Monitorage continu et automatisé de la précharge dépendance en anesthésie et en réanimation : intérêts et limites

Objectives

To describe preload dependence monitoring tools currently available as well as their limits and potential applications in the anaesthesiology setting.

Data source

References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: fluid responsiveness, cardiopulmonary interactions, preload dependence, hypovolemia, cardiac output.

Data synthesis

When measured in optimal conditions, dynamic parameters are the best predictors of fluid responsiveness as compared to static indicators in patients under general anaesthesia and mechanical ventilation. These dynamic parameters rely on cardiopulmonary interactions and allow evaluating preload dependence and the ability of the heart to transform an increase in preload into an increase in cardiac output. Recently, it is possible to monitor these dynamic parameters either invasively (from the arterial pressure waveform) or noninvasively (from the plethysmographic waveform). These tools have intrinsic limitations. However, they have potential to be used for fluid optimization during anaesthesia.     

Prevalent high‐risk respiratory hygiene practices in urban and rural Bangladesh

Objectives To identify existing respiratory hygiene risk practices, and guide the development of interventions for improving respiratory hygiene. Methods We selected a convenience sample of 80 households and 20 schools in two densely populated communities in Bangladesh, one urban and one rural. We observed and recorded respiratory hygiene events with potential to spread viruses such as coughing, sneezing, spitting and nasal cleaning using a standardized assessment tool. Results In 907 (81%) of 1122 observed events, households’ participants coughed or sneezed into the air (i.e. uncovered), 119 (11%) into their hands and 83 (7%) into their clothing. Twenty‐two per cent of women covered their coughs and sneezes compared to 13% of men (OR 2.6, 95% CI 1.6–4.3). Twenty‐seven per cent of persons living in households with a reported monthly income of >72.6 US$ covered their coughs or sneezes compared to 13% of persons living in households with lower income (OR 3.2, 95% CI 1.6–6.2). In 956 (85%) of 1126 events, school participants coughed or sneezed into the air and 142 (13%) into their hands. Twenty‐seven per cent of coughs/sneezes in rural schools were covered compared to 10% of coughs/sneezes in urban schools (OR 2.3, 95% CI 1.5–3.6). Hand washing was never observed after participants coughed or sneezed into their hands. Conclusion There is an urgent need to develop culturally appropriate, cost‐effective and scalable interventions to improve respiratory hygiene practices and to assess their effectiveness in reducing respiratory pathogen transmission.     

Accident hémorragique sous antagonistes de la vitamine K: adaptation de la détermination de l’International Normalized Ratio (INR) dans les hypertriglycéridémies majeures

Vitamin K antagonists (VKA) are the first cause of iatrogenic mortality in France. Therefore, it is crucial to monitor these treatments with the International Normalized Ratio (INR) determination, which can be altered by several plasma elements. We report a patient who presented a serious bleeding event while under VKA treatment related to INR determination difficulties due to a high hypertriglyceridemia. We suggest some solutions (fasting and mechanic method in INR determination) in order to improve the control of the VKA treatment for patients with hypertriglyceridemia.     

Apport de la saturation veineuse centrale en oxygène dans la décision transfusionnelle postopératoire

Objective

The aim of this study was to assess the value of central venous oxygen saturation (ScvO₂) for the decision of blood transfusion in comparison with the criteria of the French guidelines for blood transfusion (2003).

Study design

Prospective, observational.

Patients and methods

Sixty patients, haemodynamically stable, for whom a blood transfusion (BT) was discussed in the postoperative course of general surgery, were included. ScvO₂ (%) and haemoglobin (g/dl) were measured before and after BT. Patients were retrospectively divided into two groups according to ScvO₂ measured before BT (< or ≥ 70%). Results are expressed as median.

Results

The ScvO₂ before transfusion was greater or equal to 70% in 25 (47.2%) patients. Following BT, the ScvO₂ increased significantly (from 57.8 to 68.5%) in the group with initial ScvO₂ less than 70% whereas it was unchanged in patients with initial ScvO₂ greater or equal 70% (from 76.8 to 76.5%). Twenty patients (37.7%) did not meet the French guidelines for BT criteria. Eighteen patients out of 33 that met the criteria had ScvO₂ greater or equal 70% before BT while 13 patients with ScvO₂ less than 70% were not detected by these same criteria.

Conclusion

ScvO₂ could be a relevant biological parameter to complete the current guidelines for BT in stable patient with a central venous catheter during the postoperative period.     

Muscle infarction in a young woman with brittle type 1 diabetes

We present the first case of muscle infarction in a 30-year-old woman who had a 5-year history of type 1 diabetes mellitus that was not complicated by nephropathy, retinopathy or neuropathy. All common causes of muscle infarction were excluded, particularly microangiopathy and a hypercoagulable state. The differential diagnosis included infection (pyomyositis, necrotic fasciitis), focal inflammatory myositis, vascular events, trauma, tumor and diabetic amyotrophy, all of which were excluded. In spite of good glycaemic control, her diabetes remained brittle; alternating states of transient acute hypoglycaemia and hyperglycaemia may have been responsible for the infarction. Brittleness resumed after treatment with subcutaneous insulin infusion using a portable pump. No recurrence of muscle infarction was observed during a 18-month follow-up.     

Cerebral venous thrombosis secondary to essential thrombocythemia

INTRODUCTION: Essential thrombocythemia (ET) is a myeloproliferative syndrome; cerebral venous thrombosis (CVT) is a rare complication. OBSERVATION: We report the case of a 20-year-old woman with an uneventful history who was admitted with intracranial hypertension syndrome which had developed over the last four months in association with bilateral decline of visual acuity. Physical examination at admission revealed stage II papilloedema and absence of any focal neurological signs. The brain MRI and the venous MRA showed a thrombosis involving the superior longitudinal sinus and the lateral sinus. The etiological analysis disclosed essential thrombocythemia (ET). The patient was given an antiedema and anticoagulant treatment. Later, an etiological cytoreductive therapy was initiated. Signs of intracranial hypertension regressed progressively with persistence of acute visual disorders associated with sequelar optical atrophy. Discussion. ET is a rare cause of CVT. Reports in the literature have discussed the mechanisms, the physiology, the therapeutic modalities and the clinical course of these CVTs secondarily to ET. CONCLUSION: Stroke, especially transient ischemic attack, is the usual thrombotic expression of myeloproliferative syndrome. CVT is much more exceptional.