[Comparison of the analgesic efficacy of EMLA 5% cream and lidocaine infiltration for biopsy of the genital mucosa]. / Comparison de l'efficacité analgésique d'EMLA 5 p. 100 crème et de l'infiltration de lidocaïne pour les biopsies des muqueuses génitales.

OBJECTIVE: To compare the analgesic efficacy of EMLA 5 p. 100 cream versus Xylocaïne 1 p. 100 infiltration for biopsies of the genital mucosa. PATIENTS AND METHODS: 63 adult patients were randomized. EMLA (0.3-5 g) was applied during 7-12 minutes, and Xylocaïne 1 p. 100 (0.2-5 ml) was infiltrated 0-10 minutes before biopsy. Pain during the anaesthetic procedure and the biopsy was assessed by the patient using a Visual Analogue Scale. RESULTS: Pain scores were significantly lower with EMLA application than Xylocaïne infiltration, but infiltration resulted in better surgical anaesthesia. The combined pain scores (anaesthetic procedure and biopsy) were lower in the EMLA group, but this difference failed to reach statistical significance. CONCLUSION: EMLA is a less painful anaesthetic procedure than infiltration, but has a lower analgesic efficacy. EMLA can be used as an alternative to infiltration for biopsies of the genital mucosa.

[EMLA analgesic cream for venopuncture during anesthetic induction in children]. / Crème analgésique EMLA pour la ponction veineuse lors de l'induction anesthésique chez l'enfant.

A prospective study was designed to assess the quality of skin analgesia provided by the EMLA anaesthetic cream, an eutectic mixture of local anaesthetics (prilocaine and lidocaine). The children, aged 3 months to 15 years, and scheduled for genital and urinary surgery, were allocated to two groups, those aged less than or equal to 5 years (35 +/- 14 months, n = 17), and those aged greater than 5 years (97 +/- 26 months, n = 22). The cream (1.6 +/- 0.6 g) was applied by a nurse in the ward as a thick layer on the area of skin to be anaesthetised (on the dorsum of the hand and at the elbow), and covered by a closed adhesive dressing. This required 2.6 +/- 1.7 min, and was considered to be very easy (72%) or easy (28%). The venepuncture (22 or 20 gauge catheter) was carried out by one of the seven anaesthetists of the paediatric surgical units, 92 +/- 51 min after the cream had been applied. The children aged less than or equal to 5 years complained of pain of intensity 7.5 +/- 2.2 (CHEOPS scale, range 4 to 13) and, for those aged greater than 5 years, 24 +/- 21 on a visual analogic scale (range 0 to 100). Local adverse effects occurred in ten patients (skin paleness, erythema, or both). It was concluded that EMLA cream provides convenient analgesia for venepuncture in toddlers and children.

[Clinical study of EMLA analgesic cream in pediatric locoregional anesthesia]. / Etude clinique de la crème anesthésique EMLA en anesthésie locorégionale pédiatrique.

The advantage of EMLA cream for regional blocks (spinal or caudal blocks) was assessed in 46 children. The study included three groups: group 1, with 1 to 6 month-old children (n = 11); group 2, with children aged between 6 months and 5 years (n = 21), scheduled for emergency surgery and with full stomach; group 3, with 5 to 10 year-old children (n = 14), who were to have a regional block as an alternative to general anaesthesia. The cream was applied as a thick layer on the area of skin to be anaesthetised and covered by a closed adhesive dressing, approximately 2.2 h before performing the regional block. A dose of 1 to 2 g was used in children of more than 1 year, and 0.5 to 1 g for those of less than 1 year. All the blocks were carried out by the same anaesthetist. The technique was considered as being little (45/46) or not constraining (1/46). Patient cooperation in carrying out the regional block was judged to be good or very good in 34/46 children. Additional sedation was required in 7 children of groups 2 and 3. The block was as easy to carry out as usual in 37/46 children. In all three groups, most children complained of little or no pain. Local adverse effects occurred in 19/46 patients, consisting of erythema (14), skin paleness (4), or both (1). The investigator qualified the use of EMLA cream as satisfactory or very satisfactory in 36/46. It is concluded that EMLA cream provides convenient analgesia for regional blocks in toddlers and children.

Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis.

Between 1980 and 1986, 80 infants (less than or equal to 3 months old) with symptomatic aortic coarctation and associated severe tubular hypoplasia of the transverse aortic arch underwent surgical treatment. Extended end-to-end aortic arch anastomosis was used in an attempt to correct both the isthmic stenosis and the hypoplasia of the transverse arch. After complete excision of the coarctation tissue, a long incision was made in the inferior aspect of the aortic arch, which was then anastomosed to the obliquely trimmed distal aorta. Pure coarctation was present in 17 patients (group I); 24 infants had an additional ventricular septal defect (group II), and 39 patients had associated complex heart disease (group III). The overall early mortality rate was 26% (confidence limits 21% to 32%) (18% in group I, 17% in group II, and 36% in group III). The early risk declined with time and was 18% (confidence limits 12% to 26%) for the last 2 years (seven deaths in 39 patients). Follow-up was 100% for a mean of 19 months. Actuarial survival rate at 3 years was 82% for group I, 78% for group II, and 32% for group III. Recurrent coarctation (gradient greater than or equal to 20 mm Hg) occurred in six operative survivors (10%, confidence limits 6% to 16%) and necessitated reoperation in three. Freedom from recoarctation at 4 years was 88%. Because extended end-to-end aortic arch anastomosis provides adequate correction of the aortic obstruction and entails a low risk of restenosis, it is our procedure of choice in infants with coarctation and severe hypoplasia of the aortic arch.

Coarctation of the aorta in infants: which operation?

In this series, 178 infants (age, less than or equal to 3 months old) underwent repair of aortic coarctation. Pure coarctation was present in 63 patients (Group 1), 47 infants had additional ventricular septal defects (Group 2), and 68 patients had associated complex heart disease (Group 3). Subclavian flap angioplasty was used in 26 patients, limited resection and end-to-end anastomosis in 45 patients, extended resection and end-to-end anastomosis in 99 patients, and miscellaneous procedures in 8 infants. The early mortality was 8% for the first group, 11% for the second group, and 37% for the third group (p less than 0.001). Mean follow-up was 32 months and included 97% of patients. Actuarial survival at five years was 90% for the first group, 84% for the second group, and 40% for the third group. Recoarctation occurred in 15 operative survivors (11%); 7 necessitated reoperation. Freedom from recoarctation at five years was 89% after subclavian flap angioplasty, 81% after end-to-end anastomosis, and 86% following extended resection and end-to-end anastomosis. Early mortality and late results were not influenced by the type of coarctation repair but were determined by the clinical status and the presence of associated major cardiac anomalies. These results suggest that the surgical procedure should be individualized for each infant to optimize the aortic anatomy.

Anomalous left coronary artery from the pulmonary artery in infants. Which operation? When?

The surgical management of anomalous left coronary artery from the pulmonary artery in infants and small children remains controversial, because the ideal surgical procedure and the optimal time for operation are yet to be determined. From 1977 to 1985, 22 patients less than 4 years of age (mean age 18.2 months) underwent direct aortic reimplantation of the anomalous left coronary artery. There were five operative deaths (23%, confidence limits 13%-36%). The determinant risk factor of early mortality was the severity of preoperative left ventricular dysfunction (p = 0.05), not age at operation (p = 0.64) or preoperative clinical status (p = 0.36). There were not late deaths (mean follow-up 38 months). All survivors but one were symptom free. The reimplanted anomalous left coronary artery was patent in each reevaluated case (9/17). Left ventricular function improved significantly in all survivors. Moderate to severe preoperative mitral incompetence lessened in all patients but one, without mitral valve repair. When technically feasible, direct aortic reimplantation of the anomalous left coronary artery is an attractive procedure because it offers a high rate of patency and avoids the potential drawbacks of procedures involving autogenous venous or arterial tissue. Optimal intraoperative myocardial preservation and institution of temporary left ventricular assistance at the end of the operation may decrease the operative risk. Left ventricular function nearly always recovers after successful revascularization, and resection of left ventricular myocardium is rarely indicated, if ever. Mitral incompetence almost always lessens, and the mitral valve should not be repaired at initial operation; however, residual mitral incompetence may necessitate reoperation in a few cases. In infants with moderate left ventricular damage (usually asymptomatic with medical therapy), surgical treatment should be delayed until 18 to 24 months of age so that it can be performed with a low operative risk. Infants with severely impaired left ventricular function and persistent congestive heart failure should probably undergo operation as soon as the diagnosis has been made.

