[What to do or not, after an anaesthetic accident? The point of view of the medical advisor]. / 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.

[The surgeon's viewpoint concerning Complex Regional Pain Syndrome 1]. / Le vécu de l'algoneurodystrophie ou syndrome douloureux régional complexe de type 1 par le chirurgien.

The complex regional pain syndrome type 1 from the surgeon's point of view: description of the symptoms, imaging (nuclear medicine, MRI) and of the associated psychological context. Importance of the need for a multi-disciplinary organization from the diagnostic to the therapeutic care.

Pharmacokinetics and analgesic effect of ropivacaine following ilioinguinal/iliohypogastric nerve block in children.

BACKGROUND: The aim was to investigate the efficacy, tolerance and pharmacokinetics of ropivavcaine when administered for ilioinguinal/iliohypogastric block in children. METHODS: We examined the pharmacokinetics and analgesic efficacy after ilioinguinal/iliohypogastric nerve block with 3 mg.kg-1 ropivacaine 5 mg.ml-1 in 22 children, aged 1-12 years, who were scheduled for inguinal surgery. Sixteen of 22 patients had a postoperative pain score < 4 (Objective Pain Scale). Nine children were given supplementary analgesics during the first six postoperative hours. RESULTS: The peak plasma concentration of total ropivacaine was 1.50 +/- 0.93 mg.l-1 (mean +/- SD) (range 0.64-4.77 mg.l-1) 15-64 min after the injection. The peak plasma concentration of free ropivacaine was 0.05 +/- 0.03 mg.l-1 (0.02-0.14 mg.l-1), which is well below the threshold for toxicity in adults. The terminal half-life was 2.0 +/- 0.7 h. No safety concerns or symptoms suggestive of systemic toxicity were observed. CONCLUSION: A dose of 3 mg.kg-1 of ropivacaine given as a single ilioinguinal/iliohypogastric nerve block in 1-12-year-old children provides satisfactory postoperative pain relief, and is well tolerated.

Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists.

We report the results of a prospective study on the practice of pediatric regional anesthesia by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) during the period from May 1, 1993 to April 30, 1994. This study was designed to provide data concerning the epidemiology of regional anesthesia and its complications in a totally anonymous way. Data from 85,412 procedures, 61,003 pure general anesthetics and 24,409 anesthetics including a regional block, were prospectively collected. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics. Peripheral nerve blocks and local anesthesia techniques represented only 38% of regional blocks and Bier block was used only 69 times. Central and peripheral nerve blocks were performed in all pediatric age groups with some intergroup differences. Most blocks were performed under light general anesthesia (89%), confirming the fact that regional anesthetics are used as techniques of analgesia rather than anesthesia. Complications were rate (25 incidents involving 24 patients) and minor, and did not result in any sequelae or medicolegal action. Peripheral nerve blocks and local anesthesia techniques were generally safe. The overall complication rate of regional anesthesia was 0.9 per 1000, but because all complications occurred with central blocks, the complication rate of central blocks is in fact 1.5 per 1000 with significant variations in different age groups. This prospective study, based on a large and representative series of pediatric anesthetics, establishes the safety of regional anesthesia in children of all ages. It provides new insights on the practice of regional blocks and reveals that complications are rare and minor as they occur most often in the operating room and are readily managed by experienced anesthesiologists with resuscitative equipment at hand. The extremely low incidence of complications (zero in this study) after peripheral nerve blocks should encourage pediatric anesthesiologists to use them more often when they are appropriate, in the place of a central block.

[Caudal anesthesia in children]. / Anesthésie caudale chez l'enfant.

Caudal block is the most frequently epidural block performed in children. A better knowledge of the child anatomy, physiology and pharmacokinetics has increased the safety of regional anaesthesia in children. The technique of puncture has been adapted to the child anatomy and special needles fit for children are now manufactured. The children, as well as adult, have benefited of new drugs (opioids, alpha 2 agonists) which increase the indications regarding time duration or pain intensity. If complications are still possible the respect of safety rules and the use of adapted equipment make caudal block a safe regional anaesthesia.

New regimen for interpleural block in children.

A new regimen for postoperative analgesia after thoracic surgery is proposed. Eight children received an interpleural infusion using bupivacaine 0.1% in a regimen from 0.5 ml.kg-1.h-1 up to 1 ml.kg-1.h-1, for 48 h according to the pain scores. The plasma levels after 24 h and 48 h were measured as well as the pleural level and in two patients the free fraction of plasma bupivacaine and the plasma PPX (a metabolite of bupivacaine) and one patient the orosomucoid (main plasma protein involved in bupivacaine protein binding) were also measured pre and postoperatively. The results shows the safety of such a regimen, for two days of postoperative analgesia.

[Clinical study of EMLA analgesic cream in pediatric locoregional anesthesia]. / Etude clinique de la crème anesthésique EMLA en anesthésie locorégionale pédiatrique.

