Mécanismes neurophysiologiques de la dyspnée : de la perception à la clinique

Dyspnea is one of the major symptoms of acute and chronic respiratory diseases. In the intensive care unit, up to half of mechanically ventilated patients suffer from dyspnea. In these patients, the detection and treatment of dyspnea should be a priority, such as for pain. Recent pathophysiological key findings have individualized several and various forms of dyspnea, each of them involving given receptors, pathways, and cerebral integration areas. Dyspnea is a multidimensional feeling including emotional and sensorial components. Dyspnea results from an imbalance between the central respiratory command and the ability of the respiratory system to match this demand. Various scores and scales now allow an easy detection, evaluation and characterization of dyspnea in its different components. However, the treatment of dyspnea is still challenging. Few pharmacologically active treatments are available and they all bear potentially deleterious adverse effects. Non-pharmacological treatments are promising techniques but are still under research.     

Syndrome de l’intestin irritable. Actualités concernant les mécanismes et la prise en charge

Irritable bowel syndrome (IBS) is a frequent functional bowel disorder in association with abdominal pain and transit disorders that affects 5% of the general population. The disease, although benign, may be responsible for an impairment of the quality of life, depending on the severity of the disease and the response to first-line treatment. IBS treatment has evolved as a result of an improved knowledge of pathophysiology, sometimes leading to new treatments and improvement of care. Treatment strategy includes dietary and physical activity recommendations, conventional or alternative treatments and therapeutic education.     

Modalités et résultats de la prise en charge endoscopique des complications de la chirurgie bariatrique

Bariatric surgery is more and more practiced and appears to be the most efficient treatment against morbid obesity after failure of a medical treatment. Treatment of surgical complications is a matter for multidisciplinary approach including endoscopy. With a review of our own experience on 53 patients since 2009, we will expose an update to clarify the procedures and results of endoscopy for surgical complications treatment after bariatric surgery.     

évaluation de la prise en charge de la douleur au centre hospitalier du Lamentin en Martinique

In a quality approach, the committee against pain made an audit of every inpatient service at Lamentin hospital center, to evaluate the prevalence of pain and emotions of patients and caregivers. The audit was conducted on a specific day for all the patients. At the same time, questionnaires for caregivers were sent to care units, and the staff had one week to fill them. 140 patients, 272 paramedics and 52 doctors, about two-third of the entire hospital, replied to the questionnaire. Results showed some weaknesses of the current system: patients information on pain management, pain evaluation and treatment delays. Two-thirds of patients felt that the staff did their best to relieve their pain, but 20% of patients endured pain at the time of the audit. The low use of pain referents and analgesia protocols is a drawback observed in this study. Doctors who were not well trained on pain management represented a major barrier to the use of analgesia protocols. Other barriers were communication difficulties between medical and paramedical staff and lack of medical supplies. The overall outcome is acceptable but much remains to be done; one caregiver in five still thinks that there is more to achieve in pain management. Short-term actions were initiated since the audit: improvement of patient information, updating analgesia protocols, systematic pain evaluation, and so on. A new audit will be needed to assess the impact of these remedial actions and to provide the best care to the patient.     

Anémie de réanimation : physiopathologie et prise en charge

Anaemia is frequent in the critically ill patients, present in almost 80% of them. Anaemia is associated with worse outcome and increased mortality. Its pathophysiology combines disturbances of erythropoietin synthesis and iron metabolism. The better understanding of iron metabolism regulation by the hormone hepcidin may offer new therapeutic perspectives. However, to date, anaemia management requires mainly prevention of blood spoliations, mainly by reducing blood sampling, and tailored blood transfusions.     

Peut-on individualiser la prise en charge de la douleur ?

While most cesareans are conducted without any particular problem, in nearly 20% of cases, women may present severe postoperative pain, despite adequately managed multimodal analgesia. In terms of pain, there is significant variability because of the numerous factors involved, including physiological, cognitive, cultural, social, emotional and genetic ones.Different approaches have been proposed to identify women at risk of developing significant postoperative pain, including nociceptive tests and/or psychosocial questionnaires associated or not to genetic analyses.Although some results remain controversial, these approaches now identify a population at risk in the presence of preoperative features such as: anxiety, catastrophism, low nociceptive threshold, hyperalgesia or certain genetic polymorphisms involved in nociception or effectiveness of analgesic drugs.If nociceptive tests and especially genetic tests are currently difficult to implement, assessment of psychosocial factors using questionnaires, more or less complex, seems like a more appropriate routine approach.     

Enseignement de la prise en charge endoscopique des hémorragies digestives

Gastrointestinal bleeding is an unprevisible and serious event requiring urgent management. Endoscopic hemostasis is defined by the cessation of bleeding and prevention of rebleeding by applying one or more technical endoscopic hemostatic techniques. It is an advanced procedure. Training in endoscopic hemostasis is difficult partly due to the urgent and unpredictable condition of gastrointestinal bleeding. Training by tutoring only (performing clinical cases under the supervision of a trainee) is long and difficult because it depends on the clinical cases seen during fellowship. Endoscopic management of GI hemorrhage includes important knowledge in medical management, in systematic categorization of both source of bleeding and the technique used to control it, and basic knowledge about technical skills to perform endoscopic procedure. Various simulation platforms, including virtual reality simulators, and animal models are available and efficient for training in endoscopic hemostasis. However, validated criteria for obtaining and maintaining procedural competence in endoscopic hemostasis techniques are still lacking.     

