Vesicovaginal fistula

Urinary fistula to the vagina has been described since the beginning of the written record. In developed nations, these fistulas are usually unfortunate complications of gynecologic or other pelvic surgery and radiotherapy. Historically, birth trauma accounted for most vesicovaginal fistulas, and it remains the major cause of urinary fistulas in many underdeveloped nations. Once a vesicovaginal fistula is suspected, a thorough vaginal examination should be performed to identify its size and location, especially in relation to the trigone and eliminate a ureterovaginal fistula which can be associated in up to 10% of cases. Numerous methods for the treatment of vesicovaginal fistulae have been described. Abdominal, and vaginal approaches are used for the repair of vesicovaginal fistulae. The approach selected is dependent on many factors, but is probably best determined by the experience and training of the surgeon. The techniques of the vaginal approach involve tension-free closure of the fistula with or without excision of the tract, creation of an anterior vaginal wall flap and appropriate use of vascularized interposition grafts. The abdominal approach may be used to treat all types of vesicovaginal fistulae and is the preferred approach when concomittant ureteral reimplantation is required. Postoperative care is similar for both vaginal and abdominal vesicovaginal fistula repair. Adequate uninterrupted bladder drainage is the most critical aspect of postoperative management. A voiding cystourethrogram is performed at 10 postoperative days to confirm closure of the fistula.     

Étude rétrospective sur six années de l’anesthésie pour réduction de luxation d’épaule en urgence

Objective

The aim of this study was to assess the anaesthetic technique used for emergency shoulder luxation management in a university hospital.

Study design

Retrospective observational study.

Patients and methods

During a six-year period, all patients who were anaesthetized for shoulder luxation were included. Data were collected from administrative database and patient's files.

Results

Two hundred and twenty-four patients were included. Ninety-seven regional anaesthesias were performed (17 failures) and so, 144 general anaesthesias were performed. Among general anaesthesia, 89 patients were not fasten, only four rapid sequence inductions were performed. Sixteen (8%) complications occurred, all during general anaesthesia, among them one inhalation. In not fasten patients, anaesthesia was performed not in accordance with guidelines in 56% of cases of all anaesthetic technique and 96% for patient who had general anaesthesia. Accordance with guidelines was independent from the anaesthesiologist experience or the time of the anaesthesia (night/day).

Conclusion

We must spread guidelines information to physicians because of the morbidity.     

Complications neurologiques de l’anesthésie locorégionale : analyse des expertises et conclusions des CRCI

All the files of complications of regional anaesthesias requiring an expertise for a Regional Commission for Conciliation and Compensation for medical accidents (CRCI) between 2003 and 2008 were analyzed. The objective was to estimate the homogeneity of the appointed experts, their opinions and the opinions of the CRCI. Querying the database, shared by the National Office for Compensation for Medical Accidents (ONIAM) and the CRCI, and identified 40 files corresponding to the selection criteria. The expertise carried out involved an anaesthetist in 27 cases, always registered, either on the national list of the experts in medical accidents, or on one list of court-appointed experts. Conversely, in 13 cases, no specialist performing himself the technique in question was involved in the expertise, and sometimes the expert was registered on any list. Mostly, the non-specialists do not conclude to medical malpractice. This was not the case in a single file, where the anaesthetist sought and obtained the addition of an anaesthetist in a new expertise, which concluded differently. Damages assessed were highly variable, but the given evidence provided to understand why. The CRCI have generally followed the opinions of the experts, except in a few cases where the evidence allowed a different opinion without requiring a new expertise. In conclusion, the abnormalities in the appointment of experts do not seem to have had consequences in terms of damage assessment, but may alter the balance between causes faulty and not faulty, in favour of the latter.     

Barotraumatisme par effet Venturi lors du test d’apnée d’un patient en état de mort encéphalique : faut-il changer les modalités d’application de ce test ?

The clinical diagnosis of brain death is based on three clinical criteria, one of them being the abolition of the spontaneous breathing shown by an apnoea testing 1 and 2. During this manoeuvre, oxygen is administered by intratracheal way through oxygen supply tubing inserted into the endotracheal tube. Few cases of barotrauma with tension pneumothorax during this test have been described in the literature bringing to the loss of potential donor or grafts for transplantation. The authors report a new case of tension pneumothorax occurred during an apnoea testing despite the precautionary measures necessary to prevent such a catastrophic complication. In addition to the possible pathophysiologic explanation of the event advanced by the authors, it seems lawful to redefine the practical modalities of implementation of this test to avoid the loss of potential grafts.     

Une acidose lactique sévère révélatrice d’une hémopathie maligne

A 75-year-old woman is hospitalised for sepsis. The diagnosis of cholecystitis is made and an antibiotic therapy is debuted. The clinical worsening leads to realise an urgent cholecystectomy. A sepsis like shock persisted. The antibiotherapy was changed and a second abdominal look made. A severe lactic acidosis persisted since the cholecystectomy despite a continuous hemofiltration. The diagnosis of type B lactic acidosis secondary to malignancy was suspected. An osteomedullar biopsy revelled B-cell lymphoma EBV induced.     

Cathétérisme veineux jugulaire interne : quelle est la meilleure voie d’abord ?

Objectives

The aim of this study was to compare two approaches used for internal jugular venous cannulation: the anterior way, described by English et al. and the posterior way, described by Jernigan et al. The primary endpoint was the rate of success. The secondary endpoints were the related adverse events and the difficulty factors.

Study design

Prospective, randomized open clinical trial.

Patients and methods

The study took place in the vital emergency room, the operating room and the emergency intensive care unit of Ibn Sina University hospital (Rabat, Morocco), between June and September 2010. Hundred and one patients needing a central venous catheter were randomized to undergo one of the two techniques. We compared: demographics, success rates, number of attempts, difficulty factors and adverse events.

