Quelle pression de perfusion cérébrale après traumatisme crânien chez l’enfant ?

The management of cerebral perfusion pressure (CPP) is the one of the main preoccupation for the care of paediatric traumatic brain injury (TBI). The physiology of cerebral autoregulation, CO₂ vasoreactivity, cerebral metabolism changes with age as well as the brain compliance. Low CPP leads to high morbidity and mortality in pediatric TBI. The recent guidelines for the management of CPP for the paediatric TBI indicate a CPP threshold 40–50 mmHg (infants for the lower and adolescent for the upper). But we must consider the importance of age-related differences in the arterial pressure and CPP. The best CPP is the one that allows to avoid cerebral ischaemia and oedema. In this way, the adaptation of optimal CPP must be individual. To assess this objective, interesting tools are available. Transcranial Doppler can be used to determine the best level of CPP. Other indicators can predict the impairment of autoregulation like pressure reactivity index (PRx) taking into consideration the respective changes in ICP and CPP. Measurement of brain tissue oxygen partial pressure is an other tool that can be used to determine the optimal CPP.     

Pourquoi une fiche d’information du patient après une intubation difficile ?

Unanticipated difficult tracheal intubation may be challenging to anaesthesiologists. It is still associated with morbidity or mortality. Previous difficult intubation is vital information to organize appropriate airway management. Unfortunately, previous studies in the literature have shown that there is poor communication of this information. We propose in this article an airway alert form, following several criteria published in the literature. This is, in our opinion, an important step to improve the efficiency of guidelines on airway management and the overall quality of the anaesthesia process. Its efficacy to decrease morbidity related to difficult tracheal intubation remains to be demonstrated.     

Que faire et ne pas faire après un accident ? Le point de vue de l’assistant conseil

The objectives of this review are (1) to explain the goals of a medico-legal appraisement and describe the various jurisdictions able to order it; (2) to analyze the actions to be taken from the medico-legal point of view during and after the accident; (3) to give advise concerning communication with the patient, its family and the colleagues involved in the case; (4) to describe of the role of the medical advisor before (constitution of the file to communicate), during (assistance to the blamed practitioner) and after the expertise (to learn the practical lessons); (5) to recall the importance of the quality of the anaesthetic file, the keystone of the expertise, and the rules governing the responsibility for the doctor.     

L’adjonction de sulfate de magnésium à la morphine en intrathécal améliore-t-elle l’analgésie après césarienne ?

Background

Intrathecal morphine (IT) is commonly used for postoperative analgesia after caesarean section. The addition of intrathecal (IT) magnesium to spinal bupivacaine-fentanyl anaesthesia increases the duration of spinal analgesia for labour without additional side effects. In this prospective, randomized, double blind, controlled study, we evaluated whether adding intrathecal magnesium could prolong spinal morphine analgesia after caesarean section.

Parturient and methods

After ethics committee approval and obtaining written consent, one hundred and five (ASA I or II) adult patients undergoing caesarean section were recruited. They were randomly allocated to one of three groups: (1) group Morphine (M): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (2) group Magnesium (Mg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (3) group Morphine + Magnesium (MMg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml).We recorded the following: time to the first analgesic request, pain scores with the visual analogic scale at rest and in movement at h0, h1, h2, h4 and then every 4 h for the first 36 postoperative hours, the occurrence of adverse events and patients’ satisfaction.

Results

Time of the first analgesic request was 28 ± 8 h in group MMg versus 19 ± 6 h in group M and 7 ± 6 h in group Mg (p < 0.01). Pain scores were statistically lower in group MMg (9 ± 7 and 17 ± 9 mm respectively) compared to group M (16 ± 9 and 28 ± 11 mm respectively) and Mg (21 ± 9 and 37 ± 13 mm respectively) (p < 0.01). There was no difference in adverse events among the three groups. Patients satisfaction was better in group MMg (p < 0.01).

Conclusion

In patients undergoing caesarean section under spinal anaesthesia, the addition of IT magnesium sulphate (100 mg) to morphine 100 μg improved the quality and the duration of postoperative analgesia without increasing the incidence of adverse effects.     

Continuer,limiter ou arrêter ? Évolution des modalités de décès sur une période de 6 ans en réanimation pédiatrique

Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods to end life: FLS, brain death and cardiopulmonary resuscitation failure (CPR failure). It is a single retrospective study from 2007 to 2012. The Cochran-Armitage trend test is used in the statistical analysis. Over six years, 263 of the 5100 children who were hospitalized in our intensive care unit died, which represents a 5.2% mortality rate. FLS increased yearly from 31% of the deaths in 2007, to 71% in 2012 (P = 0.0008). The rate of CPR failure decreased over the same period (P = 0.0015). The rate of brain death remained constant. Following to the Leonetti law, FLS increase, and palliative cares develop without any increase of mortality.     

Les fractures du radius distal après 70 ans : ostéosynthèse par plaque palmaire ou broches ?

In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (?0.7 mm versus ?0.1 mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.     

Care et recovery : jusqu’où ne pas décider pour autrui ? L’exemple du programme « Un chez-soi d’abord »

To which extent is it possible to conduct a professional care defined by the care-receiver him-herself? Taking the exemple of the “Housing First program” in France, which refers to the north-american recovery model of care, this article intends to analyse the difficulties this form of care meets. Based on empirical cases, described through ethnographic observations, focus groups and interviews conducted with the members of the Housing-First Team, this article enlights two main limits to the development of a “recovery care”: the various degrees to which the model is known, understood and endorsed by the teams and their partners and some “borderline-situations” which question the ability of the teams to maintain a recovery-based care (risk to lose ones home or see ones health badly affected). This example is the occasion to explore a problem characteristic to the care relation: who may legitimely define the “best care” for someone in each case?     

L’anesthésie,l’analgésie et la modulation sympathique augmentent-elles l’incidence des récidives néoplasiques après chirurgie ? Une revue de la littérature centrée sur la modulation de l’activité des lymphocytes natural killer

Objective

The Natural Killer cells (NK) are an important part of non-specific cellular-mediated and antitumoral immunity. The goal of this review is to recapitulate data published over NK activity during the perioperative period and the influence of anaesthesia, analgesia and modulation of sympathetic system.

Data sources

Pubmed/Medline database.

Study selection and data extraction

Keywords-based selection, without limit of date: fundamental studies, randomized controlled trials and non-randomized comparative studies.

Data synthesis

In human as in animal studies, an important correlation exists between NK activity and prognosis linked to the development of metastasis. The great depression of this cytotoxicity during the perioperative period could be able to compromise host defenses. The influence of anaesthetics and analgesics is important. The effects of the opioids, the agonists and the antagonists of the sympathetic nervous system, the prostaglandins, the NSAIDs, the ketamine, the hypnotics and the locoregional anaesthesia are systematically reviewed. The limits of experimental model presented are covered.

Conclusion

The effects of anaesthetic/analgesic drugs and techniques, the consequences of sympathomodulation on NK activity are numerous and sometimes opposite. It is important for the anaesthesiologist to keep in mind that the long term consequences of his techniques on the patients’ outcome must be clarified.