Résumés

Hypertension Portale Portal Hypertension

Résumés     

Les traumatismes cranio-cérébraux mineurs

Résumé  Les traumatismes cranio-cérébraux sont un problème majeur de santé publique puisque représentant une cause importante de mortalité et de morbidité. Malgré l’importance incidentelle et financière de l’affection, il n’a pas été possible jusqu’ici de définir de fa?on certaine les éléments déterminant l’évolution des troubles, le type de traitement à utiliser et l’attitude médico-légale à adopter. Le présent article résume les connaissances et les incertitudes actuelles concernant la pathophysiologie des TCC, le tableau clinique et l’évolution de ces derniers, le r?le des différentes investigations complémentaires dans le diagnostic et le pronostic, les traitements à disposition et les aspects médico-légaux.      

Les pratiques transfusionnelles en réanimation

Blood transfusions are a common event in the ICU with about a third of all patients receiving a transfusion at some point during their ICU stay. The theoretical rationale behind blood transfusion is fairly clear-cut: by increasing the hemoglobin concentration, oxygen delivery to the tissues will be improved and organ function optimized. However, in reality the situation is more complex. While increasing red cell mass may indeed increase oxygen delivery, there may not be a corresponding increase in oxygen uptake and tissue oxygen availability. In fact, despite traditional transfusion triggers set in the region of a hemoglobin value of 10 g/dl or a hematocrit of 30%, there is evidence that the system can tolerate much lower levels of anemia with few or no adverse effects. Several studies have suggested an increase in mortality in transfused patients, however, while many patients may indeed tolerate a lower hemoglobin value than traditionally thought, anemia is not a benign feature and acutely anemic patients also have higher mortality rates. The ‘optimal’ hemoglobin is, thus, a balance between the benefits of maximum hemoglobin levels and the potential adverse effects of blood transfusion and high hematocrit. In this article we will discuss some of the epidemiological data surrounding this issue and how its implications for transfusion practice in the ICU.     

Les fibroses pulmonaires en réanimation

Introduction – Idiopathic pulmonary fibrosis and pulmonary fibroses associated with systemic diseases are the most frequent diffuse interstitial pulmonary diseases. These conditions usually evolve slowly but irrevocably towards terminal respiratory failure. Their clinical course can also be complicated by episodes of severe acute respiratory failure, whose cause is not always obvious. Admission to the intensive care unit for respiratory support can then be discussed.News and facts – Few data in the literature have described the diagnostic and therapeutic management of acute respiratory failure in patients with pulmonary fibrosis. Recent retrospective series shed some new light on this management, underlining its difficult nature. Mechanical ventilation generally leads to the patient's death, despite anti-infectious and immunosuppressive treatments.Perspectives and projects – The mortality rate of acute respiratory failure in patients with pulmonary fibrosis is very high. A non aggressive ventilatory strategy, such as proposed in the acute respiratory distress syndrome, could lead to a decrease in the ventilator-induced lesions that possibly occur in these fragile lungs. Only prospective studies, which would be difficult to set up, could evaluate the impact of such a ventilatory approach on mortality.     

Les encéphalites non infectieuses en réanimation pédiatrique

Acute encephalitis remains a frequent cause of admission in paediatric intensive care units. Although most cases are due to infective causes, non-infectious acute encephalitis is less well known and its diagnosis and treatment are frequently delayed. Hereby we describe the main causes of non-infectious acute encephalitis including acute disseminated encephalomyelitis, macrophage activation syndrome related acute encephalitis, Hashimoto encephalitis, anti-N-Methyl-D-aspartate (NMDA) receptor encephalitis and fever-infection related epilepsy syndrome (FIRES)/devastating epilepsy in school-age children (DESC) syndrome.     

Les explorations neurophysiologiques chez l’enfant cérébrolésé : quand,comment ?

Neurophysiological tests complete clinical and radiological assessments in brain-injured children. Electroencephalogram (EEG) is clearly helpful to diagnose seizures and brain death while auditory evoked potentials (EP) to assess brainstem dysfunction and predict poor neurological outcome in post-anoxic coma. During the acute phase of severe traumatic brain injury (TBI) and bacterial meningitis, early recognition and treatment of convulsive seizures is essential. The incidence of non-convulsive seizures remains, however, high, varying between 7 and 48%. Although costly and time consuming, continuous EEG monitoring techniques may allow improving seizure detection. Therefore, amplitude integrated EEG techniques have been developed; however, they still require assessment in paediatrics. Some EEG patterns are indicative of a final bad outcome, including burst suppression, isoelectric pattern, and status epilepticus. EEG predictive value remains limited and less useful than somatosensory EP (SEP). SEP have excellent predictive value in post-anoxic coma in adults as well as in children (94 to 100%), especially in combination to pupillary reflexes and motor responses assessed after 48 h. In contrast, their predictive value of a good outcome is less reliable. In severe TBI and bacterial meningitis, this performance is also limited. Investigation of cognitive EP or mismatch negativity (MMN) could improve awakening prediction.