Place de l’anesthésie locorégionale dans l’analgésie postopératoire à domicile chez l’enfant

Hospitalization at home has known for the past few years a growing interest in care of patients. It has shown its advantages in children in terms of reducing the stress of parental separation, postoperative infections and the cost of hospitalization. But, pain remains the most common complaint in the postoperative follow-up of patients. As in adults, regional anesthesia has also shown interest in children in terms of morphine consumption and quality of postoperative analgesia. However, the use of single shot regional anesthesia seems to induce an exacerbation of pain upon returning home. For management of prolonged postoperative pain at home, continuous peripheral nerve blocks are then presented as the best options. This type of analgesia is mainly reserved for major orthopedic surgery in children. The quality of analgesia obtained in different pediatric studies is excellent with a low rate of adverse events. L-enantiomer local anesthetics are predominantly used at low concentrations for the systemic safety provided. The use of elastomeric disposable pumps for LA infusion allows early and easy ambulation with a simplified management, bringing great satisfaction to parents and children.     

Rôle délétère de l’hyperthermie en neuroréanimation

Fever is a secondary brain injury and may worsen neurological prognosis of neurological intensive care unit (NICU) patients. In response to an immunological threat, fever associates various physiological reactions, including hyperthermia. Its definition may vary but the most commonly used threshold is 37.5 °C. In animal studies, hyperthermia applied before, during or after cerebral ischemia may increase the volume of ischemic lesions. The mechanism of this effect may include increase in blood brain barrier permeability, increase in excitatory amino acid release and increase in free radical production. In NICU patients, fever is frequent, occurring in up to 20–30% of patients. Moreover, after haemorrhagic stroke, fever has been reported in 40–50% of patients. In half of the patients, fever may be related to an infectious cause but in more than 25% of patients, hyperthermia may be of central origin. After ischemic stroke, hyperthermia during the first 72 hours is associated with an increase in infarct size and increase in morbidity and mortality. This holds true also after subarachnoid haemorrhage. After traumatic brain injury, fever is not related to mortality but may increase morbidity. Whereas no causal link has been established between fever and unfavourable outcome, it seems reasonable to treat hyperthermia in patients suffering from brain injuries. In such patients, antipyretics have a moderate efficacy. In case of failure, they should be replaced by physical cooling techniques.     

Traitement précoce du diabète de type 2 chez l’obèse après gastric bypass et diversion bilio-pancréatique : rôle de l’axe entéro-insulinique

Improvement in Type 2 diabetes is seen in 80-98% of obese diabetic patients who undergo gastric bypass or bilio-pancreatic diversion. This improvement is evident early after the operation before significant weight loss has occurred. Although numerous teams have extensively studied the physiology of this early post-bypass amelioration of type 2 diabetes, the exact mechanism of diabetes remission remains unclear. Studies have focused on changes in the entero-insular axis, which is mediated in part by the interaction of insulinotropic hormones GIP and GIP 1 on the beta islet cells of the pancreas. Other mechanisms which have been postulated focus on the adipo-insular axis; the actions of adiponectin and leptin seem to have an important role in insulin resistance but their action is weight-loss dependent. Post-operative caloric restriction may also contribute to the early resolution of type 2 diabetes observed after gastric bypass and bilio- pancreatic diversion.     

Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

Effets de l’hydroxyzine sur l’acceptation du masque à l’induction de l’enfant

Objective

To evaluate the effectiveness of hydroxyzine as a premedication agent for the acceptance of facial mask during induction of general anaesthesia in children.

Study design

Prospective randomized single-blind study including ASA 1 and 2 children, aged between 1 and 9 years and undergoing outpatient surgery.

Patients and methods

Patients were randomly allocated to receive orally either 1 mg/kg hydroxyzine (G1) or water 0.1 ml/kg (G2) one hour before induction of standardized inhalational anaesthesia. Tolerance of facial mask was assessed with a 3-points scale (good, moderate or poor). Chi-square and Student's t-test were used in statistical analysis; p values less than 0.05 were considered statistically significant.

Results

One hundred patients were included (G1 = 49, G2 = 51). Demographic data were similar in both groups. Acceptance of facial mask was significantly better in G1 than in G2 (p = 0,002).

Conclusion

Hydroxyzine provided better acceptance of facial mask than placebo during induction of general anaesthesia in children.     

