Petit déjeuner/débat avec le soutien de AMI France

Résumé / Abstract

Petit déjeuner/débat avec le soutien de AMI France     

Place de la laminoplastie dans le traitement de la myélopathie cervicale d’origine arthrosique

Cervical spondylotic myelopathy (CSM) is a common condition. Uninstrumented laminectomy may be complicated by postoperative instability, whereas anterior or posterior decompression with fusion may be associated with stiffness and adjacent segment disease. Cervical laminoplasty, initially oriented towards pediatric patients and ossification of the posterior longitudinal ligament, becomes an interesting surgical alternative to decompress and reconstruct cervical anatomy without fusion. Eighteen patients (12 men, 6 women), mean age 64.2 who presented with CSM were treated surgically using multilevel laminoplasty, and reviewed after 1 month, 6 months, 1 year and 2 years. Clinical evaluation was performed based on the Benzel-JOA and Nurick scores. The preoperative mean Benzel-JOA score was 13.55; Preoperative mean Nurick score was 1.88. Preoperative MRI was carried-out in 16/18 patients. Intramedullary hyperintensity in T2 was observed in 6 patients. The operation was performed on 2 levels (4 patients) 3 levels (11 patients) and 4 levels (3 patients). We used the open-door hinged laminoplasty technique, using metallic implants, without bone graft. At one month FU, mean JOA score was 15.44, and Nurick dropped to 1.05. At 6 months, mean JOA was 16.28 and Nurick was 0.71. At one year, the mean JOA score was 16.16, and Nurick was 0.83. At 2 years, mean JOA was 17.5, and Nurick was 0.25. One infection, one dural tear and one transient episode of C5 paresthesia were observed. We conclude that spinal cord decompression by open-door laminoplasty for CSM allows significant clinical improvement observed progressively in the two years following surgery.     

L’insufflation trachéale de gaz permet d’éviter l’hypercapnie chez le traumatisé crânien grave avec syndrome de détresse respiratoire aiguë

PURPOSE: The purpose of the ventilatory management of acute respiratory distress syndrome (ARDS) is to avoid any barotrauma to the lungs by decreasing the tidal volume at the expense of permissive hypercapnia. This hypercapnia is extremely dangerous for severe head trauma patients because it increases intracranial pressure. The solution could be the use of tracheal gas which insufflation (TGI) allows the reduction of arterial carbon dioxide tension (PaCO(2)) while controlling airway pressures. CLINICAL FEATURES: We report the cases of two patients with ARDS and severe head trauma. The decrease of tidal volume ( by 60 and 25% respectively) in association with tracheal gas insufflation allowed to reduce plateau airway pressure (<35 cm d'H(2)O) and PaCO(2) (in the first case by 23% and in the second case, by 11% for the second hour then by 24%), while intracranial pressure remained constant or was lowered (in the second case by 39% for the second hour). TGI consisted in insufflating fresh gas via a small catheter placed in the trachea (0(2) at 6 L*min(-1) in the first patient and 4 L*min(-1) in the second case). CONCLUSION: TGI appears to be an important component of ventilatory management when ARDS is associated with severe head trauma.     

Implication du pharmacien d’officine dans le parcours de soins de la maladie rénale chronique

Chronic kidney disease (CKD) is a major concern of public health. The pharmacist is known as a health practitioner involved in prevention and therapeutic education. Our study aimed at defining the impact of community pharmacists’ interventions for preventing and screening CKD. In our observational prospective study of 5 months conducted in 109 community pharmacy, we included 2 groups of patients: A (therapeutic optimization): CKD patients and B (CKD screening): population at risk. In group A, we included 354 patients, mainly women (51.2%), in stage 3 of CKD, mean age 73 years old, with hypertension alone (40.6%) or associated with diabetes (44%). About 70% of the patients had a follow up by a nephrologist and 45% of them were good adherent according to the Morisky-Green self-report. However, approximately 20% of patients did not have nephroprotective treatments in their regimen although they were on stage 3 or 4 CKD patients, and about half of them were not aware of medical situations at risk. Concerning group B, 532 patients were included. The pharmaceutical interventions screened 10% of patients with a GFR < 60 mL/min/1.73 m². The community pharmacists’ interventions helped to optimize the therapeutic management of CKD patients and in the early screening of patients at risk. More studies are needed to extrapolate our observations to a larger population.     

Effets de différentes doses d’édrophonium sur la neutralisation du bloc neuromusculaire induit par le mivacurium en présence de N2O,de propofol et d’alfentanil

Objectif

Cette étude a pour but de déterminer la dose optimale d’édrophonium nécessaire à l’antagonisme d’un bloc neuromusculaire induit par le mivacurium.

