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Smar.ma2

Ang1-TURP Syndrome: a complication that can occur despite precautions
S. BOUDARI, Y. ZARROUKI, O. CHOUKA, M. KHALLOUKI, MA. SAMKAOUI Service d'Anesthésie-Réanimation Hôpital Ibn-Tofail, CHU Mohammed VI, Marrakech
Introduction:
The TURP (transurethral resection of the prostate) syndrome is the most serious complication
of transurethral resection of the prostate, it can be fatal. The incidence of TURP syndrome is
decreasing, especially because of observance of requirements relating to the use of glycine,
and utilization of technologic advances (laser techniques and bipolar circuitry).
We report the case of a patient who presented a severe TURP syndrome following glycine
irrigation despite the observance of all precautions of use.
Case report:
A 72-year-old man, followed for arterial hypertension under amlodipine, proposed for TURP
for Benign prostatic hyperplasia revealed by lower urinary tract symptoms, and which the size
of prostate is sonographically estimated 40 grams. The preanesthetic assessment has shown a
patient with a good physical activity (more than 4 MET) and echocardiography, an abnormal
relaxation pattern related to age and hypertension. Biological tests were correct, in particular
Hb = 12.4 g/dL and natremia = 138 mEq/L. The procedure was performed under spinal
anesthesia and consisted on a monopolar TURP. Irrigation of bladder made with a total of 6 L
of 1.5% glycine with 1% ethanol at a pressure of up to 60 cm water. 35 minutes after the
beginning of the procedure when the surgeon finalizing hemostasis, the patient became
slightly disoriented, so the TURP syndrome was suspected, surgeon advised and irrigation
stopped. Despite stopping of irrigation of glycine, evolution was marked by rapid clinical
deterioration, with apparition in few minutes of a respiratory distress with crepitations on
auscultation, hemodynamic instability (bradycardia, hypotension 70/40 mmHg) and then
quickly occurrence of partial seizures of left upper limb. After this the patient was put under
mechanical ventilation, correction of hyponatremia started by saline serum 3.3% and an
internal jugular catheter was placed. Initial biological assessment showed :
pH=7.31 PCO2 = 46.4 mmHg PO2 = 52.1 mmHg HCO3- = 23.5 mmol Na+ =
108.3 mmol/l K+ = 5.47 mmol/l
After restoration of effective circulation, furosemide was given and the patient was
transferred to surgical intensive care unit. The sedation was stopped and 2 hours later,
extubation done in a patient respiratory and hemodynamically stable, persistent slightly
confused. The hyponatraemia was slowly corrected to 132 mmol/l and the patient discharged
day 3 from ICU with a good recovery especially neurological.

Commentaries:
In this clinical observation, the patient has presented a life threatening TURP syndrome,
despite the small prostate size, the not elevated irrigation pressure and the short duration of
resection. That illustrates how regional anesthesia is superior than general anesthesia, by
allowing an early detection of any change in mental status, enabling an early recognition of
the syndrome and avoiding thereby its expression by an intraoperative cardiac arrest. Under
general anesthesia, the diagnosis of TURP Syndrome is difficult, generally delayed and the
cardiovascular signs are prominent.
Ang2-Perioperative Management in Patients Undergoing Cephalic
H. REBAHI, S. BOUDARI, A. EJLAIDI, M. KHALOUKI, MA. SAMKAOUI Service d'Anesthésie-Réanimation Hôpital Ibn-Tofail, CHU Mohammed VI, Marrakech
Introduction:
Cephalic Pancreaticoduodenectomy (CPD) represents one of the most important and complex
surgical digestive procedure. This surgery remains the gold standard and the only potentially
curative option for pancreatic cancer with high rate of perioperative morbi-mortality. So the
anesthesiologist has a crucial role in the management of these patients. This unicentric study
aimed, in our setting, to evaluate and assess perioperative management of patients and
determine its influence on perioperative morbidity, complications occurrence and 30-day
postoperative mortality.
Patients and Methods:
From January 2005 to December 2010, a total of 25 patients, who underwent cephalic
pancreaticoduodenectomy in Mohammed VI's University-Hospital of Marrakech, were
enrolled retrospectively in the current study. The Patients were assigned to receive a
standardized anaesthesic protocol: combined Thoracic Epidural Analgesia (TEA) and general
anaesthesia followed by postoperative TEA for pain control, using a mixture of 0.125%
bupivacaine and sufentanil. The epidemiological, clinical, histological and evolutive data
were recorded and analyzed.

