Severe blunt liver injury: reappraisal of criteria for nonoperative management decision. Experience with 88 cases

AIM OF THE STUDY: To analyze the predictive value of computed tomography (CT) and initial physiologic and laboratory data findings in the immediate operative (OP) or non-operative (NOP) management of blunt liver injury (BL). METHODS: Eighty-eight BL, grade III (51), grade IV (28) and nine grade V (9), aged 26.2 years (16-75) were identified. Hemoperitoneum on CT, hemodynamic status, physiologic and laboratory data <24 hours or preoperative (transfusion, vascular filling) and follow-up >48 hours were analyzed. RESULTS: Data of 71/88 (80%) NOP and 17/88 (20%) OP patients were reviewed. A secondary laparotomy or laparoscopy was necessary in 11/71 TNO. Six OP (35%) and 1 NOP patients died. Blood units transfused were 1.33 (0-10) vs 5.9 (0-22) and vascular filling 1.45 (0.5-5.5) vs 3.6L (2-12) (P<10(-6), P<4.10(-3) respectively). NOP patients had less severe hemoperitoneum (31 vs 94%, P<10(-5)) and hemodynamic instability (8.5 vs 94%, P<10(-4)). But, there was an overlap of values of blood units transfused, amount of vascular filling and initial haemoglobin levels between NOP and OP patients and among CT grades of liver injury. No cut-off values could be determined: 33% NOP received >4 blood units and >3 L vascular filling; 30% had severe hemoperitoneum. In OP group 23.5% patients had lower values and no severe hemoperitoneum. CONCLUSION: In the management of BL, vascular filling and blood transfusion increased with the grade of CT liver injury and were globally more elevated in the operative group but did not individually correlate with hemodynamic stability and did not authorize, by themselves, to decide between operative versus non-operative management.     

Airway management in obstetrics

Objective

Reviewing problems related to the airway management in obstetrics, taking into account the recent evolutions of the anaesthetic practices in obstetrics.

Data sources

A review of the literature in English and French was performed in the Pumed^® database in April 2010. The first research used the following MeshTerms: “Anesthesia, Obstetrical” [Mesh] AND “Intubation, Intratracheal” [Mesh]. Complementary research used alone or in combination the following keywords: difficult tracheal intubation; failed tracheal intubation; airway; prediction of difficult tracheal intubation; maternal mortality; maternal morbidity; liability; aspiration pneumonia and obstetrical anesthesia.

Study selection

All the publications were retained excluding the correspondence.

Data extraction

Data analysis for the airway management in obstetrics, the prediction of difficult intubation, the prevention of pulmonary inhalation of gastric fluid, but also on maternal morbi-mortality in link with general anesthesia in obstetrics.

Data synthesis

Airway management in obstetrics remains a true challenge for various reasons. The physiological and anatomical modifications related to pregnancy are responsible for a faster hypoxemia, a reduction of the diameter of the pharyngolaryngal tract, as well as an increase of the risk of inhalation of gastric contents after 16 weeks of amenorrhea. The emergency or extreme emergency context and the presence of diseases like obesity or preeclampsia raise the risks of difficulties with airway management. The logical evolution of the practices, with the considerable rise of the regional anesthesia/analgesia limits the training and the maintenance of competences for intratracheal intubation in obstetrics. The training per simulation appears particularly interesting on the subject and this approach needs to be developed. The literature indicates that the incidence of difficult intubation is of one per 30. The impossible intubation is one per 280 in obstetrics, eight times greater than in the general population. No criterion of difficult intubation is sufficiently predictive alone. In obstetrics as in other contexts, the association of several criteria will permit to anticipate a difficult intubation. There is a worsening of the Mallampati during the pregnancy and during labour. To limit the risk of a difficult management of the airway in obstetrics, it will be paramount and capital, in addition to give priority to the regional anaesthesia/analgesia each time possible, to perform a careful and repeated evaluation of the predictive criteria of difficult intubation or ventilation. The inhalation of gastric fluid will systematically be prevented. The adapted material and algorithms for difficult intubation must be available in the labour wards. In case of a difficult intubation during an emergency caesarean section, the SFAR algorithms must be applied. In case of a “cannot intubate can ventilate situation”, the possibility of carrying on the Caesarean maintaining the Sellick manoeuvre should be considered. The place of the laryngoscopy assisted by videolaryngoscope in this context clearly remains to be defined. Even if in the literature some cases of successful intubation through these devices suggest an interest, there is a clear deviance between the guidelines and the practices concerning general anaesthesia performed at the end of the labour. Indeed they should be systematically performed with rapid sequence induction and tracheal intubation. A reflexion on this theme is necessary in order to grant the practices to the recommendations.     

