Anaesthetic management for Edward's syndrome.

We report the anaesthetic management for a Cohen procedure in a girl with Edward's syndrome (trisomy 18). Information in the literature about anaesthetic management in trisomy 18 patients is poor. The patients are dysmorphic, have severe mental retardation and multiple organ malformations of which congenital heart disease is the most important. Our patient was a 7 year-old girl, such a survival being exceptional with trisomy 18. Anaesthesia is high risk and pain assessment is difficult. Establishing good relations with the family and appraising the need for surgical procedures are the main other difficulties.

[Extramucosal pylorotomy via the umbilical route under general anesthesia and para-umbilical cord: evaluation of intra- and postoperative analgesia]. / Pylorotomie extramuqueuse par voie ombilicale sous anesthésie générale et bloc para-ombilical: évaluation de l'analgésie per- et postopératoire.

OBJECTIVE: To assess both intra- and postoperative analgesia in infants undergoing extramucosal pylorotomy via a circumumbilical incision under general anaesthesia with neither opioid nor muscle relaxant, associated with a paraumbilical block. STUDY DESIGN: Open prospective study covering a 1-year period. PATIENTS: The study included 32 infants (age = 1.1 +/- 0.7 months, body weight = 4,427 +/- 876 g). METHOD: General anaesthesia was induced with either thiopentone or halothane and, after tracheal intubation, maintained with halothane in a N2O-O2 50 vol% mixture. Para-umbilical block was obtained using 0.5 mL.kg-1 of 1% lidocaine with epinephrine. Pain was assessed using time course of respiratory rate, heart rate and mean arterial pressure. A change of more than 20% in one of these variables was considered as criterion for poor analgesia. RESULTS: Intraoperative analgesia was adequate in all patients but one, 3 minutes after incision. Surgical conditions were considered as being good or satisfactory in 76% and 24% of cases, respectively. Postoperative analgesia, assessed 1 and 6 hours after completion of surgery, was convenient in 90% of infants, the end of the action of the local anaesthetic resulting in a poor analgesia at the 6th hour in four of them. CONCLUSION: Provided a short bevel needle is used and basic safety rules of local anaesthesia are followed, the para-umbilical block provides adequate intra and postoperative analgesia in infants undergoing extramucosal pylorotomy via circumumbilical route.

Para-umbilical block: a new concept for regional anaesthesia in children.

This preliminary study describes a new technique to provide analgesia in children undergoing umbilical hernia repair. The para-umbilical block consists of infiltrating the anterior cutaneous branches of the two tenth spinal roots over and under the rectus sheath far from the operative field. Intra and postoperative analgesia as well as operative conditions were assessed in 11 children 16.7 +/- 31 months old, weighing 8421 +/- 6941 g, the block being performed before surgery under light general anaesthesia. Intraoperative analgesia, operative conditions and recovery were good in all patients. Analgesia was adequate one h after surgery in ten patients, six h after surgery in eight. The block proved to be safe and on the whole effective in this short series. The study should proceed on a multi-centre basis if possible. Indications can be extended.

[Value of ilio-hypogastric block in appendectomy in children]. / Intérêt du bloc ilio-hypogastrique pour appendicectomie chez l'enfant.

This prospective study aimed to evaluate the efficiency of ilio-hypogastric nerve block for control of post appendicectomy pain in children. Forty-two children aged 3-15 years scheduled for appendicectomy were anaesthetized in the same way. After randomization, a preoperative ilio-hypogastric nerve block was performed in 21 patients. Twenty one were not blocked. The postoperative pain assessment showed a better analgesia in the blocked children group. Analgics were required less in group. Five inefficient blocks were recorded. No complications were noted. Ilio-hypogastric block was found to be safe and efficient for control of post-appendicectomy pain in most children.

[Epidural anesthesia in children under 3 months of age. Apropos of 49 cases]. / Anesthésie péridurale chez l'enfant de moins de trois mois. A propos de 49 observations.

