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OBJECTIVE: To determine current clinical neuromuscular use in Morocco anesthetic practice. STUDY DESIGN: Clinical practice survey. METHODS: Anesthesiologists were invited to answer anonymously to question about neuromuscular blocking agents (NMBA): pharmacology, monitoring and antagonism drug use. Corrected yates test was used to compare qualitative parameters and variance analysis for quantitative parameters. P<0.05 was considered as significant. RESULTS: We had 171 answers, 54% were paramedics (n=93) and 46% (n=78) were physicians (20% global effective in Morocco). Fifty-five percent were seniors. Vecuronium was the most NMBA used in Morocco for 51% of the anesthesiologists. Mean action time of NMBA was underestimate in more than 60% of the staff questioned specially for seniors (24.6%) than juniors (19.2%). Residual neuromuscular blockade was evaluated only by clinical and spirometric parameters in 72%. TOF monitor was used in 18% more in military hospitals (36%) and insurance clinics (40%) than private hospitals (12.5%). Administration of reversal drugs was systematic in 5.8% of anesthesiologists, frequent for 36.3% and rare for 55%. CONCLUSIONS: This study show an underestimation of residual neuromuscular blockade, poor neuromuscular monitor use and lack of knowledge of NMBA specially for senior anesthesiologists and in private hospitals. We should elaborate Moroccan guideline for NMBA use and provide formal training programs for our anesthetic staff.

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INTRODUCTION: Recent study showed that neostigmine (500 microg) by intra-articular produces postoperative analgesia without adverse effect. The author's goal was to determine whether 500 microg of neostigmine added to bupivacaine in axillary plexus block could prolonged postoperative analgesia without increasing the incidence of side effects. METHODS: Ninety patients scheduled for orthopedic or plastic surgery with axillary plexus block were randomly assigned to one of 3 groups : group 1 (TGr n = 30) received saline solution (1 ml) in the axillary plexus, group 2 (NAGr n = 30) received 500 microg (1 ml) neostigmine in the axillary plexus and group 3.500 microg neostigmine subcutaneously (NSGr n = 30). We evaluated visual analog pain scores (VAS), the consumption of the ketoprofene, nausea and vomiting incidence during the first 24 h. ANOVA, Kruskall Wallis and Fisher tests were used for statistical analysis. A p value of <0.05 was considered significant. RESULTS: The VAS score was lower in NAGr (21 +/- 18) vs NSGr (31 +/- 14) and control group TGr (45 +/- 2) (p < 0.05). The consumption of the ketoprofene is 127 +/- 65 mg in NAGr vs 150 +/- 53 mg in NSGr and 200 +/- 50 mg in group TGr (p = 0.02). Incidence of nausea and vomiting was 3.5% in NAGr vs 6.8% in NSGr and 0% for TGr. CONCLUSION: Neostigmine combined to a mixture of lidocaine and bupivacaine prolongs postoperative analgesia after axillary plexus block.

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The nosocomial bacteremia (NB) are frequent and associated to a high mortality and morbidity with extension of stay in the intensive care unit (ICU). The aim of this study is to evaluate epidemiological aspect and prognosis of NB. It is a retrospective study about 872 patients hospitalized in our unit during 2 years. The diagnosis of the NB is based on two positive hemocultures with 24 hours of interval in the patients who are hospitalized more than 48 hours. The incidence of the bacteremia represents 6.6% (n = 58). The portal of entry is noticed in 55% of the cases (n = 32). The most frequent origin is respiratory infection 24% (n = 14), whereas bacteremia after catheter colonization represents 3.4% (n = 2). Gram Positive cocci were incriminated in more than 53% of the cases (n = 39). Staphylococcus aureus was the first causal germ (n = 28) whereas the Pseudomonas is the most frequent of the gram negative bacilli that represent 41% of the isolate germs (n = 31). The sensitibility of this germ to ceftazidim and imipenen was respectively 18% and 19%. The rate of the resistant Staphylococcus to meticilline was 38%. The whole mortality represented 28% (n = 16) that 7% (n = 14) of the cases were directly in relationship with the septic shock. Among prognostic factors evaluated, only septic shock and multivisceral failures are correlated to mortality. NB mortality is not negligible in ICU. Staphylococcus and Pseudomonas are the most frequent germs. Limitation of invasive acts, rigorous antibiotherapy management and observance of hygienic measures will significantly reduce incidence of NB.

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OBJECTIVE: Evaluate the effect of the addition of clonidine to lidocaine on postoperative pain after intravenous regional anaesthesia. STUDY DESIGN: Double blind prospective study. PATIENTS AND METHODS: Forty-five patients were randomly allocated to two groups: group 1 (n = 25) receiving 3 mg.kg-1 of lidocaine 0.5% added to saline and group 2 (n = 20) receiving 3 mg.kg-1 of lidocaine 0.5% added to clonidine (150 micrograms). Postoperative analgesia was assessed using a visual analogue pain score (VAPS) and the time to first analgesic request. The incidence of side effects after tourniquet release was noted. Analysis of variance, Kruskall Wallis and chi 2 tests were used for statistical analysis. A p-value of < 0.05 was considered significant. RESULTS: Age, ASA class, duration and type of surgery, tourniquet time and sensory block duration were comparable for the two groups. The time to first antalgic request after deflation of tourniquet was similar in the two groups (38 +/- 15 min versus 44 +/- 19 min), while VAPS score was lower (p < 0.05) in the clonidine group (5.2 versus 6.8). The incidence of side effects was comparable in the two groups. CONCLUSION: The addition of clonidine (150 micrograms) to lidocaine for intravenous regional anaesthesia improved postoperative analgesia but in a limited and short-lasting manner.

