[Gas tamponade following intraoperative pneumothorax on a single lung: A case study]. / Tamponnade gazeuse suite à un pneumothorax peropératoire sur poumon unique : à propos d'un cas.

Intraoperative pneumothorax is a rare complication with a high risk of cardiorespiratory arrest by gas tamponade especially on a single lung. We report the case of a female patient aged 53 years who benefited from a left pneumonectomy on pulmonary tuberculosis sequelae. The patient presented early postoperative anemia with a left hemothorax requiring an emergency thoracotomy. In perioperative, the patient had a gas tamponade following a pneumothorax of the remaining lung, and the fate has been avoided by an exsufflation. Intraoperative pneumothorax can occur due to lesions of the tracheobronchial airway, of the brachial plexus, the placement of a central venous catheter or barotrauma. The diagnosis of pneumothorax during unipulmonary ventilation is posed by the sudden onset of hypoxia associated with increased airway pressures and hypercapnia. The immediate life-saving procedure involves fine needle exsufflation before the placement of a chest tube. Prevention involves reducing the risk of barotrauma by infusing patients with low flow volumes and the proper use of positive airway pressure, knowing that despite protective ventilation, barotraumas risk still exists.

[Predictors of prolonged ICU stay following elective adult cardiac surgery: Monocentric retrospective study on 5 and half years]. / Facteurs prédictifs de long séjour en réanimation après chirurgie cardiaque programmée de l'adulte : étude rétrospective monocentrique sur 5 ans et demi.

AIM: The aim of our study was to identify predictors for prolonged ICU stay following elective adult cardiac surgery under cardiopulmonary bypass. PATIENTS AND METHODS: A retrospective study was conducted during 5 years and a half period. Were included, patients age≥18 years old, underwent elective cardiac surgery under cardiopulmonary bypass. Patients who died within 48hours of surgery were excluded. Prolonged ICU stay was defined as stay in the ICU for 48hours or more. RESULTS: During the review period, 610 patients were included. One hundred and sixty-four patients have required a prolonged ICU stay (26.9 %). In multivariate analysis, 5 predictors were identified: ejection fraction<30 % (OR 19.991, IC 95 % [1.382-289.1], P=0.028], pulmonary hypertension (OR 2.293, IC 95 % [1.058-4.973], P=0.036), prolonged ventilation (≥12hours) (OR 4.026, IC 95 % [2.407-6.733], P<0.001). Number of blood units transfused (OR 1.568, IC 95 % [1.073-2.291], and postoperative acute renal failure (OR 2.620, IC 95 % [1.026-6.690], P=0.044]. Prolonged ICU stay is significantly associated with prolonged hospital stay (17 days vs 13 days ; P<0.001) and higher in hospital mortality (22 % vs. 3 %, P<0.001). CONCLUSION: The identification of these patients at risk of prolonged ICU stay is crucial. It will aid to plan prophylactic measures to optimize their support.

[Occult pneumothorax: Does it take drain before elective surgery?]. / Pneumothorax occulte : faut-il drainer avant une intervention chirurgicale programmée ?

Pneumothorax occult is defined by the presence of a non-visible to standard asymptomatic pneumothorax and pulmonary diagnosed only by X-ray computed tomography. The presence of this type of pneumothorax before planned surgery is a rare situation. What to do remains non-consensual. Through two clinic cases and a literature review, the authors discuss the modalities of management of this entity.

[Difficult intubation: should follow the recommendations]. / Intubation difficile: il faut suivre les recommandations.

Intubation and ventilation impossible mask is a dramatic situation with potentially serious consequences. We report the case of a patient of 43 years, followed for a goiter, which was scheduled for a total thyroidectomy under general anesthesia. Preoperative evaluation is not noted signs of compression or tracheal deviation, and there were no criteria predictive of intubation or difficult mask ventilation. The induction of anesthesia was standard. Mask ventilation was effective allowing paralysis. The standard laryngoscopy showed a score of Cormack and Lehane grade IV. Several attempts at intubation were made leading to a situation of intubation and ventilation impossible mask with deep desaturation. A tracheostomy was done urgently. The patient was operated on, six months later, with a fiber optic intubation. Through this case, the authors draw attention to the difficulty of achieving an emergency tracheotomy in the presence of goiter and emphasize the need for integration of different modes of learning and retention of management skills of the upper airway.

[Systemic candidiasis in medical intensive care unit: analysis of risk factors and the contribution of colonization index]. / Les candidoses systémiques en réanimation médicale : analyse des facteurs de risque et intérêt de l'index de colonisation.

OBJECTIVES: Description of the epidemiological and clinical characteristics of the patients introducing risk factors of invasive candidiasis. Analysis of risk factors for candidiasis invasive and evaluation of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in medical intensive care. PATIENTS AND METHODS: Prospective observational study (October 2007 to October 2009). The selected patients present risk factors of system IC candidiasis with an infectious syndrome or clinical signs suggestive of Candida infection and hospitalized more than 48 hours in medical intensive care unit. Pittet's colonization index was calculated at admission and then once a week added to a blood culture. Patients were classified according to level of evidence of Candida infection and the degree of colonization (CI<0.5, CI ≥ 0.5). RESULTS: The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male prevalence. Neurological disease was the most frequent pathology in admission (48%). The most common risk factors were broad-spectrum antibiotics and foreign material. In the various mycology IC specimens, Candida albicans was the most frequent, followed by C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients, and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and specificity was 93% and 48% respectively. CONCLUSION: CI has the advantage to provide a quantified data of the patient's situation in relation to the colonization. But, it isn't helpful with patients having an invasive candidiasis in medical intensive care unit.

[Unilateral bronchospasm during general anesthesia]. / Le bronchospasme unilatéral lors d'une anesthésie générale.