La prise en charge des corps étrangers ingérés : à propos de 82 cas et revue de la littérature

The ingestion of foreign bodies is a rather frequent occurrence in our context; ingestion may be accidental or deliberate. They can be dangerous because of their location or nature, making endoscopic extraction urgent. The aim of our study was to evaluate, using a retrospective study, the success rate of extraction of foreign bodies in our context as well as the means used. Over a ten-year period (January 2001 to January 2011), all patients admitted to the emergency services of UHC Hassan-II, Fez, for the ingestion of foreign bodies were recorded. We reviewed the methods used for extraction and the treatment success rate. During this period, 82 oesogastroduodenal endoscopies (OGDE) were performed for the extraction of foreign bodies. There was a male predominance (sex ratio: 1.5), with an average age of 33.5 years (6 to 83 years); all endoscopies were performed in an emergency. Voluntary ingestion was found in 24 cases while 58 cases were accidental. Among foreign bodies frequently encountered, there were needles in 17 cases, impaction of a piece of meat in 14 cases, ingestion of dentures in 11 cases, while other objects (coins, razor blades, nails, nail cutters) were less frequent. The foreign body was found in 32 cases at a gastric level, an oesophageal level for 31 patients, the duodenum for two patients and no foreign body was found for 14 patients. The extraction was done mainly by a hot wire loop and tripod forceps procedure; extraction was a success in 43 cases (52.4%), a foreign body was not found in 17 cases (20.7%), and the extraction failed in 13 cases (16%). No complication after extraction was noted in our context.     

Impact de l'échoendoscopie dans la prise en charge de l'adénocarcinome pancréatique

Acta Endoscopica - L'hôpital de jour était utilisé par des patients plus jeunes. On notait l'importance de la consultation auprès d'un gastro-entérologue qui...     

Réanimation et cytopénies auto-immunes. Diagnostic et modalités de prise en charge

Immune thrombocytopenia (ITP) and autoimmune haemolytic anemia (AIHA) are the two main autoimmune cytopenias in adults. AIHA includes AIHA associated with warm autoantibodies and cold agglutinin-mediated anemia (CAA). Treatment of the most severe forms of ITP is based on high-dose steroids and intravenous immunoglobulins (IVIg). Platelet transfusions are indicated only for life-threatening bleedings. High-dose steroids represent the first-line treatment of warm AIHA. Red blood cell transfusions are effective for symptomatic anemia. Splenectomy should only be performed in the exceptional cases refractory to medical treatment. In CAA, transfusion of warmed packed red blood cells is the unique emergent therapy. Steroids are not effective and should be avoided. Anti-CD20 antibodies represent a promising therapy for warm AIHA and CAA and should be administered if first-line treatment has failed.     

Peut-on mesurer la souffrance liée à la douleur ?

The demand made to physicians to be more attentive to assessing the suffering of their patients was introduced by Eric Cassell as one of the fundamental goals of medicine. This call was indeed taken into account by health professionals but remained difficult to satisfy in the absence of appropriate measures. In addition, the focus on end-of-life suffering in palliative care has excluded in the vast majority of cases patients with chronic medical conditions and in particular those suffering from chronic pain whose on-going suffering is part of everyday life. To fill this gap, my integrative research proposes an interdisciplinary approach that relies on both philosophical, psychobiological and clinical concepts seeking to provide a measure accompanied by an interpretation of the person’s suffering. The practical goal is to provide a simple and effective clinical tool to assess the degree of suffering related to pain and to characterize its specific nature in each patient, allowing a more precise diagnosis and more individualized management of chronic pain patients. In answering the question « Can we measure Painrelated Suffering? » this paper addresses the main issues, both conceptual and methodological, attached to the evaluation of suffering in order to instruct the development of its assessment tool.     

Utilisation du sulfate de magnésium dans la prise en charge de l’éclampsie : à propos de 122 observations

Objective

To analyze clinical presentation, management, and outcome of eclampsia patients treated by magnesium sulfate. Patients and methods: Retrospective study conducted from January to December 2012 including patients with eclampsia admitted to the intensive care unit and treated with magnesium sulfate.

Results

A total of 582 patients were hospitalized during the study period, including 122 women (20.9 %) treated with magnesium sulfate for eclampsia. The mean age was 23.6 ± 6.3 years (16–42). In 90 patients (73.8 %), the treatment was administered during less than two days. Under this treatment, seizures stopped in all the patients within 48 hours. However, two patients (1.6 %) required boluses at the begining of the magnesium sulfate infusion due to the onset of seizures. A case of overdose was suspected, leading to the treatment discontinuation. Treatment monitoring was clinical in all the cases. Diazepam was used in the absence of magnesium sulfate in seven patients (5.4 %). Nicardipine was associated with magnesium sulfate in 92 cases (75.4 %).

Conclusion

The use of magnesium sulfate in eclampsia seems satisfactory; however, unavailability of laboratory testing may represent a drawback for optimal patient management.