[Treatment of severe hyponatremia by restricted water intake]

The outcomes of 23 patients admitted to a medical intensive care unit for severe hyponatraemia (less than 120 mEq/l) associated with neurological disorders were reviewed. All patients had restricted water intake combined with a sodium intake adjusted to the natriuresis, and some received a loop diuretic. The mean correction rate during the first 48 hours was slow (greater than 12 mmol/l.24 h) in 16 cases and fast (less than or equal to 12 mmol/l.24 h) in 7 cases. Following biochemical cure, 2 patients in the fast correction group had an unfavourable outcome: one died for an unknown reason, the other developed pontine myelinosis. A review of the literature did not provide evidence that a certain rate of correction was better than the other, but it showed that an excessive rise in natraemia or an overcorrection of hyponatraemia was dangerous. Slow correction of hyponatraemia, usually obtained with water intake restriction, may be recommended.

[Postoperative pulmonary embolism]

Post-operative thrombo-embolic disease remains a frequent occurrence in spite of advances in their prophylaxis. Evaluation of 60 case-reports of this disease which often includes peripheral manifestations and always pulmonary manifestations, enables to specify the role of the procedure itself (mostly orthopaedic surgery 60%), pelvic surgery 20%, the chronology of events (possibility of early embolism between D1 and D3 and usual occurrence of manifestations between D8 and D18, and the importance of the background, whether investigated or not: deficiencies in anti-thrombin III, protein C and S: 4 cases. The diagnosis is based on clinical signs (non-specific) and the laboratory tests, especially scintigraphy (screening) and angiography, absolutely necessary for the diagnosis and evaluation of the amputation coefficient (Miller index). With a diagnosis of pulmonary embolism, it is always necessary to look for a proximal venous thrombosis. The treatment, calls for heparin (quite seldom), thrombolytics (Urokinase, Plasminogen in our experience), the indication of which must take into consideration the delays and the nature of the previous procedure, and finally surgery (massive forms where thrombolytics are contraindicated). The thrombo-embolic manifestations with thrombogenic thrombopenia secondary to heparin are quite frequent, in a surgical environment (10 cases) and difficult to treat.

[Uremic-hemolytic syndrome occurring in extra-uterine pregnancy. Apropos of a case]

One case of uremic-haemolytic syndrome associated with an ectopic pregnancy is reported. The main signs are, from the clinical standpoint, a diffuse haemorrhagic syndrome and, from the biological standpoint, a haemolytic anemia, renal failure and thrombopenia. This pathology, exceptionally associated with an early pregnancy, required an intensive resuscitation with blood transfusion, hemodialysis and plasma exchanges. From a surgical standpoint, two procedures were necessary following salpingectomy, to drain intraperitoneal and sub-aponeurotic blood collections. The course, thereafter, was uneventful.

[Asphyxic pulmonary edema caused by upper airway obstruction in adults]

A case of pulmonary oedema following acute pharyngo-laryngeal obstruction is reported. The case is compared with the results of the literature. The haemodynamic data suggested a non-cardiogenic effect, with low pulmonary arterial occlusion pressure of 1 mmHg and right-to-left shunting. Positive end-expiratory pressure was used with success. The mechanisms underlying such oedema are not well known, and may include disturbances in the balance of transpulmonary forces or hypoxia. However the outcome is usually favourable.

[Physiopathological approach to pathological hyperlactatemia in the diabetic patient. Value of blood metformin]

Type B lactic acidosis, or pathological hyperlactatemia (PHL), is defined by an arterial lactate level greater than 5 mmol X l-1. It is a known and severe complication of diabetes mellitus treated with biguanide hypoglycaemic agents, particularly phenformin which was taken off the French pharmaceutical market in 1977. Metformin, which remains the only biguanide hypoglycaemic agent currently prescribed in France, may also lead to this complication. However it does so less frequently and mostly in the diabetic presenting with renal failure. A few well studied cases showed that PHL could be correlated with excessive metformin blood levels, i.e. a toxic mechanism. In order to find out whether this toxic mechanism was the real cause of PHL in diabetics treated with metformin, a systematic study of metformin blood levels was carried out in 20 such patients. They had all been admitted to a critical care unit presenting with PHL. The results of this study led us to distinguish between two groups of patients. The seven patients of the first group had high metformin blood levels (4.3 to 65.8 micrograms X l-1). In these, renal excretion or extrarenal dialysis lowered or normalized their hyperlactatemia, and six of the seven recovered from PHL. In the second group, with thirteen patients, metformin blood levels were within the normal therapeutic range (0.225 to 3 micrograms X l-1) for seven patients and close to zero for the other six. This second group received the same treatment as the first one. Only three patients recovered, the others all died.(ABSTRACT TRUNCATED AT 250 WORDS)

[Severe thrombopenia associated with treatment with pentosan polysulfate]

Two cases of severe thrombocytopaenia associated with acute thrombo-embolic manifestations during treatment by pentosan polysulphate, a low molecular weight heparinoid, are reported. Plasma samples from both patients caused in vitro aggregation in the presence of pentosan polysulphate. Interruption of the drug led to the recovery of the platelet count. The hypothesis of an immunoallergic mechanism similar to heparin associated thrombocytopaenia is supported. Furthermore, it seemed likely to be found with all the polysulphated X glycosaminoglycans. During treatment by pentosan polysulphate, platelet count should be monitored to avoid this potentially life-threatening syndrome.