Case Report: Bothrops lanceolatus Snakebite Surgical Management-Relevance of Fasciotomy

Bothrops lanceolatus is an endemic Crotalidae species in Martinique, where approximately 30 cases of envenoming are managed yearly. Envenoming characteristics from Bothrops species include local tissue damage, systemic bleeding, and hemodynamic alterations. We hereby report a case of severe envenomation following B. lanceolatus snakebite to the right calf. Severe local manifestations developed progressively up to the lower limb despite adequate antivenom therapy. Systemic manifestations of venom also occurred, resulting in intensive care therapy. Surgery exploration revealed soft tissue necrosis, friability of the deep fascia, and myonecrosis. The patient needed multiple debridement procedures and fasciotomy of all leg compartments and anterior compartment of the thigh. Diagnosis of necrotizing fasciitis was confirmed by positive Aeromonas hydrophila blood cultures. This clinical case illustrates that major soft tissue infection, including necrotizing fasciitis may occur after snakebite. Abnormal coagulation tests should not delay surgical management, as severe envenoming is a life-threatening condition.

Infections tropicales graves dans les départements français d’Amérique, Antilles françaises et Guyane

Les Antilles-Guyane (AG) sont les départements français du continent américain, situés en zone intertropicale. La diversité des écosystèmes ainsi que le climat tropical à très forte pluviosité exposent à un vaste panel de pathologies infectieuses. Ces territoires sont de plus l’objet de mouvements importants de populations, voyageurs ou migrants, ce qui joue un rôle significatif dans le développement d’épidémies et/ou de pathologies émergentes. Ces pathologies infectieuses dites « tropicales » peuvent nécessiter une prise en charge en réanimation. Nous rapportons ici les principales données récentes concernant ces pathologies (hors infection liée au VIH) ainsi que les stratégies diagnostiques et thérapeutiques, à l’usage des réanimateurs amenés à exercer en zone tropicale AG ou recevant en métropole des patients issus de cette région.

Hyperbaric oxygen therapy after Bothrops lanceolatus snake bites in Martinique: a brief report

Every year 10 to 20 cases of snake bites are reported on the Caribbean island of Martinique. The only snake involved, Bothrops lanceolatus, is endemic on the island, and its bite may lead to systemic multifocal thrombotic complications in the'absence of the monospecific antivenom. Between January 1988 and January 2009, more than 250 snake bites have been reported, and five patients were treated with hyperbaric oxygen (HBO2) therapy for local complications. The patients were male, bitten on the leg or the hand, and presented with severe complications such as necrotizing soft tissue infections, compartment syndrome or abscesses despite prompt wound care and administration of antivenomous serum. Outcomes were favorable for these five patients, except for one who was left with a functional defect of the hand. Although snake bites are not part of the currently recommended indications for HBO2 therapy, local complications, namely compartment syndrome, necrotizing soft tissue infections and enhancement of healing in selected problem wounds, are approved uses of HBO2 therapy as defined by the Hyperbaric Oxygen Therapy Committee and would benefit from prospective studies.

Plasma exchange in severe spinal attacks associated with neuromyelitis optica spectrum disorder

Background

Plasma exchange (PE) is increasingly undertaken in diseases involving humoral factors and is proven to be beneficial in acute demyelinating diseases. Spinal attacks in relapsing neuromyelitis optica (NMO) and in extensive transverse myelitis (ETM) – a truncated form of NMO with spinal involvement – are usually devastating.

Objective

We retrospectively studied the outcome of PE-treated versus steroid-only treated spinal attacks in relapsing NMO and ETM.

Methods

We included 96 severe spinal attacks in 43 Afro-Caribbean patients. PE was given as an add-on therapy in 29 attacks. Expanded disability status score (EDSS) was obtained before attack, during the acute and residual stage. We defined the ΔEDSS as the rise from basal to residual EDSS.

Results

The ΔEDSS was found to be lower in the PE-treated group (1.2 ± 1.6 vs 2.6 ± 2.3; P < 0.01). A low basal impairment is associated with a better outcome. Improvement was obtained in both NMO-IgG negative and positive NMO attacks. Minor adverse events manifested in seven PE sessions (24%).

Conclusion

PE appears to be a safe add-on therapy that may be employed early in severe spinal attacks in the NMO spectrum disorders in order to maximize improvement rate. PE efficiency is independent of NMO-IgG positivity.

