Perioperative management of traumatic spinal cord injured patients after the acute phase

Objective

To understand the physiopathology and the consequences of a traumatic spinal cord injury after the acute phase. The aim is to describe the preoperative management of these patients and the various anaesthetic techniques available.

Data source

The data were retrieved from the PubMed data base, papers from the major French anaesthesiology and intensive care conventions, publications from the French medico-surgical encyclopaedia, combined with reference analysis of major articles in this field.

Results

In France, there are 40,000 patients with traumatic spinal cord injury. These lesions lead to major handicap and frequent complications particularly urologic and orthopaedic ones. These patients often require surgical procedures under anaesthesia. Besides neurological deficits, the spinal cord injury leads to an imbalance between sympathetic and parasympathetic nervous systems with serious dysautonomic complications. During surgery, anaesthesia is necessary to prevent this autonomic dysreflexia. All anaesthetic techniques are usable and effective, subject to their careful implementation for those patients with cardiovascular and respiratory restricted adaptation. The use of suxamethonium can induce fatal hyperkaliemia for up to 10 years after the initial injury, with maximal frequency at six months post-trauma.

Conclusion

Notwithstanding insensitivity resulting from a spinal cord lesion, it is necessary to anaesthetize these patients before all surgical procedures.     

Physico-chemical stability and sterility of non-opioid analgesics in solution

Objectives

The combination of non-opioid analgesic drugs (P: paracetamol, K: ketoprofen and N: nefopam) is currently recommended for postoperative pain control. In practice, these analgesics are often administered in the same solution. We investigated the chemical stability and sterility of three mixtures of analgesics (P + K, P + N and K + N).

Methods

For each mixture, concentrations of active principles were measured using high-performance liquid chromatography over 24 hours. These mixtures were cultured for microbiological colonization.

Results

Our study demonstrated chemical and bacteriologic stability of these three mixtures over a 24-hour period. The results allow the use of P + K, P + N and K + N in the same ready to use solution.     

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.     

Influence of the analgesic strategy on the respiratory function after thoracic surgery for lobectomy

Objective

To compare the influence of thoracic epidural analgesia (TEA) with intravenous patient-controlled analgesia with morphine (PCA) on the early postoperative respiratory function after lobectomy.

Study design

Prospective and comparative observational study.

Patients and methods

Fourty-four patients scheduled for lobectomy (n = 22 per group) were studied on the evolution of the postoperative respiratory function assessed by the forced vital capacity (FVC) and the forced expired volume (FEV₁) during the first two postoperative days and the analysis of noctural arterial desaturation during the three first postoperative nights.

Results

The use of TEA resulted in fewer decrease both in FEV₁ (1.01 ± 0.34 versus 1.31 ± 0.51 l/s for Day 1, P = 0.03; 1.13 ± 0.37 versus 1.53 ± 0.59 l/s for Day 2, P = 0.01) and in FVC (1.23 [1.05-1.51] versus 1.57 [1.38–2.53] l for day 1, P = 0.008; 1.33 ± 0.43 versus 2.24 ± 0.87 l for day 2, P < 0.001). Moreover, the duration of arterial desaturation < 90% were longer in the PCA group during the first (8.6 [0.8–28.2] versus 1.3 [0–2.6] min, P = 0.02) and the second postoperative night (13.5 [3.5–54] versus 0.4 [0–2.6] min, P = 0.025).

Conclusion

The results of this study suggest that the use of TEA is associated with a better preservation of respiratory function assessed by spirometric data and noctural arterial desaturation recording after thoracic surgery for lobectomy.     

Anesthetic management of a child with delta sarcoglycanopathy

A 3-year-old boy of North African decent was seen in the anaesthetic preoperative clinic prior to a scheduled adenoidectomy. His history revealed that his older brother suffered from an unknown form of muscular dystrophy. On clinical exam, no signs of muscular dystrophy were present. However in light of the patient's family history a blood sample for CPK was taken. This was found to be elevated and a neurological consultation was obtained. The patient was diagnosed with a deltasarcoglycanopathy, a rare form of limb girdle muscular dystrophy. A non triggering anaesthetic technique was used, avoiding halogenated anaesthetics and succinylcholine. The preoperative evaluation for a child with a suspected myopathy and the implications for its anaesthetic management are reviewed in this article.     

L’énurésie nocturne primaire : un cas de pédopsychiatrie ordinaire

This article develops a reflection in connection with a symptom childpsychiatric, altogether rather banal in terms of frequency, namely the night primary enuresis. In a society in search of a rational comprehension of the phenomena and installation of therapeute tested, it is interesting to note that the enuresis puts in failure the too exclusive groundworks of treatment requiring kind a broad evaluative approach and a method of support based on the respect of the rythm of the child and his family. Starting from a clinical case, the author develops the relevance of format of talks including the child and the parent where the symptom if it is present is far from being centrally approched. In addition, a consideration of the various treatments shows the need for a structured clinical position, structuring but not directly confronting.