Thrombopénie immuno-allergique postopératoire en chirurgie cardiaque : un diagnostic à ne pas oublier !

Type II heparin-induced thrombocytopenia (HIT) has a low incidence in cardiac surgery, but its mortality once declared is high. Its clinical recognition can be difficult with these patients who usually have thrombocytopenia in postoperative period and who are predisposed to develop HIT prematurely. Thromboses in this context must be specific, and treatment, which is nowadays well codified, must be begun without waiting for biologic results. Besides, specificity of Elisa's test is weakened in this population since there is a high rate of serum conversion; yet, its preoperative realization associated with pre-test probability scoring for HIT, can turn out useful.     

Cécité bilatérale en postopératoire d’une chirurgie du rachis

We report the case of a 36-year-old man who underwent neurosurgery for a T9 spine fracture consecutive to a fall. The patient had complete postoperative blindness which did not totally recover during the hospital stay. Decreased visual acuity and postoperative vision loss are not uncommon in spine surgery. Such postoperative complications in spine surgery are severe. To avoid them, it is mandatory to identify the contributing factors and set up a preventive strategy.     

Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

L’œdème aigu du poumon à pression négative : illustration à partir d’un cas clinique inhabituel compliquant une paralysie récurrentielle postopératoire

Acute postoperative negative pressure pulmonary edema (NPPE) is a respiratory complication due to upper airway obstruction occurring most commonly in the postoperative period. Pathophysiologically, NPPE is explained by the abrupt generation of highly negative intrathoracic pressure that lead to fluid transudation from the pulmonary capillaries. This observation reports an unusual case of a young patient who has undergone total thyroidectomy for multinodular goiter. The postoperative period was marked by the occurrence of bilateral recurrent laryngeal nerve palsy that was complicated by a NPPE. The outcome was favorable after mechanical ventilation with reversal of NPPE and recovery of the recurrent laryngeal nerve function. This article stresses the importance of prevention of recurrent nerve palsy during thyroid surgery. It also highlights a little known respiratory complication: the NPPE. Understanding the pathophysiology of NPPE, rapid diagnosis and appropriate therapeutic measures could prevent its potential lethal consequences.     

Hémostase et prééclampsie

Clotting disorders are associated with the severe, early and complicated forms of PE. Compensated hypercoagulability states associated with a thrombocytopenia (PLT < 150k/mm³) affect 25 to 50% of severe PE patients. Laboratory markers of platelet and endothelial activation are the early increase of fibronectin levels, the worsening of the thrombocytopenia and the raised platelet turnover. The excessive thrombin formation is physiologically compensated by a rise in thrombin-antithrombin (TAT) complex levels, which is the most specific marker of a PE pregnancy, and a decrease in anti-thrombin (AT) activity. The placenta induced depression of the fibrinolysis appears to contribute towards the hypercoagulable state. The etiological importance of the erythrocyte and leucocyte activation with regards to the abnormal clotting activation is highlighted in the setting of maternal systematic inflammatory disease. The state of compensated coagulopathy found in the PE patient can suffer a pro-coagulatory imbalance because of a quantitative, or a qualitative failure (i.e. thrombophilia) of the physiological coagulation inhibitors, or a combination of both. This disseminated intravascular coagulation, qualified as chronic, is associated with clinically evident signs of fœto-placental unit impairment (i.e. IUGR, foetal death) with or without systemic repercussions in the mother (i.e. renal failure, HELLP syndrome, eclampsia). This set of haemostatic disturbances found in the PE patient is a dynamic phenomenon, which can evolve by the hour therefore requires frequent laboratory investigations. Delivery remains the only curative treatment for these haemostatic disturbances. A better understanding of the aetiology of DIC in PE, an early detection method and a specific identification of the at-risk patients could allow prophylactic and curative treatment.     

Intérêt de l’anesthésie péridurale cervicale dans la gestion périopératoire d’une thyroïdectomie chez une patiente à haut risque anesthésique

Cervical epidural anesthesia is an anesthetic technique that can be useful in patients with high perioperative risk undergoing to cervical surgery. We report the case of a patient of 49 years old with hypertension, diabetes mellitus, epilepsy, left hemiparesis sequelae of stroke and congestive left ventricular failure. The patient underwent total thyroidectomy under cervical epidural anesthesia. No difficulty breathing or decompensation of chronic underlying diseases were noted in the postoperative.     

Pneumocéphalie compressive après traitement chirurgical d’un hématome sous-dural chronique bilatéral : une complication banale et sérieuse

The occurrence of postoperative pneumocephalus is a common event and is often trivial. When the intracranial air volume is significant, it creates intracranial hypertension causing tension pneumocephalus. This case report describes the occurrence of tension pneumocephalus after surgical drainage of bilateral chronic subdural hematoma. The pneumocephalus was responsible for severe postoperative neurological deterioration. The attending physicians should be aware of the possibility of occurrence of such complication. Treatment and prevention of pneumocephalus should also be well known by the medical staff.     

