial antibiotics (p < 0.05). Bacteriological ecology of the burn centre was different from the hospital with a MRSA rate of 36.6 percent (p<0.02) and 54 percent of multiresistant Pseudomonas aeruginosa ( p < 0.05). Preventive antibiotics appear to be ineffective in severely ill burned patients. (AU)

[Electric burns: epidemiological and therapeutic aspects]. / Brûlures par électrisation: aspects épidémiologiques et thérapeutiques.

OBJECTIVES: A retrospective study of patients with electrical burns was conducted to choose criteria for initial dispatching and establish a treatment protocol for out patient management. METHODS: The study included 67 patients injured by electrical current and admitted at Edouard Herriot Hospital Burns Unit between January 1st 1990 and January 1st 1993. RESULTS: Low-voltage currents (< 1000 Volts) responsible for serious and immediate cardio-vascular diseases occurred in domestic accidents, mostly with children. High-voltage current (> 1000 Volts) responsible for deep burn injuries occurred in accidents at work and mostly with adults. Twenty-two were outpatients and 45 were admitted at once. Two died on admission, 24 were hospitalized less than five days, 11 required repeated surgical treatments and a long stay at hospital, and 8 were severely burned and were admitted to the intensive-care unit. Two required continuous venovenous hemodialysis for three weeks. Morbidity of the last three groups was nil, morbidity remained high in term of functional and aesthetic after-effects. CONCLUSION: Information on prevention of electrical burns should be intensified.

[Hemodynamic profile and serum cytokines in crush syndrome. Analogy with severe burns]. / Profil hémodynamique et cytokines sériques au cours d'un crush syndrome. Analogie avec les brûlures graves.

A 71-year-old woman remained under the rubble of her house for 4 hours after an accidental gas explosion. She suffered from a crush syndrome associating fractures, minor skin burns (< 10% body surface area), inhalation lung injury and moderate hypothermia (34 degrees C). In addition to local signs of compression of the lower limbs, the patient presented with hypovolemic shock and developed acute renal failure on day 3. We describe here the variations in hemodynamic and oxymetric parameters and cytokine response during the first post-injury week. A vasoplegic state resulting from low systemic vascular resistances with progressively increasing cardiac index, oxygen delivery and oxygen consumption closely followed the brief hypovolemic shock. Tumor necrosis factor-alpha remained below normal levels while interleukin-6 increased markedly with a major peak on day 2, in parallel with the drop in systemic vascular resistances. Interleukin-6 is a mediator of impairment in cell membrane function and a vasoconstriction inhibitor. Isolated increased interleukin-6 has been previously reported in severely burned patients suggesting a pathophysiological and hemodynamic similarity between crush syndrome and burn injury.

[Severe burnt patients: hemodynamic state, oxygen transport and consumption, plasma cytokines]. / Brûlés graves: état hémodynamique, transport et consommation d'oxygène, cytokines plasmatiques.

OBJECTIVE: To assess the haemodynamic and oxymetric variations measured by a pulmonary artery catheter and to correlate them with the variations of the circulating cytokines during the initial intensive care phase of severely burned patients. STUDY DESIGN: Prospective study covering an 18-month period. PATIENTS: Thirteen successive patients, aged over 12 years, without significant medical history, with a thermal burn affecting more than 50 percent of their total body surface area and admitted to our centre during the first six postburn hours. METHODS: The haemodynamic and oxymetric profile was investigated by inserting a blood flow-directed balloon-tipped pulmonary artery fiberoptical catheter. All patients were treated according to the protocol previously used in our centre. Blood samples were drawn on admission, every 12 hours post-injury until the 2nd day, then on the 3rd and 5th days. Cytokines were analyzed by Elisa method. Haemodynamic and oxymetric measurements were achieved simultaneously with the biological samples during the first 5 postburn days. The analysis of variance (ANOVA) with the Duncan test was utilized for multiple comparisons between continuous variables. RESULTS: (mean +/- SEM): The patients were 32 +/- 3 years-old and had a burn surface of 72 +/- 4%. After a short hypovolemic shock period lasting a 12 hours, a hyperdynamic shock occured which increased until the 5th day, with an increased cardiac index (6.9 +/- 0.4 at h120 vs 2.9 +/- 0.3 L.min-1.m-2 at h6, P < 0.05), increased oxygen transport and consumption (respectively 880 +/- 77 at h72 vs 543 +/- 58 mL.min-1 at h12, P < 0.05 and, 203 +/- 15 at h72 vs 129 +/- 25 mL.min-1 at h6, P < 0.05) and markedly decreased systemic vascular resistances (1,002 +/- 118 at h36 vs 2,330 +/- 328 dyn.s.cm-5.m2 at h6, P < 0.05). Circulating cytokines were not clearly modified except for interleukine-6 which reached early striking peaks (16,858 +/- 10,330 at h24 and 15,406 +/- 6,509 pg.mL-1 at h36) simultaneously with the decrease in systemic vascular resistances. CONCLUSIONS: During the first post-injury week, critically burned patients develop a specific hyperdynamic circulatory status during which interleukine-6 could be a mainfactor decreasing systemic arterial resistances.

