Prévention de la prééclampsie

Aspirin has shown efficacy in preventing PE with a 10 % incidence reduction.     

Influence du mode de ventilation sur la variation respiratoire de la pression pulsée artérielle : étude randomisée

Objective

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.

Study design

Double-blind randomized study, cross-over design.

Patients

Patients in intensive care unit after a cardiac surgery.

Method

Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.

Results

Among the 26 patients analyzed, mean ΔPP value was de 14.0 ± 7.3% in VVC and 11.8 ± 6.2% in VPC (P < 0,0001). On Bland-Altman representation, mean bias was +2.2 ± 2.3% and inferior and superior limits of agreement were respectively −2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.

Conclusion

ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.     

Critères d’arrêt de la grossesse en cas de prééclampsie

Few studies establishing clear criteria for the medical interruption of a pregnancy complicated by PE are available today. Most of these studies are either retrospective or observational. When combining an analysis of the available literature together with the experts’ opinions, one can propose the following set of criteria for therapeutic interruption of pregnancy in the setting of PE, which apply mainly for the severe forms of the disease. These criteria can be subdivided into maternal and fetal criteria.     

Physiopathologie de la prééclampsie

Preeclampsia is agestational complication that classically appears from the start of the second trimester and which is specific to humans.     

Comment éviter la non–conformité de la recherche biomédicale ? Recommandations aux chirurgiens

Research misconduct is defined by the Royal College of Physicians of Edinburgh as any behaviour by a researcher, whether intentional or not, that fails to scrupulously respect high scientific and ethical standards. Various types of research misconduct include fabrication or falsification of data, plagiarism, problematic data presentation or analysis, failure to obtain ethical approval by a research ethics committee or to obtain the subject's informed consent, inappropriate claims of authorship, duplicated publication, and undisclosed conflicts of interest. These can result in patient injury, deterioration of the patient-physician relationship, loss of public trust in biomedical research, as well as pollution/degradation of the medical literature. Surgical research malfeasance has been underreported, and no practical guidelines for good research and publication have appeared to date in French surgical journals. In an attempt to uphold the scientific integrity of our profession, we discuss research misconduct and emphasise preventive measures and considerations for surgeons.     

Traumatisme de la rate : facteurs prédictifs d’échec du traitement non-opératoire

Introduction

Non-operative management of blunt splenic injury in adults has been applied with increasing frequency. However, predictive criteria for successful non-operative management are still a matter of debate.

Methods

we retrospectively reviewed all cases of blunt splenic injury in adult patients from 1997 to 2006.

Results

Of 190 patients with blunt splenic trauma (median age: 33 years, range 16-98), 43.7% (n=83) underwent emergency surgical intervention (Group I), and 56.3% (n=105) of patients were admitted for conservative treatment of splenic trauma. Conservative treatment was successful in 76.6% (n=82) (Group II), while 23.4% (n=25) of patients required a laparotomy (Group III). Ultimately, 43.2% of patients were successfully managed non-operatively, and 56.9% underwent laparotomy. Mechanism of injury was not significantly different among three groups. Group I patients presented significantly more frequently with hypovolemic shock (p<0.01), associated injuries (p<0.01), and high grade of splenic injury (p<0.01). All patients with active bleeding as evidenced by extravasation on CT scan, underwent exploratory laparotomy. Failure of non-operative management increased significantly with splenic trauma grade (grade I (0%), grade II (22.6%), grade III (27.6%) and grade IV (40%), (p<0.01) and with quantity of hemoperitoneum (10.4% of patients with small, 22.2% of patient with moderate, and 47.8% with large hemoperitoneum). The median interval for conservative treatment failure was 3 days (range: 1-15).Splenic injuries were operatively controlled by splenectomy (91.6%) and splenorrhaphy (8.4%).

Conclusion

Suitability of adult patients with blunt splenic injury for non-operative management may be predicted at initial presentation, based on hemodynamic status and associated injuries. The quantity of hemoperitoneum and magnitude of splenic injury are predictive factors for failure of conservative treatment. Early definition of these factors may help identify those patients likely to be successfully treated without laparotomy.     

Aspects médicolégaux de la prise en charge de la prééclampsie

When analyzing various recommendations formulated by the colleges of specialty, as well as precedents, the following guidelines can be formulated with respect to communication as part to the management of PE.     

Traitement d'une anémie aiguë post-traumatique par érythropoïétine humaine recombinante chez un témoin de Jéhovah

A 20-year-old Jehovah's witness patient experienced a femur fracture, with a section of the femoral artery and vein. On admission, haemoglobin concentration was 5.8 g·dL⁻¹ and haematocrit 17%. Because of aponevrotomy, blood losses persisted. As the patient refused blood transfusion, recombinant human erythropoietin and parenteral iron were administered, associated with mild hypothermia, sedation and mechanical ventilation. After 21 days, the haemoglobin concentration increased to 10.9 g·dL⁻¹ and haematocrit to 33%. Recombinant human erythropoietin and parenteral iron may provide an alternative safe and effective therapy in life-threatening anaemia when blood transfusions are not accepted by the patient.     

Immobilités laryngées unilatérales après chirurgie de la glande thyroïde

Background

The authors studied a cohort of 154 patients with unilateral vocal cord paresis following thyroidectomy, analyzing the pathogenesis, symptomatology, spontaneous evolution, and management of this complication.

Objective

This retrospective study distinguished between vocal cord paresis due to recurrent laryngeal nerve injury or due to injury of the cricoarytenoid articulation. We assessed the influence multiple variables on therapeutic management. The results and complications of currently-employed surgical techniques to remedy unilateral vocal cord paresis were defined.

Patients and methods

Injury to the recurrent laryngeal nerve was the cause of vocal cord paresis in 98% of cases; injury to the cricoarytenoid articulation accounted for only 2% of cases. When the recurrent laryngeal nerve had not been actually transected, spontaneous recovery of vocal cord function occurred in 36% of cases. No spontaneous recovery was noted when the nerve had been divided. The interval to recovery of cord function ranged from 2 to 15 months (median: 4 months). Spontaneous recovery of vocal cord function had occurred in 90% of these patients by the 9th postoperative month. Three factors significantly influenced the decision to perform a median transposition of the injured vocal cord: known transection of the recurrent laryngeal nerve, the interval to consultation with an ENT specialist, and the severity of dysphonia. Medial transposition of the injured vocal cord resulted in an immediate improvement in the quality of voice and speech with no major complications.

Conclusion

Unilateral vocal cord paresis occurring after thyroidectomy is not always symptomatic and is not uniformly due to injury of the recurrent laryngeal nerve. Management does not always require surgical reintervention. The practical and medico-legal consequences of these injuries are discussed.