OBJECTIVE:The purpose of the present study was to compare how many inflate and deflate are necessary to maintain the endotracheal tube cuff pressure between 15 and 35 cm H₂O by using air, O₂-N₂O mix or saline solution. STUDY DESIGN:Randomized and prospective study. PATIENTS AND METHODS:Ninety children from 1 month to 15 years of age were included in the study. All patients were ventilated with O₂50%-N₂O50%. Subsequently, the patients were divided in three groups: (1) Group 1: patients with air inflated cuffs; (2) Group 2: patients with O₂-N₂O mix inflated cuffs; (3) Group 3: patients with saline solution inflated cuffs. In all groups cuffs were inflated to reach an intracuff pressure of 20 cm H₂O. The cuff pressure was then monitored every 10 minutes and adjusted to be between 15 and 35 cm H₂O. Laryngeal and tracheal symptoms were noted in the recovery room. RESULTS:The three groups of patients were similar for age, weight, and sex. The length of surgery was significantly longer in Group 3. The deflate rate was higher in Group 1 (60%) than in Group 2 (10%) or 3 (3.3%) (p<0.0001). The inflate rate was higher in Group 2 (76.6%) than in Group 1 or 3 (both 3.3%) (p<0.0001). Side effects were comparable in the three groups of patients. CONCLUSION:Using air or O₂-N₂O mix to inflate cuffs is not reliable. SSI helps to maintain a more stable cuff pressure but monitoring is difficult and sometimes contraindicated by tracheal tubes producers. Inflating cuffs with air and regularly monitoring pressure is the most reliable and easiest technique.

Procedural sedation and analgesia for children is widely practiced. Since 2005 to 2007, we evaluated the safety and efficacy of ketamine to control pain induced by diagnostic procedures in pediatric oncology patients. Eight hundred fifty procedures were carried out in 125 patients aged 2 to 16 years. We associated EMNO (inhaled equimolar mixture of nitrous oxide and oxygen), atropin (oral or rectal), midazolam (oral or rectal) and ketamin (intravenous). An anesthesiologist injected ketamin. Average dose of ketamine was 0.33 to 2 mg/kg depending on number and invasiveness of procedures. This method requires careful monitoring and proper precautions. With these conditions, no complication was observed. All patients were effectively sedated. These results indicate that ketamine - in association with EMNO, atropine and midazolam - is safe and effective in pain management induced by diagnostic procedures in pediatric oncology patients. The sedative regimen of intravenous ketamine has greatly reduced patient, family and practitioners anxiety for diagnostic and therapeutic procedures.

Procedural sedation and analgesia for children is widely practiced. Since 2005 to 2007, we evaluated the safety and efficacy of ketamine to control pain induced by diagnostic procedures in pediatric oncology patients. Eight hundred fifty procedures were carried out in 125 patients aged 2 to 16 years. We associated EMNO (inhaled equimolar mixture of nitrous oxide and oxygen), atropin (oral or rectal), midazolam (oral or rectal) and ketamin (intravenous). An anesthesiologist injected ketamin. Average dose of ketamine was 0.33 to 2 mg/kg depending on number and invasiveness of procedures. This method requires careful monitoring and proper precautions. With these conditions, no complication was observed. All patients were effectively sedated. These results indicate that ketamine - in association with EMNO, atropine and midazolam - is safe and effective in pain management induced by diagnostic procedures in pediatric oncology patients. The sedative regimen of intravenous ketamine has greatly reduced patient, family and practitioners anxiety for diagnostic and therapeutic procedures.

Background:  There is anecdotal evidence of changes in pediatric regional anesthesia (RA) practice. We performed a retrospective review of prospective data on pediatric RA over 17 years in our institution.

