Complications digestives sévères après chirurgie cardiaque sous circulation extracorporelle

PURPOSE: To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC). METHODS: Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997. RESULTS: Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9). CONCLUSION: Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.     

Hématome sous durai bilatéral après analgesie péridurale

Purpose

The authors report a case of bilateral subdural hematoma (SDH) which occurred following epidural analgesia for labour, complicated by post durai puncture headache (PDPH). Physiopathological mechanisms are discussed.

Clinical features

A 27-yr-old woman displayed typical PDPH following epidural anaesthesia. On the fifth day she was given a blood patch (BP) which proved immediately effective. Further developments were marked by late recurrence of PDPH and by administration of a second BP on the 24th day. With the aggravation of the headaches, the disapearance of their postural nature and with the appearance of transitory focal neurological signs on the 30th day, a CT-Scan was done and showed bilateral subdural haematoma. Following surgical drainage, the patient made an uneventful recovery.

Conclusion

The presence of PDPH complicated by a typical neurological deterioration should prompt the anaesthetist to seek an immediate clinical and x-ray diagnosis in order to look for the existence of intracranial complications.     

Place de la transplantectomie après échec de greffe rénale

The number of kidney-transplant patients that return to dialysis therapy after a failed kidney allograft is increasing sharply. These patients differ from patients treated with chronic dialysis, but who have never received a transplant; i.e., former transplanted patients display a higher risk of morbidity–mortality, particularly from cardiovascular and infectious complications. The management of immunosuppression has not been codified for patients with a failed kidney allograft: immunosuppressive therapy can be either abruptly stopped or progressively reduced. In addition, nephrectomy of the failed allograft is debatable. Some advocate this procedure only when there is intolerance, e.g., gross hematuria, local pain, or unexplained inflammatory syndrome. In contrast, others propose a systematic nephrectomy, mainly to reveal anti-HLA antibodies within peripheral blood that may have been adsorbed within the failed allograft, and are not detected, even using sensitive techniques. Prospective studies are warranted to answer these issues.     

Hypercalcémie sévère et lupus érythémateux disséminé

A rare case of severe hypercalcemia strongly associated with systemic lupus erythematosus (SLE) is reported. On admission, a young woman showed severe hypercalcemia and photosensitivity. Criteria for diagnosis of SLE were not sufficient. All causes of hypercalcemia were excluded. Radiographs of the skeleton were normal. One year later diagnosis of SLE was evident. In addition, diffuse and severe osteopenia and chest deformities had occurred. The treatment of SLE normalized persistently calcemia. Mild elevation of calcium levels occurred during flares of SLE. It has been hypothesized that hypercalcemia in patients with SLE could be caused by the presence of stimulatory anti-PTH receptor antibodies. This case report suggests that in patients with severe hypercalcemia associated with SLE early diagnosis and treatment of SLE may prevent bone loss. In these patients the prevention of severe bone damage is very important. Indeed severe osteopenia may favour skeletal deformities and fractures; in addition it may represent a serious obstacle in using adequate doses of glucocorticoids for treatment of SLE.     

Lombalgies retardées après rachianesthésie

A 50-year-old man had an inguinal hernia repair under spinal anaesthesia with bupivacaine. On the 2nd postoperative day, he complained of backache and paresis at the posterior part of the lower extremities, weil relieved by non-steroidal anti-inflammatory drugs. On the 6th postoperative day, he came back to hospital, because of low back pain associated with a heavy feet sensation. The hypothesis of a neurological complication of the spinal anaesthesia was considered. The Interview of the patient revealed a history of lumbar disk disease, not reported during the preoperative visit. After an in depth clinical examination, two causes seemed possible: subarachnoid haematoma and lumbar disk protusion. Against the first diagnosis were the initial clinical signs. However, in many cases, objective neurological deficit arise too late Reçu le 28 aoQt 1994, accepté après révision le 11 janvier 1995. to allow efficient neurosurgical treatment. Thus, a MRI examination was performed which is non invasive in comparison with a computed tomography myelogram. In our patient, it did not detect a true lumbar disk protusion, but a simple degenerative disease of the L5-S1 disk. In suppressing the lumbar lordosis, spinal anaesthesia probably allowed a distension of spinal capsules and tendons, responsible for the troubles.     