Results

The success rate was significantly higher in the posterior group (96% versus 68%, P < 0.001), with fewer attempts (1.3 ± 0.7 versus 2.1 ± 1.3; P < 0.001). There were less pneumothorax, (0 versus 6%) and more accidental arterial punctures (34 versus 25.5%) in the posterior group, but the difference wasn’t significant. Finally, none of the difficulty factors were correlated to the failure rate.

Conclusion

This study shows that the posterior approach in internal jugular venous cannulation is more efficient than and as safe as the anterior approach.     

Facteurs prédictifs de défaillance d’organes chez les patients admis en réanimation pour hémorragie digestive aiguë

Introduction

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

Design

Retrospective and observational

Methods and measurements

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

Results

During this period study, 441 consecutive patients with a mean age of 67 ± 15 years were included. The median ICU length of stay was of 4 (3–7) days and 116 (26% [IC95%: 22–30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR = 3.5 [IC95%: 1.9–6.7], P < 0.001) and an increase in troponin at the admission above the 99th percentile (OR = 3.1 [IC95%: 1.8–5.5], P < 0.001).

Conclusion

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.     

Prélèvements sur « donneurs décédés après arrêt cardiaque » : l’expérience du Samu de la Seine-Saint-Denis

The use of non-heart-beating donors (NHBD) could help shorten the list of patients who are waiting for a kidney transplant. The aim of this study was to evaluate efficiency of prehospital management of non-heart-beating donors in Seine-Saint-Denis area. We performed a retrospective cohort study of non-heart-beating donor managed by prehospital medical team of Samu 93 from February 2007 to January 2008. There were 28 non-heart-beating donors included consecutively. Twenty-five NHBD (89%) were canuled by Gillot probe within 150 min from patient collapse. Fourteen NHBD were harvested and 17 kidneys were transplanted. Six-month survival rate for NHBD grafts was 94%. In the same time, eight brain dead donors were managed by Samu 93 and were harvested leading to transplant 16 kidneys. Finally, 50% of overall kidney transplant activity in Seine-Saint-Denis was provided by NHBD grafts.     

Crise d’hyperthermie maligne de l’anesthésie après cinq heures d’anesthésie avec le sévoflurane et plusieurs anesthésies antérieures avec halogénés

We report a case of per anaesthesia malignant hyperthermia (MH) arisen in a 16-year-old young man presenting antecedents of five anaesthesia with use of halogenated agents without complication and having started a typical crisis of MH after five hours of anaesthesia with sevoflurane and with recurrence of the crisis after 14 hours in ICU. The association in the same clinical case of these three peculiarities of the crisis of MH already described separately in the international literature allows us to insist on their importance, with the French-speaking anaesthesiologists community.     

Intérêt de la simulation réaliste dans l’évaluation de l’enseignement de l’intubation difficile aux médecins urgentistes

Objectives

The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation.

Study design

Prospective.

Population

Emergency physicians.

Methods

Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan^® simulator (Laerdal^®) was assessed.

Results

Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor.

Conclusion

We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.     

Intoxication accidentelle grave à l’hydrogène sulfuré : un cas pédiatrique de survie

We report a paediatric case of survival following severe hydrogen sulfide (H₂S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H₂S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H₂S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.     

Alzheimer's disease and anaesthesia: potential relationships and clinical implications

Alzheimer's disease is the most common form of dementia. As the aging population increases, Alzheimer's disease is becoming a major concern of Public Health. Many molecular lesions have been detected in Alzheimer's disease, but physiopathology is still poorly understood. If the neurotoxicity of anaesthetics in human remains debatable, perioperative period is certainly a high-risk factor for cognitive impairment, especially in elderly population. Large clinical studies are required to develop new strategies for perioperative management in such patients, including the adjustment of anaesthesia techniques. Before that, information of patient and its relatives and a particular attention for elderly during anaesthesia and perioperative period should be considered.     

Description de la prévention et estimation de la fréquence des erreurs de programmation de vitesse d’administration en continu des médicaments en réanimation par une application informatique

Objectives

To assess the usefulness and the feasibility to use a software supervising continuous infusion rates of drugs administered with pumps in ICU.

Study design

Follow-up of practices and inquiry in three intensive care units.

Material

Guardrails software^TM of reassurance of the regulations of the rates of pumps (AsenaGH^TM, Alaris).

Methods

First, evaluation and quantification of the number of infusion-rates adjustments reaching the maximal superior limit (considered as infusion-rate-errors stopped by the software). Secondly, appreciate the acceptance by staffs to such a system by a blinded questionnaire and a quantification of the number of dataset pumps programs performed with the software.

Results

The number of administrations started with the pumps of the study in the three services (11 beds) during the period of study was 63,069 and 42,694 of them (67.7 %) used the software. The number of potential errors of continuous infusion rates was 11, corresponding to a rate of infusion-rate errors of 26/100,000. KCl and insulin were concerned in two and five cases, respectively. Eighty percent of the nurses estimated that infusion-rate-errors were rare or exceptional but potentially harmful. Indeed, they considered that software supervising the continuous infusion rates of pumps could improve safety.

Conclusion

The risk of infusion-rate-errors of drugs administered continuously with pump in ICU is rare but potentially harmful. A software that controlled the continuous infusion rates could be useful.     

Quoi de neuf en hyperthermie maligne en 2012 ?

Malignant hyperthermia (MH) is a pharmacogenetic disorder of anesthesia. Recent advances dealing with epidemiology of MH and the safe anesthetic course of MH susceptible patients are shortly presented here with a special insight into the preparation of modern anesthesia workstations, which they will share in operating room.