Apport de l’échographie pleuropulmonaire en pédiatrie

An increasingly amount of evidence suggests that lung ultrasonography constitutes a relevant complementary diagnostic tool for adults patient in acute respiratory failure. A comprehensive and standardized ultrasonographic semiology has been described, relying on accurate and reproducible data directly obtained at patient's bedside. Therefore, pleural effusion, pneumothorax, pulmonary consolidation and interstitial lung disease can be diagnosed in a critical care environment with a similar level of performance than when reference diagnosis methods such as thoracic CT-scan are employed. Furthermore, lung ultrasonography seems to be able to contribute to an early therapeutic decision based on such online physiopathological data. Pioneers works in this field have suggested an attractive similarity between the ultrasonographic patterns described in adults and children. Nevertheless, the clinical usefulness of lung ultrasonographic approach in the pediatric critical care medicine still needs to be confirmed by specifically designed studies.     

Clinical and molecular pharmacology of etomidate

This review focuses on the unique clinical and molecular pharmacologic features of etomidate. Among general anesthesia induction drugs, etomidate is the only imidazole, and it has the most favorable therapeutic index for single-bolus administration. It also produces a unique toxicity among anesthetic drugs: inhibition of adrenal steroid synthesis that far outlasts its hypnotic action and that may reduce survival of critically ill patients. The major molecular targets mediating anesthetic effects of etomidate in the central nervous system are specific γ-aminobutyric acid type A receptor subtypes. Amino acids forming etomidate binding sites have been identified in transmembrane domains of these proteins. Etomidate binding site structure models for the main enzyme mediating etomidate adrenotoxicity have also been developed. Based on this deepening understanding of molecular targets and actions, new etomidate derivatives are being investigated as potentially improved sedative-hypnotics or for use as highly selective inhibitors of adrenal steroid synthesis.     

Évaluation d’un labyrinthe pédagogique pour l’enseignement de la traumatologie grave

Background

Assess efficacy, satisfaction and usefulness of an educational maze based on posters and audioguide for major trauma care teaching to medical students. The educational maze consists of posters with audio comments recorded in an audioguide. This tool was part of a larger educational program including medical simulation.

Study design

Prospective, interventional, observational, monocentric study.

Student

Medical student of Grenoble University Hospital, in the four last years of medical school, following a training course in anesthesia, emergency medical services and intensive care units.

Method

Forty essentials key messages for major trauma management were included in 10 posters and audioguides. A first assessment with short opened answers was handed to the students at the end of the educational maze to assess their memorization. A second assessment with simple choice answers regarding satisfaction and usefulness of this new educational tool was realized at the end of the entire program.

Result

One hundred and eighty-four medical students attending the major trauma program were included in this study. On the first test, 75% of essential knowledge on major trauma management was memorized by more than 50% of the medical students. On the second test, 94% of medical students had a high satisfaction level of this educational maze.

Conclusion

An educational maze based on posters and audioguides seems to be an efficient, useful tool for teaching essential knowledge on major trauma management to medical students.     

Faut-il encore utiliser l’étomidate ?

Etomidate blocks the cortisol synthesis by specifically inhibiting the activity of 11 beta-hydroxylase, resulting in a primary adrenal insufficiency. Therefore, a serum accumulation of 11 beta-deoxycortisol and a low secretion of serum cortisol must be required as diagnostic criteria to assign that adrenal impairment to the drug. These requirements have been rarely fulfilled in studies exploring the contribution of etomidate to the adrenal insufficiency despite numerous causes of adrenal derangement. In critically ill patients without sepsis, a single dose of etomidate results in a wide adrenal inhibition, reversible in 48 h after etomidate administration. Although there are still uncertainties as to whether etomidate directly affects mortality and morbidity, it seems preferable to avoid the use of etomidate in patients with severe sepsis and septic shock. In patients with severe traumatic brain injury, arterial hypotension is one of major factors of poor outcome and can be prevented with the use of etomidate for facilitating tracheal intubation. Substitutive opotherapy with low doses of hydrocortisone should be assessed after a single dose of etomidate for critically ill patients.     

Avantages décisifs,indications et limites de l’anesthésie au xénon

Objective

To analyze the current knowledge related to xenon anaesthesia.

Data sources

References were obtained from computerized bibliographic research (Medline^®), recent review articles, the library of the service and personal files.

Study selection

All categories of articles on this topic have been selected.

Data extraction

Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect.

Data synthesis

The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas.

Conclusion

Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.     

