Chronic postsurgical pain in children: prevalence and risk factors. A prospective observational study.

BACKGROUND: Chronic postsurgical pain (CPSP) is well known in adults, with prevalence rates ranging from 10 to 50%. Little is known about the epidemiology of CPSP in children. The aim of this prospective observational study was to evaluate the prevalence of CPSP after surgery in children. METHODS: After informed consent, children aged six to18 yr were included. Characteristics and risk factors for CPSP were recorded. Exclusion criteria included ambulatory surgery, refusal, inability to understand and change of address. All eligible children completed a preoperative questionnaire the day before surgery about pain, anxiety and their medical history. All data concerning anaesthetic and surgical procedures, such as acute pain scores (VAS) during the first 24 h were recorded. Three months after surgery all included children were sent a postoperative questionnaire about pain at the surgical site. RESULTS: Altogether, 291 children were enrolled; the mean age was 12 yr, most subjects were male (60%). The most common type of surgery was orthopaedic (63%). In the 258 patients who completed the study, the prevalence of CPSP was 10.9%, most often with a neuropathic origin (64.3%). The two main risk factors were the existence of recent pain before surgery (<1 month) and the severity of acute postoperative pain (VAS >30 mm) in the first 24 h after orthopaedic and thoracic surgeries. Six months after surgery, only five children needed a visit with a chronic pain practitioner. CONCLUSIONS: These results highlight the necessity of evaluating and treating perioperative pain in order to prevent CPSP in children.

[Brutal decrease in pulse oxymetry in paediatric anaesthesia: a story of artefact]. / Chute brutale et profonde de la saturation artérielle en oxygène en anesthésie pédiatrique: une histoire d'artéfact.

Pulse oxymetry is frequently used in anaesthesia, notably in paediatric anaesthesia. This device can however present artefacts. We report the case of a sudden decrease in pulse oxymetry during surgical exploration of wound of the face in a child. This was preceded by the injection of patent blue, used for vascular cartography, and interfering with pulse oxymetry. After excluding real oxygen desaturation, this error of measurement has to be confirmed by arterial gazometry. In our case, pulse oxymetry normalized few hours later, without complication.

[Two consecutive intubations using neonatal Airtraq in an infant with difficult airway]. / Deux utilisations consécutives de l'Airtraq néonatal chez un nourrisson d'un mois présentant une intubation difficile prévue.

We used successfully Airtraq-combined to a gum-elastic boogie to intubate twice a dysmorphic infant with mucolipidosis, in whom direct laryngoscopy failed. If this result is confirmed by prospective studies, Airtraq could be a first-line device to intubate infants with difficult intubation.

The I-gel, a single-use supraglottic airway device with a non-inflatable cuff and an esophageal vent: an observational study in children.

BACKGROUND: The I-gel is a new single-use supraglottic airway device with a non-inflatable cuff. It is composed of a thermoplastic elastomer and a soft gel-like cuff that adapts to the hypopharyngeal anatomy. Like the LMA-ProSeal, it has an airway tube and a gastric drain tube. Little is known about its efficiency in pediatric anesthesia. METHODS: Fifty children above 30 kg, ASA I-II, undergoing a short-duration surgery were included in this prospective, observational study. We evaluated ease in inserting the I-gel, seal pressure, gastric leak, complications during insertion and removal, ease in inserting the gastric tube and ventilatory parameters during positive pressure ventilation. RESULTS: All devices were inserted at the first attempt. The mean seal pressure was 25 cmH(2)O. There was no gastric inflation and gastric tube insertion was achieved in all cases. The results appear similar to those in a previous study concerning laryngeal mask airway in terms of leak pressure and complication rates. CONCLUSION: Because the I-gel has a very good insertion success rate and very few complications, it seems to be an efficient and safe device for pediatric airway management.

Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases.

Infants with Pierre Robin syndrome are known to be difficult to intubate. We evaluated the paraglossal approach combined with a gum elastic bougie for intubation of these infants. Whilst under general anaesthesia, a conventional laryngoscopy was performed; if it failed to obtain a laryngoscopic grade I or II view, intubation was attempted using a paraglossal approach and a gum elastic bougie. Six consecutive infants were studied. Conventional laryngoscopy failed in all infants whilst the paraglossal approach combined with a gum elastic bougie was successful in five of the cases. The paraglossal approach combined with a gum elastic bougie made intubation easy in most children with severe Pierre Robin syndrome and difficult laryngoscopy. Therefore we recommend this as the first line for airway management in such children. However, a fibreoptic bronchoscope and an anaesthetist trained in fibreoptic intubation must still be present when dealing with severe Pierre Robin syndrome infants.

