Objectives:To determine the incidence of brain death (BD) and to evaluate the registration of potential organ donors (PD) by the organ procurement team (OPT).Study design: Two-year prospective audit in the French university hospital of Lille.Patients and methods: All deaths occurring in the intensive care units or the emergency department were studied. If death was consecutive to brain damage, on-site review of medical records and charts was performed. Death cause, presence of criteria for brain death and reference to the OPT were recorded for each death. A medical expert staff evaluated the incidence of and reasons for unsuitability for organ donation. After 12 months of observation, a protocol for "systematic alert of the OPT when brain death is suspected" was broadcast and evaluated during the next 12 months.Results: During the first period, 277 BD occurred and 119 PD were suitable for organ donation. The OPT recorded 80 PD (67.2 % of all PD) and 45 multi-organ procurements (MOP) were performed. Physicians opposed two major reasons for not calling OPT : anticipation of a non-validated medical contraindication in 18 cases and approach of the family without the OPT team in 21 cases. After broadcast of the protocol, 110 PD were identified and the OPT was called in 93 cases (84.5% of all PD, p<0.004 versus first period). Fifty-three MOP were performed.Conclusion: The OPT was not called to manage one-third of the PD. The protocol for "systematic alert of the OPT when brain death is suspected" improves the call of the OPT and increases MOP. (C) 2002 Editions scientifiques et medicales Elsevier SAS.

OBJECTIVES:To determine the incidence of brain death (BD) and to evaluate the registration of potential organ donors (PD) by the organ procurement team (OPT).STUDY DESIGN:Two-year prospective audit in the French university hospital of Lille.PATIENTS AND METHODS:All deaths occurring in the intensive care units or the emergency department were studied. If death was consecutive to brain damage, on-site review of medical records and charts was performed. Death cause, presence of criteria for brain death and reference to the OPT were recorded for each death. A medical expert staff evaluated the incidence of and reasons for unsuitability for organ donation. After 12 months of observation, a protocol for "systematic alert of the OPT when brain death is suspected" was broadcast and evaluated during the next 12 months.RESULTS:During the first period, 277 BD occurred and 119 PD were suitable for organ donation. The OPT recorded 80 PD (67.2% of all PD) and 45 multi-organ procurements (MOP) were performed. Physicians opposed two major reasons for not calling OPT: anticipation of a non-validated medical contraindication in 18 cases and approach of the family without the OPT team in 21 cases. After broadcast of the protocol, 110 PD were identified and the OPT was called in 93 cases (84.5% of all PD, p < 0.004 versus first period). Fifty-three MOP were performed.CONCLUSION:The OPT was not called to manage one-third of the PD. The protocol for "systematic alert of the OPT when brain death is suspected" improves the call of the OPT and increases MOP.

L'ischémie cérébrale, fréquente en réanimation, aggrave le pronostic des patients présentant une atteinte neurologique aiguë. La mesure du débit sanguin cérébral permet la détection et la prise en charge précoce des ischémies cérébrales réversibles alors que la surveillance de la pression de perfusion cérébrale nˈautorise pas toujours ce diagnostic. Lˈutilisation dˈune technique de mesure du débit sanguin cérébral peut améliorer le pronostic des patients porteurs dˈune atteinte neurologique aiguë. Les différentes techniques de mesure du débit sanguin cérébral utilisables au chevet du patient et leurs intérêts respectifs sont décrits ici.