An architecture for online comparison and validation of processing methods and computerized guidelines in intensive care units

Clinical decision support systems are a combination of software techniques to help the clinicians in their medical decision making process via functionalities ranging from basic signal analysis to therapeutic planning and computerized guidelines. The algorithms providing all these functionalities must be very carefully validated on real patient data and must be confronted to everyday clinical practice. One of the main problems when developing these techniques is the difficulty to obtain high-quality complete patient records, comprising data coming both from the biomedical equipment (high-frequency signals), and from numerous other sources (therapeutics, imagery, clinical actions, etc.). In this paper, we present an infrastructure for developing and testing such software algorithms. It is based on a bedside workstation where testing different algorithms simultaneously on real-time data is possible in the ward. It is completed by a collaborative portal enabling different teams to test their software algorithms on the same patient records, making comparisons and cross-validations more easily.

[Community-acquired Acinetobacter baumannii pneumonia]

We report two cases of community-acquired Acinetobacter baumannii pneumonia. Although most infections occur in hospitalized patients, a few cases of community-acquired pneumonia have been described. This disease occurs predominantly in men, and is often associated with underlying conditions such as cigarette smoking, alcohol abuse, diabetes mellitus, and chronic pulmonary diseases. Community-acquired Acinetobacter baumannii pneumonia cases are generally reported from tropical areas, especially during wet season. Microbiological identification in blood or sputum can be difficult because of frequent misinterpretation and possible confusion with Staphylococcus or Haemophilus infuenzae or neisseriae. Early antibiotherapy is required because of the fulminant clinical course, with approximatively 50% fatality rate.

Neostigmine added to lidocaine axillary plexus block for postoperative analgesia

BACKGROUND AND OBJECTIVE

We have assessed the analgesic efficacy and side-effects of neostigmine when added to lidocaine for axillary brachial plexus block, in a prospective, randomized, double-blind, placebo-controlled study.

METHODS

We studied 34 ASA I or II patients undergoing elective ambulatory carpal tunnel release. Axillary brachial plexus block was performed using a peripheral nerve stimulator to locate the median nerve. All patients were administered 1.5% lidocaine 450 mg and epinephrine 5 microg mL-1. Patients were allocated randomly to one of two groups. Neostigmine 500 microg was added in group N, and saline 1 mL in group S.

RESULTS

The duration of analgesia did not significantly differ between groups [mean (SD)]: 812.5 (456.9) for group S vs. 746.7 (474.1) min for group N (P > 0.05). The need for supplementary analgesia did not significantly differ between groups: 4.4 (1.5) extra doses for group S vs. 3.8 (2.2) extra doses for group N (P > 0.05). Visual analogue pain scores and occurrence of side-effects did not significantly differ between groups.

CONCLUSION

Neostigmine does not seem to be of clinical value for peripheral nerve blocks.

[Acute pulmonary edema caused by tocolytic therapy with salbutamol]

BACKGROUND

Acute pulmonary edema may be induced by beta 2-mimetics used for tocolysis.

CASE REPORT

A 41-year-old patient, admitted for preterm labor, presented acute pulmonary edema after parenteral tocolysis using salbutamol in combination with corticosteroid therapy to improve fetal pulmonary maturation.

DISCUSSION

The pathogenic mechanism is essentially non-cardiologic. Fluid retention is probably the main cause, potentially worsened by corticosteroid administration. If detected early, pulmonary edema is usually and adequately treated by cessation of beta 2-sympathomimetic therapy, oxygen administration and diuretics. Mechanical ventilation can be required. Cardiac function must be assessed after this complication. In preterm labor, the duration of tocolysis with beta 2-sympatomimetics should be reduced.

Caudal clonidine for postoperative analgesia in adults

We have assessed the analgesic efficacy and side effects of caudally administered clonidine in a prospective, randomized, double-blind, placebo-controlled study. We studied 64 adult patients undergoing elective haemorrhoidectomy. Caudal block was performed in all patients using a mixture of 0.5% bupivacaine 35 mg with 2% lidocaine 140 mg and epinephrine 5 micrograms ml-1. Patients were allocated randomly to one of two groups. Clonidine 75 micrograms was added in group C and saline 1 ml in group S. Median time to first analgesic requirements was significantly longer in group C (mean 729 (SD 120) min) than in group S (276 (131) min) (P = 0.01). Bradycardia occurred in seven patients in group C but did not affect mean arterial pressure.

