[Development of antifactor VIII circulating anticoagulant after surgery of the biliary tract]. / Apparition d'un anticoagulant circulant antifacteur VIII après chirurgie de la voie biliare.

In a 25-year-old woman, admitted with a haemorrhagic syndrome following biliary surgery, an inhibitor of factor VIII was detected. As bleeding was major, she was re-operated on under perioperative administration of the anti-inhibitory coagulant complex Autoplex-T, associated with polyvalent i.v. immunoglobulins. The other therapeutic agents are also considered and their indications discussed, after a review of the circumstances of the diagnosis of this disease.

[Rhabdomyolysis after ORL surgery in prolonged lateral position]. / Rhabdomyolyse au décours d'une chirurgie ORL en décubitus latéral prolongé.

Two cases are reported of upper limb rhabdomyolysis occurring after prolonged ENT cancer surgery, the patient being part of the time in the right lateral position, with the left forearm outstretched. Surgery consisted of a vertical hemilaryngectomy with immediate parascapular free graft reconstruction in a 48-year-old man (10 h of surgery, with 6 h in a lateral position) and the surgical removal of a neoplasm involving the mouth floor and larynx in a 62-year-old man including parascapsular free graft reconstruction (10 h of surgery, with 7 h in a lateral position). In the early postoperative period, the patients complained of severe pain in the left forearm. There was a tense painful swelling of the forearm, combined with an increase in creatinine kinase plasma concentration, and myoglobinaemia. The mechanism involved was most likely a compression of the forearm muscles, together with prolonged surgery and the patient position. The part played by the state of the patients is discussed. Diagnosis must be made as soon as possible, as the only efficient treatment consists of an early fasciotomy together with the administration of alkali to avoid renal failure.

[Pneumatic tourniquet paralysis. A differential diagnosis after loco-regional anesthesia of the upper limb]. / Le syndrome paralytique du garrot. Un diagnostic différentiel après anesthésie locorégionale du membre supérieur.

A case is reported of a severe neurological deficit after hand surgical using pneumatic tourniquet. The 51 year old ASA I patient underwent an axillary block for hand surgery using 50 ml of mepivacaïne 1%. The tourniquet was remained at 300 mmHg for only 45 min. The following day, the patient's arm remained lumb. Electrophysiologic tests showed a severe conduction block of sensory and motor fibers, well localized to the presume lower margin of the tourniquet. As there was no improvement, epineurotomy was carried out on day 60, to liberate the median nerve which was severely compressed in the canal brachial. The patient then started to improve slowly. But many safety factors can decrease the rate complications: the accuracy and integrity of the pressure-monitoring must be verified, a tourniquet pressure above 300-500 mmHg would rarely be required in normotensive patient with compliant vessel, a pressure of 200 mmHg will almost all cases provide a bloodless field, tourniquet must be applied on diaphysis and not on bony relief.

[Value of intravenous immunoglobulins. A case of Guillain-Barré syndrome]. / Intérêt des immunoglobulines par voie veineuse. Un cas de syndrome de Guillain-Barré.

A case of severe Guillain-Barré syndrome (GBS) was treated with high dose intravenous immunoglobulin (IVIG), 400 mg.kg-1.days-1, over three consecutive days. The treatment was repeated once. We observed a time-related response between immunoglobulins administration and clinical improvement. The pathologic lesions of the GBS suggest that this syndrome has an immunologic basis: a humoral factor is probably not the only immunological mechanism and cellular mechanisms are also likely to be of importance. Specific mechanisms might also be present in GBS, such as anti-idiotypic suppression of autoantibodies, and elimination of circulating immune complexes. Treatment with IVIG might have several therapeutic advantages over plasmapheresis: IVIG is easily infused without any delay, is easily available and has been used widely without serious complications.

[Persistent leakage of cerebrospinal fluid after removal of a device implanted for subarachnoid analgesia]. / Fuite persistante de liquide céphalorachidien après retrait d'un site d'analgésie sous-arachnoïdienne.

