Douleur postopératoire. Spécificités de l'enfant de moins de 5 ans,néonatologie exclue

For many years, postoperative pain has been undertreated in children less than 5 years old in comparison to adults. The assessment of pain is indeed difficult in this range of age, and only the scales of hetero-evaluation are used. The guidelines for treatment are similar as in adults: systematic administration, balanced analgesia, evaluation of pain and potential adverse effects. Non opioid analgesics used are mainly paracetamol, niflumic acid and ibuprofen. Morphine remains the drug of choice among opioids; however the risk of respiratory depression in higher in infants less than 3 months old. Nalbuphine is also widely used in paediatrics. In addition, regional anaesthesia, either in single shot for minor surgery, or in continuous administration through epidural catheter for major surgery, has changed the management of postoperative pain in paediatrics.     

Conditions d'intubation: importance de la fréquence de répétition du train de quatre

ObjectivesTo assess that neuromuscular relaxation onset of the adductor pollicis (AP) is related to neuromuscular stimulation rate. To assess that train-of-four (TOF) at 0.05 Hz is a more accurate indicator of optimal tracheal intubation time and conditions, than TOF at 0.08 Hz.Study designProspective, comparative, randomized doubleblind study.PatientsForty adults, physical class ASA 1 or 2, undergoing general anaesthesia with tracheal intubation were allocated to two groups (n = 20) according to the sequence of stimulation of the AP: either TOF at 0.05 Hz (test group) or TOF at 0.08 Hz (control group).MethodsInduction of anaesthesia was achieved with thiopentone, fentanyl and vecuronium (0.1 mg·kg⁻¹). Neuromuscular monitoring was obtained with force displacement transducers attached to each AP. Tracheal intubation was performed once AP muscular response obtained with TOF at 0.05 Hz for test group and TOF at 0.08 Hz for control group was abolished. Results are expressed as± SEM. Fisher exact test was used for intubation conditions comparison. Curarization time between groups was compared with unpaired Student's t test (P< 0.05 accepted).ResultsTOF with 0.05 Hz stimulation significantly increased curarization time: 217 ± 7 versus 162 ± 6 s (P< 0.001). Intubation conditions were excellent in 95% and good in 5% of patients in the study group, compared to 15 and 40% in the control group, respectively (P < 0.01). In 45% of the control group patients coughing at intubation occurred.ConclusionLow stimulation rate (TOF at 0.05 Hz) of AP is a reliable technique to determine the appropriate intubation time for patients paralyzed with vecuronium.     

Comparaison de l'efficacité analgésique de la nalbuphine et de son association au propacétamol en phase postopératoire immédiate de chirurgie gynéco-obstétricale

This prospective randomized single-blind study compared the efficacy of a combination of propacetamol (2 g) and a low dose of nalbuphine hydrochloride (10 mg) with nalbuphine hydrochloride (20 mg) alone, in a population of 152 white female patients after gynaecologic or obstetrical surgery, for alleviation of postoperative pain in recovery room. The drugs were administered intravenously in case of pain. The population was divided into two groups : group 1 received 20 mg of nalbuphine hydrochloride and group 2 received 2 g of propacetamol combined with 10 mg of nalbuphine hydrochloride. The pain intensity was studied with the visual analogue scale and comparisons use no parametric tests (Mann and Whitney test, Kruskall and Wallis test) and Chi² test. Groups were similar for age, surgical and anaesthesia procedures and initial pain level. The propacetamol-nalbuphine hydrochloride 10 mg association provided a significantly better analgesia than nalbuphine 20 mg during the first two postoperative hours (p < 0.05). In group 1, the analgesia score decrease was respectively 28 ± 25 mm (range : 33–75 mm) after 1 h and 31 ± 25 mm (range : 26–84 mm) after 2 h. In group 2, the decrease was more important : 37 ± 21 mm (range : 5–84 mm) after 1 h and 42 ± 23 mm (range : 20–84 mm) after 2 h. Side effects were minimal and similar in both groups (nausea, drowsiness). It is concluded that a propacetamol-nalbuphine hydrochloride 10 mg association provides better analgesia than single dose of 20 mg of nalbuphine. This association convenient analgesia with a decreased dose of nalbuphine.     

