Médiatisation et « greffe de visage » ou « à qui appartient la greffe de visage » ?

Mediatisation of a scientific event could be neither controlled, nor verifiable. The experience which has been lived through the first worldwide allotransplantation of composite tissues of the face confirms that the actors of a surgical innovation are not the owners. Because there is neither confidentiality nor possible patent. Curiously the scientific world, providing with a sharing ethic, which rightly privileges the free spreading of knowledge in the way that most people could benefit of it. Obviously it is made without denied controversy, for truth as purpose. This scientific word that way joins the media one, with a specific ethic of the duty of information, but also interested in mercantile preoccupations quick to cultivate controversy not to enlighten this truth but to better sell pictures or papers. Than the author should only sustain this instrumentation which could certainly flatter him, and from which he could used, but in reality that paralysed him a little to go on in serenity with his shadow worker way.     

Anesthésiques généraux en pédiatrie : risque ou bénéfice ?

The practice of paediatric anaesthesia has changed during the last 25 years, with a noticeable reduction of mortality and serious morbidity. This improvement results in part from the use of new anaesthetic agents which large therapeutic interval regarding cardiovascular effects. Parallel to this advance and following experimental or clinical studies in neurosciences, some new concerns have emerged regarding short and long time consequences of anaesthesia. Indeed, postoperative hyperalgesia due to opioids, emergence agitation and postoperative maladaptive behavioural changes are widely described in children, in the same way the potential epileptogenic effect of sevoflurane is demonstrated. Thus the hypothetical cerebral toxicity leads us to reconsider our practice. Basically, monitoring of cerebral cortical effects of hypnotics is now possible from automated devices based on EEG, allowing us to control the administration of hypnotic agents. The therapeutic interval of these agents, previously determined between movement at incision and deleterious cardiovascular effect, may be revisited with a cerebral approach, with the risk of memorisation for the lower limit and the risk of cerebral over dosage for the upper limit. Lastly, further experimental and clinical studies are required to analyse the effects of the anaesthetic agents on the brain of the neonate, and the interest of the cerebral monitoring in this population.     

Néfopam en perfusion continue et effets secondaires indésirables : quelle imputabilité ?

We report the case of a 77-year-old man, with nefopam postoperative analgesia, who developed subacute neurological symptoms, whereas he had profound hypoprotidemia and acute renal failure. Chronological, semiological and bibliographical criteria are in favour of causality assessment. The plasma nefopam concentration (135 ng/ml) during the neurological symptoms is another argument.     

Qu'apporte le modèle de Stewart à l'interprétation des troubles de l'équilibre acide–base ?

Objectives

To explain the different approaches for interpreting acid-base disorders; to develop the Stewart model which offers some advantages for the pathophysiological understanding and the clinical interpretation of acid-base imbalances.

Data source

Record of french and english references from Medline^® data base. The keywords were: acid-base balance, hyperchloremic acidosis, metabolic acidosis, strong ion difference, strong ion gap.

Data extraction

Data were selected including prospective and retrospective studies, reviews, and case reports.

Data synthesis

Acid-base disorders are commonly analysed by using the traditionnal Henderson-Hasselbalch approach which attributes the variations in plasma pH to the modifications in plasma bicarbonates or PaCO₂. However, this approach seems to be inadequate because bicarbonates and PaCO₂ are completely dependent. Moreover, it does not consider the role of weak acids such as albuminate, in the determination of plasma pH value. According to the Stewart concept, plasma pH results from the degree of plasma water dissociation which is determined by 3 independent variables: 1) strong ion difference (SID) which is the difference between all the strong plasma cations and anions; 2) quantity of plasma weak acids; 3) PaCO₂. Thus, metabolic acid-base disorders are always induced by a variation in SID (decreased in acidosis) or in weak acids (increased in acidosis), whereas respiratory disorders remains the consequence of a change in PaCO₂. These pathophysiological considerations are important to analyse complex acid-base imbalances in critically ill patients. For exemple, due to a decrease in weak acids, hypoalbuminemia increases SID which may counter-balance a decrease in pH and an elevated anion gap. Thus if using only traditionnal tools, hypoalbuminemia may mask a metabolic acidosis, because of a normal pH and a normal anion gap. In this case, the association of metabolic acidosis and alkalosis is only expressed by respectively a decreased SID and a decreased weak acids concentration. This concept allows to establish the relationship between hyperchloremic acidosis and infusion of solutes which contain large concentration of chloride such as NaCl 0.9%. Finally, the Stewart concept permits to understand that sodium bicarbonate as well as sodium lactate induces plasma alkalinization. In fact, sodium remains in plasma, whereas anion (lactate or bicarbonate) are metabolized leading to an increase in plasma SID.

