[Sedation and analgesia in the paediatric intensive care unit]. / Sédation et analgésie en réanimation--Aspects pédiatriques.

Sedation and analgesia are a constant challenging issue in paediatric intensive care units, for ethical reasons among others. Basically, goals and available treatments in that context do not differ from those in adults. For instance, while we propose midazolam as the first choice benzodiazepine, there is no evidence for encouraging the use of one morphinomimetic rather than others in children. On the other hand, numerous paediatric specificities do exist: understanding and expression of pain both different and difficult, presence and involvement of the parents, pain assessment methods, pharmacology, pathologies. It is therefore mandatory to know these specificities to ensure a proper use of evaluation tools and therapeutics. The paucity of strong evidence from the literature does not allow producing definitive consensus guidelines. However, some practices can be highlighted such as the use of written protocol on pain/sedation evaluation and therapeutics adapted to children, literature data and local habits, the training of medical/nursing staff and the constitution of local referring team. A particular attention should be paid to propofol: its use longer than several hours should be strongly discouraged in infants and children due to the risk of Propofol Infusion Syndrome. Further clinical studies should be conducted in an attempt to provide answers to routine, daily issues and questions, for example, how to tailor the level of sedation to the needs of the patient, how to stop it, which drug must be preferred or what place for non-pharmacological approaches.

[Newborn infants supported by extracorporeal membrane oxygenation: survival and clinical outcome]. / Survie et devenir clinique des nouveau-nés mis en assistance respiratoire extracorporelle.

OBJECTIVES: To assess the prognosis of newborn infants with refractory hypoxemia who required extracorporeal membrane oxygenation (ECMO). METHODS: Eighty-nine newborn infants treated by ECMO during more than 24 hours over a 8-year period (1996-2003) were included in this observational cohort study with a 9-month and 24-month evaluation. RESULTS: Respiratory failure mainly resulted from meconium aspiration syndrome (MAS, 43%), congenital diaphragmatic hernia (CDH, 15%) and sepsis (15%). Overall survival at hospital discharge was 67%. Infants with MAS had the best survival rate (82%) and those with CDH had the worst (46%). Of the remaining 60 survivors, 53% remained oxygen dependent at 28 days and 33% at 45 days. At the age of 2 years, only 1 infant remained oxygen dependent (but did not required oxygen at 3 years) and only 3 infants had significant neurodevelopmental problems. CDH group was associated with a prolonged duration in supplementary oxygen (P<0.001) and a prolonged duration for tube feeding (P=0.01) as compared with other diagnoses. Regarding neurologic outcome, CDH infants had the poorer neurological acquisition rate at 9 months but a very good evolution by the time of the 24-month evaluation. CONCLUSIONS: Morbidity in ECMO survivors is low considering the severity of illness in the newborn period, mainly related to pulmonary and feeding dysfunctions during the first months, in particular for the CDH group. Outcome at the age of 2 years of CDH infants is most often favourable regarding growth and neurodevelopmental evolution.

[Which sedation scale should be used in the paediatric intensive care unit? A comparative prospective study]. / Quelle échelle de sédation analgésie utiliser en réanimation pédiatrique? Etude comparative prospective.

OBJECTIVES: To compare pain and sedation assessments by nurses undertaken with the Objective Pain Scale (OPS) and a Visual Analogue Scale (VAS) to the current reference scale for paediatric intensive care that is the COMFORT scale. To compare the unmodified COMFORT scale to a COMFORT "behaviour" scale which does not include physiologic items. To evaluate the ease of use of these scales. METHODS: This prospective observational comparative study was carried out in children aged 1 year or older who were admitted in an intensive care unit. At 2 to 3 time points within 24 hours, a pain sedation assessment was carried out by the nurse in charge of the child with COMFORT scale, OPS and VAS. Correlation tests were used to compare the scores of each scale. RESULTS: Nurses recorded 55 assessments in 20 children. Correlation studies showed a poor correlation between OPS, VAS and the COMFORT scale (Spearman's r=0.54 and 0.53 respectively) and a strong correlation between the COMFORT scale and the COMFORT "behaviour" scale (Spearman's r=0.96). The COMFORT behaviour scale was the most frequently fully completed scale. CONCLUSION: Among the 3 scales compared to the COMFORT scale in this study, the COMFORT "behaviour" scale was the only one to show a strong correlation and it also seemed to be the easiest to use.