Results:
Mean patient age was 58.2 years. More than half of individuals were operated between 50 and
60 years of age. Most patients were men (sex-ratio=1,6). All cases had no preoperative
medical comorbidities. CPD was performed for a pancreatic adenocarcinoma in 70% of cases
and for periampullary adenocarcinoma in 30%. The nutritional status was classified II in 80%
of cases according to the Nutritional Risk Index. 91% of our patients presented a biological
cholestasis. We found a 324 mL as an average of intraoperative blood loss and the mean of
surgery duration was 340 min. The 30-day mortality was 12% (three fatal septic shocks).
Regarding complications, they occurred in 44%: 6 patients with delayed gastric emptying, 1
biliary fistula, 2 pancreatic fistulas with spontaneous healing in one patient and two post-
operative pneumonias. All patients had a suitable postoperative nutritional support (enteral
and parenteral). The TEA afforded optimal pain relief both at rest and with activities such as
deep breathing, coughing and ambulation in 88% of our patients. Furthermore, it reduces the
duration of postoperative gastrointestinal ileus and allows avoiding opioid-induced side
effects. We noticed one case of unsuccessful catheter placement and no neurologic injuries.
One case of nausea and hypotension arisen as adverse effects related to medications used in
TEA. The length of stay in intensive care unit (ICU) and hospital stay were, respectively, 3
days (range, 2-8) and 12 days (range 6-24).
Commentaries:
TEA combined with general anaesthesia associated with perioperative nutritional assistance
seems to be a good strategy to manage patients undergoing this complex surgical procedure
because it results in faster recovery and fewer complications and shorter length of ICU.
Ang3-Bilateral Pneumothorax and Pneumomediastinum Revealing a Laryngeal
Thyroid cartilage fracture after Blunt Trauma
A. EJLAIDI, Y. ROUIESSI, F. ELMANSOURI, N. HAIMEUR, Y. MOUAFFAK,
AR. EL ADIB, S. YOUNOUS Service of pediatric anesthesia and intensive care, Med VI University hospital Marrakech

