[Tramadol for acute postoperative pain in children]. / Utilisation du tramadol dans l'antalgie aiguë postopératoire en pédiatrie.

The real place of tramadol in the armatarium of postoperative analgesics in children remains to be defined. This paper presents a synthetic review of the present knowledge regarding the efficacy, dosage and possible routes of administration of tramadol to children in the postoperative period. The intravenous and oral routes are the most used. The perinervous routes (epidural, around peripheral nerves, skin infiltration) are controversial. Tramadol is a good alternative to NSAIDs and to morphine for moderate pain but its efficacy is variable due to the genetic polymorphism of its metabolism and possible drug interactions.

A comparison of intubation conditions and time-course of action with rocuronium and mivacurium for day case anaesthesia.

BACKGROUND AND OBJECTIVE: To compare intubation conditions and time-course of action of rocuronium and mivacurium for day case anaesthesia. METHODS: Fifty ASA I or II patients were enrolled. Anaesthesia was induced with propofol using a target controlled infusion system (target 6-8 microg mL(-1) ) and sufentanil (0.25 microg mL(-1). It was maintained with propofol (target 3.5-4.5 microg mL(-1) and 50% nitrous oxide in oxygen. Muscle relaxation was achieved with either mivacurium (0.15 mg kg(-1)) or rocuronium (0.3 mg kg(-1)). Neuromuscular transmission was monitored and recorded continuously by acceleromyography using a TOF-WATCH SX (Biometer; Denmark) with supramaximal train-of-four stimulation of the ulnar nerve. Tracheal intubation was carried out by an experienced anaesthetist blinded to the type of the muscle relaxant. Intubation conditions were evaluated according to a standard scheme (ease of laryngoscopy, position of vocal cords, airway reaction and limb movements). RESULTS: Intubation conditions were good or excellent for both mivacurium 0.15 mg kg(-1) (good = 8%; excellent = 92%) and rocuronium 0.3 mg kg(-1) (excellent = 100%). Times to maximum blockade and clinical duration were not different. CONCLUSIONS: There is no significant difference between mivacurium and rocuronium concerning the onset and the recovery of muscle relaxation. Rocuronium is an alternative to mivacurium for short procedures, without the risk of unexpected prolonged relaxation due to a possible defect in plasma cholinesterase.

[Peroperative desaturation during gynaecological laparoscopy-hysteroscopy: an unknown aetiology, pleural extravasation]. / Désaturation peropératoire lors d'une laparoscopie-hystéroscopie gynécologique: une étiologie méconnue, l'épanchement pleural.

A 41-year-old patient presented several episodes of desaturation during a gynaecological laparoscopy. The major complication of this procedure is the venous air embolism. Several other side-effects have been reported: heart rate disorders, subcutaneous emphysema or pneumothorax. Pleural effusions during gynaecologic laparoscopy are apparently rare and the volume of effusion must be important to induce clinical symptoms. This fact can probably explain the frequent difficulty of diagnosis. The role of the diaphragmatic lymphatic network and other physiologic aspects are discussed in this article.

Use of remifentanil in combination with desflurane or propofol for ambulatory oral surgery.

We evaluated the use of remifentanil administered as a component of an inhalation or of a Target Controlled Infusion (TCI) anesthetic technique during outpatient oral surgery. Sixty-three unpremedicated patients undergoing removal of four impacted third molars participated to this prospective, randomized study. Anesthesia was induced with Propofol and Rocuronium. Remifentanil 1 microgram.kg-1 i.v. was given over 30 s followed by a continuous infusion reduced from 25% each time a tooth was removed (0.25-->0.0625 microgram.kg-1 min-1). Anesthesia was maintained with Desflurane (group D, n = 31) (end-tidal concentration 4-6%) or Propofol (group P, n = 32) (initial infusion TCI 8 micrograms.ml-1 reduced to 2-3 micrograms.ml-1 after intubation). Corticosteroids, a non-steroidal anti-inflammatory drug (NSAID) (Diclofenac) and a partial mu agonist drug (Tramadol) were administered i.v. during the procedure to prevent early postoperative pain. Recovery time, postoperative pain, recovery of cognition and nausea or vomiting were also evaluated during the first six postoperative hours. Overall mean systolic blood pressures and heart rate were similar in the two groups during surgery. Mean times to extubation and to recall of birth-date and room number were also similar. The quality of awakening was good in the two groups. Most patients complained of moderate pain or had no pain during the first six postoperative hours. The incidence of nausea and vomiting was similar in both groups. No other side effect was observed. These data suggest that the association of Remifentanil, Methylprednisolone, Diclofenac and Tramadol is an useful technique in ambulatory oral surgery in two comparable anesthetic regimens.

