Indications et place de l'albumine au cours du remplissage vasculaire en traumatologie et en période préopératoire

The use of albumin solutions for volume replacement remains controversial. The last American guidelines recommend the use of albumin for resuscitation in case of a contra-indication of artificial colloids or the requirement of sodium restriction. Recent trials did not show any beneficial effect of albumin on the mortality and morbidity rates. Only an improvement of the rheologic conditions has been found with albumin (and dextran 40), in comparison with starch and gelatin. On the basis of cost-effectiveness considerations, artificial colloids should be at this time favoured over albumin for intravascular expansion, except in pregnant women. For resuscitation, albumin could be used when the recommended upper limit of hydroxyethyl starch vol-ume has been reached and fresh frozen plasma not yet required. During preoperative haemodilution, low molecular weight hydroxyethyl starch has at least the same efficacy as albumin. When a rheologlcal effect is required, albumin could be used.     

Indications et place de l'albumine dans le cadre du remplissage vasculaire au bloc opératoire

Prospective clinical studies on albumin and non human colloids, administered peroperatively, were analysed. Only those with a level of evidence I or II were considered. On the basis of the cost-effectiveness ratio, albumin should not be the first choice treatment for peroperative plasma volume expansion. Low molecular weight hydroxyethylstarch is as efficient for restoration and maintenance of volaemia and colloid osmotic pressure. Albumin is administered when other colloids are contra-indicated or when their upper limit of volume has been reached.     

Réponse ventilatoire au dioxyde de carbone après bloc axillaire avec fentanyl et lidocaïne

Respiratory parameters, ventilatory response to carbon dioxide and quality of anaesthesia were studied in patients undergoing upper limb surgery under axillary blockade. Thirteen patients were randomly assigned to two groups, group A (n = 6), who were given 35 ml of 1.5 % lidocaine with 1 in 200 000 of adrenaline, and group B (n = 7), who received 1 μg · kg⁻¹ of fentanyl with the same dose of lidocaine. Quality of the sympathetic, sensory and motor blocks were tested at 15 min (T1) and 45 min (T2) after the injection (T0). The other parameters measured at these three times, both with the patient in a half-sitting position breathing room air, and after a rebreathing test with CO₂ through Read's circuit, were respiratory rate (FR), tidal volume (Vt), minute ventilation (V̇e), and Petco₂. Fentanyl provided a better sensory and motor blockade at T1, without any difference in sympathetic blockade. The quality of the blocks was similar in both groups at T2. There were no significant differences in the respiratory parameters between the two groups. Moreover, there was no untoward effect due to fentanyl (nausea, pruritus). It is concluded that 1 μg · kg⁻¹ fentanyl added to a local anaesthetic solution may be useful, at least during the first hour of an axillary block, without any respiratory side-effects.     

La prise en charge médicale de l’ostéoporose après fractures périphériques chez la femme de plus de 50 ans

Objective. – To evaluate practices regarding the management of osteoporosis revealed by low-impact peripheral fractures in women older than 50 years of age.Methods. – Six orthopedic surgeons prospectively recruited patients presenting with their first low-impact peripheral fracture. Three months after the fracture, each patient’s usual primary-care physician provided information on management.Results. – The 132 patients (140 fractures) included in the study had a mean age of 73.8 years. Fracture sites in decreasing order of frequency were the wrist (29%), the hip (28%), the ankle (19%), the pelvis, the humerus, and the leg. Data on management by the primary-care physician were available for 106 patients. Fifty patients (50/106, 47%) were given a diagnosis of osteoporosis by their primary-care physician and 38 (38/106, 35%) received medications for osteoporosis.Conclusion. – In two-thirds of patients, a valuable opportunity for using the effective treatments available for osteoporosis was lost. Given the high risk of further fractures in this population, our finding is of great concern.