Tolerance and analgesic efficacy of a new i.v. paracetamol solution in children after inguinal hernia repair.

BACKGROUND: A new intravenous (i.v.) formulation of paracetamol and propacetamol (prodrug of paracetamol) were compared to determine tolerance and relative analgesic efficacy during the first 6 h after inguinal hernia repair performed under general anesthesia combined with ilioinguinal block in children. METHODS: A total of 183 ASA I or II in-patients, aged 1-12 years, admitted for unilateral inguinal hernia repair were randomized to receive in a double-blind design either i.v. paracetamol 15 mg.kg(-1) (n = 95) or propacetamol 30 mg.kg(-1) (n = 88) for postoperative pain relief as soon as pain intensity was greater than 30 on a 100 mm visual analog scale. All patients were evaluated for efficacy and tolerance. Efficacy was evaluated between 15 min and 6 h after the start of the 15 min infusion. RESULTS: The most frequently reported adverse event was injection site pain, which was significantly reduced in the new formulation group (i.v. paracetamol 14.7% vs propacetamol 33.0% of children, P = 0.005). No significant difference was obtained between treatments on pain relief (PR), pain intensity difference (PAID) from baseline, and objective pain scale intensity difference (OPSD). Also, treatment effects did not differ significantly for maximum values and weighted sums of PR, PAID (investigator and child rated), OPSD, time to first request for rescue medication, proportion of children requesting rescue medication, and investigators' global treatment satisfaction. CONCLUSION: A single infusion of i.v. paracetamol 15 mg.kg(-1) produced analgesia similar to a single infusion of propacetamol 30 mg.kg(-1) following inguinal hernia repair in children. Paracetamol i.v. 15 mg.kg(-1) was better tolerated at the injection site than propacetamol.

[Cancer-related bone pain in children]. / Douleurs et tumeurs osseuses malignes de l'enfant et de l'adolescent.

Pain often discloses the existence of bone tumors in children. The complex physiopathology of pain in malignant bone tumors remains largely unknown and is currently investigated. Cancer-related bone pain is independent from the type and the location of the tumor, and from the number and size of the malignant lesions. It does not necessarily increase with tumor growth. Pain, which is the most common early symptom of bone cancer, may also be present at every step of the disease. It may arise from postsurgery injury, side effects of chemo- or radiotherapy, tumor evolution, secondary sequels of treatments, phantom pain. Tumor eradication using cancer therapeutic strategies is the major etiological treatment option for bone cancer pain. Symptom control requires multidisciplinary medical management with drugs effective against bone lysis, analgesics, drugs with anti-neuropathic activity, as well as non-pharmacological techniques and psycho-social management. This psycho-social management must be tailored to the specific needs of teenagers who are particularly prone to this pathological manifestation. Measures to prevent the occurrence of residual chronic pain must be implemented, whereas children and their family should be clearly informed of the risks and of analgesic options available.

Evaluation of caudal anaesthesia performed in conscious ex-premature infants for inguinal herniotomies.

Ex-premature infants, before 45 weeks postconceptional age, are at high-risk of apnoea after surgery. General anaesthesia increases the risk of apnoea. We evaluated the tolerance and the efficiency of caudal anaesthesia performed in 25 consecutive conscious ex-premature infants for inguinal herniotomies. N2O/O2 and EMLA cream are used to facilitate caudal puncture. Anaesthesia procedure, patient comfort and complications following the 24 postoperative hours were studied. We report good anaesthesia conditions without compromising the baby's comfort and few perioperative complications. Only two infants with a prior history of apnoea or bronchopulmonary dysplasia had apnoea during and after surgery. A total spinal anaesthesia was the major complication in one infant and prolonged surgery requiring general anaesthesia was the main limitation of this technique in another child. The principal advantage of the procedure is to facilitate and simplify the postoperative management of the babies. The anaesthetic technique does not alter surgical conditions. Caudal epidural anaesthesia performed in awake high-risk preterm infants is beneficial for these infants but requires experienced operators.

