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.     

Douleur et troubles comportementaux après adénoïdectomie et pose d’aérateurs transtympaniques chez l’enfant

Objectives

The purpose of this study was to evaluate postoperative pain in the hospital and at home as well as behavioural changes at home following outpatient adenoidectomy (VG) and ear tube (ATT) surgery.

Study design

Prospective cohort study.

Patients and methods

Sixty-four children (mean age 4.3 ± 2.4 years): 28 VG, 16 (ATT), 20 dual surgeries (VG-ATT). Postoperative pain was evaluated (arrival in recovery room, departure from wake-up room, departure from hospital) using the Objective Pain Scale (OPS). Parents evaluated their child's pain at home over a period of seven days using a numeric pain scale. Behavioural changes were measured with the Post-Hospital Behaviour Questionnaire (PHBQ).

Results

At arrival in the recovery room, OPS = 3.5 [0–6]. A statistically significant difference (p < 0.05) was shown between the VG group (OPS = 5 [2.25–7.75]), and the ATT (OPS = 0 [0–5.5]) and VG-ATT (OPS = 2 [0–5.75]) groups. OPS was 1.0 [0–2] when leaving the recovery room, and OPS was 0 [0–1] when leaving the hospital. Numeric pain scale scores recorded at home were extremely low. Postoperatively, 75% of parents at Day 1 and 40.6% at Day 7 reported at least one postoperative behavioural change.

Discussion

In all three groups, parents reported frequent postoperative behaviour changes despite adequate analgesia.

Conclusion

The relatively high frequency of postoperative behaviour changes in this population demonstrates the need to systematically evaluate those changes in order to improve overall paediatric care.     

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.     

Effet d’épargne morphinique de la kétamine au cours de l’amygdalectomie chez l’enfant

Introduction

In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5 mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1 mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy.

Methods

We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1 mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage.

Results

No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24 hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects.

Conclusion

These results suggest that 1 mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.     

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.     

Prise en charge préhospitalière de l’arrêt cardiaque de l’enfant et du nourrisson : enquête nationale de pratique

Introduction

After the publication of new recommendations for cardiopulmonary resuscitation (2005 guidelines and 2006 French recommendations), we conducted a study amongst EMS teams concerning their approach with children and infants, nationwide. The objective was to measure the level of knowledge of guidelines and practice.

Methods

The online questionnaire was offered to emergency physicians belonging to the French emergency database, between November 1st and December 15th 2007. Incomplete questionnaires were excluded from the study. We recorded: profile of personnel, knowledge of guidelines, basic CPR and advanced CPR parameters.

Results

Four hundred and thirty-nine questionnaires were analyzed. Personnel was aged under 40 in 50.2 %, with 2–5 years experience in prehospital emergency care (57.6 %); 51,3 % declared having had training in pediatric CPR. A minority of subjects declared knowing the 2005 Guidelines (35 %), more the French 2006 recommendations (62.5 %). Basic CPR: transition age child/adult known in 30.3 %. Compression/ventilation ratio: 30/2 for one rescuer in 50.2 % (child), 46.5 % (infant); 15/2 for two or more rescuers in 57.6 % (child), 48 % (infant). AED age for use (1 year old) known in 59.8 %. Advanced CPR: epinephrine dose known in 89.3 % (intravenous) and 34.3 % (tracheal). External shock known in 57.2 %.

Conclusion

This study emphasizes the lack of knowledge, especially with regard to first aid. Formations will be developed.     

Comment je prends en charge l’enfant qui ne se réveille pas comme prévu

Regarding immediate post-anaesthesia problems, one must distinguish slow awakening and the apparition of neurologic or behavioural problems. Post-anaesthesia delirium, an usual cause of transient agitation in the recovery room following halogenated-based anaesthetic, is not included in this discussion. There are two false causes of slow awakening: residual curarization and a total spinal. Slow awakening is usually caused by overdose, either absolute or relative. Regarding the occurrence of neurologic or behavioural problems, one must consider situations at risk, patients at risk, the consequences of iatrogenicity but also the unknown cerebral tumour or metabolic disorder.     

Méta-analyse : ondansétron en prophylaxie des nausées et vomissements postopératoires chez l’adulte et l’enfant après craniotomie

Objective

To justify the use of ondansetron as a preventive treatment for postoperative nausea and vomiting (PONV) of adults and children in neurosurgery.

Study design

Meta-analysis.

Patients and methods

Six published, randomized, double-blinded, placebo-controlled trials were selected to study the efficacy of ondansetron on PONV in adults undergoing craniotomy. Similarly, three studies were selected in children. The treated adults received 4 or 8 mg of ondansetron during the peroperative period. As for children, they were given a repeated dose of 0.15 mg/kg of ondansetron. The emetic episodes noted for 24 hours in children and until 48 hours in adults were analyzed. The results were presented as relative risks (RR) following a fixed model and a 95% confidence interval (CI). The test for heterogeneity was measured with the I² Altman DG test.

Results

At 24 hours, among the 308 adults tested, nausea and vomiting were significantly reduced by 22% and 57%, respectively; no significant reduction in vomiting was noted for the 149 children patients. At 48 hours, no significant modification was observed in adults.

Conclusions

Peroperative intravenous dose of ondansetron 4 mg in neurosurgery in adults is required to prevent PONV during the first postoperative 24 hours. However, further studies are needed to determine best time and dose infusion to prolong clinical efficacy.