Pharmacokinetics of intrarectal nalbuphine in children undergoing general anaesthesia.

The pharmacokinetics of nalbuphine (0.3 mg/kg) administered by the rectal route were studied in ten children undergoing general anaesthesia for minor surgery. Blood sampling was carried out for 8 h after rectal administration and plasma drug concentrations were measured by high performance liquid chromatography using electrochemical detection after an optimized solid-phase extraction procedure. The mean time to achieve the maximum plasma concentration (Cmax = 24 +/- 15 ng/mL) was 25 +/- 11 min and the elimination half-life was 2.7 +/- 0.7 h. The coefficients of variation for Cmax and the concentration-time curve (AUC) were 62 and 68%, respectively. Although rectal absorption is considered irregular, the large intersubject variability is also explainable by a variable hepatic bypass for a drug, like nalbuphine, that undergoes extensive first-pass metabolism. No problem of analgesic efficacy or of local tolerance was reported. In conclusion, the rectal route of administration provides a rapid and reliable absorption of nalbuphine.

[Peroperative evaluation of nalbuphine in pediatric thoracic and abdominal surgery]. / Evaluation peropératoire de la nalbuphine en chirurgie viscérale pédiatrique.

Nalbuphin is a new agonist-antagonist opioid, with a noteworthy ceiling-effect in terms of analgesia and respiratory depression, a proper cardiocirculatory innocuousness, so that it seems to be a safe analgesic in children. Our study reports 40 thoracic or abdominal surgical procedures, with nalbuphine 0.22 +/- 0.04 mg.kg-1 as sole analgesic. To ensure maintenance of anaesthesia, a volatile anaesthetic agent is inhaled at 1.1 +/- 0.4 MAC concentration, and vecuronium 0.08 +/- 0.05 mg.kg-1 is administered at induction. There was no evidence of haemodynamic changes, and no change in CO2 production. There was no analgesia related adverse effect, and awakening occurred promptly. This report suggests that nalbuphin is a suitable analgesic for paediatric surgery.

[Modes of use of central venous catheters in pediatric hematology]. / Modalités d'utilisation des cathéters veineux centraux en hématologie pédiatrique.

The authors have studied a population of 51 children in which 63 central venous catheters were used for the treatment of leukemias, solid tumors and lymphomas. Two groups were isolated: continuous hospitalization (group A) and intermittent hospitalization with periodical day care (group B). Mean duration of catheterization was 129 days in group A and 176 days in group B (whole population: 149 days), with a total of 9,724 days of catheterization. There was no significant differences between the two groups concerning infection, bleeding, thrombosis or migration. So the authors believe that permanent hospitalization is not mandatory for chemotherapy in children with severe malignant diseases. Periodical day care therapy allows a near normal life for children and a better cooperation from their parents.

[Hereditary angioneurotic edema. Management in pediatric surgery]. / L'oedème angio-neurotique héréditaire. Conduite à tenir en chirurgie pédiatrique.

Hereditary angioneurotic oedema is an autosomal dominant disorder associated with serum deficiency of functionally active C1 inhibitor protein (type 1) or normal serum level of functionally deficient C1-inhibitor (type 2). These biochemical abnormalities induce a complement activation which leads to episodic swelling of interstitial tissues usually of the abdominal viscera and of the upper airway with resultant asphyxia. Vasoactive peptides from the degradation of component C2 of the complement along with an activation of basophils by chemotactic substances from the degradation of C3 and C5 are the main mechanisms involved in vasodilatation and swelling. Attacks of angioneurotic oedema, sometimes fatal when involving the upper airway, can occur during any but usually during ear-throat-nose, dental or facial surgery. This article describes the pathophysiology and the main features of the disease in children. It reviews the different treatments used to avoid attacks or to cure an attack of angio-oedema once it has begun, both during planed surgery and during emergency surgery.

[Treatment of postoperative pain in children]. / Le traitement de la douleur postopératoire chez l'enfant.