Méthode

Une dose initiale de mivacurium (0,15 mg · kg^?1) suivie d’une perfusion (7 μg · kg^?1 · min^?1) ont été administrées à 75 malades (ASA I, II) lors d’une anesthésie associant alfentanil-propofol-N₂O. Une stimulation «train-de-quatre» (TOF) du nerf cubital était appliquée aux 20 secondes et la réponse de l’adducteur du cinquième doigt était enregistrée (Relaxograph NMT-100, DATEX, Helsinki, Finlande). La vitesse d’administration du mivacurium était revue aux 5 minutes afin de maintenir la hauteur de la première stimulation du TOF (T₁) à 5% de sa valeur initiale. Les malades étaient divisés de façon aléatoire en cinq groupes afin de recevoir édrophonium 0,0, 0,05, 0,1, 0,5 ou 1,0 mg · kg^?1 + glycopyrrolate 0,0, 0,0005, 0,001, 0,005 ou 0,01 mg · kg^?1 à l’arrêt de la perfusion de mivacurium.

Résultats

Toutes les doses d’édrophonium étudiées ont permis l’obtention d’un ratio TOF (quatrième stimulation du TOF/T₁) = 0,7 plus rapidement que le placebo (0,05:780 ± 179, 0,1:727 ± 216, 0,5:547 ± 287 et 1,0:640 ± 236 vs 0,0 mg · kg^?1:1089 ± 323 sec P < 0.05). Les doses de 0,1, 0,5 et 1,0 mg · kg^?1 ont toutes trois permis une récupération plus rapide du T₁ de 10 à 95% (T_10–95) (567 ± 236, 419 ± 166, 555 ± 288 vs 861 ± 224 sec P < 0.05) et de 25 à 75% (T_25–75) (253 ± 121, 147 ± 92, 217 ± 175 vs 429 ± 154 sec P < 0.05) lorsque comparées au placebo. Cependant, il faut noter la grande dispersion des résultats obtenus, et ce avec toutes les doses d’édrophonium étudiées.

Conclusion

Lorsque comparées au placebo, des doses d’édrophonium égales ou supérieures à 0,1 mg · kg^?1 ont accéléré la vitesse de récupération de tous les indices associés au bloc produit par le mivacurium pendant une anesthésie associant l’alfentanil, le propofol et le N₂O.     

Prévalence et facteurs associés au syndrome d’épuisement professionnel chez le personnel de santé des centres d’hémodialyse au Cameroun

BackgroundHemodialysis medical staffs usually work in a stressful environment. In low resource countries, professional conditions are worse and can lead to burnout syndrome. The aim of this study was to determine the prevalence of burnout syndrome and its associated factors in hemodialysis health care workers in Cameroon.Patients and methodsWe conducted a cross sectional study in all hemodialysis centers from Cameroon between January to August 2017. The Maslach Burnout Inventory was used for assessment of burnout level. Burnout syndrome was defined as the presence of emotional exhaustion, depersonalization or decreased professional achievement.ResultsA total of 92 health workers (women 60%; n = 55) among 105 identified were recorded. The median age was 42 years. Most of the workers were nurses (78.5%) and 8.5% were nephrologists. Burnout syndrome was found in 76 (82.6%) workers, 35 (38%) had emotional exhaustion, 44 (48%) depersonalization and 57 (62%) decreased professional achievements. Burnout was significantly more prevalent in overcrowded centers (100% vs. 47%; P < 0.001). Hemodialysis position < 5 years was less prevalent in participants with emotional exhaustion and depersonalization. Desire to change position (OR 19.61 [2.074–185.4]; P = 0,009) was associated with burnout syndrome.ConclusionBurnout syndrome is very common among Cameroonian hemodialysis medical staff. Improvement of work conditions, limiting posting in hemodialysis to less than 5 years and change of position when requested may be potential preventive measures.     

Comparaison de l’incidence sur le saignement de deux techniques anesthésiques midazolam-alfentanil versus propofol-alfentanil lors de la cure d’otospongiose

This study was performed to compare the incidence of bleeding associated with two anaesthetic techniques during otolaryngological microsurgery. Twenty-eight venous interpositions for otospongiosis have been carried out at random either under local anaesthesia combined with light sedation (midazolam 0.1 mg.kg-1 and alfentanil 0 micrograms.kg-1) or using general anaesthesia (propofol 2.5 mg.kg-1, then 9 mg.kg-1.hr-1 and alfentanil 30 micrograms.kg-1, then 15 micrograms.kg-1). The patients' lungs were mechanically ventilated. Every ten minutes, heart rate, arterial blood pressure and FETCO2 were observed. Bleeding was assessed on a four-point scale and evaluated according to its duration and the annoyance that it caused. General anaesthesia was clinically better tolerated. Heart rate and arterial blood pressure were lower than with general anaesthesia. The end-expiratory CO2 was 4.7 +/- 0.2 per cent. Bleeding was less frequent, lasted less time, but when it occurred the surgical disturbance was identical in the two groups. General anaesthesia produced a less bloody operating field and local anaesthesia required the cooperation of the patient.