La transfusion sanguine est un des éléments majeurs du soutien médico-chirurgical des militaires en opération extérieure. Les moyens français comportent : des concentrés de globules rouges (CGR), du plasma lyophilisé (PLYO), le sang total (ST), mais ni plaquettes, ni plasma frais congelé. La stratégie transfusionnelle française en opérations militaires extérieures suit l'évolution des savoirs et des moyens. Nous décrivons ici les caractéristiques de la transfusion sanguine à l'hôpital militaire de Kaboul.Étude rétrospective des dossiers des patients transfusés entre octobre 2010 et décembre 2011 à Kaboul, à partir du registre local de la transfusion sanguine. Les variables étudiées ont été : les caractéristiques des patients, la biologie à l'admission, le type et la quantité des produits transfusionnels, l'évolution.Cent vingt-six patients ont été transfusés : majoritairement Afghans (n = 97 ; 77 %), 49 militaires (39 %) dont 22 militaires français (17 %), âge médian 24 ans (3–66). Deux cents soixante-treize CGR provenant de France ont été transfusés et 350, non utilisés, ont été détruits. Les pathologies ayant conduit à une transfusion ont été : 76 blessures de guerre (60 %), 21 traumatismes (17 %) et 29 autres mécanismes (23 %). Dans les 24 premières heures, les patients ont reçu en médiane : deux CGR (0–12), un poche de ST (0–18) et deux PLYO (0–14). Le ratio PLYO/CGR était de 1/1,6. Une transfusion massive (> 10 CGR ou ST) a concerné 9 % des patients. Vingt-sept pour cent des patients ont reçu du ST. On note 17 décès (13,5 %).L'utilisation du ST et du PLYO en substitution, respectivement, des concentrés plaquettaires et des PFC, permet d'apporter des soins de qualité dans un contexte logistiquement contraint tout en maîtrisant les risques et les coûts.Blood transfusion is an aspect of medical care on the battlefield. French assets include: red blood cell units (RBCu), lyophilized plasma (PLYO), fresh whole blood (FWB) but neither fresh-frozen plasma (FFP) nor platelets. French transfusion strategy in military operations follows the evolution of knowledge and resources. We describe the characteristics of the transfusion at the military hospital in Kabul.Retrospective study of records of patients transfused between October 2010 to December 2011 conducted in Kabul from transfusion register. Variables studied were: patient characteristics, biology at admission, type and amount of transfusion products, evolution.One hundred and twenty-six patients were transfused: 49 military (39%) which 22 French soldier (17%), most of time afghan (n = 97; 77%), mean age at 24 years old (3–66). Two hundred and seventy-three RBCu from France were transfused and 350 unused were destroyed. Conditions leading to a transfusion were: 76 war wounds (60%), 21 trauma (17%) and 29 other (23%). In the first 24 hours, patients received in mean: two RBCu (0–12), one unit of FWB (0–18) and two PLYO (0–14). PLYO/RBCu ratio was 1/1.6. A massive transfusion (more than 10 RBCu) concerned 9% of patients. Twenty-seven percent of patients received FWB. We note 17 dead people (13.5%).The use of the FWB and PLYO in substitution of FFP and platelets can provide cares of high quality in a logistically constrained context while controlling costs.

Objective: To compare patients undergoing valve surgery through a minithoracotomy approach with a matched group undergoing conventional valve surgery.Design: Control study.Setting: University hospital, single center.Participants: Forty-one consecutive patients scheduled for valve surgery by minithoracotomy approach were matched with a similar group of patients operated on by the sternotomy approach.Interventions: Criteria for matching included type of valve procedure (aortic valve replacement or mitral valve repair), age, surgeons, and left ventricular function. Two surgeons performed the surgical procedures. Perioperative care was standardized for all patients. Operative and postoperative data were recorded.Measurements and Main Results: The 41 pairs of patients were correctly matched, except for left ventricular function (n = 1). Twenty patients underwent mitral valve repair and 62 aortic valve replacement. Preoperative demographic data and clinical characteristics were similar in both groups. Cardiopulmonary bypass, aortic clamping, and surgery times were longer in the minithoracotomy group (p < 0.05). In 3 patients, the minithoracotomy approach had to be converted into a sternotomy during the surgical procedure for better visualization. Minithoracotomy patients had significantly increased postoperative total blood loss (p < 0.05). No difference was found between the groups for extubation time and intensive care or in-hospital lengths of stay.Conclusion: These results suggest that valve surgery is feasible in many cases through minithoracotomy. Nevertheless, this approach increases surgical complexity and in this comparative study no significant benefit was shown. (C) 2003 Elsevier Inc. All rights reserved.