Moyens mécaniques de traitement de l'insuffisance cardiaque réfractaire

Mechanical means tend to be used more frequently nowadays for the treatment of congestive heart failure which does not respond to more normal treatment. The indications and limits of such devices, as well as their cost, must be defined. The new problem created by these therapeutic tools is the evolution of the underlying cardiac disease : should it improve the patient will be weaned from the machine, whereas if it worsens heart transplantation would be the only answer. Three types of mechanical support are described. Balloon pumping, and especially intra-aortic balloon pumping, is the technique used most often. It has a true but limited efficacy. Its best indication is cardiogenic shock by left ventricular ischaemia with normal or slightly increased peripheral resistances. Intrapulmonary balloon pumping is occasionally used, but the system can only be set up surgically. Its best indication would seem to be right-sided heart failure by pulmonary hypertension. Circulatory assistance is the second type considered. All types of bypass pumps can be used. The output used is usually less than the patient's theoretical output, the aim being to allow the myocardium to recover. Vascular access for these pumps is either femoral or intrathoracic. An oxygenator may or may not be added to the bypass circuit, and support may be mono- or biventricular. Although the non pulsatile flow has not been shown to be detrimental, this has to be investigated further. The use of these devices is limited by their effects on blood coagulation and pulmonary function. The artificial heart or artificial ventricles are the last devices described. They are either orthotopic, such as the Jarvik type, or extracorporeal, such as the Pierce artificial ventricles. Their ability to support totally the circulation for weeks allows patients to recover somewhat from acute multiple organ failure, so that they can be transplanted in better conditions. The main difficulty in using such devices is patient selection, with the exclusion straight-off of those patients with chronic multiple organ failure who will in any case not be suitable for transplantation later on. Because there are numerous mechanical means now available for the treatment of congestive heart failure no longer responsive to drugs, the choice of device to be used depends on the ultimate goal aimed for, i.g. transplantation or not.     

Modification du réflexe de déglutition au cours de la période périopératoire

The swallowing reflex is one of the major mechanisms protecting the lungs against aspiration of foreign material. Its complex time course requires a perfect coordination with ventilation, as the aerodigestive crossroads are common for both functions. Physiological factors as ageing, as well as mechanical and pharmacological agents, may contribute to swallowing reflex alterations. Moreover, endotracheal intubation and most anaesthetic agents may impair the swallowing function and favour the occurrence of aspiration. This review discusses the normal swallowing process and its alterations by agents currently used in anaesthesia. Furthermore, the effect of intubation as well as changes related to co-existing diseases are considered.     

Prévalence de la maladie osseuse de Paget et de l'hémangiome rachidien chez la femme française de plus de 75 ans : résultats de l'étude Epidos

Prevalence of paget's disease of bone and spinal hemangioma in French women older than 75 years. Data from the Epidos study. Objective. To evaluate the prevalence in France of Paget's disease in elderly women. Patients and methods. The prevalences of Paget's disease and of thoracic and lumbar vertebral hemangioma were determined in a random nested cohort of 770 women from the EPIDOS study cohort. EPIDOS is a prospective study of the risk of proximal femoral fracture in 7598 female, community-dwelling volunteers older than 75 years of age. The EPIDOS study patients were recruited at five centers in France (Amiens, Lyon, Paris, Montpellier, and Toulouse). For the nested study, anteroposterior and lateral radiographs of the thoracic and lumbar spine were read by two rheumatologists and classified into four groups: no Paget's disease or hemangioma, possible Paget's disease or hemangioma, definite Paget's disease, and definite hemangioma. Radiographs in the last three groups were read by a rheumatology professor and a radiology professor, both independent from the study. Results. Twenty-five patients had incomplete or poor-quality radiograph sets, leaving 745 patients for the study. A vertebral hemangioma was found in four patients (0.54%; 95% confidence interval [Cl], 0.01–1.1%) and vertebral Paget's disease in four other patients (0.54%, 95% Cl, 0.01–1.1%). All the pagetic vertebrae were at the lumbar spine. Three of the four Paget's disease patients were unaware of the condition before their inclusion in the study. Based on previous estimates that thoracic and lumbar foci are present in 30% to 50% of Paget's disease patients, our data suggest that the overall prevalence of Paget's disease in French women older than 75 years may be in the 1.1%–1.8% range. Conclusion. The prevalence of Paget's disease in elderly French women is similar to that recently reported in Britain.     

Comparaison de l'échodoppler couleur et de l'échoendoscopie pour l'évaluation préopératoire de l'axe mésentéricoportal dans les lésions pancréatiques

Aim of the studyThis prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseasesMaterial and methodsThe study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectabilty or potential resectability (n = 34) and irresectabilty (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy.ResultsFor endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar.ConclusionsImaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.     