Les douleurs induites par les soins sont un problème quotidien en hématologie oncologie pédiatrique. Face à la répétition des myélogrammes et ponctions lombaires, certains enfants développent des comportements phobiques rendant l'anesthésie générale incontournable.L'équipe rennaise d'hématologie oncologie pédiatrique a mis en place un protocole de sédation vigile par kétamine et a recueilli de manière prospective des données concernant la sécurité et l'efficacité de ce médicament utilisé seul (avec la crème lidocaïne/prilocaïne) par des médecins non anesthésistes. De plus, des données subjectives à partir d'un questionnaire concernant le vécu de l'équipe soignante a été réalisé après 18 mois d'utilisation afin d'évaluer la faisabilité du protocole.L'évaluation a eu lieu sur une période de 17 mois durant lesquels 115 gestes ont été réalisés sur 48 patients âgés en moyenne de 7,4 ans et pour la plupart atteints d'une hémopathie maligne. La kétamine est un médicament sûr à conditions de respecter l'absence d'association à d'autres médicaments par voie générale (prémédication ou chimiothérapie). L'ajout du MEOPA augmente les effets secondaires (type vomissements) et la surveillance doit être prolongée (intervalle libre entre effet secondaire hémodynamique ou respiratoire et injection). Les patients sont satisfaits de ce protocole à 90,9 %, la douleur ressentie pendant et au décours est minime (89,5 % FLACC < 4/10 pendant et 96,6 % FLACC/EVA < 4/10 après) et on obtient une amnésie dans 78 % des cas. Les infirmiers sont globalement satisfaits (n = 20/22) mais expriment des difficultés d'ordre organisationnel (matériel, durée de surveillance). De plus, certains affirment que les techniques non médicamenteuses sont moins utilisées depuis la mise en place du protocole kétamine.La kétamine est une bonne alternative à l'anesthésie générale mais ne doit pas être généralisée pour tous les gestes douloureux du fait de la lourdeur de ce soin et des conséquences encore mal connue de son utilisation de manière répétée.Pain management during invasive procedures is a current issue pediatric oncologists have to face up to. Because of repetitive bone marrow aspirations or lumbar punctions, children develop phobic behavior, therefore general anesthesia sometimes becomes unavoidable.A sedation protocol using ketamin has been performed in a monocentric prospective study in order to determine the security and efficacy of this drug used by non anesthesiologists only associated with licocain/prilocain patch. Moreover subjective data were collected from a questionnaire proposed to nurses after 18 months of utilization of the "ketamin protocol".The study took place over 17 months during which 115 procedures were performed on 48 patients of an average age of 7.4 years old. Most of them were treated for hematological malignancies. Ketamin is a secure drug as long as there is no systemic associated medication (sedation ou chemotherapy drugs). The risk of side effect such as vomiting is increased when associated with MEOPA. Monitoring must be extended because of the interval between ketamin injection and side effects. Patients are satisfied with this protocol (90.9%), pain is under control during and after the procedure (89.5% FLACC < 4/10 during and 96.6% FLACC/EVA < 4/10 after). Amnesia is obtained for 78% patients. Nurses are satisfied (n = 20/22) but they report some organizational problems (material, time of monitoring). Moreover some of them explained that non-medical therapeutics such as hypnosis or distraction are underused since "ketamine protocol".Ketamin is a good alternative to general anesthesia for invasive procedures in paediatric oncology but cannot be generalized because of organizational problems related to monitoring and unknowledgement about consequences of a repetitive use.

Background: Spinal anesthesia (SA) remains the 'gold standard' in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects.Methods: We conducted a prospective observational study of 124 infants undergoing herniorrhaphy under SA with bupivacaine and clonidine. Two cohorts, term (n = 57) and former preterm (n = 67) infants, were evaluated and compared with regard to episodes of apnea, desaturation, and bradycardia within 24 h of SA.Results: In both groups, postoperative desaturation episodes were unchanged after SA, compared with the 12 preoperative hours, despite significantly increased apnea (P < 0.003 and < 0.011 respectively). Transient bradycardias occurred in former preterm infants (P < 0.014): they spontaneously resolved in all cases. Mean arterial pressure did not vary during the study. Upper sensory level of SA, sedation on entering the postanesthesia care unit (PACU) and duration of stay in the PACU were similar in both groups.Conclusions: The clinical significance of short apneas, recovering spontaneously without desaturation, remains debatable. It is concluded that addition of clonidine to neonatal SA results in acceptable side effects. Side effects must be compared with the potential advantages before future recommendations.

BACKGROUND:Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children.METHODS:After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months.RESULTS:Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome.CONCLUSION:Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.