Conclusion

Due to its simplicity, the traditionnal Henderson-Hasselbalch approach of acid-base disorders, remains commonly used. However, it gives an inadequate pathophysiological analysis which may conduct to a false diagnosis, especially with complex acid-base imbalances. Despite its apparent complexity, the Stewart concept permits to understand precisely the mechanisms of acid-base disorders. It has to become the most appropriate approach to analyse complex acid-base abnormalities.     

L’admission du sujet âgé en réanimation : l’âge influence-t-il l’accès aux soins ?

Objectives

The life expectancy of the population increasing, contrary to the resources of beds in reanimation, the question of the admission of the old subject in reanimation is increasingly frequent. We will be interested in the role of the age in the medical decision-making.

Patients and methods

A questionnaire was sent to the intensivists of the same department, then the troop of the subjects refused within an intensive care of the University Hospital of this same department was studied.

Results

The age arrives in third place among the factors of refusal of admission quoted. It does not seem to be an appalling criterion for access to intensive care, but rather to lead to a thorough evaluation of the patient. This idea is translated in the open questions as in the clinical settings in situation. The age modulates the recourse to the entry in intensive care. It tends to be integrated in a total process of evaluation of a patient, even if the consensus is not total… The analysis of the troop of the refused subjects showed a first reason for refusal which is the lack of place. The age is not quoted.

Conclusion

The age does not seem a determining element. It cannot solve the question which is to know if the admission in reanimation is relevant or not for the patient proposed. More than the admission or not of a possibly old subject in reanimation, the problem lies in the resolution with accuracy of the acute dilemma which is the decision-making to admit or refuse a patient whatever it is for the benefit of the person.     

Exérèse des nævus congénitaux géants : jusqu’où aller avec la chirurgie ?

Surgical excision of giant congenital nevi is recommended by principle for dermatological reasons. Malignant potential is real but its incidence remains widely discussed. Their excision represents a surgical challenge but is also a real assault course for the child and his family. The sequelae and the psychological effects can be important. Can an incomplete excision to limit these aesthetic after-effects and relieve the surgical treatment be acceptable? We present the case of a child affected by a giant congenital nevi of the cephalic extremity where the excision was partial. A review of the literature on the degenerative risk of the giant congenital nevi allowed us of noticed that this one tends to be overestimated. The advantages and the disadvantages to practise a preventive, premature excision and complete of the giant congenital nevi are approached. We discuss the possibility to resort to a partial excision in certain cases delicate of reconstruction under the cover of a strict and moved closer dermatological surveillance.     

Quelle anesthésie pour les IRM en pédiatrie ? Résultats d'une enquête par Internet dans les CHU de France

Objective

To investigate the procedures used by French anaesthesiologists in children undergoing MRI.

Methods

A questionnaire was sent by Internet to every university hospital in France. Information concerning the specialty of the doctor in charge of the child, the age of the children, premedication, airway control, the agents used, presence of a specific recovery room, length of hospitalization and number of children undergoing MRI was obtained.

Results

Out of the 28 hospitals contacted, one did not reply and two did not perform anaesthesia for MRI. In 80% of cases, paediatric anaesthesiologists were in charge of the children. Only one team applied an age limit and performed sedation only in children over 10 kg. Specific monitoring for MRI was used by all teams. Premedication was given in 52% of cases. Parents were present during induction in 52% of cases. Sevoflurane was used in 52%, propofol in 40% and propofol with sufentanil in 8%. Presence of a venous line is systematic in 92% of cases. Intubation is systematic in 36% of cases, laryngeal mask in 20%, one or the other in 24%, and face mask and/or oral canula in 20%. The most widely used ventilation mode is spontaneous breathing (52%). All children go to the recovery room, which was close to the MRI unit in only 48% of cases and was less than 1 hour away in 72%. In 83% of cases, MRI is performed on a day-case basis and the number of procedures varies from 4 to 30 per week.