[Which anaesthesia for children undergoing MRI? An Internet survey in the French university hospitals]. / Quelle anesthésie pour les IRM en pédiatrie? Résultats d'une enquête par Internet dans les CHU de France.

OBJECTIVE: To investigate the procedures used by French anaesthesiologists in children undergoing MRI. METHODS: A questionnaire was sent by Internet to every university hospital in France. Information concerning the specialty of the doctor in charge of the child, the age of the children, premedication, airway control, the agents used, presence of a specific recovery room, length of hospitalization and number of children undergoing MRI was obtained. RESULTS: Out of the 28 hospitals contacted, one did not reply and two did not perform anaesthesia for MRI. In 80% of cases, paediatric anaesthesiologists were in charge of the children. Only one team applied an age limit and performed sedation only in children over 10 kg. Specific monitoring for MRI was used by all teams. Premedication was given in 52% of cases. Parents were present during induction in 52% of cases. Sevoflurane was used in 52%, propofol in 40% and propofol with sufentanil in 8%. Presence of a venous line is systematic in 92% of cases. Intubation is systematic in 36% of cases, laryngeal mask in 20%, one or the other in 24%, and face mask and/or oral canula in 20%. The most widely used ventilation mode is spontaneous breathing (52%). All children go to the recovery room, which was close to the MRI unit in only 48% of cases and was less than 1 hour away in 72%. In 83% of cases, MRI is performed on a day-case basis and the number of procedures varies from 4 to 30 per week. CONCLUSION: While there is no standard anaesthetic protocol in France for children undergoing MRI, only specialist teams undertake such procedures.

Pressure-controlled ventilation is superior to volume-controlled ventilation with a laryngeal mask airway in children.

BACKGROUND: This prospective, randomized, crossover study had two purposes: first, to determine whether pressure-controlled ventilation (PCV) is safer than volume-controlled ventilation (VCV) by preventing gastric insufflation in children ventilated through an laryngeal mask airway (LMA); second, to assess whether the measurement of LMA leak pressure (P(leak)) is useful for preventing leakage during positive pressure ventilation (PPV). METHODS: Forty-one, 2 to 15-year-old children underwent general anesthesia with an LMA. The expiratory valve was set at 30 cmH(2)O and P(leak) was measured using constant gas flow. Children were randomly ventilated using PCV or VCV for 5 min in order to reach a P(ET)CO(2) not exceeding 45 mm Hg, and then they were ventilated with the alternative mode. If the target P(ET)CO(2) could not be obtained in one mode, we switched to the other. If both modes failed, children were intubated. Tidal volumes, P(ET)CO(2) and airway pressures were noted and compared between modes. Gastric insufflation was checked by epigastric auscultation. RESULTS: PCV provided more efficient ventilation than VCV, as targeted P(ET)CO(2) was obtained without gastric insufflation using PCV in all cases except one, whereas VCV failed in three cases. No gastric insufflation occurred when ventilating below peak. CONCLUSIONS: These findings suggest that in the age group studied, PCV is more efficient than VCV for controlled ventilation with a laryngeal mask. Gastric insufflation did not occur with this mode.

Intravesical instillation of ropivacaine reduces bladder spasms following paediatric ureteroneocystostomy.

OBJECTIVE: Bladder spasms are a common cause of pain after surgical procedures that call for postoperative catheter drainage. Several therapeutic methods have been used to lessen these spasms but none have received widespread success. PATIENTS AND METHODS: Twenty-six children were included in a prospective randomized trial to evaluate the safety and efficacy of daily intravesical instillation of ropivacaine as prophylactic treatment for bladder spasms following ureteroneocystostomy. RESULTS: Although six patients experienced mild transient pain during instillation, there was no systemic toxicity attributable to the ropivacaine. The average number of spasms per day fell by half in the instillation group (p<0.01). CONCLUSION: Intravesical instillation of ropivacaine is a feasible alternative prophylactic treatment for postoperative bladder spasms.