Nécrose columellaire après intubation prolongée

A case is reported of necrosis of the columella nasi due to prolonged intubation in a 21-year-old road traffic accident patient. He was intubated by the nasal route because of combinated head and facial injuries. The necrosis was discovered during surgery for repair of the bony facial injuries. As the patient was in a poor condition, the lesion was not immediately repaired, and the necrotic area was only removed. Definitive repair was carried out four and a half months later, with closure of the oronasal communication with an intravelar veloplasty. Such maxillofacial complications of prolonged endotracheal intubation are rare. They are related to prolonged vascular compression by the tube. Such accidents must be recognized without any delay by carefully examining patients.     

Hypercalcémie sévère et insuffisance rénale aiguë induites par étanercept

Drug-induced sarcoidosis-like disease is a rare, but not exceptional, side effect of anti-tumor necrosis factor (anti-TNF) agents. The organs most commonly involved are lungs, skin and lymph nodes. Kidney involvement is exceptional. Histology usually reveals non-caseating granulomas. Some of the biological features usually described in sarcoidosis are very infrequent in drug-induced granulomatosis. We report a case of sarcoid-like granulomatosis manifesting as life-threatening hypercalcemia and acute kidney injury in a woman treated with etanercept for a rheumatoid arthritis. Seven days after admission, she developed hypoxemic interstitial pneumonia with negative mycobacterial and fungal analysis. This picture suggested sarcoid-like disease induced by tumor necrosis factor blockers and prompted etanercept cessation. Kidney biopsy performed 30 days after admission revealed significant acute interstitial nephritis and intratubular calcium crystals. Staining for acid-fast bacilli and fungi was negative. Clinical picture improved gradually after etanercept withdrawal and cortisone treatment. Three weeks after admission, serum creatinine and calcium levels were normal. Clinical presentation of sarcoidosis-like disease induced by anti-tumor necrosis factor agents may be extremely variable. Our observation shows that severe, life-threatening hypercalcemia may occur. Renal involvement is very unusual. This case highlights this diagnostic difficulty and the importance of a close clinical monitoring in patients treated with these drugs. Cessation of the anti-tumor necrosis factor agent leads to resolution of this condition in most cases.     

Paraplégie après arrêt cardiaque

Paraplegia subsequent to cardiac arrest. We report a case of a permanent flaccid paraplegia, with a sensory loss at T12 level, not associated with cerebral damage, subsequent to a cardiac arrest of 15 minutes duration, in a 67-year-old patient, undergoing haemorragic surgery for gangrenous purulent cholecystitis. Besides cardiovascular collapse and subsequent circulatory arrest, possible favouring factors include anatomical anomalies in the territory of anterior spinal artery, surgical posture with hyperlordosis generating venous stasis, emergency haemostatic maneuvers with compression of the arterial territory providing spinal blood supply. Spinal cord lesions are probably more frequent than expected, as the often associated cerebral anoxic encephalopathy impedes their recognition. Only a systematic anatomopathological examination of the spinal cord, in patients who died after a cardiac arrest, would provide the accurate incidence of spinal complications.     

Modalités de décision de limitation thérapeutique chez les traumatisés crâniens sévères : enquête auprès des neurochirurgiens en France

Background/Introduction

In France, the law defines and prohibits “unreasonable obstinacy” and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons’ involvement in decision-making in regard to treatment limitation after severe traumatic brain injury.

Coagulopathie évocatrice d'une fibrinolyse primaire après traumatisme crânien avec mort cérébrale

Coagulopathies associated with severe head trauma are usually of disseminated intravascular coagulation type with secondary fibrinolysis. We report a case whose semeiology was in part suggestive of a primary fibrinolysis.