Objective: To assess the effect of endotoxin on cytochrome aa(3) (Caa(3)) redox status in a controlled blood flow preparation of pig isolated hindlimb, at a constant oxygen delivery ((D) over dotO(2limb)) (constant flow period) and during progressive ischemia (decreasing flow period).Design: Randomized, controlled experimental study.Setting: University hospital experimental laboratory.Subjects: Ten piglets.Interventions: Hindlimb blood flow was restricted to the femoral vessels. The arterial femoral blood flow coming from the carotid artery was controlled by a roller occlusive pump. The femoral venous blood flow was returned to the jugular vein. During the first 100 mins, the hindlimb blood flow was maintained at a normal level and then decreased stepwise. Animals were randomized to receive 150 mu g/kg endotoxin lipopolysaccharide (LPS; n = 5) or saline (control; n = 5).Measurements and Main Results: Hindlimb muscle Caa(3) redox status was monitored by near-infrared spectroscopy, Hindlimb (D) over dotO(2limb) and oxygen consumption ((V) over dotO(2limb)) were calculated. In the LPS group, a rapid reduction of Caa(3) redox status was observed after LPS administration, whereas the hindlimb blood flow remained normal with no change in (D) over dotO(2limb) and (V) over dotO(2limb). A progressive simultaneous decrease in (D) over dotO(2limb) and (V) over dotO(2limb) was observed during the decreasing flow period with no further reduction in Caa(3) redox status. In the control group, no change was observed in Caa(3), (D) over dotO(2limb), or (V) over dotO(2limb) during the constant flow period. During the decreasing flow period, Caa(3) redox status was reduced as (D) over dotO(2limb) and (V) over dotO(2limb) decreased.Conclusion: Our results suggest that endotoxin may induce a reduction of Caa(3) redox status independently of (D) over dotO(2) and (V) over dotO(2).

We evaluated the reliability and immediate results of celioscopic management of acute small bowel obstruction. From January 1995 to April 1998, 39 patients underwent a primary celioscopic procedure for small bowel obstruction. The most common etiology was post operative adhesions (34 patients). The whole operation could be carried out exclusively by celioscopy in 22 patients (56%). A laparotomy had to be performed in 17 patients due to: impossibility to identify or treat the cause of obstruction, bowel necrosis or intraoperative complication (3 bowel wounds). Post operative complications were: 1 death (not directly related to the surgical procedure), 2 early recurrences of obstruction after exclusive celioscopy, 1 evisceration after laparotomy and 1 small bowel fistula after conversion to laparotomy. Mean hospital stay was 5 days after exclusive celioscopy and 9.5 days after conversion to laparotomy. Celioscopic management of small bowel obstruction is feasible, but it is often difficult and may be hazardous; a careful selection of patients must be made, based on the importance of obstruction and the type of previous abdominal surgery.

We evaluated the reliability and immediate results of celioscopic management of acute small bowel obstruction. From January 1995 to April 1998, 39 patients underwent a primary celioscopic procedure for small bowel obstruction. The most common etiology was post operative adhesions (34 patients). The whole operation could be carried out exclusively by celioscopy in 22 patients (56%). A laparotomy had to be performed in 17 patients due to: impossibility to identify or treat the cause of obstruction, bowel necrosis or intraoperative complication (3 bowel wounds). Post operative complications were: 1 death (not directly related to the surgical procedure), 2 early recurrences of obstruction after exclusive celioscopy, 1 evisceration after laparotomy and 1 small bowel fistula after conversion to laparotomy. Mean hospital stay was 5 days after exclusive celioscopy and 9,5 days after conversion to laparotomy. Celioscopic management of small bowel obstruction is feasible, but it is often difficult and may be hazardous; a careful selection of patients must be made, based on the importance of obstruction and the type of previous abdominal surgery.

To compare three techniques of brachial plexus blockade for emergency surgery of the upper limb.Prospective, randomised study.One hundred eleven patients admitted to an emergency surgical service, randomly assigned to three groups.The patients were given 2% lidocaine with epinephrine 20 mL and 0.5% bupivacaine 20 mL. The three groups were as follows: brachial plexus block using a peripheral nerve stimulator (group St, n = 38); transarterial brachial plexus blockade with injection of 2/3 of the anaesthetic in back of and 1/3 in front of the artery (group TAP, n = 36); transarterial brachial plexus blockade with one single injection in back of the artery (group TP, n = 37). The success rate, time required to perform the technique, latency of analgesia, quality of motor blockade, and adverse effects were compared between the three groups. Analysis of variance was used to compare quantitative data and chi 2 test were used for qualitative data.Rates of success varied between 65 and 75%. Success rates, latency of analgesia and quality of motor blockade were not significantly different between groups. Time to perform the technique was longer when using a nerve stimulator.As these three techniques for brachial plexus block in emergency surgery are comparable, no one can be recommended instead of the others.