[Thoracic epidural analgesia for a thrombocytopenic child]. / Analgésie péridurale thoracique chez un enfant thrombopénique.

Per- and postoperative analgesia of patients with chronic pain is a challenging issue for anaesthetists and can be achieved with locoregional anaesthesia, unless it is contraindicated. We report the case of a thrombocytopenic child presenting for thoracotomy and in whom intravenous analgesia failed after previous surgeries. Due to the central origin of the thrombocytopenia, thoracic epidural analgesia could be achieved, after platelet transfusions. When clinical advantage of thoracic epidural is unquestionable, central thrombocytopenia is a relative contraindication.

[Clinical study of the laryngeal mask in paediatric. Comparison of the LMA-ProSeal and LMA-classic]. / Etude clinique du masque laryngé en pédiatrie. Comparaison du LMA-classic et du LMA-ProSeal taille 2 et 2,5.

OBJECTIVES: To compare the Classic laryngeal mask airway (MLC) and the ProSeal LMA (MLP), size 2 and 2.5 in terms of ease of insertion, leak pressure and side effects during insertion and extraction in the recovery room. STUDY TYPE: Randomised prospective. MATERIAL AND METHOD: All children between 10 and 30 kg scheduled for general anaesthesia with laryngeal mask (ML) were included. There was no imposed protocol for the anaesthesia. The ML size was determined according to the child's weight. The MLC was inserted using the standard technique. The MLP was inserted following the recommendations, with or without the handle according to the operator's choice. The data analysed were: insertion type, ease of insertion of the mask, of the nasogastric tube (SG), number of attempts of mask insertion, complications, gastric leaks. RESULTS: One hundred (and) twenty children were included. There was no statistical difference in terms of difficulty of insertion, number of failed attempts, leak pressure or side effects. The use of the handle did not make insertion easier. Insertion of a nasogastric tube was possible in 92% cases. CONCLUSION: MLP is as easy to use in children as the MLC. MLP has the advantage of allowing rapid access to the stomach. It seems that the MLP is safer since its correct position is confirmed by easy gastric tube insertion.

Comparison of the intubating laryngeal mask airway with the fiberoptic intubation in anticipated difficult airway management.

BACKGROUND: The intubating laryngeal mask airway (ILMA; Fastrach; Laryngeal Mask Company, Henley-on-Thames, UK) may provide an alternative technique to fiberoptic intubation (FIB) to facilitate the management of the anticipated difficult airway. The authors therefore compared the effectiveness of the ILMA with FIB in patients with anticipated difficult intubation. METHODS: One hundred patients, with at least one difficult intubation criteria (Mallampati class III or IV, thyromental distance < 65 mm, interincisor distance < 35 mm) were enrolled (FIB group, n = 49; ILMA group, n = 51) in this prospective randomized study. Anesthesia was induced with propofol and maintained with alfentanil and propofol after an efficient mask ventilation has been demonstrated. The success of the technique (within three attempts), the number of attempts, duration of the successful attempt, and adverse events (oxygen saturation < 90%, bleeding) were recorded. RESULTS: The rate of successful tracheal intubation with ILMA was 94% and comparable with FIB (92%). The number of attempts and the time to succeed were not significantly different between groups. In case of failure of the first technique, the alternative technique always succeeded. Failures in FIB group were related to oxygen desaturation (oxygen saturation < 90%) and bleeding, and to previous cervical radiotherapy in the ILMA group. Adverse events occurred significantly more frequently in FIB group than in ILMA group (18 vs. 0%, P < 0.05). CONCLUSION: The authors obtained a high success rate and comparable duration of tracheal intubation with ILMA and FIB techniques. In patients with previous cervical radiotherapy, the use of ILMA cannot be recommended. Nevertheless, the use of the ILMA was associated with fewer adverse events.

[Untreatable ventricular hemorrhage revealing cerebral metastasis of malignant melanoma]. / Hémorragie intraventriculaire incoercible révélatrice d'une métastase cérébrale d'un mélanome malin.

High levels of tissue-like plasminogen activator in cerebrospinal fluid reported in a patient with an intracerebral haemorrhage associated to cerebral metastasis of malignant melanoma could support the hypothesis of cerebral haemorrhage induced by tPA tumoral synthesis.