[Massive paraquat poisoning. Favorable course after treatment with n-acetylcysteine and early hemodialysis]

Case report of a 30-year-old patient, admitted one hour after an intentional ingestion of paraquat (60 g). The initial treatment included gastric washing, parenteral n-acetylcysteine and forced diuresis. Considering the severity of the intoxication, conventional haemodialysis was started four hours after the ingestion. Plasma concentrations of paraquat, in the lethal range at admission, decreased rapidly and significantly after haemodialysis. This case raises the question of the part played by n-acetylcysteine and haemodialysis respectively in a favourable outcome. As the determination of paraquat blood concentrations requires some delay, these data are of no help for therapeutic decisions. Therefore, in cases of massive poisoning or uncertainty of the ingested dose, a technique of blood purification in indicated. Charcoal haemoperfusion is the most efficient, however conventional haemodialysis, which is more widespread, should be considered if the former is not available.

Early dermabrasion of deep dermal burns with sandpaper. Case reports

Deep dermal burns are initially difficult to evaluate, and they sometimes heal spontaneously. We present our experience of dermabrasion with sandpaper in four patients. It is a useful alternative to early excision of the scar. Skin grafts are not always required and the aesthetic results are excellent. Dermabrasion should be considered routinely for all deep dermal burns and particularly for facial burns and those caused by scalds.

[Acute renal insufficiency and cerebral infarction during high-dose intravenous immunoglobulin therapy]

INTRODUCTION

Side-effects of immunoglobulins administered via the intravenous route are usually minor. However, acute renal failure and more rarely thrombotic events, including ischemic stroke, have been reported in association with immunoglobulin infusion. To our knowledge, no case of both acute failure and stroke following immunoglobulin has been described until now.

EXEGESIS

Two days after immunoglobulin infusion (2 g/kg), a patient who presented with autoimmune thrombocytopenia suffered severe acute renal failure associated with an ischemic stroke in the right anterior choroid artery territory. Moreover, the stroke worsened immediately following a second infusion (1 g/kg). Clinical and neuroradiological examinations were conducted.

CONCLUSION

Results indicate the need for both close monitoring of serum creatinine and diuresis before starting immunoglobulin therapy, and limiting the total dose to prevent thrombotic events such as stroke.

Prognostic significance of clinical grading of patients envenomed by Bothrops lanceolatus in Martinique. Members of the Research Group on Snake Bite in Martinique

The correlation between clinical grading of patients bitten by Bothrops lanceolatus and the subsequent development of their envenoming was examined. Severity of envenoming was graded using a 1-4 scale (minor to major). Patients were classified into 2 groups according to the time elapsed between bite and treatment with a specific purified equine F(ab')2 antivenom. The late/no treatment group (n = 33) was characterized by a systemic thrombotic complication rate of 14/33 (42.4%) leading to 4 deaths, which increased with the maximum severity assessed on the first day following the bite (P = 0.003). However, infarctions could develop in patients who presented initially with signs of moderate envenoming, normal blood clotting and low serum levels of venom antigens. No such complication of fatality occurred in the early (0.5-6 h) treatment group (n = 70). Multiple regression analysis showed that duration of stay in hospital in this group increased with the length of the snake (P = 0.017), venom antigenaemia (P = 0.016), initial grading (P < 0.001), and with the need for surgical debridement (n = 10/70, P < 0.001). Outcome was correlated with initial severity of envenoming. However, the only factor with a positive prognostic significance for the individual envenomed patient was the early infusion of specific antivenom, which led to 100% recovery in our series.

Nasotracheal intubation in patients with immobilized cervical spine: a comparison of tracheal tube cuff inflation and fiberoptic bronchoscopy

Tracheal intubation may pose problems in patients with cervical spine injury (CSI). In patients without CSI, the success rate of blind nasotracheal intubation is increased by endotracheal tube (ETT) cuff inflation in the pharynx. The purpose of this study was to assess the efficacy of ETT cuff inflation in the pharynx as an aid to blind nasotracheal intubation in patients with an immobilized cervical spine. The technique was compared with fiberoptic bronchoscopy. Twenty ASA physical status I and II patients undergoing elective surgery in which the trachea was to be intubated nasally were enrolled in this prospective, randomized study. The cervical spine of each patient was immobilized. The trachea of each patient was intubated twice, once using fiberoptic bronchoscopy and once blindly using the technique of ETT cuff inflation in the pharynx. A maximum of three attempts was allowed for intubation using ETT cuff inflation. A maximum of 3 min was allowed for intubation using fiberoptic bronchoscopy. When ETT cuff inflation was used, intubation was successful in 19 of 20 patients (95%); the first attempt at intubation was successful in 14 of 20 patients (70%). Intubation was successful in 19 of 20 patients (95%) when using fiberoptic bronchoscopy. Mean times to intubate were 20.8 +/- 23 s when the ETT cuff was inflated in the pharynx and 60.1 +/- 56 s when using fiberoptic laryngoscopy (P < 0.01). We conclude that both ETT cuff inflation in the pharynx and fiberoptic bronchoscopy are valuable for nasotracheal intubation in patients with an immobilized cervical spine and that ETT cuff inflation can be used as an alternative to fiberoptic bronchoscopy in patients with CSI.