Rapacuronium 2.0 or 2.5 mg kg-1 for rapid-sequence induction: comparison with succinylcholine 1.0 mg kg-1.

The purpose of this nine-centre study in 602 patients was to show that the frequency of acceptable intubating conditions after rapacuronium 2.0 or 2.5 mg kg-1 is not more than 10% lower than the frequency after succinylcholine 1.0 mg kg-1 during rapid-sequence induction of anaesthesia with fentanyl 1-2 micrograms kg-1 and thiopental 2-7 mg kg-1. Laryngoscopy and intubation were carried out 60 s after administration of muscle relaxant by an anaesthetist blinded to its identity. Intubating conditions were clinically acceptable (excellent or good) in 91.8% of patients given succinylcholine and in 84.1 and 87.6% of patients given rapacuronium 2.0 and 2.5 mg kg-1 respectively. With respect to the percentage of clinically acceptable intubating conditions, the estimated difference (and the upper limit of the one-sided 97.5% confidence interval) between succinylcholine and rapacuronium 2.0 mg kg-1 was 7.8 (14.4)% and between succinylcholine and rapacuronium 2.5 mg kg-1 it was 4.0 (10.2)%. For both comparisons, the upper limit of the one-sided confidence interval exceeded the predefined 10% difference. Hence, it could not be demonstrated that the intubating conditions with either of the two doses of rapacuronium were not inferior to those with succinylcholine 1.0 mg kg-1. The increase in heart rate was significantly greater during the first 5 min in the rapacuronium groups, but the arterial pressure increased significantly only in the succinylcholine group (P < 0.001). Respiratory side-effects were observed in 4.0, 13.5 and 18.5% of patients after succinylcholine and rapacuronium 2.0 and 2.5 mg kg-1 respectively (P < 0.05). As the non-inferiority of intubating conditions after rapacuronium 2.0 and 2.5 mg kg-1 could not be proven, succinylcholine should be considered the neuromuscular blocking agent that provides better intubating conditions for rapid-sequence induction.

Double-blind randomized study of tramadol vs. paracetamol in analgesia after day-case tonsillectomy in children.

Fifty children (2-9 years) scheduled for tonsillectomy were enrolled in a double-blind randomized prospective study to compare postoperative analgesia provided with propacetamol/paracetamol (acetaminophen) or tramadol. A standard anaesthetic technique was used; each patient received sufentanil 0.25 microg kg(-1) intravenously followed with either i.v. propacetamol 30 mg kg(-1) or tramadol 3 mg kg(-1) before surgical incision. For postoperative analgesia, each child received either tramadol drops (2.5 mg kg(-1)) or paracetamol (acetaminophen) suppositories (15 mg kg(-1)), 6 and 12 h after surgery the first day and three times a day during postoperative days 2 and 3. This dosage of paracetamol is lower than the current recommended dosage, which is 40 mg kg(-1) loading dose followed by 20 mg kg(-1) 8 h(-1). Rescue medication consisted of i.v. diclofenac (1 mg kg(-1)) during the first six postoperative hours and oral ibuprofen (6-9 mg kg(-1)) afterwards. Postoperative pain scores (Children's Hospital of Eastern Ontario Pain Scale) in recovery, numerical pain scale in the ward and at home, and rescue analgesic use were significantly lower in the tramadol group. No serious adverse effects were observed.