Surveillance du bloc neuromusculaire par accéléromyographie : concepts,applications et limites d’utilisation

A recent survey among French anesthesiologists revealed that monitoring of curarization is used in approximately in 50% of cases after a unique dose of curare and in 75% of cases after repeated doses of curare. In this survey, a majority of clinicians used a quantitative monitor based on acceleromyography, i.e. that the majority of clinicians used a device from the TOF-watch^® product line. Results obtained by these monitors depends on the model used, TOF-Watch^®, TOF-Watch S^® or TOF-Watch SX^®, as well as if it is used for a single point measurement at the end of the operation or continuously throughout the operation, with or without calibration, and if a calibration is used, should we used Cal 1 or Cal 2? Technical specifications and their impact on results will be developed in this technical note. This will help clinicians to better interpret results obtained by TOF-watch^® monitors in order to improve clinical decisions based on monitoring of neuromuscular transmission.     

HIV infection and care pathway: From guidelines to clinical practice

Objectives

To quantify within a cohort of HIV-infected individuals the number of medical visits and procedures to be carried out according to comorbidities and risk factors to implement a personalized care pathway.

La sédation–analgésie au quotidien : enquête de pratiques auprès de 218 services de réanimation en France

Objectives

To assess the current use of sedation and analgesia in a large sample of French intensive care units (ICUs) and to define structural characteristics of the units that use a written procedure.

Study design

Self-reported survey.

Participants

Three hundred and sixty French ICUs were presented the questionnaire in September 2007.

Results

Surveys were received from 228 (60.6%) ICUs. Midazolam was used in more than 50% of the patients in 79.2% of the ICUs and propofol in 22.2% of the ICUs. Sufentanil was the most frequently used morphinic. A sedation-scale was used in 68.8% of the units (80.3% Ramsay score). Sedation was assessed at least every 4 hours in 61% of ICUs. A pain-scale was used in 88.9% of the ICUs, but only 12.5% in the non-communicant patients. A written procedure was used in 29.4% of the units only. In multivariate analysis, use in the ICU of a written procedure for the early management of patients with septic shock and/or intensive insulin therapy was the single variable significantly associated with presence of a written procedure for sedation and analgesia (respectively OR 4.37; p < 0.0001 and OR 5.64; p = 0.032).

Conclusion

Although more than two-third of the responding ICUs reported the use of sedation-and-pain-scales, frequency of assessment was low, and objective assessment of pain in the non-communicating patients was extremely uncommon. Similarly, the use of written procedure was low. The use of sedation-analgesia written procedure in an ICU seems strongly influenced by a more global involvement of the ICU in the protocolisation of complex care. These findings support the reinforcement of educational programs.     

Immunohistochimie: un progrès majeur pour la classification des CAPI

Carcinoma of unknown primary (CUP) site refers to a metastatic malignant epithelial tumour. Lymph nodes are the most frequently encountered sites, followed by the liver, bones, lungs and brain. CUP is considered a heterogeneous entity owing to the variety of its histopathological types and sites. However, the primary site remains unknown in more than 25% of patients. Immunohistochemistry is necessary to the diagnostic accuracy with regard to the challenge constituted by therapy in CUP. Thus, differential diagnosis with primary carcinomas and other types of tumors (lymphoma, germ cell tumor, melanoma, sarcoma...) is of major importance. Specific strategies for particular histopathological types are proposed in two algorithms for undifferentiated malignant tumour, undifferentiated carcinoma or adenocarcinoma (adenocarcinomas account for more than 50% of CUP) and squamous cell carcinoma. Strategies depend also on the anatomic localization. Several new antibodies are available for immunohistochemistry when considering targeted treatments. Immunohistochemistry is a cost-effective tool that provides valuable clues in CUP.