The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: assessment by continuous esophageal aortic blood flow echo-Doppler.

UNLABELLED: Cardiovascular changes due to pneumoperitoneum during laparoscopic surgery are established in adult patients, but not known in infants. We investigated the hemodynamic effects of laparoscopy during general anesthesia in 12 ASA physical status I infants by using noninvasive continuous esophageal aortic blood flow (ABF) echo-Doppler monitoring. During the laparoscopic procedure, intraabdominal pressure was maintained automatically at 10 mm Hg by a CO2 insufflator, and minute ventilation was adjusted to avoid hypercapnia. Hemodynamic changes were continuously recorded on soft magnetic support and assessed at three time intervals: t0 (after the initiation of anesthesia), t1 (5 min after peritoneal insufflation), and t2 (5 min after exsufflation). The induction of pneumoperitoneum resulted in a significant decrease in ABF and stroke volume, and in a significant increase in systemic vascular resistance, compared with control values: 67% +/- 9% (P < 0.001), 68% +/- 10% (P < 0.001), and 162% +/- 34% (P < 0.001), respectively. These changes were completely reversed after peritoneal exsufflation. Pneumoperitoneum caused no significant changes in mean arterial pressure or in end-tidal CO2 pressure. These findings demonstrate that laparoscopy is associated with hemodynamic changes without clinically deleterious consequences in healthy infants during a short duration of pneumoperitoneum. IMPLICATIONS: The peritoneal insufflation achieved during laparoscopic surgery is associated with cardiovascular impairments (decrease in cardiac performance and increase in vascular resistance). We found that these changes had no clinically deleterious effects in healthy infants.

[Pain in hospitalized children]. / La douleur de l'enfant hospitalisé.

Pain is present in many hospitalized children and this requires from every physician a constant attention to its recognition, evaluation and treatment. The semeiology of pain differs whether it is acute or chronic. Acute pain can be recognized from its various behavioural, motor and neurovegetative manifestations. Pain evaluation must be adapted according to age: autoevaluation procedures for children older than 5 years, behavioural scales for children younger than 5 years. One must know that there is an appropriate and efficient treatment for each stage of pain intensity. For a better recognition and management of pain in hospitalized children, the organization of teams specialized in the evaluation and treatment of pain in children is to be encouraged.

[Gastroesophageal reflux with combined caudal and halothane anesthesia in children]. / Reflux gastrooesophagien sous anesthésie caudale et halothane au masque chez l'enfant.

Sixteen children, aged 2 to 5 years and ranked ASA 1, were included in this study assessing gastro-oesophageal reflux occurring under halothane anaesthesia, before and during, caudal anaesthesia. They were scheduled for surgery below the umbilicus lasting 1 to 5 h. After premedication with oral hydroxyzine (2 mg.kg-1) and intravenous atropine (10 micrograms.kg-1), induction was carried out with 3% halothane. A gastro-oesophageal pH probe was inserted via the nose after calibration at 37 degrees C. A neutral pH for the oesophageal electrode and an acid pH for the gastric one demonstrated the correct position of the probe. The pH was then registered every 4 s. The probe was left in situ until the patient left the recovery room. The caudal anaesthesia catheter was then inserted with the patient lying on his left side. Caudal anaesthesia was began with 2.5 mg.kg-1 of plain bupivacaine and 5 mg.kg-1 of plain lidocaine. When the patient was lying supine again, narcosis was maintained with 0.5% halothane and 50% nitrous oxide. A dose of 1.5 mg.kg-1 of bupivacaine was injected every 30 to 45 min. None of the children displayed any respiratory signs (coughing, dyspnoea, bronchospasm, cyanosis) during the combined anaesthetic. Two episodes of asymptomatic gastro-oesophageal reflux were revealed by this method, one lasting 7 minutes and occurring during insertion of the caudal catheter, and the other, lasting 4 minutes, during recovery. There were no pulmonary sequels. There was excellent respiratory and haemodynamic stability throughout. The two episodes seemed to have been triggered off by rapid displacement of the patient and too deep an anaesthetic.(ABSTRACT TRUNCATED AT 250 WORDS)

[Locoregional anesthesia in pediatrics]. / L'anesthésie locorégionale en pédiatrie.