Use of Anaesthesia Simulator: initial impressions of its use in two Belgian University Centers.

459 trainees in Anesthesia and Intensive Care Medicine, accompanied by fully certified specialists from several Belgian University Hospital Centers, spend at least a 3 hour session at the Anaesthesia Simulator. Each session comprises three segments: the briefing, the simulation session and the debriefing. The use of simulations allows significant individualization of the learning experience. The simulator helps to develop the capacity to understand, explain a phenomenon and to resolve problems. Another important aspect of the use of the simulator involves the trainee's "right to make mistakes". This allows to widen the spectrum of executional situations, and decreases the number of dangerous situations. Two University Centers (ULg and UCL) have each organized simulator sessions despite some differences in their approaches. The simulator is a teaching tool worthy of an obligatory role in the most up-to-date training possible of modern anesthesiologist. This is all the more important given that the current practice of anesthesiology is so complex that any error could cost a human life.

Anaesthetic management of a child with Marshall-Smith syndrome.

PURPOSE: The Marshall-Smith Syndrome (MSS) is a rare disease characterized by orofacial dysmorphism, failure to thrive, accelerated osseous maturation and mental retardation. It has anaesthetic implications due to upper airway problems and possible atlanto-axial instability. We present the perioperative problems (difficult intubation, airway obstruction) encountered in a child with MSS who underwent several anaesthetics during his first two years of life. CLINICAL FEATURES: At birth, the child presented with asphyxia due to obstructive apnoea. His trachea was, therefore, intubated immediately. The morphological diagnosis of MSS was confirmed by the pathognomonic radiological appearance of the bones (bone age was eight months at the age of four days). Upper airway difficulty was caused by functional problems at the level of the hypopharynx (inspiratory collapse at the level of the velum palatinum), and was solved by the use of a nasopharyngeal airway (NPA) during the induction of anaesthesia and early postoperative period. CONCLUSION: The use of an NPA during both induction and recovery of anaesthesia may be particularly useful to prevent upper airway problems in children with MSS.

Ketorolac tromethamine for postoperative analgesia in oral surgery.

Sixty patients were randomly allocated to receive placebo or i.v. ketorolac tromethamine 30 mg during the induction of anaesthesia for dental removal. Pain score (VAS), mouth opening and oedema were evaluated. Pain intensity was assessed by the patient using a visual analog scale 1, 2, 6 and 24 hrs after surgery. Mouth opening and oedema were evaluated at the same times by an observer not implicated in the study. In ketorolac group, pain relief was better at each considered time (VAS: p < 0.001). Oedema was also significantly lesser. There was no difference in mouth opening. No side effect was observed. These data suggest that ketorolac reduces post-oral surgery pain and oedema.

Mivacurium chloride for short laparoscopic procedures.

We have studied the effects of mivacurium after induction of anesthesia with fentanyl-propofol in healthy adult women. Anesthesia was maintained with nitrous oxide in oxygen and continuous infusion of propofol (6-10 mg/kg/hr.). A myorelaxograph (Datex NMT 100) measuring the responses of the adductor pollicis to Train of Four (TOF) stimulations of the ulnar nerve was installed after induction. Three bolus dosages of mivacurium were administered just after induction: 0.15 mg/kg (group A), 0.17 mg/kg (group B) and 0.19 mg/kg (group C). Intubation was attempted at 75% TI-suppression. The conditions of intubation were good to excellent in the three groups except for one patient in group A (0.15 mg/kg). Successful intubation was performed faster in group C(p = 0.017). The curarization time was significantly longer in group C(0.19 mg/kg) vs the other groups (p = 0.002). As soon as the first signs of recovery (TI increment) appeared, a continuous infusion of mivacurium (10 micrograms/kg/min) was started to maintain a complete neuromuscular block. After stopping the continuous infusion, there were no differences in spontaneous recovery between groups A and B but patients from group C showed a lenghtening of the recovery time. There is no effect of the different bolus dosages on vital signs. We conclude that a bolus dosage of 0.19 mg/kg after induction of anesthesia with fentanyl-propofol offers the best choice when a rapid sequence of induction is required. Mivacurium could be an interesting muscle relaxant in one-day surgery even if a risk of prolonged curarization exists due to its degradation by plasma cholinesterases.