Objective: To assess incidence of secondary brain insults of systemic origin (SBISOs) such as arterial hypotension, hypoxaemia, hypercarbia, and anaemia in severely head injured children; to assess their impact on mortality and morbidity in the short-and long-term.Study design: Prospective, open study covering a 24-month period.Patients: Seventy-one children, under 15 years of age, admitted to a trauma centre for severe brain injury,Method: Analysis of SBISOs and outcome.Results: Twenty-five children were admitted with SBISOs. The mortality rate was 37%. After hospitalization, 84% of the children with SBISOs vs 46% without SBISOs had severe disability (Glasgow outcome score = 1, 2 and 3), After 1 year, 20 out of the 45 children still alive were contacted. One of the four with SBISOs communicated a bad recovery. Fifteen children without SBISOs presented good recovery: GOS = 4-5, paediatric overall performance category (POPC scale) = 1-2.Conclusion: Hypotension was associated with significant increase in mortality (x 3.6) in children with severe head injury. The consequences were worse when anaemia was associated. (C) 1998 Elsevier, Paris.

An uncommon disorder: Malignant hyperpyrexia is an uncommon disorder of skeletal muscle. Inheritance is autosomal dominant in humans and most cases seem to affect children and young adults. The reasons for the increased incidence in children is probably related to the increased incidence of masseter muscle rigidity and the mis-diagnosis of malignant hyperpyresia after cardiac arrest in children with undiagnosed myopathies after being given volatile agents and succinylcholine.Characteristic features: Hypermetabolic response to potent inhalation agents and succinylcholine characterized by increased CO2 production, oxygen consumption and muscle membrane breakdown is characteristic. As a result of the changes, tachycardia, tachypnea, acidosis, hyperkalemia, myoglobulinuria are often seen. Not all elements are easily diagnosed in a given case.A grading scale: A grading scale for malignant hyperpyrexia has been introduced. The pathophysiology of malignant hyperpyrexia is believed to be related to intracellular hypercalcemia caused by either disturbance of the sarcoplasmic reticulum or excitation contraction coupling.Treatment: Dantrolene sodium is a non-specific but safe efficacious life-saving drug for the treatment of malignant hyperpyrexia. The only available, agreed upon diagnostic test is the exposure of biopsied vastus lateralis muscle to halothane and caffeine and observing an abnormal contracture response. This test is available in 24 centers in Europe.

OBJECTIVE:To assess incidence of secondary brain insults of systemic origin (SBISOs) such as arterial hypotension, hypoxaemia, hypercarbia, and anaemia in severely head injured children; to assess their impact on mortality and morbidity in the short- and long-term.STUDY DESIGN:Prospective, open study covering a 24-month period.PATIENTS:Seventy-one children, under 15 years of age, admitted to a trauma centre for severe brain injury.METHOD:Analysis of SBISOs and outcome.RESULTS:Twenty-five children were admitted with SBISOs. The mortality rate was 37%. After hospitalization, 84% of the children with SBISOs vs 46% without SBISOs had severe disability (Glasgow outcome score = 1, 2 and 3). After 1 year, 20 out of the 45 children still alive were contacted. One of the four with SBISOs communicated a bad recovery. Fifteen children without SBISOs presented good recovery: GOS = 4-5, paediatric overall performance category (POPC scale) = 1-2.CONCLUSION:Hypotension was associated with significant increase in mortality (x 3.6) in children with severe head injury. The consequences were worse when anaemia was associated.

