[Spleen trauma during pregnancy (a case report)]. / Traumatisme de la rate au cours de la grossesse (à propos d'un cas).

Splenic injury during pregnancy after blunt abdominal trauma is rare. The physiological and anatomical changes during pregnancy modify the clinical, biological and radiological signs. The authors report a case of a 30-year-old-woman in the 32nd week of pregnancy, with an isolate splenic injury after a motor vehicle accident. Splenectomy was realised 4 days after an initial decision of abstaining from surgery. In pregnancy, the frequency of recurrent bleeding, the possibility of concomitant uterine injuries and the risk of foetal loss should modify the surgeon's attitude to splenic rupture after abdominal blunt trauma.

[Respiratory failure caused by megaesophagus and tracheomalacia]. / Détresse respiratoire par mégaoesophage et trachéomalacie.

We report a case of acute respiratory failure in an 83-year-old woman suffering from a megaoesophagus compressing the posterior tracheal wall. Naso-oesophageal aspiration did not allow tracheal extubation because of associated tracheomalacia. Treatment included tracheostomy and decrease of cardial tonus by administration of botulinic toxin, after weaning from mechanical ventilation.

Improvement of internal jugular vein cannulation using an ultrasound-guided technique.

OBJECTIVE: To determine whether ultrasound guidance can help operators to improve the results of jugular vein access in the ICU. DESIGN: Prospective, randomized study. SETTING: General Intensive Care Unit of a University Hospital. PATIENTS: Seven-nine patients were assigned to internal jugular vein cannulation using anatomical landmarks alone (control group, n = 42) or with ultrasound guidance (ultrasound group, n = 37). INTERVENTION: All cannulations were performed by junior house staff under the direct supervision of a senior physician. In the ultrasound group, an ultrasonography (7.5 MHz) was used and the transducer was covered by a sterile sheath. The placement and direction of the cannulating needle were determined on the ultrasound image. MEASUREMENTS AND RESULTS: Internal jugular vein cannulation was successful in 37/37 (100%) patients in the ultrasound group and in 32/42 patients (76%) in the control group (p < 0.01). Average access time was longer in the control group (235 +/- 408 s vs 95 +/- 174 s, p = 0.06) and carotid artery puncture occurred in five patients in each group (p = 0.83). Jugular cannulation was successful at the first attempt in 26% in the control group and 43% in the ultrasound group (p = 0.11). Thirty-two patients (86%) in the ultrasound group and 23 patients (55%) in the control group (p < 0.05) were cannulated within 3 min. The cannula could therefore not be inserted within 3 min in 19 patients (45%) in the control group. Failure was explained by thrombosis (n = 1), small caliber of the internal jugular vein (< 5 mm, n = 3), abnormal vascular relations (n = 3). Among the ten primary failures of cannulation, an internal jugular vein catheter was able to be inserted in four cases by an experienced physician on the side initially selected and with ultrasound guidance in two cases. The catheter was inserted into the contralateral internal jugular vein under ultrasound guidance in the remaining four cases. CONCLUSION: Ultrasound guidance improved the success rate of jugular vein cannulation in ICU patients. Our results suggest that ultrasound guidance should be used when the internal jugular vein has not been successfully cannulated within 3 min by the external landmark-guided technique.

Intrapericardial fibrinolysis: a useful treatment in the management of purulent pericarditis.

Since the introduction of antibiotics into clinical practice, purulent pericarditis has become a rare disease. The major complication of the standard management for this condition is constrictive pericarditis. We report two cases of purulent pericarditis in which intrapericardial fibrinolysis was performed in order to minimize this complication. The first case was a 38-year-old man admitted to our intensive care unit (ICU) for management of constrictive pericarditis complicating purulent pericarditis diagnosed 17 days previously. The patient was treated with four intrapericardial injections of streptokinase (250,000 IU each). Fluid drainage and cardiac output were improved. No change in clotting parameters was noted. Pericardiectomy and esophagectomy were then performed for a diagnosis of esophageal neoplasm. The postoperative course was uneventful. The second case was a 16-year-old boy admitted with loss of consciousness due to cardiac tamponade. Percutaneous pericardiocentesis drained 900 ml of cloudy fluid. Two intrapericardial injections were performed (day 1 and day 5) without any complication. Pericardial drainage was withdrawn on day 13 and the patient was discharged from ICU on the same day. Six months later, there was no evidence of constrictive pericarditis. Intrapericardial fibrinolysis appears to be safe and effective when prescribed rapidly in the course of purulent pericarditis.

