Gestion du risque infectieux chez le splénectomisé

Each year in France 6000 to 9000 patients are splenectomised or spleen embolized. As spleen has immunological functions, it contributes to protect against infections. Thus, hypo or asplenia increase the risk of infection, especially the risk of Overwhelming Post-Splenectomy Infection (OPSI). OPSI is a medical emergency, characterized by aspecific symptoms, which may rapidly progress to fulminant infection and death in 50% of cases within 48 h. Encapsulated bacteria as Streptococcus pneumoniae, Haemophilus influenzae and Neisseria meningitidis are most of the time responsible of these infections in asplenic patients. To prevent OPSI, several measures are essential and must begin before a scheduled surgery or just after an urgent splenectomy. Patients must carry a card. The first proposed prevention measure is to enhance partial surgery when it's possible. Then, the two other measures, antibiotic prophylaxis and vaccination, shall be implemented whatever is the indication of surgery. Postoperative antibiotic prophylaxis by phenoxymethyl-penicillin is prescribed for two years minimum and lifelong prophylaxis should be offered to high risk of pneumococcal infection patients. Pneumococcal, H. influenzae type b and meningococcal vaccination should be administered 2 to 6 weeks before scheduled splenectomy and 2 weeks after urgent surgery. Yearly, patients must receive Influenza vaccination. As an interindividual variation exists in vaccinal response, measurement of serotype-specific antibodies can be used, if available, to individualized risk patients and to organize revaccination. Finally, to prevent OPSI, patient and next-of-kin must be educated about prevention measures and infectious risk to optimize patient's compliance.     

L’hémofiltration en cascade : principe,premières données expérimentales

High-volume hemofiltration has been suggested as an adjuvant treatment of septic shock (renal support and immunomodulation of the host response via the removal of middle molecular weight molecules such as cytokines). Nevertheless, high-volume hemofiltration presents some important drawbacks, such as the depletion of low molecular weight molecules (nutriments, vitamins, trace elements and antibiotics) due to the high ultrafiltration rate, or the significant financial cost and nursing workload. We describe cascade hemofiltration, a new high-volume hemofiltration system, which has been developed to limit these drawbacks by using a special extracorporeal circuit. Results of the first experimental study using this prototype are also reported. They demonstrate the technical feasibility, security and safety of the cascade system although other experimental and clinical studies are needed to continue evaluating this system.     

Méningite à streptocoque du groupe A : il n’y a pas que le pneumocoque qui s’infiltre dans la brèche ostéoméningée !

We reported a case of group A streptococcal meningitis in a patient with a CSF fluid leak. This case underlined several relevant points: (i) an unfrequent cause of bacterial meningitis; (ii) the main diagnosis to evoke when the direct examination of CSF shows Gram+ cocci with a negative pneumococcal antigen; (iii) that bacteria other than Streptococcus pneumoniae are possible in front of a meningitis associated with a CSF fluif leak.     

Choc cardiogénique ischémique révélateur d’une maladie de Vaquez,un événement rare

We present the case of a 46-year-old patient without any past medical history, admitted to our ICU for cardiogenic shock complicating acute coronary syndrome. The blood tests found polycethemia, a polycethemia vera was suspected and confirmed by genetic analysis. Ischemic heart failure as an initial symptom of polycethemia vera and its treatment by arterial bleeding is a rare event that we describe in this article.     

Analgésie péridurale obstétricale et maladie de Willebrand de type 2B

Type 2B von Willebrand disease (vWD) is an inherited bleeding syndrome resulting from a qualitative abnormality of von Willebrand Factor with an increased affinity for the glycoprotein Ib platelet receptor. Pregnancy increases the severity of this disease by decreasing the platelet count restricting epidural anaesthesia because of adverse risk of spinal bleeding. There is a phenotypic variability of Type 2B vWD depending of the von Willebrand Factor mutation. We report here the strategy we used to administer epidural anaesthesia for a patient with Type 2B vWD resulting from the P1337L mutation of von Willebrand Factor.     

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.     