Local anaesthesia may consist of a sensitive and a motor blockade. It is essentially used in human clinic for the sensitive blockade which is induced. All techniques or nearly are possible in regional anaesthesia for children if they are practised with discernment by a physician accustomed to the same techniques in adults. But caudal anaesthesia remains the most commonly performed and simple. The main advantages consist in abolition of intra- and postoperative pain, calm and comfort but also in a decrease of respiratory complications. There are two leading risks: infectious and especially toxic after an accidental injection of bupivacaine. These techniques should be systematically proposed but carefully carried out in all suffering children.

[Caudal anesthesia in pediatric surgery. Pharmacokinetic study and clinical significance]. / Anesthésie caudale en chirurgie pédiatrique. Etude pharmacocinétique et intérêt clinique.

In 1987, 758 caudal anaesthesia allowed the execution of 41% of all our department's operations. Urological, genital, inguinal and lower limbs surgery were the most frequent. The injection into the extradural space through the hiatus sacralis always included the mixture of lidocaine with bupivacaine to speed up the beginning of the operation. The patients were split up into 2 equal groups and were given 1.25 ou 2.50 mg.kg-1 of bupivacaine (i.e. 0.50 ml.kg-1 of a 2.50 or 0.50% solution). Bupivacaine plasma levels were determined by high performance liquid chromatography in 40 patients from the first group and in 42 patients from the second. They reached their maximum about 500 or 1,000 ng.ml-1 respectively, 30 mn after the injection and always fell back 4 hours after the administration. These concentrations were compared with the levels obtained by infusion to the dog, which cause serious cardiac disorders with 6,000 to 8,000 ng.ml-1 levels, and elicit ventricular fibrillation with 8,000 to 10,000 ng.ml-1. So the safety margin appears greater when overdose and/or intravascular injection are avoided. Caudal anaesthesia is easy, fast acting and allows to relieve post-operative pain. It is suitable for all surgery below the umbilicus and can be used on an outpatient basis.

[Coagulopathy and anemia caused by anticonvulsants]. / Coagulopathie et anémie sous anticonvulsivants.

Long-term antiepileptic polytherapy regularly induces some slight impairment of haemostasis without clinical manifestations, but serious clinical disorders may appear, even in the absence of over-dosage. In the case reported here the patient was undergoing surgery for correction of scoliosis. Preoperative laboratory tests only showed a slight decrease of fibrinogen and a moderate lengthening of thrombin time; there was no anaemia. Immediately after the incision a severe haemorrhagic syndrome occurred. It was treated with a massive transfusion and administration of some blood coagulation factors, but bleeding was so profuse that surgery was abandoned. Later, the patient developed acute thrombocytopenia, progressive decrease of Quick time and of plasma blood coagulation factors, and anaemia due to folate deficiency. Awareness of these disorders should lead to prophylactic measures.

[Peranesthetic monitoring of ventilation in children: value of capnometry]. / Surveillance peranesthésique de la ventilation chez l'enfant: intérêt de la capnométrie.

Continuous measurement of the end-expiratory partial pressure of carbon dioxide (PETCO2) during anaesthesia has been proposed for non-invasive monitoring of arterial PCO2 (PaCO2). The values and the stability of the difference (PaCO2-PETCO2) during anaesthesia were studied for two ventilatory settings in eight children with healthy lungs and normal cardiac function undergoing minor surgery. PaCO2 values were all within a physiological range (30.2-43.6 mmHg). PaCO2-PETCO2 values ranged from 0.2 to 9.9 mmHg. With either mode of ventilation, there was no significant variation in PaCO2-PETCO2. It is concluded that estimation of PaCO2 was reliable during anaesthesia when haemodynamic and ventilatory states were stable, but a first determination of the PaCO2-PETCO2 gradient remained necessary for each child.