Deux cas d’encéphalite autoimmune à anticorps antirécepteur N-méthyl-D-aspartate en réanimation

We report here two cases of autoimmune encephalitis associated with antibodies against the N-methyl-D-aspartate receptor. The primary cause was an ovarian teratoma in one case. The outcomes were good. The first case was a late diagnosis, despite a typical clinical presentation. The clinical presentation of this disease remains unknown, especially in the intensive care unit. The treatment was recently codified and transformed the prognosis of this encephalitis. The second case was early treated in the course of the disease, due to the experience related to the previous case. In case of unexplained acute or subacute encephalitis or psychiatric-like disorders without prior medical history, the determination of the level of expression of antibodies against the N-methyl-D-aspartate receptors and other antineuroreceptors antibodies can help to identify this diagnosis. The initial picture of the disease, its variability and the unawareness of the recent reports on this encephalitis may lead to a wrong diagnosis and inappropriate management.     

Comparison of Amsorb®, Sodalime, and Baralyme® Degradation of Volatile Anesthetics and Formation of Carbon Monoxide and Compound A in Swine In Vivo

Background: Consequences of volatile anesthetic degradation by carbon dioxide absorbents that contain strong base include formation of compound A from sevoflurane, formation of carbon monoxide (CO) and CO toxicity from desflurane, enflurane and isoflurane, delayed inhalation induction, and increased anesthetic costs. Amsorb(R) (Armstrong Ltd., Coleraine, Northern Ireland) is a new absorbent that does not contain strong base and does not form CO or compound A in vitro. This investigation compared Amsorb(R), Baralyme(R) (Chemetron Medical Division, Allied Healthcare Products, St. Louis, MO), and sodalime effects on CO (from desflurane and isoflurane) and compound A formation, carboxyhemoglobin (COHb) concentrations, and anesthetic degradation in a clinically relevant porcine in vivo model.

Methods: Pigs were anesthetized with desflurane, isoflurane, or sevoflurane, using fresh or partially dehydrated Amsorb(R), Baralyme(R), and new and old formulations of sodalime. Anesthetic concentrations in the fresh (preabsorber), inspired (postabsorber), and end-tidal gas were measured, as were inspired CO and compound A concentrations and blood oxyhemoglobin and COHb concentrations.

Results: For desflurane and isoflurane, the order of inspired CO and COHb formation was dehydrated Baralyme(R) >> soda-lime > Amsorb(R). For desflurane and Baralyme(R), peak CO was 9,700 +/- 5,100 parts per million (ppm), and the increase in COHb was 37 +/- 14%. CO and COHb increases were undetectable with Amsorb(R). Oxyhemoglobin desaturation occurred with desflurane and Baralyme(R) but not Amsorb(R) or sodalime. The gap between inspired and end-tidal desflurane and isoflurane did not differ between the various dehydrated absorbents. Neither fresh nor dehydrated Amsorb(R) caused compound A formation from sevoflurane. In contrast, Baralyme(R) and sodalime caused 20-40 ppm compound A. The gap between inspired and end-tidal sevoflurane did not differ between fresh absorbents, but was Amsorb(R) < sodalime < Baralyme(R) with dehydrated absorbents.     

A Multicenter Study Comparing the ProSealTM and ClassicTM Laryngeal Mask Airway in Anesthetized, Nonparalyzed Patients

Background: The laryngeal mask airway ProSeal(TM) (PLMA(TM)), a new laryngeal mask device, was compared with the laryngeal mask airway Classic(TM) (LMA(TM)) with respect to: (1) insertion success rates and times; (2) efficacy of seal; (3) fiberoptically determined anatomic position; (4) orogastric tube insertion success rates and times; (5) total intraoperative complications; and (6) postoperative sore throat in nonparalyzed adult patients undergoing general anesthesia, hypothesizing that these would be different.

Methods: Three hundred eighty-four nonparalyzed anesthetized adult patients (American Society of Anesthesiologists physical status I-II) were randomly allocated to the PLMA(TM) or LMA(TM) for airway management. In addition, 50% of patients were randomized for orogastric tube placement. Unblinded observers collected intraoperative data, and blinded observers collected postoperative data.

Results: First-attempt insertion success rates (91 vs. 82%, P = 0.015) were higher for the LMA(TM), but after three attempts success rates were similar (LMA(TM), 100%;PLMA(TM), 98%). Less time was required to achieve an effective airway with the LMA(TM) (31 +/- 30 vs. 41 +/- 49 s;P = 0.02). The PLMA(TM) formed a more effective seal (27 +/- 7 vs. 22 +/- 6 cm H2O;P < 0.0001). Fiberoptically determined anatomic position was better with the LMA(TM) (P < 0.0001). Orogastric tube insertion was more successful after two attempts (88 vs. 55%;P < 0.0001) and quicker (22 +/- 18 vs. 38 +/- 56 s) with the PLMA(TM). During maintenance, the PLMA(TM) failed twice (leak, stridor) and the LMA(TM) failed once (laryngospasm). Total intraoperative complications were similar for both groups. The incidence of postoperative sore throat was similar.