Conclusion

While there is no standard anaesthetic protocol in France for children undergoing MRI, only specialist teams undertake such procedures.     

L'entropie : un moyen d'apprécier le défaut d'analgésie ?

Objective

Comparison between BIS (Bispectral Index) and state (SE) and response (RE) entropy during laparotomy for inflammatory bowel disease patients (IBD) and evaluation of the variations of RE and SE during nociceptive stimulation.

Study design

Prospective, observational study.

Patients and methods

Fourteen IBD's patients undergoing laparotomy were included. Anaesthesia aimed to maintain BIS between 40 and 60 by isoflurane and nitrous oxide. Analgesia was performed by sufentanil bolus administrated according to an increase of 20% of systolic blood pressure (SBP) and heart rate compared with the baseline values. BIS, RE and SE were measured at each nociceptive stimulation. A variance analysis (Anova) was used to assess BIS, RE and SE variations throughout surgery (p < 0.05 as significant). Relationship between BIS, RE and SE was assessed by Pearson correlation (p < 0.01 as significant). The ability for SE and RE to predict depth of anaesthesia and intraoperative analgesia was performed by calculating aera under the receiver operated curves (AUC).

Results

BIS and entropy parameters had strictly the same evolution during anaesthesia. SBP increased significantly during nociceptive stimulation while no variation of RE was observed. A significant correlation was shown between BIS, RE and SE. The evaluation of anaesthesia depth was good for RE (AUC: 0.932 ± 0.26) and SE (AUC: 0.926 ± 0.27). There was however no difference between RE and SE to predict analgesic requirement.

Conclusion

Because RE includes muscular frequency analysis, it does not allow analgesic requirement evaluation in paralyzed patients.     

Existe-t-il encore une place pour la dopamine en réanimation pédiatrique ?

Dopamine is mostly used in patients with cardiogenic or septic shock, but its place in critical care medicine is often questioned. Dopamine, of which pharmacology in children is variable, is prescribed for its inotropic effect, associated with an increase in cardiac output and at a lesser degree blood pressure. Beneficial effects (need for renal replacement therapy and mortality) of low dose in patients at risk of, or with acute renal failure are not demonstrated. Dopamine has numerous potential deleterious effects on local circulations (pulmonary, cerebral, coronary and cutaneous), respiratory function, gastroduodenal motility, endocrine function (further depression of the hypothalamic-pituitary axis induced by stress) and immunity (partially due to decreased production of prolactin). Finally, in shocked adults dopamine infusion might be associated with an increase in mortality rate. Dopamine remains the most prescribed catecholamine, either in adults or children. It still is one of the first line drug included in the recent recommendations for the treatment of septic shock (norepinephrine tends to replace it), cardiogenic shock (dobutamine is the first drug), severe head trauma, and organ donor in cerebral death. In conclusion, if dopamine is today less used, there is no proof that its deleterious effects are associated with an excess of mortality. Thus, dopamine still is part of the stock of drugs that act on the cardiocirculatory system (but for how long?).     

Kétamine en anesthésie pédiatrique : utile,futile ou … ?

The use of ketamine for paediatric sedation-anaesthesia-analgesia is still growing despite the availability of adequate alternatives. Based on the literature, the present work will briefly review the well-known properties underlying the widespread use of this drug in this particular clinical situation. In adult patients, the use of ketamine as a new element of the balanced anaesthesia-analgesia is also ever growing. This is based on the recently demonstrate antihyperalgesic and anti-pro-inflammatory properties of this drug. This work questions the existence of such benefits in the paediatric population. Finally, the "dark side" of ketamine will be discussed. Experimental studies on developing brain clearly demonstrate that this old anaesthetic is a potent trigger for pathologic neuronal apoptosis.