Contribution de l'hémodilution préopératoire par érythrophérèse à l'épargne de sang homologue au cours de l'arthroplastie totale de hanche

ObjectivesTo compare three techniques for decreasing homologous blood requirements in total hip arthroplasty (THA), including preoperative autologous donation (PAD), preoperative acute normovolaemic haemodilution with erythrocytapheresis (erythro) and intraoperative normovolaemic haemodilution (haemo).Study designProspective clinical trial.PatientsThe study included 45 patients scheduled for THA, under general anaesthesia and operated on by the same surgeon. The patients were allocated into three groups of 15 each.MethodsBlood loss was assessed, during surgical procedure, by the weight of sponges and, the amount of blood collected in the suction bottles during and after surgery. The haemoglobin concentration was measured at the time of preoperative assessement (d-30), just prior to surgery (d-1), in the recovery room (d+3h), and 1, 3, and 8 days later (d8). The transfusion end-point in the three groups was to obtain a haemoglobin concentration of 100 g·L⁻¹ from d+3h until d8. Every pack of red blood cells transfused was weighed and its haematocrit assessed to determine the accurate volume of red blood celts.ResultsIn the three groups haemoglobin concentration was similar from d+3h until d8. In the PAD group, no patient required homologous blood transfusion. There was no significant difference between the two other groups in the mean volume of homologous red blood cells required (308 ± 197 mL in erythro group and 331 ± 202 mL in the haemo group, respectively). The intraoperative blood loss was significantly higher (P = 0.001) in the erythro group: 914 ± 305 ml vs 665 ± 263 in the PAD group and 512 ± 146 ml in the haemo group, respectively. There was an inverse correlation between haematocrit at d-1 and intraoperative bleeding (r = −0.7) (P = 0.0001). The distribution of the points was fitted as an exponential curve.ConclusionsIn THA, PAD is obviously the best technique to avoid homologous blood transfusion. However, when PAD is not feasible, removal of blood prior to surgery does not decrease requirements of homologous blood, as intraoperative blood loss is higher. Our results strongly question the use of major haemodilution during a surgical procedure exposing a major blood loss.     

Anomalies de l’équilibre hydrosodé

Water balance control is aimed at normalizing cellular hydration, and sodium balance control at normalizing extracellular volume. Water balance control is based on the regulation of body fluid tonicity, while the control of sodium balance is based on the regulation of effective arterial volume. Disorders of water balance act on cellular hydration: primary disorders induce a proportional change in tonicity; secondary disorders are induced by a change in tonicity or effective arterial volume. Disorders of sodium balance act on extracellular volume: primary disorders of sodium balance induce a change in effective arterial volume; secondary disorders are induced by a change in effective arterial volume. Physical examination of the patient allows assessing the extracellular volume and the severity of the sodium balance disorder. Natremia – that generally reflects tonicity – allows to assess cellular hydration and to determine the type of water balance disorder. In the case of natremia disturbance, the assessment of both the tonicity and the extracellular volume allows the determination of the type of water and/or sodium balance disorder that is necessary for prescribing the adequate therapy.     

101. Gastrectomie de nécessité

Zusammenfassung Nach dem Prinzip gastrectomie de nécessité wird der Magen nur dann vollständig entfernt, wenn der Abstand des Tumors zum oesophago-gastralen Übergang keine sichere Resektion im Gesunden erlaubt. Für dieses Prinzip spricht, dass eine grössere Patientengruppe (ca. 20%) von den Vorteilen einer Teilresektion -sie betreffen v. a. den Ernährungszustand und somit Lebensqualität und körpereigene Tumorabwehr - profitieren kann. Gegen dieses Prinzip spricht, dass beim Vorliegen eines diffusen Carcinoms die Gefahr eines lokalen intragastralen Rezidivs erhöht ist.     

Chirurgie hémorragique chez deux enfants de témoins de Jéhovah refusant l'autotransfusion programmée: place de l'érythropoïétine

We report two cases of haemorrhagic surgery in a 6-year-old and 16-year-old girl, respectively, whose parents were Jehovah's witnesses and therefore opposed to preoperative blood donation, but accepting intraoperative blood salvage. Erythropoietin and intravenous iron were administered preoperatively to increase red cell mass. Intraoperative blood salvage, including normovolaemic haemodilution and intraoperative autologous transfusion, avoided homologous blood transfusion.