L'efficacité et la sécurité des immunoglobulines intraveineuses sont explorées avec attention depuis 1970. Les indications reconnues actuellement en hématologie relèvent pour l'essentiel du traitement substitutif des déficits immunitaires primitifs ou secondaires d'une part, de leur effet immunomodulateur au cours d'hémopathies auto-immunes avec pour modèle les purpuras thrombopéniques auto-immuns d'autre part. L'indication longtemps consensuelle que représentait l'allogreffe de cellules souches géno-identiques est désormais abandonnée. Les mécanismes d'action évoqués incluent le blocage du récepteur Fc, un effet anti-idiotypique, la neutralisation d'endotoxines bactériennes et la modulation de la production de cytokines. Le risque de transmission infectieuse, à ce jour essentiellement viral, de ce produit dérivé du sang souligne l'importance de la qualité des indications pour ces produits par ailleurs fort coûteux.The efficacy and the safety of intravenous immunoglobulins (IVIG) have been attentively explored since 1970. Their mechanisms of action involve the Fc-receptor blockade, the neutralization of microbial toxins, and the modulation of cytokine production. Their indications depend both on their replacement and immuno-modulation abilities. They include primary antibody deficiencies, secondary hypogammaglobulinemic states with serious repetitive infections, and autoimmune disorders such as the immune thrombocytopenic purpura, whereas IVIG are no more systematically used in sibling hematopoietic stem cell transplantation. Despite major precautions in the manufacturing process, there is still a possible transmission of hitherto unrecognized or recognized infective agents for blood-derived preparations. This emphasizes the need of excellent indications for these expensive products.

UNLABELLED:Spinal anesthesia may reduce the incidence of morbidity that follows general anesthesia in neonates and in former preterm infants. However, bupivacaine alone provides a block too short for complete surgery in up to 40% of the patients. Clonidine lengthens spinal anesthesia in adults and caudal block in children without significant side effects. We conducted a controlled, prospective, dose-ranging study of clonidine in spinal anesthesia in 75 neonates, including 50% of former preterm infants, undergoing elective inguinal herniorrhaphy. Patients were given a spinal anesthetic with either 0.5% plain isobaric bupivacaine (1 mg/kg), or bupivacaine plus 0.25, 0.5, 1, or 2 micro g/kg clonidine. Mean arterial blood pressure, heart rate, SpO(2), sensory block extension and duration were the main data recorded. Mean arterial blood pressure, heart rate, SpO(2), and block extension were similar in the five groups. Duration of spinal block increased from 67 (58-82) min in the control group up to 111 (93-125) min in the group receiving 1 micro g/kg clonidine (P < 0.003). Transient hypotension occurred more often (P < 0.05), and caffeine was given more often, when 2 micro g/kg clonidine was given. We conclude that 1 micro g/kg clonidine provides a significant improvement in spinal anesthesia duration in newborns without significant side effects. IMPLICATIONS:Spinal anesthesia is suitable but often too short for complete surgery in newborns. This controlled, randomized, prospective, dose-ranging study was conducted in 75 neonates to test the hypothesis that clonidine could significantly lengthen bupivacaine spinal block. Clonidine 1 micro g/kg, added to spinal isobaric bupivacaine, doubles the duration of the block without significant deleterious hemodynamic or respiratory side effects.