[Induction anesthesia in the child]. / Induction anesthésique chez l'enfant.

The anesthesic induction in children must be technically carefully performed, but also in the child's mind. Inhalation has the advantage to be painless and easy to perform. It seems more advisable to allow the child to choice his own kind of induction. The experience of our institution is reported.

Late results after left-sided cardiac valve replacement in children.

Selection of types of cardiac valve substitutes for children remains controversial. Between 1976 and 1984, 166 children, 15 years of age or younger, underwent aortic (N = 53) or mitral valve replacement (N = 90) or both (N = 23). Biological prostheses were used in 84 patients and mechanical prostheses in 71; both a mitral bioprosthesis and an aortic mechanical valve were used in 11 patients. The overall early mortality was 9%. Mean follow-up intervals were 4.1 years for the bioprosthesis group, 3.3 years for the mechanical valve group, and 3.5 years for the group receiving both. The 7 year survival rates (+/- standard error) were 63% +/- 6% in the bioprosthesis group and 70% +/- 7% in the mechanical valve group (p = NS). After aortic valve replacement the 7 year survival rates were 66% +/- 14% (bioprosthesis group) and 77% +/- 9% (mechanical valve group) (p = NS); after mitral valve replacement the rates were 65% +/- 7% (bioprosthesis group) and 54% +/- 17% (mechanical valve group) (p = NS). The incidence of thromboembolic events was 0.6% +/- 0.4% per patient-year in the bioprosthesis group (none after aortic valve replacement, 0.8% +/- 0.6% per patient-year after mitral valve replacement) and 1.4% +/- 0.8% per patient-year in the mechanical valve group (0.7% +/- 0.7% per patient-year after aortic valve replacement, 4.0% +/- 2.8% per patient-year after mitral valve replacement) (p = NS). The linearized rates of reoperation were 10.4% +/- 1.8% per patient-year (bioprosthesis group) and 2.3% +/- 1.0% per patient-year (mechanical valve group) (p less than 0.001). The 7 year probability rates of freedom from all valve-related complications were 43% +/- 6% in the bioprosthesis group and 86% +/- 4% in the mechanical valve group (p less than 0.001). In the aortic position, a mechanical adult-sized prosthesis can always be implanted, and satisfactory long-term results can be anticipated. In the systemic atrioventricular position, the results are less than satisfactory with either type of prosthesis; every effort should be made to preserve the natural valve of the child.

[Spontaneous rupture of the ascending aorta. A surgically treated case]. / Rupture spontanée de l'aorte ascendante. Un cas traité chirurgicalement.

Rupture of the ascending aorta may follow thoracic trauma or complicate an aortic aneurysm or acute dissection. It is otherwise extremely rare. The authors report a case of spontaneous rupture of the ascending aorta occurring in a patient with a pre-existing incomplete rupture of the ascending aorta, and treated surgically. The clinical presentation was of acute dissection with pericardial effusion. This diagnosis was excluded by aortography with multiple views which showed abnormalities of the aortic wall: an abnormal notch, continuity of the internal wall and extravasation of the contrast medium. These abnormalities are often minimal but should be recognised and surgery proposed as this is the only chance of a favourable outcome.