Introduction:
Laryngeal injury due to a traffic accident is rare and can be under diagnosed if not suspected.
Association of a pneumothorax and a laryngeal traumatism is rare, only a case reported in the
literature. We present a laryngeal fracture in a child after a blunt chest trauma during a traffic
accident that it was revealed by pneumomediastinum and bilateral pneumothorax.
Case report:
A previously healthy 8-year-old girl was knocked down by a cyclist with a direct thoracic
impact. At admission, she was unconscious, dyspneic with an oxygen saturation of 40% in
room air. Laryngeal hematoma causing a difficult intubation, an emergency tracheostomy was
performed on scene. Once, the airway was secured, we found emphysema and edema in the
cervico-thoracic area with an important bilateral pleural gas effusion. Consequently a prompt
exsufflation was required before a computed tomography scan of the chest. This CT scan
showed a bilateral pneumothorax and pneumomediastinum. The pneumothorax evacuation
was effective by the insertion of two chest tubes. The evolution of the respiratory and
hemodynamic states was favorable. Regarding these clinico-radiologic findings, an upper
airway damage was suspected, and the cervical tomography revealed thyroid cartilage
fracture. The nasofibroscopic exam found an extensive edema of the left arythenoid cartilage
without hematoma. he thyroid fracture was treated surgically and the tracheostomy was
maintained in position until laryngeal healing.
Commentaries:
Laryngeal fracture due to blunt trauma is a rare pathology characterized by a delayed
diagnosis. As a consequence, it may have a high rate of morbidity and mortality. We will
discuss clinical, radiological and therapeutic features.
Ang4-Anesthetic management of the child with an upper respiratory tract infection : a
new algorithm
A.EJLAIDI, H. REBAHI , Y. ROUIESSI , N. HAIMEUR, Y. MOUAFFAK, AR. ELADIB, S. YOUNOUS Children frequently develop upper respiratory tract infections (URI). The decision to proceed with or cancel surgery for the child with a URI remains controversial and difficult. On one hand, the presence of an URI increases the risk of complications, on the other hand these complications can, for the most part, be anticipated, recognized, and treated. In fact, the child with an URI still presents a challenge, but anesthesiologists are now in a better position to make informed decisions regarding the assessment and management of these children, such that blanket cancellation has now become a thing of the past. Despite the importance of this clinical problem, there is no single definition for URI, there is still no consensus regarding the optimal anesthetic management of children with URI who require elective surgery. Although several studies have addressed this issue, it has been difficult to develop evidence-based practice guidelines given differences in study design, URI criteria, and outcomes. We aim from evidence based literature to identify risk factors for perioperative respiratory adverse events, to establish helping form decisions, and to define the means for optimizing anesthetic management. Ang5-Rhabdomyolysis associated to glossopharyngeal edema: a rare side effect of
diclofenac
S.MASSOU*, L.WARTTITI, H.BAKKALI, K.ABOULAALA, H.BALKHI, C.HAIMEUR, N.DRISSI KAMILI. Pole d'anesthésie réanimation, hôpital militaire d'instruction Mohammed V, Rabat, Maroc.
Abstract:
Diclofenac potassium is a widely used non-steroid anti-inflammatory drug which is absorbed
more quickly than diclofenac sodium, Reported cases of rhabdomyolisis after only diclofenac
are rare, we survey three cases in the literature. We report a case of a 50 year-old man,
chronic smoker and allergic to aspirin who developed a rhabdomyolysis associated with
glossopharyngeal edema after oral administration of diclofenac for dental pain
.Rhabdomyolysis associated with glossopharyngeal edema due to diclofenac has not been
reported.

Abstract
Objectives:
Description of the epidemiological and clinical characteristics of the patients introducing risk
factors of invasive candidiasis.Analysis of risk factors for candidiasis invasive and evaluation
of the contribution of colonization index (CI) in the diagnosis of the systematic candidiasis in
medical intensive care.

Patients and methods:
Prospective observational study (October 2007 to October 2009). The selected patients
present risk factors of system IC candidiasis with an infectious syndrome or clinical signs
suggestive of Candida infection and hospitalized more than 48 hours in medical intensive
care unit. Pittet's colonization index was calculated at admission and then once a week added
to a blood culture. Patients were classified according to level of evidence of Candida
infection and the degree of colonization (CI < 0.5, CI ≥ 0.5).

Results:
The study included 100 patients. Mean age of our patients was 55.8 ± 18.2 years with male
prevalence. Neurological disease was the most frequent pathology in admission (48%). The
most common risk factors were broad-spectrum antibiotics and foreign material. In the
various mycology IC specimens, Candida albicans was the most frequent, followed by
C. tropicalis, then C. glabrata. The CI was greater than or equal to 0.5 at 53% of the patients,
and less than 0.5 in 47% of the cases. Among the patients, 15% developed an invasive
candidiasis. In multivariate analysis, the corticosteroid therapy was associated with a high
colonisation (IC ≥ 0.5) and neutropenia with a high risk of systemic candidiasis. The positive
predictive value of CI was 26%. The negative predictive value was 98%, the sensitivity and
specificity was 93% and 48% respectively.

Conclusion:
CI has the advantage to provide a quantified data of the patient's situation in relation to the
colonization. But, it isn't helpful with patients having an invasive candidiasis in medical
intensive care unit.

Source: http://www.smar.ma/pdf/abstracts2013/anglais.pdf