Réanimation aux urgences pédiatriques

Learning material (2010)

précis des principales situations aux urgences pédiatriques

Comparison of functional residual capacity and static compliance of the respiratory system during a positive end-expiratory pressure (PEEP) ramp procedure in an experimental model of acute respiratory distress syndrome.

in Critical Care: the Official Journal of the Critical Care Forum (2008), 12(4), 91

INTRODUCTION: Functional residual capacity (FRC) measurement is now available on new ventilators as an automated procedure. We compared FRC, static thoracopulmonary compliance (Crs) and PaO2 evolution in ... [more ▼]

INTRODUCTION: Functional residual capacity (FRC) measurement is now available on new ventilators as an automated procedure. We compared FRC, static thoracopulmonary compliance (Crs) and PaO2 evolution in an experimental model of acute respiratory distress syndrome (ARDS) during a reversed, sequential ramp procedure of positive end-expiratory pressure (PEEP) changes to investigate the potential interest of combined FRC and Crs measurement in such a pathologic state. METHODS: ARDS was induced by oleic acid injection in six anesthetised pigs. FRC and Crs were measured, and arterial blood samples were taken after induction of ARDS during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O. RESULTS: ARDS was responsible for significant decreases in FRC, Crs and PaO2 values. During ARDS, 20 cm H2O of PEEP was associated with FRC values that increased from 6.2 +/- 1.3 to 19.7 +/- 2.9 ml/kg and a significant improvement in PaO2. The maximal value of Crs was reached at a PEEP of 15 cm H2O, and the maximal value of FRC at a PEEP of 20 cm H2O. From a PEEP value of 15 to 0 cm H2O, FRC and Crs decreased progressively. CONCLUSION: Our results indicate that combined FRC and Crs measurements may help to identify the optimal level of PEEP. Indeed, by taking into account the value of both parameters during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O, the end of overdistension may be identified by an increase in Crs and the start of derecruitment by an abrupt decrease in FRC. [less ▲]

Thromboprophylaxis in microsurgery

in Acta Chirurgica Belgica (2006), 106(2), 158-64

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical ... [more ▼]

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture. [less ▲]

A European, multicenter, observational study to assess the value of gastric-to-end tidal Pco(2) difference in predicting postoperative complications

in Anesthesia and Analgesia (2004), 99(1), 166-172

Automated online tonometry displays a rapid, semicontinuous measurement of gastric-to-end tidal carbon dioxide (Pr-etCO(2)) as an index of gastrointestinal perfusion during surgery. Its use to predict ... [more ▼]

Automated online tonometry displays a rapid, semicontinuous measurement of gastric-to-end tidal carbon dioxide (Pr-etCO(2)) as an index of gastrointestinal perfusion during surgery. Its use to predict postoperative outcome has not been studied in general surgery patients. We, therefore, studied ASA physical status III-IV patients operated on for elective surgery under general anesthesia and a planned duration of >2 h in a European, multicenter study. As each center was equipped with only 1 tonometric monitor, a randomization was performed if more than one patient was eligible the same day. Patients not monitored with tonometry were assessed only for follow-up. The main outcome measure was the assessment of postoperative functional recovery delay (FRD) on day 8. Among the 290 patients studied, 34% had FRD associated with a longer hospital stay. The most common FRDs were gastrointestinal (45%), infection (39%), and respiratory (35%). In those monitored with tonometry (n = 179), maximum Pr-etCO(2) proved to be the best predictor increasing the probability of FRD from 34% for all patients to 65% at a cut-off of 21 mm Hg (2.8 kPa) (sensitivity 0.27, specificity 0.92, positive predictive value 64%, negative predictive value 70%). We conclude that intraoperative Pr-etCO(2) measurement may be a useful prognostic index of postoperative morbidity. [less ▲]

Pratique d'urgence: particularites dans la prise en charge des polytraumatises complexes

in Revue Médicale de Liège (2001), 56(3), 149-54

Almost twenty years ago, Trunkey showed that deaths due to trauma followed a trimodal distribution over time. Half of these deaths were delayed by at least one to two hours after the initiating insult ... [more ▼]

Almost twenty years ago, Trunkey showed that deaths due to trauma followed a trimodal distribution over time. Half of these deaths were delayed by at least one to two hours after the initiating insult. This interval (the "golden hour") can be exploited, especially in specialized trauma centers (where the most severely injured patients are cared for), to aggressively treat these patients, thereby reducing morbidity and mortality. In Belgium, this hierarchy of trauma care centers is non-existent; patients are distributed within the healthcare system randomly, depending on the localisation of the accident and the directives of the unified "100" call centre. Because this limits the number of cases any one centre treats, this type of arrangement acts to inhibit the acquisition of competency in the handling of these complex patients. The relative lack of experience of individual emergency departments leads to difficulties in establishing diagnostic and treatment priorities for the most severely injured trauma victims. The approach to these patients must follow very precise guidelines, established scientifically in order to minimize the impact of the injury on life and maximize chances of satisfactory functional recovery. In this paper, we describe the general principles of the initial approach to victims of complex multiple trauma. [less ▲]

Management of Difficult Intubation

in European Journal of Anaesthesiology (2001), 18(1), 3-12

Appropriate airway management is an essential part of the anaesthetist's role. Difficult intubation, which can now be quantified using the 'Intubation Difficulty Scale', should be anticipated whenever ... [more ▼]