UNLABELLED:Femoral shaft or hip surgeries are very painful for children. We conducted both computed tomographic (CT) and clinical prospective studies to define new landmarks in children and to evaluate the effectiveness of continuous psoas compartment blocks (CPCBs) using disposable elastomeric pumps. In a preliminary CT scan study of 20 patients, the plexus depth was correlated to patient age and the optimal point of puncture for CPCB was three-quarters of the distance from the spinous process of L4 to a line parallel to the spinal column passing through the posterior superior iliac spine. In a subsequent prospective series, a CPCB was administered before surgery to 15 children for pain relief after femoral and hip osteotomies. After general anesthesia, a 0.5 mL/kg bolus of a mixture of 1% lidocaine with epinephrine (1/200.000) and 0.5% ropivacaine was injected through the CPCB catheter. After contrast media assessment of the catheter location, a disposable pump (Infusor LV); Baxter, Paris, France) with 0.2% ropivacaine was connected and pump flow was adjusted to the patient's weight (0.2 mg x kg(-1) x h(-1)). Postoperative pain was evaluated using a visual analog scale or the Children and Infants Postoperative Pain Score at hour H1, H6, H12, H18, H24, H36, and H48, and in terms of rescue analgesia, adverse events, and motor blocks. All blocks were effective during surgery. Postoperative analgesia was excellent. The median pain scores were 1 for H1 and 0 beginning H6. The motor blockade was minimal before 24 h and absent thereafter. No major adverse event was noted. Parents of 93% of the children were satisfied. We conclude that postoperative analgesia with CPCB is a very effective technique in children after major proximal lower limb orthopedic surgery. The CT scan landmarks described in this study were more medial than the conventional landmarks used in the literature. IMPLICATIONS:Continuous psoas compartment blocks provide optimal pain relief in children after major orthopedic surgery without major adverse events. The landmarks used, defined in a preliminary computed tomographic scan study, were more medial than conventional landmarks.

Continuous peripheral nerve blocks (CPNB) after pediatric major orthopedic surgery are not widely used. We conducted a prospective descriptive study to evaluate the effectiveness of disposable elastomeric pumps for CPNB in children. After inducing general anesthesia, 25 consecutive children scheduled for major orthopedic surgery received a 0.5-mL/kg bolus of a mixture of 1% lidocaine with epinephrine and 0.25% bupivacaine in axillary, femoral, or popliteal catheters. After surgery, disposable pumps with 0.2% ropivacaine were connected. Pump flows were adjusted to the. patient's weight. Postoperative pain was evaluated using a visual analog scale or Children and Infants Postoperative Pain Scale scores at H1, H6, H12, H24, and H48, as well as amounts of rescue analgesia, adverse events, and motor and sensory block. An ambulation score for the children was also evaluated. Eleven popliteal, nine femoral, and five axillary continuous blocks were performed. All the blocks were effective for surgery. The mean total dose consumption of 0.2% ropivacaine was 10.1 mg/kg. Disposable pump flow varied from -9.61% to +8.6% compared with the theoretical one. Postoperative analgesia was excellent. The median of pain score was zero at each period studied. Sensory and motor block were noted at H1 and decreased from the sixth hour. No adverse events were noted. We concluded that the use of elastomeric disposable pumps for CPNB in children was an effective technique.

In Brief IMPLICATIONS: Continuous infraclavicular brachial plexus blocks provide optimal anesthesia and analgesia in children.

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Paediatric Anaesthesia and Intensive Care

Background: Myocardial trauma has been described during gastroesophageal reflux laparoscopic surgery, in association with the proximity of cardiac structures. In addition, specific haemodynamic changes induced by CO2 pneumoperitoneum could exacerbate perioperative cardiac complication even in patients without cardiac risk factors. The aim of this study was to evaluate the influence of gastroesophageal reflux laparoscopic surgery on the perioperative ECG, cardiac troponin I and myocardial enzyme changes.Methods: Forty‐two ASA I–II patients without ischaemic heart disease or combined double‐risk factors were studied. Automated ST segment analysis was used intraoperatively. ECG, plasma myocardial enzyme and cardiac troponin I concentrations were reported on arrival in the recovery room (H0), 4 h (H4) and 24 h (H24) postoperatively.Results: Intraoperative ST segment changes occurred in two patients: the first during a hypotensive episode (MAP<55 mmHg; 3/42 patients) and the second during a hypertensive episode (MAP >110 mmHg; 3/42 patients). One case of intraoperative subcutaneous emphysema occurred without ST disturbance. One case of pneumothorax was observed at H0–H4 in another patient without clinical symptoms. Cardiac troponin I and CK‐MB were not increased postoperatively. Transaminase concentrations increased (2‐fold normal values) in 26/42 patients. In these 26 patients, 7 experienced 5‐fold isolated transaminase increase, associated with left hepatic artery section.Conclusion: According to perioperative ECG changes and/or specific cardiac troponin I measurements, we did not identify specific myocardial damage following gastroesophageal reflux laparoscopic surgery. Unexpectedly, the incidence of hepatic cytolysis was frequent (62%) and has not previously been reported in the literature.