Anesthésie pour chirurgie non cardiaque chez l’enfant atteint d’une cardiopathie congénitale ou acquise

The goals of this review are to recall some pathophysiological principles at work in most of congenital heart diseases; to specify factors to be considered when defining perioperative risk for a child with an acquired or congenital heart disease; to describe an anaesthetic management strategy in the context of some specific heart diseases.     

Enquête sur l’apprentissage de l’échographie par les internes d’anesthésie-réanimation de l’inter-région Est

Objective

Ultrasonography is in continuing expansion in anesthesiology and critical care medicine (ACCM). It is an operator-dependent tool whose contribution is partly related to the quality of the user's initial and subsequent training. Within the framework of the ACCM residency, the French north-east anesthesiology residents have an initiation to ultrasonography by 24 hours of formal lectures. The evaluation of this teaching has not yet been performed. The objective of this survey is to depict this learning and delineate the expectations of the residents.

Methods

An anonymous computerized self-rated survey, published on a specific internet website, was performed between September 2011 and January 2012, and addressed to the ACCM residents of the French north-east anesthesiology residency by the local coordinators. It consisted in several items: current abilities and aims in echography, equipment availability and frequency of use, existence of a potential independent ultrasonography training, desired improvements, evaluation of the teaching and interest of rendering it mandatory, potential interest in creating a form of assessment.

Results

In total, 105 questionnaires were analyzed (response rate 44%). The distribution of respondents was homogeneous from the 1st to the 5th year of residency. Thirty percent of residents had good knowledge or mastered echocardiography. Ultrasound-guiding during vascular access was the best acquired technique: 73% masterized or had good knowledge of it. The results were more mitigated regarding ultrasound-guided regional anesthesia (UGRA) (60%), trans-cranial echography (46%), FAST-echo (23%), pleuro-pulmonary echography (38%). At the end of the ACCM residency, 69% wished to master echocardiography and 86% UGRA. The echograph was used more than once a week (76%) and of easy access (93%). The teaching was mainly theoretical; 76% of the residents were unsatisfied and nine out of ten had followed an echography training outside the ACCM residency courses or intended to do so. Moreover, 78% wished a mandatory echography learning, with seminars and a strengthened practical training: 94% considered workshops indispensable, and 62% simulation sessions. An assessment of knowledge was found useful, particularly in practical form. The realization of a training rotation with echographic orientation was desired by 78% of respondents.

Conclusion

A clear gap exists between the real capability in echocardiography and the intended one. UGRA and echocardiography raise a particular interest. The practical training in ultrasonography using simulation and workshops is to be favored.     

Monitorage de la dilatation pupillaire dans l’évaluation d’une tolérance aiguë au rémifentanil en chirurgie cardiaque

Introduction

Remifentanil is a powerful morphinic agonist often ordered for anaesthesia. The use of peroperative large doses of this opioid increases the risk to develop postoperative hyperalgesia and acute tolerance. But how early these effects can occur? Despite the fact that these effects could be masked during the preoperative time because of general anaesthesia, it seems they could occur precociously. In order to try to describe this time, this study evaluated the acute tolerance under general anaesthesia requiring large doses of remifentanil by using an effective peroperative monitoring of nociception: the continuous pupillary diameter monitoring.

Materials and methods

In this prospective observational clinical study, a continuous infusion of remifentanil was started at a range of 0.3 μg/kg/min after induction of anaesthesia by using propofol (TIVA), remifentanil bolus and cisatracurium. The pupil monitoring started 10 min later (T + 10 min) and lasted until the surgical incision (T + 65 min). So, there was no surgical stimulus during this time.

Results

Thirty patients undergoing major cardiac or vascular surgery were included in this study. The continuous pupil diameter evaluation showed a significant increase of the pupil diameter from T + 45 min. No significant variation of heart rate, blood pressure, bispectral index (BIS) values were observed.

Discussion

The development of acute remifentanil tolerance could possibly explain these results. If evaluations with continuous pupillary diameter monitoring are still limited, these results suggest that the use of powerful opioids such as remifentanil should be associated with a N-methyl-d-aspartate (NMDA) receptor antagonist agent, including short time administrations.     