Since its first use by Swan et al in 1970} pulmonary artery catheters (PAC) have become widely used to assist in the care of critically ill surgical or medical patients.In cardiac ~,urgery, PAC monitoring helps to assess ventricular function, pulmonary and systemic vascular resistances, and determination of ~-he need of fluid or inotropic therapy.However, numerous minor and maior complications have been reported} Few of these complications were observed during cardiopulmonary bypass (CPB).A rare, but potentially lethal, complication of PAC monitoring is total obstruction of the venous return catheter (VRC) by the PAC balloon during a routine aortic valve replacement (AVR) procedure.An 89-year-old woman with symptomatic aortic stenosis was referred for AVR.Before anesthetic induction, a 7-Fr thermodilution PAC was introduced through the right internal jugular vein.During the insertion procedure, a ventricular arrhythmia with premature ventricular contractions occurred, leading the anesthesiologist to withdraw the PAC into the right atrium.Cardiopulmonary bypass (CPB) was performed using a 36/51-Fr two-stage VRC (Jostra Medizintechnik, Hirrlingen, Germany), and a 21-Fr aortic canula (Jostra Medizintechnik).Normothermic CPB was sta=ted uneventfully, and the aortic valve replaced by a 21 mm Cryolife-O'Brien stentless bioprosthesis (Gamida, Marietta, GA).After a shot of warm cardioplegia solution, the aortic cross-clamp was removed, and the heart resumed a regular rhythm.Then the perfusionist had difficulties with venous blood return, and the surgeon checked :for kinking of the venous return line.Venous return was first dramatically diminished then suddenly interrupted.Cardiopulmonary bypass was immediately stopped and the VRC promptly removed.The PAC was entrapped in the VRC (Fig 1), with the inflated balloon tip totally obstructing the lumen.The PAC was reinserted into the right atrium and placed in the pulmonary artery.Termination of the procedure was uneventful and the patient recovered without incident.An increasingly older and sicker population of patients undergoes cardiac surgical procedures, and invasive monitoring may contribute to a better outcome.Preinduction insertion of a PAC is justified in the majority of patients, especially those with aortic stenosis who often show marked hypovolemia that could be dangerous if unknown before induction.Ventricular arrhythmias are one of the common complications reported with PAC monitoring and are most likely the result of mechanical stimulation of the endocardinm or the conduction pathways.3 Various risk factors have been identified as predisposing to the development of ventricular arrhythmias, including acidosis, hypoxemia, electrolyte imbalance, and myocardial ischemia or infarction.4 None of these risk factors was present in this patient.The anesthesiologist rapidly withdrew the PAC from the right ventricle to the right atrium, abating the arrbythmia during insertion.5 As previously described 6 this manipulation created the circumstances for two complications.First, the withdrawal of the catheter into the right atrium allowed it to migrate into the cannula's lumen where the blood flow is directed during CPB.The second complication was that the balloon was intermittently inflated to help the catheter tip float to the pulmonary artery.During CPB, successive inflations produced successive episodes of obstruction, and, when the balloon was locked in the inflated position, dramatic interruption of venous return occurred.When examined, the external diameter of the inflated balloon was 13 ram, exactly the size of the VRC internal diameter.

La prévention de la douleur postopératoire a donné lieu à différentes approches pharmacologiques et non pharmacologiques. L'influence de la chronologie entre l'administration du traitement et le stimulus chirurgical, qui correspond à la ≪pre-emptive analgesia≫ des Anglo-Saxons (comparaison entre l'administration préopératoire et l'administration perou juste postopératoire du même agent antalgique), a fait l'objet de nombreux travaux de bonne qualité méthodologique. En dépit de résultats initiaux encourageants, les études actuellement publiées sont très majoritairement négatives. Dans une conception plus large de la prévention de la douleur postopératoire, un certain nombre d'essais ont documenté les bénéfices liés au choix de la voie d'abord chirurgicale, ainsi qu'à la préparation psychologique des patients en vue de l'intervention.Postoperative pain can be prevented through pharmacological and non pharmacological means. The influence of the interval between therapy and surgical stimulus, which corresponds to “pre-emptive analgesia” in English-speaking countries (comparison of preoperative administration with pre- and postoperative administration of the same analgesic) has been assessed by numerous studies of good methodological quality. In spite of the initial promising results, most of the results published at present are negative. In an enlarged concept of postoperative pain prevention, various trials have demonstrated the benefits of the choice of the surgical approach, as well as the psychological preparation of the patient for surgery.

Various ab initio electron-correlation methods are applied to calculate second hyperpolarizabilities (γs) of MnCH+, MnCH2+ and MnCH3+. These systems showed significant dependences on the electron correlations. MnCH3+, which have a single MnC bond, exhibited the larger γ than MnCH+ and MnCH2+, which have weak π bonds.

Forty one patients were admitted with a diagnosis of prosthetic valve thrombosis. One patient was thrombolysed successfully, and 40 underwent surgical procedures. In 13 cases, prosthetic valve thrombosis occurred in the first month after valve replacement. 18 patients were in functional class IV of the NYHA classification. Among the thrombosed prostheses, 91% were mechanical, and 61% in mitral position. Adequacy of anticoagulation was the most important risk factor, as this treatment was inappropriate in 20 patients. In 10 other patients, it had been changed for medical (bleeding events, pregnancy) or surgical (non cardiac surgery) reasons. The perioperative mortality rate was high (32.4%). It was 12% in patients in functional class II and 46% in those in class IV (p < 0.05). This underlines the value of early diagnosis, in which echocardiography, especially with a transesophageal probe, takes a major place, allowing prompt surgical treatment.