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This study was designed to determine the efficacy of oral etilefrine in preventing hypotension induced by spinal anaesthesia. Forty patients, ASA grade I or II, aged 23-60 years, scheduled for orthopaedic surgery involving the lower extremity under spinal anaesthesia were studied. The patients were randomly allocated to one of two groups; the etilefrine group (n = 20) received oral etilefrine 15 mg (30 drops), 60 min before the subarachnoid block, and the control group (n = 20) received no etilefrine. Patients were given 0.5% isobaric bupivacaine intrathecally. Hypotension was defined as a 30% decrease from base-line for systolic arterial pressure and mean arterial pressure or systolic value <90 mmHg, and was treated with intravenous boluses of etilefrine 2 mg. The overall incidence of spinal anaesthesia induced hypotension was 25%, ranging from 20% in the etilefrine group to 30% in the control group. The fall in systolic arterial pressure and mean arterial pressure was significantly greater in the control group than in the etilefrine group (P < 0.05). The patients in the etilefrine group received less etilefrine supplement than those in control group and no subject in the etilefrine group required repeat etilefrine doses, while in the control group five patients received multiple etilefrine doses (P < 0.05). The mean heart rate remained fairly stable throughout the study periods. We conclude that oral etilefrine, given 60 min before surgery, reduces the fall in blood pressure during spinal anaesthesia.

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BACKGROUND: Neurological hemorrhagic complications are unusual in hemophiliacs. Extradural hematoma is an exception, particularly at the cervical level. Less than 10 cases have been reported in the literature. We report a new case which was the inaugural sign of hemophilia A. CASE REPORT: Moderate hemophilia A was revealed by post-traumatic cervical extradural hematoma in a 12-year-old boy. Pain in the cervical spine and progressive tetraplegia led to the diagnosis, confirmed by cervical CT scan. The dissonance between the injury and the minor trauma led to hemostasis exploration which revealed factor VIII at 3%. After prompt correction of the deficiency, total laminectomy allow removal of the hematoma. The neurological course was satisfactory. CONCLUSION: We stress the specific character of this association and the previously unreported mode of hemophilia disclosure. CT scan and MRI facilitate diagnosis allowing satisfactory course after emergency decompressive laminectomy.

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We report two cases of tetraplegia caused by cervical stab wounds. In the first one, in a 34-year-old patient, the injury caused an immediate tetraplegia from cervical spine section and had a rapid lethal outcome. The second case occurred in a 30-year-old woman, who experienced a progressive tetraplegia associated with a Brown-Séquard syndrome from an oedema of the bulbo-spinal junction. Three months later, the motor recovery was satisfactory, however a thermo-algesic hemi-anaesthesia still persisted after the 6th month.

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Phostoxin is a mixture of aluminium phosphide and ammonium carbonate. When exposed to water, it releases phosphorus hydrogen (PH3), a highly-poisonous gas. In Morocco, death rate from suicide due to self-administration of phostoxin pills is high. Clinical signs include abrupt digestive and nervous disorders. Pulmonary oedema or cardiogenic shock dominate early prognosis. Liver and renal damage is secondary. Prevention requires both legal constraints and regulation of sales.

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Sixty cases of severe eclampsia were treated in an intensive care unit between January 1989 and September 1993. Mean age was 26, and 70% of patients were primipara. The pregnancy has been unsupervised in almost all cases. All had visceral lesions and/or hematologic problems and there was impaired conscious level in 9 cases out of 10. Medical treatment involved the control of seizures and of hypertension. Cesarean section was performed in 34 cases. The maternal death rate was 23.3%. Our experience indicates that mortality depends upon visceral lesions (cerebral, disseminated intravascular coagulation, acute pulmonary edema, Hellp syndrome). Better awareness of severity factors in preeclampsia improves both maternal and fetal prognosis by precisely indicating the best time for fetal extraction.

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Neurologic manifestations are usual and variable during post-traumatic fat embolism. The pathogenesis of these lesions continues to be a source of considerable controversy. Thirteen cases of post-traumatic fat embolism with neurologic signs were treated in a surgical intensive care unit. All patients had impaired consciousness. Focal neurologic disorders were reported in 5 cases [hemiplegia (2), tetraplegia (2), aphasia (1)]. The aspects on brain CT scan seemed to be related to ischemic lesions (1 case), appeared normal in ten cases, or revealed post-traumatic hemorrhagic lesions (2 cases). The outcome at 2-4 weeks was spontaneously good, with complete resolution, without neurologic sequellae, in 11/13 patients. Two deaths were related to brain trauma severity (one case) and nosocomial pneumonia (one case).

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The authors report a case of pre-eclamptic toxemia, characterised by extensive cortical, sub-cortical and vertebro-basilar neurological lesions. The appearance of these lesions and their course were suggestive of the role played by toxemic vasculitis and vasospasm.

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