This retrospective study includes 45 patients (age: 32 +/- 28 days; weight: 4,077 +/- 988 g) who underwent epidural analgesia with a catheter for various surgical operations. Epidural space was detected by the loss of resistance to air technique. The anaesthetic solution administered was bupivacaine 0.25% with 1/200,000 epinephrine. Four technical failures were recorded; intraoperative analgesia was adequate for all other patients. In 17 patients, postoperative analgesia was maintained by continuous infusion (0.125% bupivacaine or 0.25% lidocaine: 0.2 mL.kg -1.h-1). In 18 patients, it was managed by iterative injections (0.25% bupivacaine with epinephrine: 0.25 mL.kg -1.h-1). In 10 patients, a single shot was sufficient. Postoperative analgesia was found to be inadequate in four patients. No incidents or accidents were recorded. A benefit-risk analysis with the support of the literature attempts to define the main indications of this method.

[Cystic ectasia of the rete testis: apropos of a case]. / Ectasie kystique du rete testis: à propos d'un cas.

We report a case of a simple testicular cyst developing on the rete testis. Nine cases have been reported in children. In our patient, the cyst was associated with aplasia of the homolateral kidney and termination of the left ureter in the left deferens. According to the literature, the diagnosis is usually fortuitous at histology examination. The cause is probably embryonic malformation. Castration is the therapeutic solution. In our case, simple enucleation allowed preservation of the deferens since the controlateral tree was damaged. There have been no complications with a 6-year follow-up.

[Epidural anesthesia and esophageal atresia. Apropos of a case]. / Anesthésie péridurale et atrésie de l'oesophage. A propos d'une observation.

We report the good results of a thoracic epidural analgesia for oesophageal atresia repair in a 3-day old girl. Surgery was performed under light general anaesthesia combined with a single epidural injection of bupivacaine 0.25% (0.5 ml.kg-1) with epinephrine through a 19 G catheter (T7 space, descending to T5). During the three following days, a continuous epidural infusion was used (0.2 ml.kg-1.h-1 bupivacaine 0.125%). Intraoperative analgesia and postoperative analgesia were adequate, the latter being assessed by the Barrier-Amiel-Tison pain scale. Thus heavy postoperative care could be avoided, namely mechanical ventilation. Recovery was uneventful.

[Laryngeal masks in pediatric anesthesia. Apropos of 251 cases]. / Le masque laryngé en anesthésie pédiatrique. A propos de 251 observations.

A series of 251 anaesthesias with a laryngeal mask (LM) in a paediatric surgery unit is studied retrospectively. After some short training, using LM is most often easy and allows a good airway control without any frequent or severe complications. Therefore this technique should quickly supplant the facial mask and many endotracheal intubations.

[Evaluation of laryngeal masks]. / Evaluation du masque laryngé.

The size 1 laryngeal mask (LMA1) was studied prospectively in a series of 37 infants (weight less than 6.5 kg) undergoing 42 routine surgical procedures. LMA1 insertion was successful at first attempt in 80.9% of all cases and a good airway control was obtained in 93%. The most frequent cause of insertion failure was an insufficient depth of anaesthesia. Only one incident occurred peroperatively. The recovery incidents rate, higher than in other studies, was mainly due to the laryngeal hyperreactivity of infants. LMA1 provides high safety for infant anaesthesia woith food working conditions for bot anaesthetist and surgeon. However, an accurate determination of the anaesthesia level and a close monitoring of recovery are strongly recommended.

[Evaluation of the Hotline perfusion warmer in infants with body weight under 10 kg]. / Evaluation du réchauffeur de perfusion Hotline chez l'enfant de moins de 10 kg.

This randomized study assessed the efficacy of the Hotline fluid warner in 42 children under 10 kg, undergoing surgery of more than 1 h of duration. In all a heating mattress and a heating humidifier were also used. The decrease in core temperature was more important in children without warner (1.1 +/- 1.4 degrees C vs 0.1 +/- 0.3 degrees C in those with a warner). Efficiency of this device is demonstrated even at the low perfusion flows requested for surgery in newborns and infants.

[The detection of thromboembolism in orthopedic traumatology: the value and limitations of D-dimer determination by the latex method]. / Détection thromboembolique en orthopédie traumatologie: intérêt et limite du dosage du D-dimère par la méthode au latex.