Recent advances in neurophysiology and neurochemical management of pain has lead to a new concept in pain relief in the post-operative period. After a review of the pain perception mechanism and of the effects of antinociceptive drugs, the authors present simplified protocols for the management of post operative pain in pediatric surgery.

[A rare case of bladder exstrophy with a completely malformed complex in a girl]. / Un cas inhabituel d'extrophie vésicale avec ensemble malformatif complexe chez une fille.

Report of the observation of a female newborn presenting a complex malformative set: distal anorectal malformation without fistula; bladder exstrophy without epispadias, with cutaneous bridge; congenital urethrovaginal fistula; malformative sexual ambiguity with bulky genital tubercle, whole urethra, urethral meatus on the apex of the genital tubercle, associated with a mid labial genital joint and a high genital orifice; unilateral multicystic kidney; vertebral abnormalities with supernumerary thoracolumbar vertebrae; no karyotype abnormalities and no familial pathological history; no endocrine abnormalities. The therapeutic multistage program permitted a good reconstruction of the different lesion, particularly with bladder functioning witch in hope a good continence with two years of follow-up. No similar case is reviewed in the literature.

[Aconite in homeopathic relief of post-operative pain and agitation in children]. / Aconit en dilution homéopathique et agitation post-opératoire de l'enfant.

Despite the use of modern analgesic methods and an improved use of narcotics, the combination pain-agitation sometimes persists in the recovery-room. Aconit seems to be an appropriate homeopathic treatment in this case. To prescribe it, the following conditions must be combined: violence and suddeness of the stress bringing about intense and anguish. The study included 50 children with such symptoms; it was carried out double-blind, the children being given either placebo or Aconit. Aconit proved to be effective for children's postoperative agitation with 95% good results. It is usually stated in such studies that the placebo effect is high and may reach rates higher than 30%. Aconit is an amazing cure when well prescribed, as much for the speediness of its action as for its efficiency. This remedy has a place in the recovery-room and should be in every physician's emergency case. The fundamental research could specify how the remedy works and may be discover other molecules effective for stress.

[Venous approach in children. Apropos of central venous catheterization in pediatrics. Technics excepted]. / Abord veineux chez l'enfant. A propos du cathétérisme veineux central en pédiatrie. Techniques exceptées.

After a short history report the authors emphasize the mains problems encountered within the central venous catheterization procedures in pediatric intensive care: indications and contraindications, complications, mainly mechanicals and septics. Various kinds of venous access, according to their proper advantages and drawbacks are discussed, and therefore some special applies. A very main strictness is indispensable for good issue and benefits in this high risk technology.

Calcium oxalate precipitation in urine following T.U.R. with glycine as irrigation fluid.

Precipitation of calcium oxalate was studied in a group of ten patients who underwent transurethral prostatectomy with glycine irrigation. Post operatively all patients showed hyperoxaluria; 60% with oxaluria higher than 10 times the critical concentration of calcium oxalate in urine. Other factors, known to favour crystallogenesis were modified during the same period: low urinary output, relative hypercalciuria and uraturia and hypomagnesuria. Thus, conditions for intraluminal precipitation of calcium oxalate were present post operatively. We suggest the use of a xanthine oxidase inhibitor to prevent hyperoxaluria.

[Catabolism of glycine used in lavage solutions in urologic surgery. Apropos of a prospective study of 20 patients undergoing endourethral resection of the prostate]. / Etude du catabolisme du glycocolle utilisé dans les solutions de lavage en chirurgie urologique. A propos d'une étude prospective de 20 patients soumis à une résection endourétrale de prostate.

A prospective study was carried out on 20 patients admitted for transurethral prostatic resection, measuring renal function, body hydratation and levels of glycine metabolic products. This study has shown that only the haematocrit measurement during surgery allowed the early and reliable recognition of resorption of the solution. High glycine levels after resorption were reduced by increasing urinary excretion of glycine, serine, creatinine and to a lesser extent, threonine. The increased production of oxalate, another elimination pathway, leads to a urinary saturation with consequent risk of lithogenesis. Furthermore, this hyperoxaluria may cause an intersticial nephropathy as do the other secondary hyperoxalurias, including Crohn's disease, bowel by-pass or xylitol intoxication.