Effects of intravenous clonidine on the secretion of growth hormone in the perioperative period.

Growth hormone (GH) improves the metabolic and immunitary parameters in the postoperative period. Clonidine, a central acting alpha 2-adrenoceptor agonist stimulates GH release and is currently used as a screening test for GH-deficiency. A continuous iv infusion of clonidine may lead to a sustained increase in GH secretion during the perioperative period. With institutional approval and after informed consent, 20 healthy (ASA 1) patients scheduled for functional middle ear surgery under deliberate hypotensive anesthesia were studied. The anesthetic technique consisted of isoflurane, fentanyl and atracurium. Patients were randomly assigned to two groups. In group 1, hemodynamic stabilisation was obtained with a loading dose of clonidine (4 micrograms.kg-1 in 30 min) and maintained with an infusion of 1 microgram.kg-1.h-1. In group 2, a loading dose of labetalol 0.2 mg.kg-1 was followed by an infusion of 0.1 mg.kg-1.h-1. These infusions were stopped 30 min. before the end of the procedure. GH and glucose concentrations were assayed before the induction of anesthesia, after the loading dose and every 30 min. during the procedure and after the recovery during 2 hours. Serum clonidine levels were assayed after the loading dose, 1 and 3 hours later. Somatomedin C (IGF-I) concentration was measured before the induction and in the first postoperative morning along with GH, glucose and clonidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal cleft lip repair: the anesthesiologist's point of view.

Neonatal cleft lip repair is no longer an unusual procedure and several series have been published to date. We present our 3-year experience from the anesthesiologist's point of view. Preoperative evaluation, perioperative management, and postoperative problems are described. A thorough preoperative evaluation in order to exclude associated malformations (especially cardiac) and experience in neonatal anesthesia are essential for the sake of safety.

[Fibrous histiocytoma of the larynx: report of a case]. / Histiocytome fibreux du larynx: rapport d'un cas.

A case of subglottic fibrous histiocytoma of the larynx, is reported. Fibrous histiocytoma is uncommon in the head and neck region, and rare in the larynx. It is a tumor of mesenchymal origin consisting of two separate components: histiocytic and fibroblastic cells. The clinical behaviour and the degree of malignancy can not be predicted. Surgery is the treatment of choice.

Open placebo controlled comparison of the antiemetic effect of droperidol, metoclopramide or a combination of both in pediatric strabismus surgery.

In children, strabismus surgery is frequently followed by vomiting. The present study compares the antiemetic effects of droperidol (10 micrograms/kg) and/or metoclopramide (0.1 mg/kg) in 104 children undergoing strabismus surgery. The patients were randomly divided into four groups. Group I (n = 28) received placebo (saline), Group II (n = 26) droperidol 10 micrograms/kg, Group III (n = 25) metoclopramide 0.1 mg/kg and Group IV (n = 25) droperidol 10 micrograms/kg and metoclopramide 0.1 mg/kg. Droperidol was given just after induction and metoclopramide at the end of surgery, just before recovery. The technique of anesthesia involved an anticholinergic premedication, IV fentanyl (2 micrograms/kg), controlled ventilation using isoflurance and N2O in oxygen and systematic gastric emptying before extubation. Vomiting, retching and nausea were noted at 5 different moments: in the Post Anesthetic Care Unit, when arriving on the ward (= after carriage by lift), during the first hour following the return in the ward, from the 6th to the 12th postoperative hour and on the morning of day 1. There was no statistically significant difference in the incidence of vomiting among these four groups. Moreover, the incidence of vomiting in the placebo group was much lower (17.9% in the recovery room, 3.6% at return in the ward, 25% during the first hour, 7.1% from 6 to 12 hours and 3.6% the next day) than that reported in previous studies. We think that this could result from the additive effects of some aspects of the technique of anesthesia described and discussed in this paper.