Spinal anaesthesia in neonates and infants: what about the cerebral oxygen saturation?

BACKGROUND: Spinal Anaesthesia (SA) has been firmly established as an efficient and safe technique, with minimal cardio-respiratory disturbance when administered in the neonatal period. Our objective was to assess the haemodynamic consequences of SA in infants, particularly its impact on cerebral perfusion using near-infrared spectroscopy (NIRS)-based cerebral oximetry (rSco2). METHODS: All infants up to 60 weeks' postmenstrual age, whether formerly preterm or not, and undergoing spinal anaesthesia, were enrolled. Haemodynamic data records, rSco2 and mean arterial blood pressure (MAP), were prospectively collected before SA (T0) and every five min for 30 min (T30) after the puncture. Compared with baseline measures, any changes of > 10% in rSco2 and of > 20% in MAP were considered clinically significant. Relative variations of data between T0 and T30 were analysed. RESULTS: Data of 103 infants were analysed. The mean relative changes in rSco2 were -2.25% (97.5% CI [-3.97; -0.5]) at T15, and 0.11% (97.5% CI [-1.67; 1.90]) at T30. No significant variation of rSco2 was recorded. The mean changes in MAP were respectively -13.94% (97.5% CI [-17.74; -10.14]) at T15 and -20.27% (97.5% CI [-24,25; -16.29]) at T30. MAP decrease was statistically and clinically significant 30 min after SA. No correlation between changes in MAP and rSco2 was found. The subgroup analysis did not reveal any effect of added intrathecal clonidine or preterm birth history on these results. CONCLUSIONS: In neonate and infants, SA did not cause clinically significant variation in cerebral oxygen saturation. Despite a significant decrease in MAP, cerebral auto-regulation seems to remain effective in neonates and not altered by spinal anaesthesia.

[Cerebral near-infrared spectroscopy (NIRS) in paediatric anaesthesia]. / L'oxymétrie cérébrale transcutanée en anesthésie pédiatrique.

Cerebral oximetry allows continuous real-time and non-invasive monitoring of cerebral oxygen saturation (cSO(2)), by measuring oxyhaemoglobin and deoxyhaemoglobin near infrared light absorption, similarly to pulse oximetry. cSO(2) measurement predominantly reflects brain venous compartment, and is correlated with jugular venous saturation. As jugular venous saturation, cSO(2) must therefore be interpreted as a measure of balance between transport and consumption of O(2) in the brain. Cerebral oximetry should be used as a trend monitoring, because its accuracy is insufficient to be considered as reliable measure of absolute value of ScO(2). In adult, correction of intraoperative cerebral desaturation reduces hospital stay, heavy morbidity and mortality, and serious postoperative neurocognitive impairment after cardiac and major abdominal surgery. In children, the occurrence of intra- and postoperative cerebral desaturations during congenital heart surgery is associated with increased neurological morbi-mortality. Cerebral oximetry could be a useful monitoring during anaesthesia of (ex) preterm neonates, due to the risk of impaired cerebral blood flow autoregulation in these patients.

[Regional anesthesia for postoperative analgesia at home in children]. / Place de l'anesthésie locorégionale dans l'analgésie postopératoire à domicile chez l'enfant.

Hospitalization at home has known for the past few years a growing interest in care of patients. It has shown its advantages in children in terms of reducing the stress of parental separation, postoperative infections and the cost of hospitalization. But, pain remains the most common complaint in the postoperative follow-up of patients. As in adults, regional anesthesia has also shown interest in children in terms of morphine consumption and quality of postoperative analgesia. However, the use of single shot regional anesthesia seems to induce an exacerbation of pain upon returning home. For management of prolonged postoperative pain at home, continuous peripheral nerve blocks are then presented as the best options. This type of analgesia is mainly reserved for major orthopedic surgery in children. The quality of analgesia obtained in different pediatric studies is excellent with a low rate of adverse events. L-enantiomer local anesthetics are predominantly used at low concentrations for the systemic safety provided. The use of elastomeric disposable pumps for LA infusion allows early and easy ambulation with a simplified management, bringing great satisfaction to parents and children.

Intraoperative use of transoesophageal Doppler to predict response to volume expansion in infants and neonates.

