Anesthésie des enfants en dehors du bloc opératoire : les expériences allemande et québécoise

The authors describe the way pediatric anesthesia is organized outside the operating theatre in their country. In Germany, children can be anesthetized outside the operating theater in the hospital but also outside the hospital according to the concept of office-based anesthesia. National recommendations have been published and their revision is currently underway. In Quebec, pediatric anesthesia outside the operating theatre are well organized in order to ensure quality of care, patient's safety and efficiency of the system.     

Anesthésie et prééclampsie

An assessment of the patient must take place as early as possible in view of anaesthesia. It is recommended to perform a clotting screen as close as possible to the performing of an epidural anaesthesia.     

Anesthésie locorégionale chez le patient obèse

Objective

To detail specificity of regional anaesthesia techniques in the obese patient.

Data sources

Articles were selected from Medline database using the combination of the following keywords: obesity, peripheral nerve block, spinal anaesthesia, epidural, morbidity, mortality.

Study selection

Most recent original articles or review have mainly been selected. Some case reports that highlighted specific points were added.

Data extraction

Articles were analyzed for advantages and drawbacks, and risks of different techniques in obese patient.

Data synthesis

Techniques avoiding obese patient's mobilization are recommended. The use of skin landmarks may be challenging for both central and peripheral blocks. Ultrasound techniques should improve block performance, even though deep fat layers seem limit sound diffusion. Success rate and incidence of complications are usually increased after regional anaesthesia technique in obese patient. The reduction of intrathecal local anesthetic dose remains controversial in this population.

Conclusion

Regional anaesthesia techniques could represent an alternative to general anaesthesia (less cardiorespiratory complications). However, many specific considerations have to be taken into account.     

Photographie épidémiologique d’une année d’anesthésie pédiatrique en France

Introduction

Nowadays, the epidemiological data on French pediatric anesthesia is limited. The purpose of this study was to perform an “epidemiological picture” of this activity.

Material and method

From the national Program Information System Medicalization, we have identified the institutions of France performing more than 50 anesthesia by year in children under 15 years in 2008 and noted the demographic data, types of institutions, hospital stay and surgeries.

Results

Seven hundred and eighty-nine thousands and two hundred anesthetic procedures have performed during 648,018 hospital stays in 929 institutions. A percentage of 68.4% of children were between 3 and 15 years old, 26.7% between 1 and 3 years, 4.1% between 1 year and 1 month and 0.8% less than one month, including 62% of boys and 38% of girls. A percentage of 53.6% of hospital stays were realized in private institutions, 20.9% in University Hospitals (UH), and 20.4% in General hospitals (GH), mainly in day-case surgery (60%), 15.2% in stay of 24 h and 24.8% in full hospital stay (FHS). The main surgeries were ENT (29%), digestive (21%), orthopedic (14%), urology (12%) and plastics (9%). Children less than 1 year old were managed by University Hospital and during FHS. Older children were managed in private institution and during day-case surgery.

Conclusion

Over 50% of stays with anesthesia were performed in private institution and during day-case surgery. Controversially, the management of children younger than 1 year was mainly in University Hospital.     

Anesthésie et hypertension artérielle pulmonaire chez l’enfant en chirurgie non cardiaque

Paediatric pulmonary arterial hypertension (PAH) is a challenge for the paediatric anaesthetist. Due to its high morbidity and mortality, support should be provided by a dedicated team. Understanding the pathophysiology of PAH allows performing an appropriate therapeutic approach. In case of high vascular pulmonary resistance, the main objectives of anaesthetic management are to maintain an optimal pulmonary flow and to avoid the decrease in systemic arterial pressure. Haemodynamic monitoring is essential to detect the onset of an acute PAH crisis but also to give direct information on the efficacy of treatment.     

Amélioration transitoire d’un syndrome Parkinsonien après anesthésie générale

We describe the case of a patient with an untreated Parkinson's disease who underwent surgery for a temporal meningioma. Extrapyramidal syndrome, initially attributed to the meningioma, had improved over the 48 hours following the procedure and then reappeared. This observation raises the question about the impact of drugs used during perioperative days in patients with Parkinson's disease not treated with levodopa.     