[Respiratory obstruction during anesthesia in cases of mediastinal malignant lymphoma]. / Obstruction respiratoire peranesthésique en cas de lymphome malin médiastinal.

Three cases of asphyxia at the beginning of general anaesthesia for mediastinoscopy or biopsy of adenopathy are described in patients with malignant lymphoma. One of them died in spite of endobronchial intubation, artificial ventilation and steroids. The two others recovered when specific chemotherapy was added to the same symptomatic treatment. The risk of respiratory obstruction seems higher in non-Hodgkin than in Hodgkin lymphomas. This kind of obstruction is not relieved by an antiasthmatic therapy. Pulmonary lymphatic filtration may be hindered in case of mediastinal lymphoma, especially during anaesthetic induction, and pulmonary interstitial congestion may occur impeding gas propagation. Specific chemotherapy according to the histological type of the tumour may relieve the compression and respiratory obstruction in a few hours.

[Hemodynamic and hormonal study of electronarcosis and neuroleptanalgesia. Clinical study in 17 surgical patients]. / Etude hémodynamique et hormonale de l'anesthésie électro-médicamenteuse et de la neuroleptanalgésie. Travail clinique chez 17 opérés.

The blocking effect of electropharmaceutical anesthesia (EPA) and neuroleptanalgesia (NLA) on adrenergic and hormonal reactions to abdominal surgery were compared in 17 ASA class I to III randomized patients. This study was intended to define the indications for each of these techniques in patients with heart diseases. Each individual received the same anesthetic premedication and induction and was submitted to iterative identical measurements and biological dosages. Before and during surgery, both groups were catheterized with a Swan-Ganz and a radial catheter. Blood sampling for catecholamines, cortisol, glycemia, blood gases dosages were regularly drawn. Electrical stimulation was performed in the EPA group, and fentanyl injections were repeated in the NLA group patients only. The same doses of pancuronium and droperidol were given to every patient. A circulatory hyperkinesia and hyperadrenergia were observed during surgery in all of the subjects but, during EPA, the tachycardia, the cardiac index and the rate-pressure product were higher than during NLA. The body temperature increased towards normal in EPA, not in NLA. Adrenergic and hormonal levels were equal in both groups. The slow variations of all the important parameters demonstrate that the measured phenomenons have a long time-course what legitimates this kind of prolonged on-the-spot observation. The role of droperidol, pancuronium and fentanyl in the observed variations is discussed. The characteristic high hyperkinesia in EPA may be due partly to an inefficacious analgesia because of the fentanyl suppression after induction, partly to the preserved thermogenesis partly to a direct effect of the electrical stimulation on cerebral tissues.

[Traumatic rupture of the isthmic region with bowel ischemia (author's transl)]. / Rupture traumatique de l'isthme aortique compliquée d'ischémie mésentérique.

One case of traumatic rupture of the isthmic region of the aorta is reported. Acute ischemia of the inferior limbs, anuria and paraplegia have led to the diagnosis. During the first hours after the trauma bowel ischemia appeared. The repair of the aorta was achieved within the seven hours after the accident but the bowel ischemia stayed irreversible. A such complication has not been reported in the literature as long as we know and we are think that it is possible to range this complication among some of the ischemic enterocolitis.

[Electropharmaceutical anaesthesia for transcervical thymectomy (author's transl)]. / Anesthésie électro-médicamenteuse pour thymectomie.

One case of electropharmaceutical anaesthesia for transcervical thymectomy in myasthenia gravis is reported. Easiness of procedure, slightness of pharmaceutical intoxication, quality of awakening, simplicity of postoperative course, illustrate the interest of trying this kind of anaesthesia, whenever tonic awakening is required.