[Successful use of recombinant factor VIIa in the control of a massive bleeding in two patients with biventricular assist device (Thoratec)]. / Utilisation bénéfique de facteur VIIa recombinant chez deux patients porteurs d'une assistance biventriculaire (Thoratec).

Massive bleeding is a dreaded complication of biventricular mechanical assistance implantation. Its origin is multifactorial. Blood products transfusion associated with correction of coagulopathy are sometimes insufficient. We report two cases of massive bleeding after a Thoratec biventricular assistance implantation. After surgical haemostasis failure and despite the correction of coagulation disorders, a major bleeding persisted, so these patients received a single injection of 90 microg/kg of rFVIIa. This allowed in both cases a significant reduction of the bleeding and the restoration of normal haemodynamic conditions. This treatment was not complicated by any thrombotic accident.

[Pupillary dilatation monitoring to evaluate acute remifentanil tolerance in cardiac surgery]. / Monitorage de la dilatation pupillaire dans l'évaluation d'une tolérance aiguë au rémifentanil en chirurgie cardiaque.

INTRODUCTION: Remifentanil is a powerful morphinic agonist often ordered for anaesthesia. The use of peroperative large doses of this opioid increases the risk to develop postoperative hyperalgesia and acute tolerance. But how early these effects can occur? Despite the fact that these effects could be masked during the preoperative time because of general anaesthesia, it seems they could occur precociously. In order to try to describe this time, this study evaluated the acute tolerance under general anaesthesia requiring large doses of remifentanil by using an effective peroperative monitoring of nociception: the continuous pupillary diameter monitoring. MATERIALS AND METHODS: In this prospective observational clinical study, a continuous infusion of remifentanil was started at a range of 0.3 microg/kg/min after induction of anaesthesia by using propofol (TIVA), remifentanil bolus and cisatracurium. The pupil monitoring started 10 min later (T+10 min) and lasted until the surgical incision (T+65 min). So, there was no surgical stimulus during this time. RESULTS: Thirty patients undergoing major cardiac or vascular surgery were included in this study. The continuous pupil diameter evaluation showed a significant increase of the pupil diameter from T+45 min. No significant variation of heart rate, blood pressure, bispectral index (BIS) values were observed. DISCUSSION: The development of acute remifentanil tolerance could possibly explain these results. If evaluations with continuous pupillary diameter monitoring are still limited, these results suggest that the use of powerful opioids such as remifentanil should be associated with a N-methyl-D-aspartate (NMDA) receptor antagonist agent, including short time administrations.

[Use of activated recombinant FVII in the control of haemorrhage following trauma]. / Contrôle d'une hémorragie traumatique persistante par le facteur VII activé recombinant.

Uncontrolled haemorrhage is a major cause of death in trauma patients: sometimes inaccessible to surgery and often associated with coagulopathy. We report a case of severe blunt pelvic trauma associated with suicide. The conventional treatments were unsuccessful and embolization was impossible. The patient required massive blood product transfusion. A 100 microg/kg recombinant activated factor VII dose was infused, twice. After administration of the first dose, the blood requirement decreased dramatically. Further work and trials are required to assess the safety profile and dose regimen for this drug.