A case is reported of a persisting leakage of cerebrospinal fluid (CSF) occurring after removal of a subarachnoid analgesia kit. The kit had been inserted in a 79-year-old man who had severe perineal cancer pain. Fifteen months later, after a second episode of meningitis, the kit was removed. The leakage was noticed a few hours after removal of the kit. Biological parameters confirmed the fluid was most certainly CSF. Despite making the patient lie prone, water restriction and a compressive dressing, the leakage was still present three days later. A blood patch, and the epidural injection of biological glue, were of no avail. The leakage was only stopped by tying off the fistula with a ligature. The actiology and treatment of skin CSF fistulae after puncture of the dura mater are discussed.

[Acute adult respiratory distress syndrome in leptospirosis]. / Syndrome de détresse respiratoire aiguë de l'adulte au cours d'une leptospirose.

The respiratory manifestations of leptospirosis are usually benign. A case is reported of leptospirosis with serious pulmonary affection. Pulmonary involvement in leptospirosis is infrequently predominant and usually without bearing on prognosis. Clinical and roentgenological features are reviewed. Severe forms with massive hemoptysis or acute respiratory failure occur occasionally. The clinical symptoms, the radiological manifestations and haemodynamic investigation were suggestive of an acute respiratory distress by non haemodynamic pulmonary oedema. In accordance with other authors, one could be justified in including this acute respiratory failure as part of the adult respiratory distress syndrome. Since leptospirosis has extremely diverse clinical features, physicians should have this diagnosis in mind in many circumstances and should request the appropriate examinations at the right moment. Carefully performed microbiological techniques may reduce the problems encountered in isolating leptospires. Serological tests requested after the 12th day of the disease and repeated several times should improve the diagnosis confirmation. The potential severity of certain forms justifies curative antibiotic therapy.

[Controlled trial of a non-invasive continuous blood pressure monitor: Cortronic AMP 770]. / Essai contrôlé d'un moniteur continu non invasif de pression artérielle, l'APM 770 Cortronic.

The performances of a Cortronic AMP 770 monitor, a new apparatus for non invasive continuous blood pressure monitoring was assessed. Its working principle is derived from oscillometry. The blood pressure cuff is kept at a low pressure (about 20 mmHg), and the oscillations induced by the arterial pulse are converted into blood pressure. Systolic, mean and diastolic blood pressure was measured in 9 healthy volunteers, under physiological conditions, using both the AMP 770 and a traditional oscillometer (Physiogard SM 785 NI, Odam). A group of 124 paired measurements was obtained, with values ranging from 87 to 150 mmHg for systolic pressure, from 48 to 97 mmHg for diastolic pressure, and from 63 to 114 mmHg for mean pressure. The mean differences (APM 770-Physiogard) were -1.2 +/- 10 mmHg for systolic pressure, 3.2 +/- 8 mmHg for diastolic pressure, and -3.8 +/- 8 mmHg for mean pressure. There was no correlation between blood pressure levels and discrepancy in the measurements obtained with the two methods. The Cortronic AMP 770 was reliable under normal circumstances, when compared with a traditional oscillometer. However further studies are required to assess its reliability under pathological circumstances (severe hypotension or hypertension, arrhythmias and sudden changes in blood pressure).

[Postoperative pulmonary leukostasis responsible for fatal respiratory distress]. / Poumon hyperleucocytaire postopératoire responsable d'une détresse respiratoire fatale.

A case is reported of a 78-year-old woman with a history of chronic leukemia and who developed after emergency appendicectomy a fatal respiratory distress syndrome related to pulmonary leukostasis. Clinically, the patient had fever, dyspnea and severe hypoxaemia. Chest x-ray showed diffuse pulmonary infiltrates. The patient died from progressive respiratory failure despite ventilatory support. Post mortem lung biopsies were taken for pathologic examination. They showed thrombi composed of leukaemic blast cells which obstructed and distended the lumens of pulmonary arterioles and capillaries. The respiratory distress is attributed to pulmonary leukostasis. Toxic substances released from the leukostatic leukaemic cell or local hypoxia due to vascular occlusion produce this endothelial cell and basement membrane damage. An infectious origin or endogenous pyrogen substances released from leukaemic monocytes may explain the fever. The frequent occurrence of pulmonary leukostasis in patients with leukocyte count greater than 100,000/mm3 point out the need for prevention or therapy of pulmonary leukostasis in these high-risk patients. They need chemotherapy and, if rapid reduction is not observed, leukopheresis which may favourably influence the outcome of patients.