Psychophysiological characteristics of women suffering from stress‐related fatigue

Stress‐related fatigue has been attributed to excessive sympathetic nervous system and hypothalamic–pituitary–adrenal (HPA) axis activation, but findings have been equivocal as to whether the HPA axis or the autonomic nervous system (ANS) are affected in this condition and how. Whether task performance deficits are associated with this condition is also uncertain. The present study investigated possible differences between women with stress‐related fatigue and healthy women in heart rate variability (HRV) and other autonomic and respiratory measures, task performance and in salivary cortisol response to awakening. Thirty‐six women with stress‐related fatigue were compared with 19 female healthy controls matched in age. Four indices of HRV and other autonomic and respiratory measures were recorded during baseline, task performance and relaxation phases of a laboratory session. Saliva cortisol was measured four times during the hour after awakening. The fatigued group showed less HRV in three measures, higher temperature, lower O₂ saturation at the surface of the finger, lower end‐tidal pCO₂, and greater cortisol response. This group responded faster on the task but with more errors. Women with stress‐related fatigue show signs of hyperarousal on ANS, respiratory and HPA axis measures. The lower HRV may indicate greater cardiovascular risk. Results for task performance confirm subjectively reported deficits. Copyright © 2009 John Wiley & Sons, Ltd.     

Complications cardiovasculaires de l’agression cérébrale

The clinical importance of cardiovascular consequences resulting from cerebral injury has long been recognized. However, interactions between the brain and the cardiovascular system remain poorly defined and their importance for the management of patients suffering from acute brain injury is largely underestimated. This should have profound consequences on treatment strategies during anaesthesia and intensive cares of these patients, taking into account not only brain perfusion, but also cardiovascular optimisation. This report summarizes the main data available regarding the cardiovascular consequences of brain death, traumatic brain injury, stroke and epilepsy.     

Age of Trauma Onset and HPA Axis Dysregulation Among Trauma‐Exposed Youth

The hypothalamic–pituitary–adrenal axis (HPA axis) is a pathway through which childhood trauma may increase risk for negative health outcomes. The HPA axis is sensitive to stress throughout development; however, few studies have examined whether timing of exposure to childhood trauma is related to differences in later HPA axis functioning. Therefore, we examined the association between age of first trauma and HPA axis functioning among adolescents, and whether these associations varied by sex. Parents of 97 youth (aged 9–16 years) completed the Early Trauma Inventory (ETI), and youth completed the Socially‐Evaluated Cold‐Pressor Task (SECPT). We measured salivary cortisol response to the SECPT, the cortisol awakening response, and diurnal regulation at home across 2 consecutive weekdays. Exposure to trauma during infancy related to delayed cortisol recovery from peak responses to acute stress, d = 0.23 to 0.42. Timing of trauma exposure related to diverging patterns of diurnal cortisol regulation for males, d = 0.55, and females, d = 0.57. Therefore, the HPA axis may be susceptible to developing acute stress dysregulation when exposed to trauma during infancy, whereas the consequences within circadian cortisol regulation may occur in the context of later trauma exposure and vary by sex. Further investigations are warranted to characterize HPA axis sensitivity to exposure to childhood trauma across child development.     

Intérêt de la simulation réaliste dans l’évaluation de l’enseignement de l’intubation difficile aux médecins urgentistes

Objectives

The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation.

Study design

Prospective.

Population

Emergency physicians.

Methods

Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan^® simulator (Laerdal^®) was assessed.

Results

Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor.

Conclusion

We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.     

Stress system dysregulation in pediatric generalized anxiety disorder associated with comorbid depression

Because chronic stress is an important risk factor for anxiety states and depressive disorders, we studied hypothalamus–pituitary–adrenal (HPA) axis and sympathetic system activity via changes in cortisol and alpha amylase activity levels in pediatric generalized anxiety disorder (GAD) patients (n = 26) with comorbid depression and a healthy comparison group (n = 26). Morning plasma cortisol and diurnal profiles of salivary cortisol and salivary alpha amylase (sAA) activity were assessed, also reactivity of HPA‐axis, sAA activity, and heart rate following a psychosocial stressor (Trier Social Stress Test for children). GAD patients with comorbid depression showed increased morning plasma and salivary cortisol levels, ameliorating throughout in‐patient treatment, and higher sAA activity in their diurnal profile. Both HPA and sympathetic activity positively correlated with the severity of anxiety and depression. We also demonstrated a blunted HPA and sympathetic response to acute stress in patients. This pattern of neuroendocrine and sympathetic changes seems to be distinct from the one previously reported in pediatric patients with only social anxiety or depressive disorders. We propose morning plasma and saliva cortisol levels as potential physiological indicators for supporting the evaluation of symptoms' severity and treatment progress in children with GAD and comorbid depressive disorder.