Dysfonctions cognitives postopératoires : stratégie de prévention, de dépistage et de prise en charge

The femoral neck fracture is a major cause of morbidity and mortality in the elderly. The etiology of cognitive impairment observed in this population of aged patient seems to be multifactorial. In the strategy of prevention, elderly patient must have the clearer information dealing with the postoperative cognitive dysfunction. This would reduce the incidence of POCD and some cognitive complaints, which often reflect the anxiety of the elderly patient facing the possibility of cognitive impairment. During the anaesthesia consultation, it seems important to assess the cognitive function of this elderly patient (like using neuropsycholgical scale as the MMSE) and to identify associated risk factors of cognitive dysfunction. The management of cognitive disorders should be multidisciplinary, the anesthesiologist being the main referent, in collaboration with the geriatrician and the surgeon. In the clinical setting of femoral neck fracture in the elderly, this multimodal management (pain, nutrition, functional rehabilitation to make these patients autonomous as quickly as possible), seems to improve the functional prognosis and to have the observed POCD decreased.     

La préhabilitation. Préparer les patients à la chirurgie pour améliorer la récupération fonctionnelle et réduire la morbidité postopératoire

Objective

Prehabilitation consists in providing a repetitive physical exercise before surgery to improve the postoperative recovery course. This review aims to evaluate the feasibility and the expected benefits of prehabilitation on the postoperative recovery course and the reduction of the postoperative morbidity.

Data sources

Data research has focused on English-language articles in the Medline database, published from 1989 to 2013. Keywords, used separately or in combination, were: prehabilitation, functional capacity, postoperative morbidity, physical activity.

Study selection

Selected articles were original articles, clinical cases, review articles and meta-analysis.

Data extraction

Articles were analyzed for feasibility, benefits and limitations of preoperative physical preparation techniques.

Data synthesis

Poor preoperative functional status is associated with increased postoperative morbidity. Elderly are more prone to postoperative complications. The improvement of preoperative physical status of these patients is possible and may reduce morbidity and allow faster recovery after major surgery. In order to improve efficiency, the training program must provide endurance and muscle reinforcement exercises, whose intensity must be adapted to the patient's baseline physical abilities. An average of three sessions per week over a period of six to eight weeks before surgery seemed a good compromise between feasibility and effectiveness.

Conclusion

The effectiveness of prehabilitation has been demonstrated in cardiovascular surgery and probably in abdominal surgery. Prehabilitation must be integrated into the overall patient medical management, and must be associated with preoperative refeeding and postoperative rehabilitation protocols. By optimizing all stages of the surgical patient management, from diagnosis to recovery, prognosis of high-risk surgical patients could be improved.     

Évaluation du Risque CARDiaque de l’Opéré (RICARDO) : enquête nationale auprès des anesthésistes-réanimateurs concernant la prise en charge périopératoire du patient à risque cardiaque

Objectives

Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations.

Materials and methods

Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations.

Results

We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography.

Conclusion

This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.     

Défaillance multiviscérale compliquant une pancréatite aiguë au décours d’une hypertriglycéridémie majeure : à propos d’un cas

We report the case of a 42-year-old man admitted for a multi-organ failure with a coma, a hemodynamic instability, a respiratory distress syndrome, an acute renal failure and a thrombocytopenia. The blood samples highlighted a milky serum and allowed to diagnose an acute pancreatitis associated with a major dyslipidemia: hypertriglyceridemia 11,800 mg/dL and hypercholesterolemia 1195 mg/dL. The CT-scans do not reveal any cerebral abnormalities but highlighted pancreatic lesions without biliary obstruction. A multi-organ failure complicating a severe acute pancreatitis secondary of a major hypertriglyceridemia was mentioned. Despite the absence of clear guidelines, a session of plasma exchange was started in emergency. Symptomatic treatment with protective ventilation, vasopressors, continuous heparin and insulin was continued. The clinical and biological course was good in parallel of the normalization of lipid abnormalities. The patient was discharged at day 17 with a lipid-lowering therapy. We discuss the various treatments available for the management of acute pancreatitis complicating a severe hypertriglyceridemia and their actual relevance in the absence of clear recommendations.     

Gestion des thérapeutiques transdermiques en anesthésie

Objective

To provide guidance on perioperative management of most frequently encountered transdermal therapeutics in anaesthesiology: nicotine, fentanyl, nitroglycerin, scopolamine and estradiol.

Data sources

A review of the last decade literature was carried out on the Pubmed database using the following keywords (transcutaneous or percutaneous or transdermal or transdermic or skin or dermal) and (drug delivery systems or therapeutic systems or drug administration) grouped under the Mesh terms cutaneous administration, perioperative care, surgery, pharmacokinetics, nicotine, fentanyl, nitroglycerin, scopolamine, estradiol.

Study selection

Original articles, general articles reviews, guidelines, letters to the editor and case reports have been selected.

Data extraction

Articles were analyzed for each transdermal treatment in terms of pharmacokinetics as well as anaesthetics and surgical interactions.