Appropriate airway management is an essential part of the anaesthetist's role. Difficult intubation, which can now be quantified using the 'Intubation Difficulty Scale', should be anticipated whenever possible. A strategy needs to be developed in order to anticipate problems. The first part of this paper reviews the different factors that contribute to make intubation and/or ventilation difficult. Problems with intubation (or ventilation of the lungs) can be caused by abnormal laryngeal structures (e.g. tumour, stenosis), or by difficulty in seeing the glottis. The clinical history will usually help identify the former problem, while physical examination of the airway is required to reveal either disproportion between the various structures of the airway (e.g. tongue, larynx), and/or difficulties in aligning the oral, pharyngeal, and laryngeal axes. The different techniques used to diagnose these problems are described. The second part of this paper summarizes the algorithms used by the anaesthetist when management of the airway is found difficult. Three situations are considered: (a) anticipated difficult intubation, for which awake fibreoptic intubation would appear to be the technique of choice in the majority of cases, (b) unforeseen difficult intubation in a patient whose lungs can be ventilated; here, various techniques for control of the airway will be briefly described, and (c) both tracheal intubation and lung ventilation are impossible; this is a life-threatening emergency, for which three solutions are proposed. These include use of the laryngeal mask airway, the Combitube, or transtracheal ventilation. These situations will be analysed with the aim of proposing management strategies that always guarantee the safety of the patient. [less ▲]

Transplantation combinée du foie et du coeur chez un patient souffrant de thalassémie majeure

in Médecine & Chirurgie Digestives (1999), 28(3), 109-110

L'abord coelioscopique des phéochromocytomes est-il acceptable? Réflexions à propos d'une étude prospective de 6 cas personnels

in Annales d'Endocrinologie (1997), 58(1), 65-74

Today, laparoscopy is for us the technique of choice for approaching presumed benign adrenal tumors. With regards to pheochromocytoma however, two major questions must be addressed. First, is it ... [more ▼]

Today, laparoscopy is for us the technique of choice for approaching presumed benign adrenal tumors. With regards to pheochromocytoma however, two major questions must be addressed. First, is it acceptable to resect potentially multifocal tumors with such a targeted approach? Second, can peroperative hemodynamic changes be anticipated and controlled by the anesthetist, taking into account the additional effects of pneumoperitoneum and catecholamine release on the cardiovascular system? The present prospective study attempts to answer these two questions. From November 1993 to November 1995 we operated on four women and two men, with ages ranging from 33 to 71 years (mean of 47) and a mean Body Mass Index of 25 kg/m2 (range 17-35). Four patients were assigned ASA (American Society of Anesthesiologists) physical status 2, one grade 1 and one grade 3. Comprehensive preoperative work-up, including a CT scan and an I131 MIBG Scan in all, a C11 Hydroxyephedrine PET Scan in 4 and a MRI in one patient, showed a solitary lesion in each case. There were four right-sided and two left-sided tumors, ranging from 30 to 60 mm in diameter. Laparoscopy was always performed transperitoneally. Systemic and pulmonary hemodynamics were thoroughly assessed. Epinephrin and norepinephrin concentrations were measured at the 10 key-time of surgery. Use of continuous intravenous infusion of nicardipine allowed tight control of hemodynamics despite impressive increases in circulating catecholamines. The mean operative time was 76 minutes (range 59-130). Blood loss was minimal. We observed neither mortality nor morbidity. Mean hospital stay ranged from 3 to 13 days (median = 3). All patients are normotensive without drug after a follow-up of 9 to 33 months. In conclusion, we think that laparoscopic removal of selected cases of pheochromocytoma may be performed safely from both the hemodynamical and oncological standpoints. [less ▲]

Treatment of Excessive Mediastinal Bleeding after Cardiopulmonary Bypass

in Annals of Thoracic Surgery (1996), 62(6), 1951-4

BACKGROUND: Excessive mediastinal bleeding after cardiopulmonary bypass is one of the most frequently reported complications of cardiac operations. Appropriate treatment requires a rapid and effective ... [more ▼]

BACKGROUND: Excessive mediastinal bleeding after cardiopulmonary bypass is one of the most frequently reported complications of cardiac operations. Appropriate treatment requires a rapid and effective diagnostic work-up, based on the knowledge of the pathophysiology induced by cardiopulmonary bypass. METHODS: Possible causes, diagnostic methods available, and therapeutic approaches are reviewed in the light of the literature published on excessive bleeding after cardiac operations. RESULTS: When bleeding is massive (> 250 to 300 mL/h for the first 2 hours, > 150 mL/h thereafter), immediate surgical reexploration is mandatory. When bleeding is less important (50 to 150 mL/h), the decision to reoperate should be based on the presence of hemodynamic compromise or a suspected surgical cause. Otherwise, coagulation testing should allow the correction of hemostatic defects as appropriate with protamine, platelet concentrates, fresh frozen plasma, desmopressin, or antifibrinolytics. Hypothermia and hypotension should be corrected and a trial of positive end-expiratory pressure may be considered if diffuse mediastinal oozing (especially from the bed of the mammary artery) is suspected. CONCLUSIONS: A protocol is suggested to guide treatment, taking into account the rapidity of blood loss and the suspected underlying cause. [less ▲]

Spontaneous Rupture of the Iliac Vein

in Journal of Vascular Surgery (1993), 17(4), 757-8

A spontaneous rupture of the left iliac vein is described. A 2 cm tear on the anterior surface of the left iliac vein was discovered at emergency laparotomy on a patient who was suspected of having a huge ... [more ▼]

A spontaneous rupture of the left iliac vein is described. A 2 cm tear on the anterior surface of the left iliac vein was discovered at emergency laparotomy on a patient who was suspected of having a huge intraabdominal hemorrhage. Prodromal symptoms, cause, and treatment are discussed. The nine previously reported cases are reviewed. This case represents the seventh successful repair of an idiopathic rupture of an iliac vein. [less ▲]