Réveil peropératoire et mémorisation au décours d’une césarienne sous anesthésie générale

Awareness with recall in association with general anaesthesia for caesarean section occurs more frequently than in other operations (0.1–0.2%). The 5th National Audit Project (NAP5) of the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland identified many risk factors for awareness. These included: physiological changes during pregnancy such as higher cardiac output resulting in a wider distribution of drugs and thus lower blood levels of induction agents and volatile anaesthetics, omission of, or decrease in the dose of some drugs to minimize their effects on uterine tone and to avoid fetal exposure, a brief period between anaesthetic induction and start of surgery with little time for reinforcement of the intravenous in duction dose with a volatile agent, use of neuromuscular blocking drugs, difficult airway management, obesity and a high incidence of urgent/immediate surgery often performed out of hours, resulting in higher rates of nonconsultant care. The period from the start of induction of anaesthesia to the start of the surgical intervention, including induction of anaesthesia, is the time when awareness most commonly occurred. Such awareness with recall may cause severe postoperative psychological sequelae, including posttraumatic stress disorder, anxiety, neurosis, nightmares, fear of hospitals. Assessing depth of anesthesia remains a challenge for the anesthesia provider as clinical signs are unreliable, induction drugs vary in their ability to produce amnesia and the period of hypnotic effect is affected by the rate at which they are redistributed. After initiation of anesthesia, volatile anesthetics should be administered to a target of 0.7 minimum alveolar anesthetic concentration, which has been shown to consistently achieve mean Bispectral Index scores <60. Routine brain function monitoring of patients undergoing caesarean section under general anaesthesia does not guarantee unconsciousness as lower Bispectral Index goal of scores seems to be necessary in this population.     

Oxymétrie cérébrale

Two main technologies have been proposed to monitor cerebral oxymetry. Near infrared spectroscopy (NIRS) is a non invasive device theoretically dedicated to measure cerebral blood oxygen saturation (ScO₂). The second device allows the invasive measurement of interstitial O₂ partial pressure in brain tissue (PtiO₂). Despite improvements in technologies, NIRS does not allow to measure exclusively cerebral blood saturation since NIRS signal is strongly affected by extracranial tissue blood saturation. In contrast, the invasive measurement of PtiO₂ is reliable and allowed to identify frequent episodic cerebral hypoxic injuries unrelated to known determinants of cerebral O₂ transport. Interestingly, integration of PtiO₂ measurement in multimodal monitoring allowed the identification of a new pathologic entity involved in secondary cerebral ischemic insults.     

Sclérothérapie par entéroscopie de varices jéjunales hémorragiques

Intestinal varices related to portal hypertension are rare. Their bleeding is difficult to stop. We report on hemostasis of bleeding jejunal varices performed by sclerotherapy via enteroscopy in a patient under anticoagulant treatment.     

Particularités pédiatriques des coagulations intravasculaires disséminées

More than half of the DIC reported in children are observed in neonates. In children like in adult patients, microvascular thromboses play an important role in the pathogenesis of the multiple organ failure due to DIC and its anti-fibrinolytic component.Diagnosing DIC in neonates needs the knowledge of the particular aspects of hemostasis and levels of coagulation and fibrinolysis factors at this age. There are no consensual DIC criteria for neonates, but recent diagnostic criteria have been proposed for both term and preterm neonates.Causes of DIC in children are similar to those observed in adults except for neonates in whom DIC is mainly related to prematurity, respiratory diseases, preeclampsia, infections and hypothermia. Another particular but infrequent cause is represented by congenital protein C and S deficiencies. In children, bacterial (mainly meningococcal) and post-infectious (mainly post-varicella) purpura fulminans have been extensively studied. Several hemostatic gene polymorphisms that may influence severity have been reported in children with meningococcal infections. Their detection at the bedside could be used, in the future, to define the therapeutic strategy. Post-infectious purpura fulminans is observed several days after varicella or streptococcal infections, which are often associated. It is due to an acquired protein S deficiency related to high levels of protein S IgG antibodies that lasts a few months.Like in adults, treatment of DIC is first directed against the causal disease. In neonates with DIC, fresh-frozen plasma infusion must be considered. Treatment of congenital protein C (and S) deficiency is not clearly defined, but activated or non-activated protein C administration represents the best choice. Treatment of the DIC secondary to meningococcal purpura fulminans is not standardized. Heparin and plasmapheresis cannot be recommended. Antithrombin, protein C (activated or not), and recombinant tissue-plasminogen activator administration, which is based on strong pathophysiological data, has been proposed by several authors. At the present time, except the study conducted in adults with severe sepsis, which has showed that mortality is significantly decreased after activated protein C treatment, there are no pediatric prospective studies allowing to precise their efficacy in terms of mortality and morbidity (amputations) and their benefit-risk ratios. Treatment of post-infectious purpura fulminans is not yet well-defined.The hemostatic treatment of DIC is still a subject of debate. Further studies, specifically designed for children and tacking in account morbidity as an outcome measure, are needed.     