[Meconium aspiration syndrome requiring mechanical ventilation: incidence and respiratory management in France (2000-2001)]. / Inhalations méconiales nécessitant une ventilation mécanique: indicence et prise en charge respiratoire en France (2000-2001).

OBJECTIVES: To precise the number of term neonates with a meconium aspiration syndrome requiring mechanical ventilation in 2000 and 2001 in continental France and the related mortality. To study the different respiratory management. METHOD: A written questionnaire was sent to all intensive care units of continental France. RESULTS: Thirty-nine units were contacted and 31 answered (80%). On 30 answering centers, 265 cases are reported in 2000 and 249 in 2001. Extrapolation to the 39 centers led to a number of 347 cases in 2000 and 324 in 2001. Mortality rate was 6.4% for 2 years. Causes of death were: neurological 61%, respiratory 18% and others 21%. Twenty-six on 29 units used exogenous surfactant and/or high frequency oscillatory ventilation (HFOV) and/or inhaled nitric oxide (iNO). The sequence of use and the indication criteria of these therapies were quite variable with a majority of units using HFOV in the first place. CONCLUSIONS: Meconium aspiration syndrome is still a frequent neonatal condition despite a codified prevention strategy. Respiratory management in intensive care units remains very variable.

[Evolution of extracorporeal membrane oxygenation (ECMO) in neonatal acute respiratory failure, fifteen years of experience]. / Evolution sur 15 ans de l'assistance respiratoire extra-corporelle dans la prise en charge des détresses respiratoires néonatales sévères.

UNLABELLED: Over the last decade, several new therapies including exogenous surfactant therapy, inhaled nitric oxide and high-frequency ventilation have become available for the treatment of neonatal pulmonary failure. The aim of this retrospective study was to evaluate to what extent these modalities have impacted the use of neonatal extracorporeal membrane oxygenation at our institution and to discuss the role of ECMO in 2003 in the management of newborn infants with refractory hypoxemia. POPULATION AND METHODS: Two hundred and twenty six newborn infants treated by ECMO before 15 days of life and during more than 24 h in our intensive care unit were retrospectively included from two time periods (group 1: 1988-1993 and group 2: 1996-2003). RESULTS: As compared with the first group, the number of newborns supported by ECMO in the second group has clearly diminished and their severity has increased. Overall survival rate was 80% in the first group and 69% in the second group. Meconium aspiration syndrome remains the major indication for ECMO (44%). Pulmonary sequelae, assessed by bronchopulmonary dysplasia rate (41%) are more frequent that neurologic sequelae (4.8%). CONCLUSION: ECMO remains an useful technique in the management of newborn infants with refractory hypoxemia, with a consideration to institute ECMO early in order to increase survival rate.

[Extracorporeal oxygenation in newborn infant born to diabetic mother with severe hypertrophic myocardiopathy]. / Oxygénation extracorporelle chez un nouveau-né de mère diabétique avec une myocardiopathie hypertrophique sévère.

UNLABELLED: Hypertrophic cardiomyopathy is a common complication in infants born to diabetic mothers but it is rarely life threatening. CASE REPORT: A neonate born to a diabetic mother with a severe hypertrophic cardiomyopathy with life threatening respiratory and haemodynamic distress was successfully supported by extracorporeal membrane oxygenation. CONCLUSION: Extracorporeal membrane oxygenation can be an efficient transitory therapy for very severe hypertrophic cardiomyopathy in infants of diabetic mothers.

[Pneumopericardium with favorable outcome in a ventilated premature infant]. / Pneumopéricarde d'évolution favorable chez un prématuré ventilé.

UNLABELLED: Pneumopericardium is a rare and severe complication of artificial ventilation in neonates. CASE REPORT: A preterm neonate born after 29 weeks of gestation was placed under ventilatory support for bronchopulmonary dysplasia. At 63 days of life, just after a severe bronchospasm which required bag ventilation with high pressures, she collapsed and required immediate cardiopulmonary resuscitation with epinephrine infusion. The diagnosis of pneumopericardium was deduced from the chest X-ray obtained in emergency, on which there was also a right pneumothorax. Cardiac recovery with return of spontaneous circulation was only obtained after evacuation of the pneumopericardium with a 23-gauge needle via the sub-xiphoid route. The pneumothorax was drained and the long-term evolution was favorable. CONCLUSION: In the case of cardiopulmonary compromise, the early diagnosis of pneumopericardium should lead to the immediate evacuation of the pneumopericardium in order to improve the prognosis.