Data synthesis

Transdermal nicotine must be removed before anaesthesia of patients with coronary disease or with high risk of inhalation and in case of reconstructive surgery. Transdermal fentanyl must be maintained during the perioperative period and associated with preventive treatments of hyperalgesia. Transdermal administration of fentanyl by iontophoresis is a promising system for postoperative analgesia. Transdermal nitroglycerin must be maintained before scheduled surgery of a coronary patient. Transdermal scopolamine must be removed the day before surgery because of its side effects. It could have an interest in the prevention of postoperative nausea and vomiting, but its therapeutic method remain to be defined. Transdermal estradiol can be maintained during the perioperative period.

Conclusion

The management of transdermal therapeutics in peri operative care can be adapted for each treatment and for each patient by knowing pharmacokinetics as well as anaesthetics and surgical interactions. In emergency situations, the actions to be taken do not generally differ, but one must be aware that the effects of trandermal treatments do not disappear immediately when removed, due to their pharmacokinetics properties.     

Stratégie de réhabilitation postopératoire de la fracture du col fémoral

The femoral neck fracture in elderly patient is an entity that is within the scope of “disease causing a femoral neck fracture”. The specific factors for successful management of these elderly patients are centered around patient's comorbidities, specific management in a clinical pathway, and more or less early rehabilitation after surgery. The type of fracture, surgery, specific treatment, early active recovery for the patients lying in bed after surgery optimize the functional outcome at mean term. The improvement of nutritional status, equilibrium for comorbidities and early rehabilitation with walking activities and physiotherapy significantly improve functional outcome at short and medium terms and postoperative mortality. The use of multimodal analgesia and regional analgesia primarily by perioperative continuous femoral nerve blocks also improve the medical prognosis and functional outcome of the patient.     

Extubation difficile imprévue

Complications at extubation remain an important risk factor in anaesthesia. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. We report a new case of respiratory complications associated with tracheal extubation in a 59-year-old woman. Her medical history included obesity, no criteria difficult intubation and no adverse events during her previous anesthetic procedures. At the end of surgery, immediately after extubation, the patient developed respiratory distress requiring reintubation. A second extubation performed in postoperative recovery room was complicated by a new respiratory distress with reintubation. The patient was then admitted to the ICU. The examination on admission was unremarkable. Chest X-ray and a chest CT scan were performed in search of an etiology. Both tests showed a large thyroid “goitre plongeant” (plunging goiter) and compressive. In the suites, a thyroidectomy was performed with excision of a large cervical plunging goiter para- and retropharyngeal bilateral chest, allowing extubation successfully. The postoperative course was uneventful.     

Pulmonary valve replacement after tetralogy of Fallot repair in a patient with immune thrombocytopenia

Marked thrombocytopenia causes significant bleeding in cardiovascular surgery. Herein, we describe the case of a 47-year-old woman with immune thrombocytopenia who underwent successful pulmonary valve replacement for pulmonary valve regurgitation and stenosis after complete repair of tetralogy of Fallot. Her platelet count decreased significantly to less than 5 × 10⁹/L on postoperative day 3, thus multiple platelet transfusions were given. Pulse steroid therapy with dexamethasone was subsequently administered systemically for 4 days. After the treatment, her platelet count started to recover. There were no significant postoperative bleeding events, and red blood cell transfusion was not required. Other than the platelet event, the postoperative course was uneventful and the patient was discharged on postoperative day 15.     

Une méningo-encéphalite herpétique après chirurgie lombaire : à propos d’un cas

We report a case of a patient with an herpetic meningoencephalitis complicating lumbar surgery. A combination of factors like a postoperative sepsis, an abnormal MRI, and a positive viral PCR and culture made the diagnosis. A prolonged acyclovir treatment was employed with satisfactory results. This case remembers us the possibility of herpes reactivation in a stressful situation (including surgical stress).     

Amélioration transitoire d’un syndrome Parkinsonien après anesthésie générale

We describe the case of a patient with an untreated Parkinson's disease who underwent surgery for a temporal meningioma. Extrapyramidal syndrome, initially attributed to the meningioma, had improved over the 48 hours following the procedure and then reappeared. This observation raises the question about the impact of drugs used during perioperative days in patients with Parkinson's disease not treated with levodopa.     

Incidences et causes d’insatisfaction des patients vis-à-vis de la prise en charge de la douleur postopératoire

Introduction

Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief.

Objective

To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48 h postoperative period.

Patients and methods

The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons.

Results

Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period.

Conclusion

There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.     

Retroperitoneal phlegmon following transanal endoscopic microsurgery for rectal adenoma

Summary. We report the case of a 55-year-old male patient who underwent transanal endoscopic microsurgery for recurrent benign rectal adenoma. He developed severe postoperative retroperitoneal phlegmon and sepsis and died 28 days after the operation due to untreatable diffuse intraabdominal bleeding caused by persistent thrombocytopenia.