Analgésiques opiacés et hyperalgésie implications thérapeutiques

Résumé  Il est bien admis que certaines lésions tissulaires peuvent induire de longues hyperalgésies, allodynies voire des douleurs spontanées. Bien que les substances opiacées soient de puissants analgésiques, nous avons pu observer qu’ils peuvent également activer des systèmes facilitateurs de la nociception (systèmes pronociceptifs) qui s’opposent dès la première administration aux effets analgésiques des substances opiacées et peuvent conduire à des hyperalgésies de longue durée. Les antagonistes des récepteurs NMDA, tels que le MK-801 ou la kétamine, peuvent prévenir totalement ces phénomènes et amplifier l’effet analgésique opiacé. Nous avons pu également observer que l’administration répétée d’une substance opiacée entra?ne une augmentation de la sensibilité à la douleur qui masque de plus en plus un effet analgésique qui appara?t invariant donnant l’impression d’une tolérance aux effets analgésiques. Ce phénomène de sensibilisation à la douleur peut également être prévenu par les antagonistes NMDA. La capacité de la naloxone à induire une hyperalgésie chez les animaux qui ont retrouvé progressivement un seuil nociceptif normal après sevrage suggère que les animaux préalablement traités par la substance opiacée ne sont pas revenus à leur état initial mais sont dans un nouvel état correspondant à un nouvel équilibre à haut niveau entre systèmes analgésiques opio?de-dépendants et des systèmes pronociceptifs NMDA-dépendants. L’ensemble de ces données suggère que tolérance et sensibilisation à la douleur relèvent d’un même continuum adaptatif dans lequel les systèmes glutamatergiques NMDA-dépendants pourraient jouer un r?le majeur. Le r?le possible d’un tel processus dans le phénomène de chronicisation de la douleur est discuté.      

Détection génotypique des résistances bactériennes : de la phénotypie à la génotypie,deux méthodes complémentaires

The problem of emerging resistance urges clinicians to prescribe narrow-spectrum antibiotic targeted to the specific causative pathogen. In hospital, a high level of antibiotic use and a propensity for genetic exchange between bacteria provide a perfect environment for multiresistant micro-organisms. Detection of antimicrobial resistance is important to optimise decisions about antimicrobial therapy. In order to prevent or to slow the spread of resistance among bacterial strains, clinicians must know as soon as possible which bacteria they are dealing with and to which antibiotic the strain is susceptible. This essential information can take several days up to weeks using traditional culture-based methods. In most cases such phenotypic susceptibility tests continue to be useful and get improve. Now automated systems are available to determine the infectious strain and its susceptibility to antibiotics within hours. In the near future, genetic methods as DNA-based solutions will be able to identify an infectious agent and its resistance pattern in less than an hour. Applied DNA technology progresses and will lead to the development and application of sophisticated new strategies for the analysis of antibiotic resistant bacterial strains. In the present knowledge, both methods for the determination of antimicrobial resistance, the phenotypic and the genotypic tests, are complementary.     

Résumés

Hypertension Portale Portal Hypertension

Résumés     

Céphalées chroniques quotidiennes, céphalées par abus médicamenteux Définitions, épidémiologie

Résumé  La nosologie des céphalées chroniques quotidiennes (CCQ) est, pour le non-spécialiste, quelque peu complexe: la publication récente de la deuxième version des critères diagnostiques IHS des céphalées rend plus précise la réalisation des études en recherche clinique, mais complexifie notre travail d’enseignement des céphalées aux non-spécialistes. La définition actuelle des céphalées par abus médicamenteux (CAM) est comportementale, en nombre de jours avec prise d’un traitement de crise, alors qu’elle était auparavant plus quantitative, en poids de médicaments utilisés quotidiennement ou par mois. Ces CAM sont présentes dans un tiers des cas de CCQ, ellesmêmes présentes chez 3% de la population générale. La connaissance de l’affection par les professions médicales, paramédicales, et par la population générale elle-même doit s’améliorer, permetant de prévenir le développement des céphalées par abus médicamenteux, pas toujours réversibles.      

Œsophagite herpétique révélée par une hémorragie digestive haute

Herpes simplex esophagitis is well recognized as an opportunistic infection in immunodeficient patients, but can occur even in immunocompetent patients. Clinical symptoms such as chest pain, odynophagia and dysphagia are not specific. However, complications such as bleeding or perforation have been reported in a few cases in adults. We report a herpes simplex esophagitis case revealed by a serious upper gastrointestinal bleeding.     

Asthme et obésité

Introduction

Asthma is a chronic disease whose prevalence continues to increase. Obesity is a comorbidity makes it difficult to support and control of asthma.

Material and Methods

A retrospective study on 39 cases of obese asthmatics, whose body mass index (BMI) exceeds 30 kg/m², followed by allergy consultation service between January 2007 and August 2009.

