Epidemiology and complications of anaesthesia in the French centres that participated to NECTARINE: A secondary analysis.

INTRODUCTION: Neonatal and infant anaesthesia are associated with a high risk of perioperative complications. The aim of the current study was to describe those risks in France using the French data from the NECTARINE study. MATERIAL AND METHODS: Data from the French centres that participated to the NECTARINE study were analysed. The primary goal of the study was the description of patients' characteristics, procedures and perioperative management and their comparison with the results of the European NECTARINE study. Secondary outcomes were the description of major perioperative complications and death. RESULTS: Overall, 926 procedures collected in 15 centres (all teaching hospitals) were analysed. Comparison between the French and European NECTARINE cohorts found few differences related to patients' characteristics and procedures. The rate of interventions for critical events (respiratory, haemodynamic, and metabolic) was similar between the two cohorts. Near-infrared spectroscopy monitoring was used in 12% of procedures. Nearly none of the thresholds for these interventions met the published standards. By day 30, complications (respiratory, haemodynamic, metabolic, renal, and liver failure) and death were observed in 14.4% [95% CI 11.6-16.4]% and 1.8% [95% CI 1.1-2.9] of cases, respectively. DISCUSSION: Although the health status of the patients in the French cohort was less severe, procedures, management and postoperative complications and mortality rates were similar to the European cohort. However, thresholds for interventions were often inadequate in both cohorts. Efforts should be undertaken to improve the knowledge and use of new monitoring devices in this population.

Frequency and risk factors for malnutrition in children undergoing general anaesthesia in a French university hospital: A cross-sectional observational study.

BACKGROUND: Malnutrition is often underdiagnosed in hospitalised children, although it is associated with postoperative complications, longer hospital lengths of stay and increased healthcare-related costs. OBJECTIVE: We aimed to estimate the frequency of, and identify factors associated with, malnutrition in children undergoing anaesthesia. DESIGN: Cross-sectional observational study. SETTING: Paediatric anaesthesia department at the University Children's Hospital, Bordeaux, France. PARTICIPANTS: A total of 985 patients aged less than 18 years. MAIN OUTCOME MEASURES: Anthropometric measurements, American Society of Anesthesiologists physical status classification score and the Pediatric Nutritional Risk Score (PNRS) recorded at the pre-anaesthesia evaluation. RESULTS: When assessed as a Waterlow index less than 80%, malnutrition was present in 7.6% children. This increased to 8.1% of children assessed by clinical signs and to 11% of children when defined by a BMI less than the third percentile. In a univariate analysis, children with a BMI less than the third percentile were more often born prematurely (22.4 vs 10.4%; P = 0.0008), were small for gestational age at birth (18.4 vs 4.5%; P < 0.0001), were admitted from the emergency department (12.0 vs 5.6%; P = 0.02), had a high American Society of Anesthesiologists score (P < 0.0001), or had a high Pediatric Nutritional Risk Score (P < 0.0001). Presence (P = 0.01) and type (P = 0.002) of chronic disease were also associated with malnutrition. In the multivariate analysis, a premature birth, a lower birth weight and a higher Pediatric Nutritional Risk Score were significantly associated with a higher odds of malnutrition when defined by BMI. CONCLUSION: All children should be screened routinely for malnutrition or the risk of malnutrition at the pre-anaesthesia visit, allowing a programme of preoperative and/or postoperative nutritional support to be initiated. We suggest that as well as weight and height, BMI and a pediatric nutritional risk score such as PNRS should be recorded routinely at the pre-anaesthesia visit.

Comparison of the McGrath® MAC video laryngoscope with direct Macintosh laryngoscopy for novice laryngoscopists in children without difficult intubation: A randomised controlled trial.

INTRODUCTION: Airway management and tracheal intubation are routinely performed in paediatric anaesthesia and yet are associated with preventable adverse events. The McGrath® MAC is a video laryngoscope with a curved blade similar to the Macintosh blade, which has not been previously described in first intention paediatric tracheal intubation. We aimed to compare direct laryngoscopy to the McGrath® MAC video laryngoscope among novice laryngoscopists. METHODS: Six paediatric anaesthesia residents with novice skills in paediatric laryngoscopy were randomly assigned to perform tracheal intubation using either direct Macintosh laryngoscopy (DL) or the McGrath® MAC video laryngoscope (MM) as the first attempted device in children weighing between 10 and 20kg without difficult intubation. RESULTS: Our study enrolled 132 children between August 2013 and April 2015. The time to intubation was shorter in the DL group (n=67) compared to the MM group (n=65) with 42s (35-50) versus 48s (43-58) P=0.002. The time to best view was similar between the two groups (10s [7-16] versus 10s [8-15]; P=0.50). The tube passage time was shorter with DL (29s [25-35] versus 35s [30-45]; P=0.0002) and either Cormak & Lehane grade or Percentage Of Glottis Opening (POGO) scores were similar between groups. Minor reversible respiratory adverse events were similar between groups: 12 in the DL group (17.9%) versus 12 in the MM group (18.5%). DISCUSSION: McGrath® MAC video laryngoscopy, when performed by a novice laryngoscopist on easy-to-intubate children, is associated with longer intubation times.

Facemask pressure-controlled ventilation in children: what is the pressure limit?