BACKGROUND: Volume expansion (VE) in neonates or infants during volatile anaesthesia may lead to fluid overload if inappropriate. Transoesophageal Doppler (TED), a non-invasive cardiac output monitoring technique, can provide a comprehensive estimation of the volaemic status. We evaluated whether intraoperative TED-derived parameters can predict volume responsiveness. METHODS: Neonates and infants under general anaesthesia without myocardial dysfunction were prospectively included when the attending anaesthetist, blinded to TED measurements, decided to provide VE based on clinical appreciation and standard monitoring data. Standard and TED-derived data were recorded before and after VE. After VE, patients were classified as responders and non-responders, if their indexed stroke volume (iSV) increased by more than 15% or not, respectively. The attending anaesthetist assessment of VE responsiveness was recorded at the end of VE. RESULTS: Fifty patients aged 42 (4) post-conceptional weeks were included, among which 26 (52%) were responders. Baseline iSV was the only parameter associated with VE responsiveness. Baseline iSV was fairly correlated with VE-induced changes in iSV (ρ=-0.64) and was associated with an area under the receiver operating characteristic curve of 0.90 (0.80, 0.99). Using a cut-off of 25 ml m(-2), baseline iSV predicted volume responsiveness with a sensitivity of 92% and a specificity of 83%. Attending anaesthetists' assessment of VE effectiveness agreed only moderately with TED measurements of iSV changes. CONCLUSIONS: TED-derived iSV measurement during volatile anaesthesia is useful to predict and follow VE responsiveness in neonates and infants without myocardial dysfunction.

[Comparison of saline, air, and a mixture oxygen-nitrous oxide for endotracheal cuff tracheal tube inflation in children? A prospective randomized trial]. / Comparaison de sérum salé, d'air et d'un mélange oxygène-protoxyde d'azote pour le remplissage des ballonnets de sondes d'intubation chez l'enfant? Étude prospective randomisée.

OBJECTIVE: The purpose of the present study was to compare how many inflate and deflate are necessary to maintain the endotracheal tube cuff pressure between 15 and 35 cm H2O by using air, O2-N2O mix or saline solution. STUDY DESIGN: Randomized and prospective study. PATIENTS AND METHODS: Ninety children from 1 month to 15 years of age were included in the study. All patients were ventilated with O250%-N2O50%. Subsequently, the patients were divided in three groups: (1) Group 1: patients with air inflated cuffs; (2) Group 2: patients with O2-N2O mix inflated cuffs; (3) Group 3: patients with saline solution inflated cuffs. In all groups cuffs were inflated to reach an intracuff pressure of 20 cm H2O. The cuff pressure was then monitored every 10 minutes and adjusted to be between 15 and 35 cm H2O. Laryngeal and tracheal symptoms were noted in the recovery room. RESULTS: The three groups of patients were similar for age, weight, and sex. The length of surgery was significantly longer in Group 3. The deflate rate was higher in Group 1 (60%) than in Group 2 (10%) or 3 (3.3%) (p<0.0001). The inflate rate was higher in Group 2 (76.6%) than in Group 1 or 3 (both 3.3%) (p<0.0001). Side effects were comparable in the three groups of patients. CONCLUSION: Using air or O2-N2O mix to inflate cuffs is not reliable. SSI helps to maintain a more stable cuff pressure but monitoring is difficult and sometimes contraindicated by tracheal tubes producers. Inflating cuffs with air and regularly monitoring pressure is the most reliable and easiest technique.

[Continuous epidural block versus continuous psoas compartment block for postoperative analgesia after major hip or femoral surgery in children: a prospective comparative randomized study]. / Analgésie péridurale continue versus bloc continu du compartiment psoas pour l'analgésie postopératoire après chirurgie majeure du bassin ou du fémur chez l'enfant : étude prospective comparative randomisée.