Rhabdomyolyse massive : une complication rare de la maladie des emboles de cholestérol

A 79-year-old man with atherosclerosis presented blue toes and livedo reticularis. The patient had eroded aortic atheromatous plaques, and cholesterol embolization syndrome was suspected. An endovascular technique to exclude sources of cholesterol emboli was however performed. The patient immediately presented with severe muscle pain and total functional disability of lower limbs, new ischemic lesions of toes, anal and genital necrosis, and a livedo extended up to the abdomen. A massive rhabdomyolysis occurred associated with acute kidney injury and hyperkaliemia treated by continuous renal replacement therapy with regional citrate anticoagulation. Steroids have been introduced and renal function improved. Cholesterol crystals were also found on a skin biopsy, performed before endovascular procedure.     

Association hélium-sévoflurane : une thérapeutique de sauvetage dans l’asthme aigu grave

We report the case of a severe acute asthma, which required, after optimal medical therapy, helium and sevoflurane CO-administration after tracheal intubation. The Anesthetic Conserving Device^® allowed sevoflurane use with intensive care unit's ventilator. The helium-sevoflurane association was maintained during 9 days to decrease the bronchospasm, waiting for the efficiency of an aetiologic treatment. We discuss the suitability of this association to treat severe acute asthma, and its administration modalities.     

Troubles de la coagulation lors du traumatisme cranio-encéphalique : physiopathologie et conséquences thérapeutiques

Early activation of coagulation is common after traumatic brain injury. Its origin is probably mainly intracerebral, due to tissue factor release from the injured brain. Abnormalities in blood coagulation tests are associated with poor neurological prognosis. Coagulation activation may induce disseminated intravascular coagulation and fibrinolysis. Disseminated intravascular coagulation is linked to brain ischemia caused by intravascular microthrombosis. This review will focus on pathophysiology of coagulation disorders after traumatic brain injury, and on their implications for therapeutic approaches.     

Césarienne et sismothérapie concomitante chez une patiente psychotique sévère : à propos d’un cas

Psychiatric disorders may complicate the pregnancy and is one of the causes of maternal and fetal morbidity. We report the case of a patient with severe decompensated schizophrenia during her pregnancy that required prolonged hospitalization in psychiatric ward. The psychiatric status of the patient required the realization of a caesarean section at 36 weeks of amenorrhea. In our case, we decided to perform this cesarean section under general anaesthesia, since regional anaesthesia was not feasible in this patient in a state of uncontrolled agitation. Moreover, general anaesthesia permitted to combine cesarean section with a first session of electroconvulsive therapy, which had been declined during pregnancy. Given the huge amount of antipsychotic agents administered to the patient, we also studied their transplacental transfer and found a very high loxapine concentration in the fetus. Finally, this case raised several important ethical issues related to the management of the mother and her fetus in case of severe psychiatric disorders.     

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.     

Épiploolastie de couverture des vaisseaux au cours d’une duodénopancréatectomie céphalique : technique modifiée

Introduction

In 1994, a technique of omental flap development and interposition to cover the celiac and mesenteric vessels was described. Its aim was to isolate the pancreatic anastomosis from the vessels dissected during pancreaticoduodenectomy (PD) and thereby to reduce the consequences of postoperative pancreatic fistula – particularly the risk of postoperative bleeding.

Technique

We describe this technique adding a simple modification consisting of passage of the pancreatic remnant through an omental window before completion of the pancreaticodigestive anastomosis.

Results

Sixty-four patients underwent PD using an omental flap to cover the celiomesenteric vessels. No postoperative deaths occurred. The rate of PF was 23% and the rate of postoperative hemorrhage was 3% (two patients). No complications related to the omental flap were observed. All postoperative hemorrhages originated from the transected surface of the pancreatic remnant and were successfully treated by transgastrotomy simple suture.

Conclusion

This simple technique has no specific morbidity; it isolates the celiac and mesenteric vessels from the pancreatic anastomosis and therefore may reduce the risk of severe postoperative bleeding after PD.