Dermohypodermite bactérienne nécrosante avec fasciite nécrosante : complication d’une installation opératoire ?

Necrotizing fasciitis is a hypodermis, muscular fascia then dermis necrotizing infection. It disseminates along fascias with a mortality sometimes within 18 hours. The average mortality, reported in the literature, is about 30%. A 65-year-old man, with a history of Vaquez disease (under hydroxurea) and a smoke addiction, had an epidermoid carcinoma of the left vocal cord (T2 N0 M0). The cancer treatment consisted of a functional lymph node excision, followed by tracheotomy then by partial laryngectomy. At the end of the intervention, after removal of operative fields, it was noticed that the Montandon cannula had slid and was between the medial side of the left upper limb and the lateral side of the chest. There was a cutaneous imprint with ecchymosis on the route of the cannula. At the second postoperative day, a necrotizing fasciitis quickly developed on the left side of the chest, the medial side of the left upper limb, and the left hip without infection of the operating site. An Escherichia coli was identified in tracheal secretions and operative samples. The presumed hypothesis of this necrotizing infection is the cutaneous contamination of the thoracic wall by tracheal secretions colonized by E. coli, whose penetration was induced by the cutaneous traumatism due to the cannula. We remind, by analyzing this unusual case, the caring principles one of which diagnosis and the surgical excision must be as premature as possible. We insist on the elementary measures of protection of the support points and the good binding of cannulas.     

Médiatisation et « greffe de visage » ou « à qui appartient la greffe de visage » ?

Mediatisation of a scientific event could be neither controlled, nor verifiable. The experience which has been lived through the first worldwide allotransplantation of composite tissues of the face confirms that the actors of a surgical innovation are not the owners. Because there is neither confidentiality nor possible patent. Curiously the scientific world, providing with a sharing ethic, which rightly privileges the free spreading of knowledge in the way that most people could benefit of it. Obviously it is made without denied controversy, for truth as purpose. This scientific word that way joins the media one, with a specific ethic of the duty of information, but also interested in mercantile preoccupations quick to cultivate controversy not to enlighten this truth but to better sell pictures or papers. Than the author should only sustain this instrumentation which could certainly flatter him, and from which he could used, but in reality that paralysed him a little to go on in serenity with his shadow worker way.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Lésions ischémiques secondaires : comment les prévenir ?

In addition to the initial lesions related to the brain injury, the final outcome depends also largely on the secondary ischaemic lesions. These lesions result from hypoperfusion whatever the mechanisms. It is then essential to detect early the conditions at risk of ischaemia, to be treated aggressively since the initial care. The multimodal monitoring is the only way to diagnose these conditions, to provide information about the mechanisms, and then to better adapt the treatment. Such an early detection helps to limit the consequences of the initial trauma, and may improve outcome.     

L'entropie : un moyen d'apprécier le défaut d'analgésie ?

Objective

Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation.

Study design

Prospective, observational study.

Patients and methods

Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p < 0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p < 0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating aera under the receiver operated curves (AUC).

Results

BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932 ± 0.26) and SE (AUC: 0.926 ± 0.27). There was however no difference between RE and SE to predict analgesic requirement.

Conclusion

Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.     

Le certificat de décès : comment le remplir et pourquoi ?

The death certificate must be established within 24 hours following the death and handed to the mayor. The obligation to place in the coffin immediately is planned by a defined list of contagious diseases. Medicolegal obstacle must be ticked if there is a doubt on the cause of death. In order to look into the causes of the death, swabs can be asked by the physician. It is a medical or scientific autopsy to look into the causes of the death apart from a juridical procedure. The presence of a battery prosthesis (pacemaker) must be specified, so that it can be removed by a physician or a thanatopractionner before the placing in the coffin. Death certificate is passed on by the city hall to Insee, which updates the identification national register of physical people. Inserm receives anonymous data of the causes of death allowing to establish the mortality national statistics. In the absence of medicolegal obstacle or obligation to place in the coffin immediately, funeral operations can begin: preservation care, body transport, placing in the coffin and finally burial or cremation.     

Kétamine en anesthésie pédiatrique : utile,futile ou … ?

The use of ketamine for paediatric sedation-anaesthesia-analgesia is still growing despite the availability of adequate alternatives. Based on the literature, the present work will briefly review the well-known properties underlying the widespread use of this drug in this particular clinical situation. In adult patients, the use of ketamine as a new element of the balanced anaesthesia-analgesia is also ever growing. This is based on the recently demonstrate antihyperalgesic and anti-pro-inflammatory properties of this drug. This work questions the existence of such benefits in the paediatric population. Finally, the "dark side" of ketamine will be discussed. Experimental studies on developing brain clearly demonstrate that this old anaesthetic is a potent trigger for pathologic neuronal apoptosis.     

Pratique de l’anesthésie réanimation en milieu pénitentiaire. Un détenu peut-il bénéficier d’une anesthésie ambulatoire ?

Ambulatory anaesthesia is an anesthesia allowing the return of the patient home the same day. Even if the ambulatory hospitalization can, in theory, be applied to a prisoner as to every patient, caution is essential in such approach. Every anaesthetist reanimator doctor practicing in public hospitals may give care to patient prisoners while he is far from dominating all features of the prison world and while he must put down his therapeutic indications. The ambulatory anaesthesia in prison environment does not guarantee full security for the patient. Procedures could be set up between hospital complexes, caretakers practicing within penal middle (Unit of Consultation and Ambulatory Care [UCAC]) the prison service and hospital, the prefecture, to identify possible ambulatory interventions for a patient prisoner and to set up all guarantees of patient follow-up care in his return in prison environment. The development of interregional secure hospital units (ISHU) within teaching hospitals, allows an easier realization of interventions to the prisoners, but exists only in seven teaching hospitals in France.     

Reconstructions mammaires différées,quelles stratégies ?

Breast reconstruction is part of the treatment of breast cancer needing mastectomy. To deal with the numbering technics in breast reconstruction surgery and with the number of patients seeking reconstruction, the authors proposed a strategy taking care of the patients wishes, of the patients morphology and of the surgicals limits of the different technics. On this aim, the authors reviewed a 30 patients series of secondary breast reconstruction composed of 23 inferior gluteal free flaps, 4 transverse rectus abdominus myocutaneous flaps and 3 latissimus dorsi musculocutaneous flaps.