BACKGROUND: Intravenous opioids and/or continuous epidural block (CEB) are used for postoperative analgesia after hip and/or femoral shaft surgery but adverse effects limit their use in children. A continuous psoas compartment block (CPCB), effective technique in adults can be an alternative. In this randomized comparative study, we wanted to evaluate CEB and CPCB in children after major hip surgery in terms of adverse events, pain relief and ropivacaine plasma concentrations. METHODS: After ethical committee and parents' approval, 40 children scheduled for hip surgery were included and randomly allocated to receive CPCB or CEB. After general anaesthesia induction, 0.5 mL/kg of 0.375% ropivacaine were injected via the epidural or lumbar plexus catheter. After surgery, 0.1 ml/kg per hour (group CPCB) or 0.2 ml/kg per hour (group CEB) of 0.2% ropivacaine was infused for 48h. Post-operative pain was evaluated using VAS or CHIPPS scores values at h1, h6, h12, h18, h24, h36 and h48, as well as doses of first line (paracetamol 15 mg/kg/6h) or second line rescue analgesia (0.2mg/kg intravenous nalbuphine), if pain score remained high after 30 mm. niflumic acid was systematically used. Adverse events were noted as well as parents' satisfaction at 48h. Ropivacaine plasma concentrations were measured four times up to 48h (h1, h6, h24 and h48) by high performance gas chromatography. RESULTS: Forty children 1 to 12 years old (CPCB=20, CEB=20) were included. The demographic data were equivalent in both groups. Postoperative analgesia was excellent for both continuous block techniques during the whole studied period. Doses of rescue analgesics were comparable in both groups at the end of the 48h. Number of children who had at least one side effect is significantly higher in CEB group. Furthermore, the number of local anaesthetic premature stops was significantly more frequent in this group. Median values of ropivacaine plasma level in CEB group were significantly higher than CPCB group at h6 and h24. Ten parents in the CEB group and 15 in CPCB group were satisfied. CONCLUSION: Continuous psoas compartment block is an effective technique of postoperative analgesia after major hip or femoral surgery in children. It equally manages postoperative pain with significantly less adverse event and decreased ropivacaine doses and plasma concentration than CEB.

[Interest of ultrasonographic guidance in paediatric regional anaesthesia]. / Intérêt de l'échographie en ALR pédiatrique.

The use of ultrasonographic guidance for regional anaesthesia has known recently a big interest in children in recent years. The linear ultrasound probes with a 25 mm active surface area (or probes with 38 mm active surface area in older children), with high sound frequencies in the range 8-14 MHz, allow a good compromise between excellent resolution for superficial structure and good penetration depths. In children, the easiest ultrasound guided blocks are axillar blocks, femoral blocks, fascia iliaca compartment blocks, ilio-inguinal blocks and para-umbilical blocks, caudal blocks. They permit a safe and easy learning curve of these techniques. The main advantage of ultrasound guided regional anaesthesia is the visualization of different anatomical structures and the approximate localization of the tip of needle. The other advantages for ultrasound guided peripheral nerve blocks in children are: faster onset time of sensory and motor block, longer duration of sensory blockade, increase of blockade quality and reduction of local anesthetic injection. The use of ultrasonographic guidance for central block allows to visualize different structures as well as spine and his content. Spinous process, ligament flavum, dura mater, conus medullaris and cerebrospinal fluid are identifiable, and give some information on spine, epidural space and the depth between epidural space and skin. At last, in caudal block, ultrasounds permit to evaluate the anatomy of caudal epidural space, especially the relation of the sacral hiatus to the dural sac and the search of occult spinal dysraphism. Benefit of this technique is the visualization of targeted nerves or spaces and the spread of injected local anaesthetic.

Avoiding propofol injection pain in children: a prospective, randomized, double-blinded, placebo-controlled study.

BACKGROUND: Pain on injection limits the use of propofol in children. The combination of lidocaine and propofol is widely used to reduce pain. A new solvent [medium-chain triglyceride (mct)/long-chain triglyceride (lct)] has been advocated to be less painful than standard (lct) propofol in adults, but no information is available of its usefulness in pre-school children. We designed a prospective, randomized, double-blinded, placebo-controlled study to assess injection pain with two different propofol emulsions, each given with or without lidocaine in children <7 yr. METHODS: A total of 160 ASA I-III children were randomly assigned to receive lct-propofol or mct/lct-propofol, 5 mg kg(-1), with lidocaine 10 mg ml(-1) or saline. The site and size of venous cannulation and restlessness before injection were recorded in each patient. A pain score graded 0-6 was established based on spontaneous verbal and motor reaction during injection, each graded 0-3. Kruskall-Wallis and Mann-Whitney tests were used for statistical analysis. RESULTS: Median pain scores decreased in all groups compared with lct-propofol-saline (P<0.001) and were least in the lct/mct-propofol-lidocaine group (P<0.001). Painless injection (score, 0-2) occurred in 92.5% of patients in the mct/lct-propofol-lidocaine group compared with 41-77% in the others (P<0.001). CONCLUSIONS: Mct/lct-propofol caused significantly less pain than lct-propofol in preschool children. Mixing of lidocaine with mct/lct-propofol resulted in a further significant decrease, virtually eliminating the pain on injection.