[Headaches after spinal anesthesia: prospective multicenter study of a young adult population]. / Céphalées postrachianesthésie: étude prospective multicentrique dans une population d'adultes jeunes.

OBJECTIVE: We assessed the occurrence of post-dural puncture headache (PDPH) in a group of young adults following spinal anaesthesia using a 24-gauge Sprotte needle. STUDY DESIGN: Prospective, multicentre, non-randomized study. PATIENTS: This 9 month-long study, included 1,122 patients less than 50 years-old, consisting of 502 women and 620 men. METHODS: Assessment of PDPH after 48 hours and 7 days. RESULTS: PDPH occurred in 0.8 percent of patients. There was no statistically significant difference in terms of age group or gender between the patients. Incidence of PDPH did not depend on type of anaesthetic solution, puncture level or ease of puncture. DISCUSSION: The use of 24-gauge Sprotte needles was associated with a low rate of puncture difficulties. Usual predisposing factors for PDPH, such as age below 50 years and female gender do no longer apply with this type of needle. The rate of puncture difficulties was low (6.7 percent), in contrast with ultra-fine 27 or 29 gauge needles, which sometimes result in puncture failure. Acceptance of the technique was excellent, as 99.38 percent of patients were satisfied. CONCLUSION: The indications of spinal anaesthesia could be extended to young patients, whatever their gender, using a non-traumatic 24-gauge Sprotte needle.

Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis.

OBJECTIVE: To evaluate the diagnostic and therapeutic implications of transesophageal echocardiography (TEE) in intensive care patients. DESIGN: Comparative study. SETTING: A 10-bed general intensive care unit. PATIENTS: Between 1 January 1992 and 31 May 1993, 61 patients prospectively identified with shock (n = 14), severe, unexplained hypoxemia (Partial pressure of oxygen in arterial blood/fractional inspired oxygen < 200) (n = 31), or suspected endocarditis (n = 16) underwent a TEE examination to supplement transthoracic echocardiography (TTE) examination. INTERVENTIONS: The results of each TEE examination were compared with the clinical findings and TTE data. TEE examinations were classified as follows: 0, TEE results were similar to TTE results; 00, TEE examination resulted in exclusion of suspected abnormalities; 1, TEE revealed a new but minor diagnosis compared to the TTE diagnosis; 2, TEE revealed a new major diagnosis not requiring a change of treatment; 3, TEE results revealed a new major diagnosis requiring an immediate change of treatment. RESULTS: Intraobserver reliability of the TEE classification was confirmed by a 100% concordance and interobserver reliability was evaluated as an 84% concordance. Results of the TEE classification were: class 0, n = 21 (34%); class 00, n = 13 (21%); class 1, n = 7 (12%); class 2, n = 8 (13%); class 3, n = 12 (20%). Therapeutic implications of TEE in class 3 patients were cardiac surgery in 5 patients (2 cases of acute mitral regurgitation, 2 valvular abscesses, and 1 hematoma compressing the left atrium), discontinuation of positive end-expiratory pressure in 1 ventilated patient with an atrial septal defect, weaning off mechanical ventilation in 1 patient with an atrial septal defect, prescription of antimicrobial therapy in 3 patients with endocarditis, and prescription of anticoagulant therapy in 2 patients with left atrial thrombus. No difficulty inserting the transducer was observed in any of the 61 patients studied. The only noteworthy complication was a case of spontaneously resolving atrial fibrillation. CONCLUSION: TEE is safe and well tolerated and is useful in the management of patients in the intensive care unit with shock, unexplained and severe hypoxemia, or suspected endocarditis when TTE is inconclusive.

[Changes in intraocular pressure during anesthesia with intratracheal intubation or laryngeal mask]. / Variations de la pression intraoculaire selon l'utilisation d'une sonde d'intubation ou d'un masque laryngé en cours d'anesthésie.