Anesthésie pour traitement des tumeurs endocrines

Endocrine tumors could be defined by their ability to produce structural proteins or hormones commons to nervous and endocrine cells. They might induce physiological transforms or outcome adverse events which should be well known in order to prevent or treat them early. The goal of this review was to describe these changes, to describe preoperative assessment, and to discuss intraoperative monitoring and drugs choice based on the literature from the last 30 years. As an example, it should be noticed that: (1) preoperative blood pressure control is essential to prepare phaeochromocytoma for surgery. It should be followed during anaesthesia by intensive fluid load, reversible anaesthetic drugs and rational cardiovascular medications use (as for example remifentanil, sevoflurane, calcium channel blockers and esmolol), and after surgery by narrow clinical and biological monitoring; (2) after medullar thyroid cancer, main adverse events include cervical compressive haematoma and recurrent laryngeal nerve injury as for any thyroid surgery; (3) during pituitary surgery, air embolism might be expected, whereas water dysregulation (diabetes insipidus), corticotroph insuficiency, cerebrospinal fluid (CSF) leak might occur postoperatively. In acromegaly, difficult endotracheal intubation is possible whereas severe Cushing's syndrome may be complicated with hypertensive cardiac failure, infections, thrombosis, delayed cicatrisation; (4) somatostatine analogs are a keystone in carcinoid tumors preoperative and anaesthetic management.     

Chirurgie éveillée des gliomes cérébraux : plaidoyer pour un investissement accru des anesthésistes

The recent development of awake surgery in neuro-oncology allowed a conceptual change, i.e. the realization of resection for invasive brain tumors according to functional and not anatomic boundaries. This paradigmatic shift enabled a significant improvement of results in surgery for gliomas, by opening the door to resections within eloquent areas classically considered as “inoperable”, while preserving and even improving the quality of life of patients. In addition, the extent of resections has been maximized, leading to an increase of median survival – especially in low-grade gliomas. Strong relationships between the different teams (surgeons, neuropsychologists, anaesthesiologists) are crucial for the development and improvement of awake surgery. Thus, it seems important that anesthesiologists can benefit from a clear and accurate knowledge of the real contribution of this procedure, in order to better evaluate the balance between the theoretical risks of surgery under local anesthesia versus the actual risk of not performing resection with a maximum of safety and efficiency for the patients. The purpose of this plea is to advocate the spread of awake surgery in routine practice, due to its major impact on both functional and survival outcomes, by nonetheless keeping in mind that a multidisciplinary staff is mandatory for selection of patients as well as into the operating room. In this state of mind, anaesthesiologists have to play a central role, through an increased involvement in this field.     

Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

Plastic surgery is more and more developing. Facial blocks are adapted to surgical procedures performed in this setting. They are easy to perform and may prolong postoperative analgesia. Facial blocks may be used in ambulatory surgery as a single technique or combined with general anaesthesia or intravenous sedation. After a reminding of facial nerve anatomy, facial and cervical blocks are described with their indications. Guidelines for performance and monitoring are also indicated.     

Évaluation du Risque CARDiaque de l’Opéré (RICARDO) : enquête nationale auprès des anesthésistes-réanimateurs concernant la prise en charge périopératoire du patient à risque cardiaque

Objectives

Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations.

Materials and methods

Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations.

Results

We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography.

Conclusion

This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.     

Consentement éclairé en anesthésie pédiatrique pour les soins courants et pour la recherche

This short review is aimed at describing the particularities of consent in paediatric patients. For routine procedures, the consent of one of the parents is required whereas both parents should sign the consent for research protocols. In case of difficulties such as Jehovah witnesses or parental opposite opinions, doctors should ask the question to the judge in charge of protection of children. Consent or at least assent of minors enrolled in research protocols should be obtained provided their maturity is sufficient to understand correctly the purpose of clinical research.     

Analgésie postopératoire à domicile : évaluation de la douleur par les parents,information

Postoperative analgesia at home induces necessarily pain assessment by self-report or observational measure. A special scale has been validated for day-case surgery: the PPMP. Nevertheless, children's and parents’ information and education are essential.     