Benefits of the thoracoscopic approach for short- or long-gap esophageal atresia.

OBJECTIVE: To evaluate the feasibility and results of thoracoscopy in various types of esophageal atresia (EA). MATERIALS AND METHODS: From April 2001 to August 2002, 5 patients with EA were treated by thoracoscopy. Their mean gestational age was 38 weeks and mean birth weight was 2700 g. Two patients had short-gap atresia with tracheo-esophageal fistula (type III according to Ladd's classification). Three had long-gap atresia: 2 with low fistula to the carina (type IV) and 1 without fistula (type I). Patients were placed in a prone position with the right side elevated at 80 degrees . Four intrapleural ports were necessary. The fistula when present was dissected and sutured with intrathoracic knots and esophageal anastomosis performed in the same manner. RESULTS: Positive airway pressure increased in all patients after insufflation but was kept in a safe range to prevent lung injury. An esophageal anastomosis was performed in 3 cases (2 short gaps and 1 long gap). Oral feeding started on day 6, and their mean length of hospital stay was 14 days. For one child with type IV EA, the anastomosis was impossible because of a long gap confirmed by an immediate thoracotomy. The ends were just approximated. A "spontaneous" fistula developed, and normal feeding was possible 2.5 months later. For the child with type I EA, the pouches could be only approximated at 2 months of age. A spontaneous fistula developed with a stenosis. A redo anastomosis by open surgery allowed for normal feeding. CONCLUSION: The thoracoscopic repair of an esophageal atresia is a reasonable choice for experienced surgeons treating patients, including those with long gaps.

Continuous psoas compartment blocks after major orthopedic surgery in children: a prospective computed tomographic scan and clinical studies.

UNLABELLED: Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV); Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient's weight (0.2 mg x kg(-1) x h(-1)). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature. IMPLICATIONS: Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.

Conditions required for laparoscopic repair of subacute volvulus of the midgut in neonates with intestinal malrotation: 5 cases.

BACKGROUND: This study aimed to evaluate the optimal conditions for laparoscopic management of neonatal subacute volvulus with malrotation. METHODS: Between 1994 and 2002, 13 neonates with midgut volvulus and malrotation entered the authors' institution. Five of these neonates met the eligibility criteria for laparoscopy: good hemodynamic parameters, no gut perforation, and no severe ischemic distress of the bowel shown on preoperative ultrasonography. RESULTS: The results were excellent for only three infants, associated with a shorter postoperative course. One underwent reoperation for a residual duodenal band, and one conversion to open laparotomy was necessary. The predictors of success were no difficulty identifying the abnormal anatomy, no important chylous stasis, and the learning curve of the surgeon. CONCLUSIONS: Despite its previously reported feasibility, neonatal laparoscopy for volvulus with intestinal malrotation is appropriate only for a small number of patients. Strict selection criteria with a clear understanding of the optimal conditions for success may improve the outcome.

Piloromiotomía para estenosis hipertrófica de píloro: Reporte de 186 casos , estudio comparativo entre abordaje transverso transrectal vs. vía circumbilical / Pyloromyotomy ub hypertrophic pyloric stenosis. Report of 186 cases. comparative study between trnasverse incision over the rectus vs. circumbilical incisión

Entre enero de 1986 y diciembre de 1994, fueron operados 186 pacientes con estenosis hipertófica de píloro.La vía de abordaje transrectal de Robertson fue utilizada hasta junio de 1992 (110 casos) desde entonces se prefirió utilizar la vía circumbilical de Tan y Bianchi (76 casos). Ambas poblaciones de pacientes fueron estadísticamente comparables en cuanto a tiempo y manejo preoperatorio. el timepo quirúrgico fue similar (28 minutos vs. 32 minutos).Las complicaciones infecciosas de la herida quirúrgica ocurrieron en 4,6 por ciento y 6,4 por ciento en el segundo grupo. No se halló una diferencia significativa entre estas dos vías de abordaje, excepto para el resultado cosmético, que fué superior en el abordaje circumbilical

Piloromiotomía para estenosis hipertrófica de píloro: Reporte de 186 casos , estudio comparativo entre abordaje transverso transrectal vs. vía circumbilical / Pyloromyotomy ub hypertrophic pyloric stenosis. Report of 186 cases. comparative study between trnasverse incision over the rectus vs. circumbilical incisión