IMPLICATIONS

We compared the technique of endotracheal tube cuff inflation in the pharynx for blind nasotracheal intubation in patients with an immobilized cervical spine with fiberoptic bronchoscopy. There was no significant difference between the success rates of the techniques.

[Retinal vein occlusion and deep-sea diving]

We report a case of retinal vein occlusion after breath-holding diving. After one hour of diving at a maximal depth of eight meters, each apnea no longer than one minute, the patient complained of a diminution of the visual acuity in the left eye. Ophthalmological examination revealed an occlusion of the superior branch of the central vein of the retina in the left eye. This could be considered as a decompression sickness even if the occlusion could happen fortuitously in water. Secondary to the multiple descents, a bubble would have appeared in the vein leading to an obstruction. The purpose of this paper is to discuss a possible link between the breath-holding diving and this kind of accident. We also report the different ophthalmological features that may occur while diving.

[Gayet-Wernicke encephalopathy and centropontine myelionolysis induced by hyperemesis gravidarum]

A 24-year-old woman developed hyperemesis gravidarum, complicated by Wernicke's encephalopathy and central pontine myelinolysis. The first-was due to a deficiency of thiamine, and was hastened by intravenous dextrose without thiamine supplements. However, no changes in serum sodium or phosphorus values were observed. In this case, the pathophysiology of central pontine myelinolysis remained obscure.

[Extensive cerebral venous thrombosis resistant to heparin: local fibrinolysis with urokinase]

A 37 year-old man had headaches for 10 days, then a single tonic-clonic seizure and coma due to an extensive cerebral venous thrombosis. In spite of full-dose heparin treatment for 7 days, the clinical picture worsened along with increasing edema on CT-Scan. Direct thrombolytic treatment was then performed using transvenous catheterization and instillation of Urokinase (2.6 MU over 4 days). A near complete repermeabilization of the sinuses was obtained and the patient improved dramatically in a few days. The only adverse effect of Urokinase was hematuria. Based on our experience and review of the literature which includes 26 previous cases, direct thrombolytic therapy appears to be a relatively safe procedure. This treatment should be considered in a patient with extensive dural sinus thrombosis which fails to respond to heparin treatment.

[First case of dengue hemorrhagic fever with shock syndrome in Martinique]

Since mid 95, many Caribbean islands and America's countries suffer from a new outbreak of an epidemic of dengue fever and dengue haemorrhagic fever. Until today, no case of dengue haemorrhagic fever was reported in Martinique (FWI) in spite of the high prevalence of dengue fever in the island. The first identified case asserts the severity of illness. In Martinique, these arbovirosis is often underestimated. Nowadays, the disease prevention must become one of the principal targets of the medical corporation and the Public Health Authorities. Consequently, epidemiologic survey and principally vector's control must be reinforced.

Diagnostic value of direct examination of the protected specimen brush in ventilator-associated pneumonia

Interpretation of the protected specimen brush (PSB) technique is based on quantitative bacterial cultures (QC), which unfortunately requires at least 24 h. We prospectively compared the diagnostic value of direct examination (DE) and QC of PSB specimens in 75 patients with suspected pneumonia. We also determined the optimal technique for DE. QC was performed using the serial dilution technique. From the original suspension, two cytospin slides were obtained and stained by the May-Grünwald Giemsa (MGG) and the Gram method for DE. If the prescreening on the MGG-stained slide was positive, the morphology and the Gram staining of the organisms were assessed on the Gram-stained slide. Using the 10(3) colony forming units (cfu.ml-1) threshold for defining PSB as positive or negative, DE had a sensitivity of 85% and a specificity of 94%. In a parallel in vitro study, 18 pairs of PSB specimens were collected from respiratory secretions inoculated with S. aureus. From each pair, one brush was processed as described above and the other was smeared on a glass slide prior to performance of QC. Using direct smear instead of cytocentrifuged preparation, slightly but significantly affected QC. Direct examination of cytospin slides is highly predictive of quantitative bacterial culture results, and provides rapid information regarding the Gram-stain morphology of the causative organisms. It may therefore guide initial therapy.