Pour ou contre les halogénés en neuroanesthésie pour chirurgie intracrânienne

Isoflurane, desflurane and sevoflurane all preserve cerebrovascular carbone dioxide (CO₂) reactivity. They are all concentration-dependant cerebral vasodilatators and decrease cerebral metabolism. Sevoflurane induces the smallest cerebral vasodilatation and preserve cerebral autoregulation up to 1.5 CAM, compared to isoflurane and desflurane which impair it upon 1 CAM. Propofol has been compared to inhaled agents. Propofol preserve cerebrovascular CO₂ reactivity, blood flow-metabolism coupling, cerebral autoregulation and has no vasodilatation effect. None of the three inhaled agents induce any clinical relevant increase of intracranial pressure (ICP), but studies were conducted in patients without any intracranial hypertension (ICHT). However, compared to propofol, ICP and brain swelling were higher with inhaled agents, more with isoflurane compared to sevoflurane. Finally, neuroprotective properties have been described in experimental model for all the inhaled agents but clinical proofs are still lacking. In conclusion, for intracranial surgery without any ICHT inhaled agents can be used as a maintenance anesthetic with a preference for sevoflurane. In case of ICHT or a risk of ICHT during the surgery, propofol is preferred for it slightest effect on ICP and cerebral hemodynamic.     

Hémorragie cérébrale chez un enfant asthmatique ventilé : mécanismes multifactoriels

We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.     

Intérêt de l’anesthésie péridurale cervicale dans la gestion périopératoire d’une thyroïdectomie chez une patiente à haut risque anesthésique

Cervical epidural anesthesia is an anesthetic technique that can be useful in patients with high perioperative risk undergoing to cervical surgery. We report the case of a patient of 49 years old with hypertension, diabetes mellitus, epilepsy, left hemiparesis sequelae of stroke and congestive left ventricular failure. The patient underwent total thyroidectomy under cervical epidural anesthesia. No difficulty breathing or decompensation of chronic underlying diseases were noted in the postoperative.     

Anesthésie locorégionale périphérique sous échographie : efficacité de stratégie de décontamination de la sonde

Objectives

The objective of this study was to determine if the ultrasound probe can act as a vector for cross-infection and to compare two cleaning methods for ultrasound probes in order to limit or control the transmission risk.

Study design

Prospective study.

Patients and methods

The first part of the study (P1) was conducted to evaluate the possibility of the ultrasound probe to serve as a source of cross-contamination. Thirty blocks were placed under ultrasound guidance in elective outpatients. After each procedure (Proc), the ultrasound probe was decontaminated/cleaned using either an antiseptic solution spray (AS: n = 15) or just wiped with two dry paper sheets (DP: n = 15), in a randomly assigned order. Bacteriological samples were collected before and after each decontamination/cleaning methods and inoculated on a chocolate agar plates. The second part of the study (P2) was conducted to compare the effectiveness of two cleaning methods for ultrasound probes. The ultrasound probes were exposed to a large inoculum of three bacteria (Inoc). They were then cleaned/decontaminated using either DP (n = 10) or AS (n = 10), in a randomly assigned order. Bacteriological samples were collected before and after each cleaning/decontamination methods and inoculated on a chocolate agar plates.

Results

During P1, after Pro, all probes were found to be sterile before and after both AS and DP. During P2, after Inoc, all probes were found infected (CFU > 150) but were considered sterile (CFU < 10) after both DP and AS.

Conclusion

The results of this study suggest that the risk of cross-infection during ultrasound guidance in locoregional anaesthesia is really low. Our data suggest that wiping ultrasound probe with two dry paper sheets is an adequate cleaning method to prevent cross-contamination risk.     

Association d’une rééducation sous analgésie péri-nerveuse continue et d’une capsulo-distension de l’épaule dans le traitement du syndrome épaule-main rebelle

Objective

Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter.

Material and methods

It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later.

Results

After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment.

Conclusion

After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.     

Accident hypoxique en anesthésie pédiatrique dû à un réglage inadapté du respirateur

A 3-year-old child was anesthetized for ENT examination and surgery. After induction and tracheal intubation, the patient was ventilated (controlled mode). The respirator screen showed information compatible with a failure of intubation: no expired CO₂, no expired flow, no alarm of high pressure limit, and no respiratory chest movement. A fall of SpO₂ appeared rapidly which recovered after extubation and manual ventilation through a face mask and reintubation. The expiratory CO₂ was present when the patient was ventilated manually and disappeared under controlled ventilation. The increase in the value of the maximal insufflation pressure allowed efficient ventilation with an expiratory CO₂ curve and showed high ventilation pressure compatible with a bronchospasme. This case report shows that in case of bronchospasme, if the value of the maximal insufflation pressure is low, this may lead to an erroneous diagnosis of failure of intubation.