We report a case of unilateral bronchospasm encountered following an induction of anesthesia of healthy young man with no significant past medical or surgical history. The differential diagnosis and management are discussed. Unilateral bronchospasm was probably caused by topical lidocaine injected with a Laryngojet injector at the vocal cords.

[Acute respiratory distress syndrome secondary to influenza A (H1N1) infection: a report of a case]. / Le syndrome de détresse respiratoire aiguë secondaire à une infection par le virus de la grippe A (H1N1) : à propos d'un cas.

Through a clinical case of acute respiratory distress syndrome after infection with influenza virus H1N1 and a review of the literature the authors discuss treatment options, prognostic factors and the problems raised in support this pathology in Moroccan center.

[Ischaemic stroke secondary to viper envenomation in Morocco in the absence of adequate antivenom]. / Accident vasculaire cérébral ischémique à la suite d'une envenimation vipérine grave au Maroc, traitée par un antivenin inadapté

An ischaemic stroke is a rare complication of viper envenomation that is due to multifactorial pathophysiological mechanisms. The authors describe the case of a 55-year-old patient bitten by the viper Cerastes cerastes. The patient was admitted to the intensive care unit with multiple organ failure, disseminated intravascular coagulopathy, rhabdomyolysis, anuria and elevated troponin level. The persistent disturbance of consciousness has motivated a brain scan which has revealed a bifocal ischemic stroke. The complex venom of the species C. cerastes may induce hypotension, tissue necrosis, acute renal failure, bleeding disorders or DIC. With the cessation of a non-indicated heparintherapy and haemodialysis, the patient recovered in a few weeks despite the initial infusion of an unsuitable antivenom due to the late identification of the reptile. The preventive treatment of the complications of this envenomation is based on the infusion of the polyvalent antivenom Favirept(®).

[Central venous catheter-related bacteraemia: prospective study in a Moroccan medical intensive care unit]. / Bactériémies liées aux cathéters veineux centraux : étude prospective dans une unité de réanimation médicale marocaine.

OBJECTIVE: to determine the incidence of catheter-related bacteremia (CRB) in a Moroccan medical intensive care unit, the microbiological profile of this infection and risk factors associated with its occurrence. STUDY DESIGN: Prospective observational study. METHODS: over a period of 8 months, patients who required central venous catheter (CVC) placement for a duration greater than 48 h were included in the study. The CRB has been defined by the criteria of the SRLF Consensus Conference. The proportions of colonization and CRB were expressed as incidence density (ID). Risk factors for colonization were studied in univariate analysis. RESULTS: one hundred and two CVC were inserted in 70 patients. The average age was 54 ± 20 years with an APACHE II of 28 ± 10. The ID of colonization and CRB were respectively 34 for 1000 days of CVC use and 8 for 1000 days of CVC use. The isolated microorganisms were Gram-negative bacilli in 73 %, Gram-positive cocci in 22 % and finally yeast in 5 %. A prolonged duration of catheterization and the absence of systemic antibiotic therapy before catheterization were the main risk factors for colonization. CONCLUSION: the incidence of CRB was high. These results impose a reflection of the care team to improve protocols for prevention of such nosocomial infections.

[Invasive aspergillosis of the cavum associated with candidal meningitis]. / Aspergillose invasive du cavum associée à une méningite à Candida albicans.

Aspergillus fumigatus is a resistant filamentous fungus, common in the environment and pathogenic for human. The most common sites of primary aspergillosis are the maxillary sinus and lungs. Intracranial location is rare and may develop after hematogenous dissemination or contiguity. The invasive pseudotumoral form usually concerns immunodepressed patients. Invasive aspergillosis of the cavum is rare and its diagnosis is difficult. This infection can be fatal because of endocranial involvement and permeabilization of the blood-brain barrier, facilitating other neuromeningeal mycotic infections. We report the case of a 70-year-old diabetic and hypertensive female patient having presented with an invasive aspergillosis of the cavum and endocranial involvement complicated by Candida meningitis.

Severe amlodipine intoxication treated by hyperinsulinemia euglycemia therapy.

The objective of this study was to report a use of hyperinsulinemia euglycemia therapy in severe amlodipine intoxication. Intoxication with 420 mg of amlodipine caused severe hypotension in a 20-year-old female patient. The patient was initially treated with fluids, calcium gluconate, and epinephrine without effect. She was then given hyperinsulinemia euglycemia therapy. We observed a rise in blood pressure (BP) approximately 30 min after insulin was given and the BP was subsequently responsive to epinephrine. The patient was weaned from pressors 5 h after insulin therapy. The trachea was extubated 24 h after ingesting amlodipine, and the patient was transferred for psychiatric treatment 3 days later. This possible positive inotropic effect of insulin therapy in patients with calcium channel blocker intoxication supports previous findings. It is suggested that hyperinsulinemia euglycemia therapy may be considered as a first-line therapy in amlodipine intoxication.

[Timing of tracheostomy and outcome of patients requiring mechanical ventilation]. / Délai de la trachéotomie et devenir des patients sous ventilation mécanique.

OBJECTIVES: To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV). STUDY DESIGN: Retrospective clinical study in a twelve beds intensive care unit (ICU). PATIENTS AND METHODS: From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups. RESULTS: During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10+/-3 vs 17+/-5 days, P<0.001), length of MV (21+/-19 vs 29+/-17 days, P=0.02) and length of stay in ICU (33+/-22 vs 42+/-18 days, P=0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P=0, 13), weaning from MV (50 vs 36%, P=0.19), and mortality rates between the 2 groups (38 vs 54%, P=0.15). CONCLUSION: This study demonstrated that early tracheostomy (< or =7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.