Entre enero de 1986 y diciembre de 1994, fueron operados 186 pacientes con estenosis hipertófica de píloro.La vía de abordaje transrectal de Robertson fue utilizada hasta junio de 1992 (110 casos) desde entonces se prefirió utilizar la vía circumbilical de Tan y Bianchi (76 casos). Ambas poblaciones de pacientes fueron estadísticamente comparables en cuanto a tiempo y manejo preoperatorio. el timepo quirúrgico fue similar (28 minutos vs. 32 minutos).Las complicaciones infecciosas de la herida quirúrgica ocurrieron en 4,6 por ciento y 6,4 por ciento en el segundo grupo. No se halló una diferencia significativa entre estas dos vías de abordaje, excepto para el resultado cosmético, que fué superior en el abordaje circumbilical

A simple method for the quantitative evaluation of functional effects of xenobiotics with cultured cells.

We present a simple, noninvasive, nondestructive all-purpose method for the quantitative evaluation of functional effects of xenobiotics with cultured cells and the work station for its routine, easy implementation. At present 1 to 150 cells growing in one to six dishes can be studied in parallel or otherwise at time intervals ranging from 10 s to 6 h or more, over periods of time ranging from a few tens of minutes to 3-4 days. Any aspect of cell physiological behavior can be studied (differentiation-dedifferentiation, migration, division, degeneration, death) without preliminary staining and/or fixation provided it results in optically visible changes.

[Heroin-induced acute rhabdomyolysis]. / Rhabdomyolyse aiguë à l'héroïne.

A 24 year ald-man, was admitted in intensive care with coma and shock, 4 hours after intravenous injection of heroin. Awakening was obtained by naloxone. Diagnosis of acute rhabdomyolysis associated with heroin addiction was asserted by association of anury, hyperkalemia, and CPK increase. Recovery was obtained with, however, neurologic after-effects. Pathophysiology of acute rhabdomyolysis associated with heroin addict is obscure. Hypotheses for the cause of the muscle damage include the effects of toxicity (either directly or immunologically mediated) of the drug or an adulterant. However prolonged coma and immobilization in one position with either direct compression of the muscles or occlusions of the regional vascular supply can play a major role.

[Hyperkinetic shock and cerebral malaria]. / Choc hyperkinétique et accès pernicieux palustre.

Two cases of cerebral malaria with hyperkinetic shock are reported. The first case concerned a 39-year-old european male who was not taking any prophylactic anti-malarial drugs. After having had headache and fever for a week, he was admitted to the intensive care unit (ICU) in coma and with jaundice. His initial systolic blood pressure was 60 mmg, with a central venous pressure (CVP) of -3 cmH2O. Five-hundred ml of modified fluid gelatin increased the CVP without raising the blood pressure. Haemodynamic investigations revealed a cardiac index (CI) = 5.2 l.min-1.m-2, peripheral arterial resistances (Rsa) = 290 dyn.s.cm-5, oxygen consumption (VO2) = 120 ml.min-1.m-2. Despite treatment with dopamine and dobutamine, the patient died 3 h after his admission, with a CI of 1.9 l.min-1.m-2. The second patient was a 14-year-old senegalese girl, admitted in circumstances similar to the first case. Initial haemodynamic investigations gave the following figures: CI 6.5 l.min-1.m-2, Rsa = 476 dyn.s.cm-5, VO2 = 174 ml.min-1.m-2. Recovery was obtained with fluid replacement therapy and dopamine. In the absence of another associated infectious disease, the plasmodial origin of the septic shock would seem to be the most likely in both cases. Pathophysiological mechanisms of these algid forms of malaria remain enigmatic. Various factors are discussed: cytoadherence of erythrocytes infected with Plasmodium falciparum, immunological disturbances, or a specific endotoxin.

[Severe tetanus and intrathecal baclofen]. / Tétanos sévère et baclofène intrathécal.

Case report of a 48-year-old man with a severe tetanus managed with conventional treatment associated with subarachnoid administration of baclofen. An epidural catheter was placed in spinal fluid at level L3-L4. Two injections of 1 mg baclofen at an interval of 1 hour amended the spasticity. Thereafter the treatment was maintained with a continuous infusion of 2 mg.24 h-1 over 20 days which resulted in an efficient control of spasticity. The final outcome was favourable.