Prognostic value of the dobutamine test in patients with sepsis syndrome and normal lactate values: a prospective, multicenter study

OBJECTIVES

To determine the oxygen supply (DO2) and uptake (VO2) responses to a 60-min dobutamine infusion in critically ill septic patients without circulatory shock and with normal blood lactate concentrations. Also, to determine whether these responses would predict outcome.

DESIGN

Prospective, cohort study.

SETTING

Five intensive care units in university-affiliated, city hospitals.

PATIENTS

Fifty critically ill patients with sepsis syndrome were studied from April 1990 to August 1991.

INTERVENTIONS

Pulmonary artery catheterization; fluid loading if pulmonary artery occlusion pressure was < 10 mm Hg; and 10 micrograms/min/kg dobutamine infusion for 60 mins.

MEASUREMENTS AND MAIN RESULTS

Cardiac index, DO2, VO2, and oxygen extraction ratio were determined immediately before and 1 hr after the onset of the dobutamine test. Using receiver operating characteristic curves, responders to the dobutamine infusion were identified by a > 15% increase in VO2 from the time immediately before to 1 hr after the onset of the dobutamine test. We identified 23 responders and 27 nonresponders. Groups differed significantly in age (responders 46 yrs vs. nonresponders 55 yrs) and associated chronic disease (responders one cancer vs. nonresponders six cancers). Significant changes in responders were: a) cardiac index increased 42.9%; b) systemic vascular resistance decreased 20.7%; and c) DO2 increased 39.1% while VO2 increased 40.8%, with no changes in oxygen extraction or blood lactate concentration. Significant changes in nonresponders were: a) cardiac index increased 14.2%; b) DO2 increased 13.2% and c) oxygen extraction decreased from 0.26 to 0.22. Lactate concentration increased significantly by 25.1% in nonresponders. The mortality rate in responders (8.7%) was significantly less than that rate in nonresponders (44.4%).

CONCLUSIONS

Most of these septic patients without shock or hyperlactatemia responded to dobutamine infusion in one of two ways: with little increase in DO2 and no increase in VO2, or with significant increases in both DO2 and VO2. The latter response is typical of healthy volunteers given dobutamine. Because of the calorigenic effect of dobutamine, our results imply nothing about the presence or absence of oxygen supply limitation. Still, patients who had increases in DO2 and VO2 had a much higher survival rate than patients who did not. We speculate that the inability of some patients to respond to dobutamine and the associated higher mortality rate may be related to beta-adrenoreceptor dysfunction.

[Relation between oxygen delivery and consumption during septic states. Value of an early dobutamine test]

From previous studies it has been hypothesized that multiple organ failure and high level of mortality, seen in critically ill septic patients, may be due to defective oxygen extraction and tissue hypoxia occurring early in the course of sepsis. Oxygen flux test has been proposed as a method of revealing an occult oxygen debt. We used a one hour dobutamine infusion test, in septic patients, without increase in blood lactate. Fifty patients with sepsis syndrome entered a multicentric prospective study. After fluid loading to increase pulmonary artery occlusion pressure (Paop) to a minimum value of 10 mmHg, all the patients were given 10 mcg/kg.min of dobutamine for one hour. Hemodynamic and metabolic variables were recorded before, HO, and after the test, H1 (cardiac index, Paop, oxygen deliver, DO2, and consumption, VO2, oxygen extraction ratio, (OER), blood lactate). The dobutamine test allowed to identify responders (R) who increased VO2 by more than 15% and non-responders. R and NR differed significantly in mortality (8.5% vs 44.4%). The test has a good predictive value for surviving. Without respect of the result of the test, the patients were randomized in two groups. The group D+ was given conventional therapy and dobutamine at the same rate of infusion for 9 consecutive days and the D- group received only conventional therapy. The RD+ patients improved more rapidly when compared with RD-, NRD+, NRD-. We concluded that a one hour dobutamine test is able to identify R and NR critically ill septic patients. The response is associated with significant difference in outcome.(ABSTRACT TRUNCATED AT 250 WORDS)