BACKGROUND: In this study, we sought to determine the level of inspiratory pressures allowing adequate and safe ventilation without any risk of gastric insufflation (GI) in children according to age. METHODS: One hundred children, aged 1 day to 16 years, ASA physical status I to II, scheduled for general anesthesia were studied prospectively. After induction of anesthesia, children's lungs were ventilated with pressure-controlled ventilation. The initial inspiratory pressure was 10 cm H(2)O and was increased by steps of 5 cm H(2)O, up to a maximum of 25 cm H(2)O. At each step, GI was detected by epigastric auscultation. The recorded data were age and weight. At each step, the inspiratory pressure, the respiratory rate, the expired tidal volume, the minute ventilation, and the occurrence of GI were also recorded. RESULTS: GI occurred in 78 children. GI occurred in 95% of children younger than 1 year, in 93% of children aged 1 to 5 years, and 56% of children older than 5 years (P = 0.001). The pressure threshold at which GI occurred increased with age: the younger the child, the lower the GI pressure threshold. Tidal volume increased with inspiratory pressure, but at >15 cm H(2)O, tidal volume did not change significantly. CONCLUSION: The inspiratory pressure threshold at which GI can occur depends on age. It is low in infants and increases with age. In most cases, proper ventilation without GI was obtained with an inspiratory pressure

Target-controlled inhalation induction with sevoflurane in children: a prospective pilot study.

BACKGROUND: Target-controlled inhalation induction (TCII) with sevoflurane is becoming possible with new anesthesia platforms. Although TCII has already been performed in adults, it remains to be evaluated in children. METHODS: In a prospective study, we compared TCII using the Felix AInOC anesthetic station (Taema, Anthony, France) to our standard protocol inhalation induction in children scheduled for elective surgery under general anesthesia. After preoxygenation, sevoflurane induction was performed in both groups without priming of the circuit. Sufentanil was administered after venous line placement. RESULTS: In the TCII group, no overdosage or underdosage was observed except in two children where TCII failed owing to high agitation, and the number of adjustments was lower compared with our standard protocol inhalation induction (1(1-2.5[0-5]) vs 6(5-6[4-10]) respectively). Moreover, the delay to obtain target end-tidal sevoflurane concentration was shorter in the TCII group (2(1.6-2.7[1.3-4]) min vs 3.4(2.5-3.8[2.3-6.5]) min respectively). No significant difference in the delay of loss of consciousness or in the conditions for intubation or laryngeal mask placement was observed between the groups. CONCLUSION: The Felix AInOC allows TCII to be performed satisfactorily in children. Manual inhalation induction induced a higher number of adjustments and overdosages.

Postoperative cystography and endoscopic treatment of low-grade vesicoureteral reflux.

INTRODUCTION: The endoscopic subureteral injection of tissue-bulking agents has become an established alternative to long-term antibiotic prophylaxis and open surgery with a high success rate, especially for low-grade reflux (>90%). Though it is recognized that a routine postoperative voiding cystourethrography (VCUG) is unnecessary following a ureteroneocystostomy, most teams perform one after an endoscopic treatment. MATERIALS AND METHODS: In this paper, we report on our experience with the endoscopic correction of vesicoureteral reflux in 72 ureteral units, for whom no routine postoperative cystography was performed. DISCUSSION: Two children presented with postoperative recurrent febrile urinary tract infections (UTIs), which were not correlated with cystography findings. Postoperative VCUGs after a ureteroneocystostomy are invasive and expose the child to radiation, they are associated with a substantial cost, and most of all, they do not allow the identification of those patients at risk of recurrent febrile UTIs. Further, the endoscopic subureteral injection of tissue-bulking agents have been used for several years, and numerous studies, set in various clinical settings, have since been published, confirming excellent long-term results for low-grade reflux. CONCLUSIONS: We feel that postoperative cystograms should be reserved for children who present with recurrent UTIs, new sonographic abnormalities, or who were treated for high-grade reflux.

Clinical assessment of the laryngeal tube in pediatric anesthesia.

BACKGROUND: The aim of this study was to evaluate a new device for airway management in children: the laryngeal tube (LT). METHODS: The LT is available in sizes S0-S3 for pediatric anesthesia. This prospective open study included 70 children ASA 1. The local Ethics Committee approval and parental consent were collected. The primary criterion was the success rate for insertion and ventilation. Secondary criteria were additional maneuvers and incidents elicited from LT use. RESULTS: Seventy children were included: S0 = 5, S1 = 8, S2 = 36, and S3 = 21. Insertion was successful: at the first attempt in 78.6%, second in 17.1%, and third or more in 4.3%. In 12% of cases it was not possible to successfully insert the LT and proceed to adequate ventilation. Failures were explained by: inability to obtain satisfying ventilation (n = 4), hypoxemia (n = 1), gastric insufflation (n = 6), cough (n = 1), and laryngospasm or stridor (n = 2), some with the same child. Minimal additional maneuvers for adequate ventilation were necessary in 35% of cases (all groups), but <20% when considering only sizes 2 and 3. Moreover, after five cases, the anesthesiologists became more proficient at inserting the LT (respectively 73.3% failure before five cases vs 13% afterwards). Gastric insufflation occurred in eight cases (11.4%). Controlled ventilation was used in 30 children and peak inspiratory pressure was 19.2 +/- 4 cmH(2)O. CONCLUSIONS: The LT is not recommended for children <10 kg. Over 10 kg, it provides a clear airway in most children, with a low rate of minimal additional maneuvers for sizes 2 and 3. The failure rate also decreases with the operator's training.