. Un etat d'hypermetabolisme aigu : L'hyperthermie maligne (HM) est une myopathie infraclinique genetiquement determinee a transmission autosomique dominante. La crise interesse le plus souvent l'enfant ou l'adulte jeune et se caracterise par un etat d'hypermetabolisme aigu du muscle strie declenche par tous les agents anesthesiques halogenes et la succinylcholine. thypermetabolisme se traduit par une surproduction de CO 2 , une consommation d'O 2 , un epuisement des reserves en ATP entrainant des desordres biochimiques de la membrane musculaire et une rhabdomyolyse. - Cliniquement : La crise se caracterise par une tachycardie, une tachypnee, une hyperthermie et une contracture musculaire intense. L'ensemble de ces signes ne sont pas toujours presents et une echelle graduee de probabilite diagnostique a ete proposee. Le dantrolene sodique est un medicament non specifique de la chaine mais particulierement efficace dans le traitement de la phase aigue. - Physiopathologie de la crise : Elle met en cause une augmentation du calcium intracellulaire secondaire a un defect au niveau du reticulum sarcoplasmique (recepteur ryanodine) ou, d'une maniere plus generale, a une etape intracellulaire du couplage excitation-contraction. - Pour le diagnostic : Le seul test diagnostique actuellement reconnu de la sensibilite a l'HM est l'exposition de segments du muscle quadriceps preleves par biopsie chirurgicale et soumis in vitro a des concentrations d'halothane et de cafeine. Une contracture anormale signe le diagnostic de sensibilite. Ce test est realise par 24 centres en Europe.

A 39-year-old patient was admitted to the emergency department for acute abdominal pain. Physical examination showed a peritoneal syndrome. However, CT-scan, Doppler and blood analysis were unremarkable. As the patient had a history of auto-medication with benzodiazepines at high doses, a withdrawal syndrome was considered. An intravenous administration of 3 mg of midazolam determined the relief of all symptoms in a few minutes.

Objectif: To assess the possibility to differentiate clinically intraoperative malignant hyperthermia (MH) and sepsis.Study design: Comparative retrospective study of clinical ca ses.Patients: Sixteen patients operated on for acute appendicitis and developing clinical signs of MH confirmed or not by in vitro caffeine halothane contracture tests (IVCT).Method: To isolate the patients' characteristics with regard to the diagnosis of sepsis and MH crisis. To compare both groups of clinical features with results of IVCT.Results: The diagnosis of MH sensitivity has been excluded in ten hyperthermic patients and confirmed in four others with IVCT. No correlation was existing between the importance of perioperative sepsis, MH features and IVTC results.Conclusions: This study confirmed the difficulty to differentiate clinically MH and sepsis during surgery. Considering the severe outcome of MH crisis, it is recommended to start the specific therapy even in case of appendicular sepsis.

OBJECTIVE:To assess the possibility to differentiate clinically intraoperative malignant hyperthermia (MH) and sepsis.STUDY DESIGN:Comparative retrospective study of clinical cases.PATIENTS:Sixteen patients operated on for acute appendicitis and developing clinical signs of MH confirmed or not by in vitro caffeine halothane contracture tests (IVCT).METHOD:To isolate the patients' characteristics with regard to the diagnosis of sepsis and MH crisis. To compare both groups of clinical features with results of IVCT.RESULTS:The diagnosis of MH sensitivity has been excluded in ten hyperthermic patients and confirmed in four others with IVCT. No correlation was existing between the importance of perioperative sepsis, MH features and IVTC results.CONCLUSIONS:This study confirmed the difficulty to differentiate clinically MH and sepsis during surgery. Considering the severe outcome of MH crisis, it is recommended to start the specific therapy even in case of appendicular sepsis.

A 39-year-old patient was admitted to the emergency department for acute abdominal pain. Physical examination showed a peritoneal syndrome. However, CT-scan, Doppler and blood analysis were unremarkable. As the patient had a history of auto-medication with benzodiazepines at high doses, a withdrawal syndrome was considered. An intravenous administration of 3 mg of midazolam determined the relief of all symptoms in a few minutes.