OBJECTIVE: To compare the effects of the laryngeal mask airway (LMA), and the tracheal tube (TT) insertion on intra-ocular pressure (IOP) in eye surgery. STUDY DESIGN: Prospective non-randomized study. PATIENTS: Eighty patients scheduled for eye surgery under general anaesthesia were allocated into either a LMA group (n = 37) or a TT group (n = 43). METHODS: After induction of anaesthesia with propofol, vecuronium and phenoperidine, either a TT or a LMA were inserted. IOP, heart rate (HP) and mean arterial pressure (MAP) were measured before (TO) and after induction (T1), after TT or LMA insertion (20 s:T2, 6 min:T3), and before extubation (T4). RESULTS: The HR, MAP and IOP increased significantly at T2 (compared to T1 but not to T0) in the TT group, for a short time, whereas no significant changes occurred in the LMA group. CONCLUSION: LMA insertion does not elicit significant haemodynamic or IOP changes. Conversely, the TT increases HR, MAP and IOP. These changes can be deleterious in case of emergency surgery for perforating eye injuries. The LMA can be recommended as an alternative to TT in eye surgery, provided security rules are followed, because of the risk of displacement of LMA during surgery.

[Amiodarone-induced thyrotoxicosis cured by thyroidectomy]. / Cardiothyréose induite par l'amiodarone guérie par thyroïdectomie.

We report a case of amiodarone-induced thyrotoxicosis, diagnosed with a systematic laboratory investigation in a 64-year-old patient, for haematuria. Despite the interruption of amiodarone, hyperthyroidism and a goiter occurred. Conventional therapy betablockers, antithyroid agents, prednisone, potassium perchlorate) did not result in any clinical improvement. The development of a malignant thyrotoxicosis with neurologic disturbances and acute respiratory insufficiency required mechanical ventilation and a subtotal thyroidectomy. The patient's status improved progressively and he was discharged without sequelae. The respective roles of medical therapy and thyroidectomy in amiodarone-induced thyrotoxicosis are discussed.

[Postoperative analgesia by auriculotherapy during laparoscopic cholecystectomy]. / Analgésie postopératoire par auriculothérapie lors de la cholécystectomie par coelioscopie.

Auriculotherapy based on traditional Chinese cartography can be used for pain relief after laparoscopic cholecystectomy. It consists of palpating and pricking some well defined ear points corresponding to the surgical site. Relief was quickly obtained and compares favourably with minor parenteral analgesics.

[Unilateral spontaneous adrenal hematoma during the postpartum period. Apropos of a case]. / Hématome surrénal unilatéral spontané en post-partum. A propos d'un cas.

Spontaneous unilateral haematoma of the adrenal gland in post-partum is a rare event. We report a case in a 20 year-old woman without any medical history. The diagnosis could be suspected on upper abdominal pain and confirmed by sonography and CT-scan. There was no sign of endocrine dysfunction. Laboratory data were helpful to eliminate a phaeohromocytoma and histologic examination revealed only unilateral adrenal haemorrhage without tumour. Haematoma of the adrenal gland should be suspected in patients with upper abdominal pain without previous trauma, stress, or infection: however it occurs more frequently after severe stress and in association with other conditions. Surgery should be as conservative as possible.

[Factor XI deficiency, a new way of substitution: human purified concentrates]. / Déficit en facteur XI, un nouveau moyen de substitution: les concentrés humains purifíes.

Case report of a 26-year-old patient, admitted for severe craniofacial trauma, with facial injuries and intracranial haemorrhage. Preoperative tests showed an aPTT = 64 s (control = 29 s), rapidly recognized as being caused by a major constitutional factor XI deficiency (0.06 Ul.mL-1). Considering the neurological risk and the indication for surgery, concentrates of factor XI were administered at a dosage of 25 Ul.kg-1. This treatment was associated with a biological normalization and uneventful surgery. In patients experiencing a factor XI deficiency, the use of fresh frozen plasma will probably decrease and only administered in emergency cases when factor XI concentrates are not available.