We studied the usefulness of plasma D-dimer determination by a latex agglutination test used as a deep venous thrombosis (DVT) detection method in patients undergoing recent orthopaedic or traumatologic surgery. Asymptomatic patients with a level of D-dimer up to 1.5 micrograms/ml suffered phlebographic venous thrombosis in 49.3% of the cases. Because a predictive value of negative test of 0.77 the latex assay cannot be recommended for screening in symptomatic DVT. However, post operative measurement of cross linked fibrin derivatives in plasma may play a role in the selection of asymptomatic patients for venography.

[Errors in the measurement and interpretation of pulmonary artery pressure values evaluated by the Swan-Ganz method]. / Erreurs de mesure et d'interprétation des valeurs des pressions artérielles pulmonaires évaluées selon la méthode de Swan-Ganz.

The data collected by way of the catheter has for goal to give a better therapeutic treatment and is therefore directly related to the quality of the analysis of the signal. The fidelity of the measurements depend on the performance of the material used and also to other distortions linked to their utilization. In intensive care and in perioperative resuscitation, the interpretation must also take into account the possible interference from physiopathologic mechanisms which are sometimes very complex and can modify results in a number of situations both clinical and therapeutic and in particular when they are accompanied by vascular and respiratory perturbations.

[An open study on the efficacy and tolerance of a low molecular weight heparin (CY 216) in the therapeutic treatment of deep venous thrombi in orthopedics]. / Etude ouverte de l'efficacité et de la tolérance d'une héparine de bas poids moléculaire (CY 216) dans le traitement curatif des thromboses veineuses profondes en orthopédie.

A prospective clinical trial was performed to evaluate the efficacy and safety of a low molecular weight heparin (nadroparine, CY 216) in the treatment of patients with deep venous thrombosis following recent orthopaedic surgery or trauma. Forty-three patients received nadroparine subcutaneously, 100 IU AXa.kg-1 every 12 hours for a period of 10 days. A quantitative assessment of deep vein thrombosis was made according Marder's scoring after 10 days of treatment. A substantial lysis was observed in 73 per cent and a revascularisation in 52 per cent of the patients. These results are statistically significant, although not correlated with the clinical symptoms and the size of the thrombi. Tolerance was assessed on the rate of bleeding events: a minor bleeding occurred in 6 per cent of the patients. Laboratory adjustment was performed in 8 per cent of the cases. The results of this study suggest that nadroparine administered subcutaneously at a fixed daily dose of 200 IU AXa.kg-1 is as efficient and safe as unfractionated heparin in the treatment of early venous thrombosis following orthopaedic surgery or trauma.

[Non controlled prospective study of the efficacy and tolerance of a low molecular weight heparin]. / Etude prospective non contrôlée de l'efficacité et de la tolérance d'une héparine de bas poids moléculaire (tédelparine) dans la prophylaxie thrombo-embolique en chirurgie traumatologique du col du fémur.

A prospective trial has been carried out on 50 patients to test the efficacy and tolerance of low molecular weight heparin in surgery involving a high risk of thromboembolic complications. Tedelparin shows a tendency to reduce the frequency of post-operative thromboembolic disease in post-traumatic hip surgery. The effectiveness of the different low molecular weight heparins still remains to be quantified by comparative pharmacological studies. The alternative use of these treatments, whose high tolerance level make suitable for geriatric surgery do not exempt them from the biological monitoring of platelet count as they do not exclude the risk of heparin induced thrombocytopenia syndrome.

[Prevention of thromboembolism using low molecular weight heparin and hemodilution in traumatologic geriatric surgery of the femur neck]. / Prophylaxie thrombo-embolique par héparine de bas poids moléculaire et hémodilution en chirurgie traumatologique gériatrique du col du fémur.

A routine method of prophylaxis of thromboembolic disease is evaluated on 181 elderly patients undergoing post-traumatic hip surgery. A low incidence of proximal thrombosis and fatal embolism is noted and rated as a beneficial effect of the association of low molecular weight heparin therapy and moderate hemodilution; it is also connected with a precocious diagnosis of the thrombotic complications--before the proximal extension of silent thromboses--by the measurement of specific fibrin derivatives used as a screening technique in order to select the patients who will have to undergo venographical examination.