Results

These 31 women and 8 men aged between 23 and 79 years (average age: 48.5 years). Diabetes is associated in 2 cases, hypertension in 5 cases and a sick syndrome in one case. The asthma was intermittent in 17 cases (43.5%), mild persistent in 7 cases (18%), moderate persistent in 11 cases (28.25%) and severe persistent in 4 cases (10.25%). The gastro-esophageal reflux was found in 25% of cases, an allergic rhinitis in 41% cases, conjunctivitis in 28% of cases, eczema in 7.6% cases, food allergy in 10% of cases especially Fish and drug in 0.7% cases mostly aspirin. A family atopy was noted in 10% of cases. The recommended treatment based on inhaled corticosteroids and béta2mimétiques long duration of action in 22 cases associated with xanthine in 4 cases, antihistamines and nasal corticosteroids in 16 cases and inhibitors of proton pump in 10 cases. Asthma is well controlled in 60% of cases, partially controlled in 30% of cases and uncontrolled in10% of cases. The flow volume curve done in all our patients had obstructive ventilatory disorder objectified in 89.7% and mixed in 10.3%. The obstructive ventilatory disorder wasmild in 60%of cases, moderate in 28.6% cases and severe in 11.4%.

Conclusion

According to this study the female and the difficulty of controlling asthma in the obese population.     

Contraception et obésité

Obesity prevalence in industrialized countries has been dramatically increasing for several decades. Obese women are sexually active but they use fewer contraceptive methods and are at high risk of unintended pregnancy. In addition, obesity is an important risk factor for venous thromboembolism events and arterial thrombosis (myocardial infarction and ischemic stroke). All these data are to be considered when choosing a contraceptive method for obese women. The purpose of this paper is to exhaustively review contraceptive methods available in France in 2017 and to evaluate the benefits–risks balance of each of them in obese women.     

La douleur en médecine générale

Résumé   Objet de l'étude: décrire les pratiques ?douleur?, repérer les domaines à problèmes et les besoins en formation.Méthodologie: Etude épidémiologique, prospective, randomisée, multicentrique (20 centres de 10 MG), en lle-de-France, sur une journée d'exercice (C et V). Les données de tous les malades ont été recueillies, et les détails précisés pour les patients douloureux. Un questionnaire d'évaluation du soulagement a été renvoyé dans une enveloppe T.Principaux résultats: 1. 89% des médecins ont rendu des observations exploitables;2. 43% des M. G. estiment leur formation ?douleur? insuffisante;3. 1408/3291 (43%) des patients ont présenté des douleurs;4. L'incidence de la douleur est indépendante du lieu de la rencontre, du sexe ou de l'age, hormis pour les enfants de moins de 2 ans (19%), et les plus de 65 ans (39%);5. Les douleurs les plus fréquentes sont: rhumatologiques (31%), ORL (28%), digestives (14%), céphalées et migraines (11%);6. Seulement 1% de douleurs d'origine cancéreuse;7. 20% de douleurs chroniques, sauf en rhumatologie 50%;8. La douleur a entra?é l'arrêt de l'activité (scolaire ou professionnelle) pour 29%;9. 7% de recours à un spécialiste, tandis que seulement 0,3% ont été adressés à une consultation anti-douleur;10. Les antalgiques du paliers I et les AINS sont prescrits pour des périodes plus courtes que ceux des paliers II et III. Palier III que pour 1% (cancer);11. 1037 malades (73,7%) ont répondu à l'auto-évaluation de l'efficacité. L'observance était de 95%;12. 86% s'estimaient soulagés en 4 jours, dont 30% à 100%. 11% non soulagés, surtout en rhumatologie;13. Seulement 6% d'utilisation des échelles d'évaluation de la douleur CONCLUSIONS: La douleur est très fréquente en soins primaires. La très bonne participation des médecins et des patients, choisis par tirage au sort, renforcent la validité de la méthodologie et des résultats. 80% des patients ont été soulagés. La formation para?t mal adaptée à la pratique quotidienne. Les échelles de la douleur sont-elles inadaptées, ou mal connues?      

Hyponatrémies en réanimation : actualités

Hyponatremia is a common hydroelectrolytic disturbance which can result from multiple origin, particularly iatrogenic. Usually, hyponatremia is related to hypotonia, inducing intracellular hyperhydration and swelling. The prevention of cellular swelling, especially in the brain, depends on the type of onset, acute or chronic, but also on other factors such as: female gender, young age, hypoxia... The management of hyponatremia is guided by the understanding of the pathophysiology and relies on routinely available data: patient’s history, clinical assessment of the extracellular fluid volume, routine blood and urine laboratory tests. The evaluation of clinical tolerance and of the type of onset are determinant in the therapeutic strategy. It is always more important to treat the symptoms rather than to correct laboratory values. Myelinolysis is a severe neurologic disorder that can occur after a rapid correction of chronic hyponatremia. According to recent preliminary data, myelinolysis could be reversed by reinducing hyponatremia but this point needs further research.