Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

Plastic surgery is more and more developing. Facial blocks are adapted to surgical procedures performed in this setting. They are easy to perform and may prolong postoperative analgesia. Facial blocks may be used in ambulatory surgery as a single technique or combined with general anaesthesia or intravenous sedation. After a reminding of facial nerve anatomy, facial and cervical blocks are described with their indications. Guidelines for performance and monitoring are also indicated.     

Diminution de l’expression monocytaire de HLA-DR et risque d’infection hospitalière

Objectives

The aim of this bibliographic review is to evaluate the usefulness of the measurement of HLA-DR expression on circulating monocytes (mHLA-DR) in predicting the development of nosocomial infections and unfavourable outcome in critically ill patients.

Data source

References obtained from the medical database PubMed^® in English and in French were reviewed. The keywords included separately or in combination were: HLA-DR antigens, sepsis, trauma, injuries, wounds, burns, stroke, pancreatitis, postoperative, prognostic, immunity, monocytic.

Data extraction

Data in selected articles were reviewed, clinical and basic science research relevant information were extracted.

Data synthesis

Low mHLA-DR expression appears as a marker for monocytic dysfunctions and immunosuppression, temporarily present in the majority of critically ill patients admitted to the ICU (sepsis, trauma injuries, postoperative, burns, pancreatitis and stroke). The decrease in mHLA-DR expression is a predictor of septic complications in all these clinical conditions. However, no predictive threshold value could be determined regarding unfavourable outcome.

Conclusion

The monitoring of mHLA-DR expression could be a biomarker to detect ICU patients at high risk of developing secondary nosocomial infections. Those patients could probably benefit of preemptive strategies to prevent these infections.     

Déficits rares de la coagulation et gestes invasifs

Rare inherited bleeding disorders include fibrinogen disorders, and deficiencies of factors II (prothrombin), V, VII, X, XI, XIII, and combined V + VIII, and combined vitamin K-dependent factors, with general population prevalence rates between 1/500,000 and 1/2,000,000. These inherited disorders, transmitted as autosomal recessive traits, are characterized by a heterogeneous clinical presentation (asymptomatic, mild, moderate or severe bleeding tendency); this variability is more important for deficiencies with factor levels ranging from 5 to 50%. Individual bleeding risk assessment before an invasive procedure or during peri-partum period remains difficult, although an essential step to decide whether a substitution with clotting factor is necessary or not. Because there is a poor correlation between factor activity levels and the severity of bleeding symptoms, factor correction before an invasive procedure should not be based on factor level only, but physicians must also take into account the patient phenotype as well as the haemorrhagic risk of the procedure.     

Incidence et évolution des images thrombotiques dans la veine jugulaire interne après cathétérisme de Swan-Ganz en chirurgie cardiaque

Objectives

Insertion of Swan-Ganz catheter for a few days may be necessary in cardiac surgery. This study was aimed at determining the incidence and the evolution of thrombotic images within the internal jugular vein as well as assessing their association with the presence of a prolonged fever at postoperative day 7 in the lack of any documented infection.

Material and methods

All the patients undergoing cardiac surgery had a two-dimensional ultrasonography of internal jugular veins preoperatively, at discharge (day 7) and at postoperative day 90 if thrombotic images were seen at day 7.

Results

Sleeve-like and compact thrombotic images have been observed in site of venipuncture in 52 patients (70.3%). None had any residual thrombotic image 90 days after the operation. No clinical thromboembolic migration has been observed. There was no statistical association between the presence of a thrombotic image at the ultrasonography and the duration of catheterization. Moreover, there was no association between the anticoagulation before, during and after the surgery and the presence of a thrombotic image. We found a non-significant association between fever at day 7 and the presence of a thrombotic image within the internal jugular vein.

Conclusion

Thrombotic images in the internal jugular vein after catheterization are frequent and disappear at day 90. The limited sample size of this study does not provide strong evidence of the role of jugular thrombi in the prolongation of fever after cardiac surgery.     

Étude de faisabilité pour la mise en place d’une filière de chirurgie ambulatoire en urgence

Introduction

Development of outpatient care is one of the major goals of public health policy in our country. For the purpose of this study, we set up an emergency outpatient surgery unit 24 hours a day in our hospital. We assessed the feasibility of such a unit with a length of stay less than 12 hours and no patient readmission.

Patients and methods

A prospective observational and monocentric study was conducted in our hospital by systematically including patients eligible for emergency surgery outpatient care. We built a database compiling patient characteristics, lengths of stay, surgical and anesthesic procedures, complications and readmission rate. Satisfaction was then assessed by the « EVAN-G » questionnaire.

Results

From May 2011 to October 2012, 147 patients were included in our research. They were 31 years old [25–43]. Hundred and twenty-six of them (86%) remained in the outpatient procedure without any readmission. Twenty-one (14%) were excluded, essentially for surgical contraindications or due to the absence of an accompanying person. Length of stay was of 10.5 hours [8.5–13]. The satisfaction survey showed an average score of 83/100.

Conclusion

The setting up of an ambulatory emergency surgery unit is possible after proper training of emergency care specialists, anesthesiologists, and surgeons. This activity is compatible with safe care and a high level of patient satisfaction. It must be considered as part of the emergency procedures available and should not be systematically ruled out.