Non-invasive continuous haemodynamic and PETCO2 monitoring during peroperative cardiac arrest.

We describe a cardiac arrest which occurred during general anaesthesia in the prone position for surgical correction of lumbar kyphosis in a patient with Marfan's syndrome. Peroperative monitoring was routine with ECG, non-invasive arterial pressure, oximetry, PETCO2 and central venous pressure, plus aortic blood flow and and systolic time intervals via an oesophageal echo-Doppler device. Forty-five minutes after the start of surgery, a sudden decrease in aortic blood flow followed by a decrease in PETCO2 suggested acute cardiac failure despite continuation of the ECG signal. Initial CPR in the prone position produced a slight increase in PETCO2. When the patient was turned to the supine position and the legs elevated, chest compression was more efficient and spontaneous circulation was rapidly restored. Circulatory arrest could be explained by incompletely treated hypovolaemia, or by myocardial depression (decrease in aortic blood flow and lengthened pre-ejection period) combined with excessive hypotension in a patient with Marfan's syndrome, thus compromising coronary blood flow producing ST segment depression. Continuous non-invasive aortic blood flow and PETCO2 monitoring proved valuable in the early detection and treatment of circulatory arrest and in the evaluation of the efficiency of peroperative CPR.

[Problems caused by anesthesia of patients with severe burns]. / Problèmes posés par l'anesthésie du brûlé grave.

The treatment of severe burns requires repeated and various surgical procedures under general anaesthesias. Requirements differ according to the evolution phase of the burnt lesion. Three first post-traumatic days are marked by a major oedema and a large haemodynamic instability. Hypovolemia during 12 to 24 hours is followed by an hyperkinetic phase. The secondary period can last several weeks to several months before the cutaneous recovery is complete. Septic risk is then major and dénutrition constant. Problems raised by surgery differ according to the type of surgery: early excision of deep bums, bath therapy, skin graft, dressing. These procedures are often haemorrhagic and painful. Thermal status is constantly threatened. This type of pathology interferes with the pharmacology of anaesthetic drugs. Hypoprotidemia and change of protein-binding modify drug kinetics. Continuous use of opiates and sedatives is source of tolerance and tachyphylaxis. The number of acetylcholine receptors is increased, contraindicating the use of depolarizing muscle relaxants and often induces a resistance to the nondepolarizing muscle relaxants. The knowledge of these alteration leads to discuss indications of anaesthetics, analgesics and muscle relaxants most frequently used in these patients. During anaesthesia the positioning of the patient takes into account the surgical needs. Hypothermia prevention is mandatory. Peroperative resuscitation is dominated by maintenance of haemodynamic balance, compensation of hydroelectrolytic and blood losses, treatment of septic complications. Should be the same who has in change the patient in the intensive care unit.

[Diagnosis of heart arrest caused by CO2 embolism during laparoscopic surgery by monitoring of aortic blood flow and capnography]. / Diagnostic par surveillance du débit aortique et du capnogramme d'un arrêt circulatoire par embolie de CO2 au cours de la chirurgie laparoscopique.

We report the case of a 25-year-old woman undergoing a laparoscopic cholecystectomy, who suffered, one min after the beginning of intraperitoneal insufflation of CO2 (2.5 L at a pressure of 10 mmHg), a sudden decrease to 0.8 L.min-1 of the aortic blood flow (ABF), monitored in the descending aorta by an oesophageal echo-Doppler probe, associated with a decrease of PetCO2 to 15 mmHg and of SpO2 readings to 88%. Despite the lack of simultaneous changes in heart rate and arterial pressure, pulmonary gas embolism (GE) was suspected. The pneumoperitoneum was exsufflated and CPR was started because of circulatory inefficiency. Ten min later, efficient spontaneous cardiac activity restarted, whereas PetCO2 and ABF returned rapidly to normal values. At this time, a typical gas noise was clearly obtained through the oesophageal Doppler transducer. The patient remained in deep coma (GCS:6) with a left sided hemiplegia. However, she fully recovered after four sessions of hyperbaric oxygenation. Simultaneous continuous monitoring of ABF and PetCO2 allows an undelayed recognition of major circulatory disturbances, before significant changes in heart rate and arterial pressure occur.