Analgésie systémique à domicile après chirurgie pédiatrique ambulatoire

Currently, day-case surgery has a significant development. In pediatrics, a big part of interventions can be performed as a day-case surgery. However, postoperative pain, often wrongly regarded as minor, should not be underestimated or undertreated. The aim of this paper is to review the available systemic analgesics and to propose a way to use them in order to improve children's comfort and experiences in their own families.     

Réhabilitation précoce après césarienne programmée : enquête de pratique auprès des maternités des régions Provence - Alpes - Côte d’Azur et Île-de-France

Aims

Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France.

Type of study

Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d’Azur [PACA] and Île-de-France [IDF]).

Methods

Questionnaire related to scheduled caesarean delivery.

Results

Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24 hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0–6), the median value was 3 (2–4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use.

Conclusion

The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions.     

Syndrome de Parkes-Weber et grossesse : implications anesthésiques

We report two deliveries in a patient with a Parkes-Weber syndrome. This parturient had a complex angiodysplasia including a soft tissue hypertrophy of a lower limb, a cutaneous angioma and arteriovenous malformations. The risk of perimedullar arteriovenous malformations was ruled out by angiographic magnetic resonance imaging of the spinal cord. We also describe other aspects of the management, including prepartum cardiovascular assessment, mode of delivery, the use of epidural analgesia and the prevention of haemorrhagia and thromboembolism.     

Accident hypoxique en anesthésie pédiatrique dû à un réglage inadapté du respirateur

A 3-year-old child was anesthetized for ENT examination and surgery. After induction and tracheal intubation, the patient was ventilated (controlled mode). The respirator screen showed information compatible with a failure of intubation: no expired CO₂, no expired flow, no alarm of high pressure limit, and no respiratory chest movement. A fall of SpO₂ appeared rapidly which recovered after extubation and manual ventilation through a face mask and reintubation. The expiratory CO₂ was present when the patient was ventilated manually and disappeared under controlled ventilation. The increase in the value of the maximal insufflation pressure allowed efficient ventilation with an expiratory CO₂ curve and showed high ventilation pressure compatible with a bronchospasme. This case report shows that in case of bronchospasme, if the value of the maximal insufflation pressure is low, this may lead to an erroneous diagnosis of failure of intubation.     

A Critical Analysis of Myths About Dissociative Identity Disorder

In a review of the literature in this journal, Piedfort-Marin et al. (1921) identified what they purported to be myths about dissociative identity disorder (DID) and dissociative amnesia. When responding to these beliefs, they supported the Trauma Model of dissociation and argued for a causal etiological link between trauma and dissociative conditions. In contrast, they challenged the Sociocognitive Model (SCM), which they claimed rejects the existence of DID and associated disorders (e.g., dissociative amnesia) and considers symptoms to be the byproduct of fantasy, suggestion, and the iatrogenic effect of psychotherapies. In this article, we critically evaluate the authors’ arguments and propose a more balanced, accurate, and comprehensive view of the sociocognitive model. We demonstrate that this model neither rejects the existence of DID, nor a link between trauma and dissociation potentially mediated by a variety of cognitive-affective-behavioral variables. We argue, contrary to Piedfort-Marin et al., that the tendency to confabulate and other cognitive and sociocultural variables may also contribute to the development of DID. We contend that a multifactorial integrative etiological perspective can move the field beyond a limited focus on controversies that divide the TM and SCM models of dissociation.