The advantage of EMLA cream for regional blocks (spinal or caudal blocks) was assessed in 46 children. The study included three groups: group 1, with 1 to 6 month-old children (n = 11); group 2, with children aged between 6 months and 5 years (n = 21), scheduled for emergency surgery and with full stomach; group 3, with 5 to 10 year-old children (n = 14), who were to have a regional block as an alternative to general anaesthesia. The cream was applied as a thick layer on the area of skin to be anaesthetised and covered by a closed adhesive dressing, approximately 2.2 h before performing the regional block. A dose of 1 to 2 g was used in children of more than 1 year, and 0.5 to 1 g for those of less than 1 year. All the blocks were carried out by the same anaesthetist. The technique was considered as being little (45/46) or not constraining (1/46). Patient cooperation in carrying out the regional block was judged to be good or very good in 34/46 children. Additional sedation was required in 7 children of groups 2 and 3. The block was as easy to carry out as usual in 37/46 children. In all three groups, most children complained of little or no pain. Local adverse effects occurred in 19/46 patients, consisting of erythema (14), skin paleness (4), or both (1). The investigator qualified the use of EMLA cream as satisfactory or very satisfactory in 36/46. It is concluded that EMLA cream provides convenient analgesia for regional blocks in toddlers and children.

[Ten years' locoregional anesthesia in children in a private hospital]. / Dix ans d'anesthésie loco-régionale chez l'enfant dans un hôpital privé.

Retrospective study during a ten years period of 5,512 regional anaesthesias on children in a private hospital. This work identifies the peculiarities due to recruiting and to RA techniques, shows the practical conditions (preoperative samples, equipment, drugs) and studies the complications, before pointing out good practice rules.

Temporal variations in transcutaneous passage of drugs: the example of lidocaine in children and in rats.

Because a eutectic mixture of lidocaine and procaine (EMLA cream) is used to treat pain in children who are undergoing venipuncture for screening clinical presurgery laboratory tests, this study was designed to investigate the influence of the time of application of EMLA cream on lidocaine transcutaneous absorption in children. The same phenomenon was also studied in rats. Local application of EMLA (right and left cubital fossae) was performed 1 hour before venipuncture in two groups of children (0.5 g/kg body weight at two sites), at 08:15 or 16.15 h; blood samples were performed 1 h later. Two groups of five rats each received 12 mg/kg lidocaine at 07:30 or 19.30 h by application to the back skin. Blood samples were collected 0.5, 1, 1.5, 2, 3, and 4 h after application. Plasma lidocaine levels were assayed according to an immunoenzymatic method (Abbott). Our data indicate that the lidocaine plasma levels were significantly different: higher in the evening for the children or in the morning for the rats. The plasma level of the local anesthetics (LA) represents an elimination route and thus may be inversely correlated to the skin amount of the LA.

Bupivacaine free plasma levels in children after caudal anaesthesia: influence of pretreatment with diazepam?

Diazepam-induced modifications in bupivacaine distribution have been noted in previously reported data investigating the influence of diazepam on bupivacaine plasma levels in children undergoing surgery under caudal block with a mixture of lignocaine and bupivacaine. Possible diazepam-induced changes in protein binding were therefore examined in this study. Our data did not demonstrate significant modifications in bupivacaine protein binding when diazepam is used concomitantly.

Influence of midazolam on the plasma concentrations of mepivacaine after lumbar epidural injection in children.

Twenty children undergoing surgery received a lumbar block using 0.4 ml/kg mepivacaine 2.0%. They were randomized into two groups, one of which received midazolam 0.4 mg/kg rectally as premedication. Midazolam administration did not significantly influence the plasma concentrations of mepivacaine.

The influence of midazolam on the plasma concentrations of bupivacaine and lidocaine after caudal injection of a mixture of the local anesthetics in children.

Twenty children undergoing surgery received a caudal block using 1 ml per kg of a mixture of 50% lidocaine (1%) and 50% bupivacaine (0.25%). They were randomly allocated to two groups, one of which received midazolam 0.4 mg/kg rectally as premedication. Midazolam administration resulted in a significantly lower AUC value for lidocaine but did not influence the plasma concentrations of bupivacaine.

The influence of diazepam on the plasma concentrations of bupivacaine and lignocaine after caudal injection of a mixture of the local anaesthetics in children.

Twenty-one children undergoing surgery received a caudal block using 1 ml kg-1 of a mixture of 50% lignocaine (1%) and 50% bupivacaine (0.25%). They were randomized into two groups, one of which received diazepam 10 mg rectally as premedication. Diazepam administration resulted in significantly higher Cmax and AUC values for bupivacaine but did not influence the plasma concentrations of lignocaine.

[Rapid acquired tolerance to cow's milk by oral route in a case of severe childhood food allergy]. / Accoutumance rapide par voie orale au lait de vache dans un cas d'allergie alimentaire sévère chez l'enfant.

An attempt to desensitize to cow's milk a 5 year-old girl who had been forced to follow a strict egg and milk-free diet with concomitant impossibility of attendance at school, posed major practical problems. In a hospital environment, under cover of treatment with Nalcron and Solemedrol, the re-introduction of milk was started with 10(-10) ml of milk. After a severe episode on the 1st day, the child was able to take 100 ml on the 10th day and thereafter. Today, the child continues with Nalcron treatment, but she no longer has a diet and she leads a normal lifestyle.

[Caudal epidural anesthesia in children. Study of endocrine changes]. / Anesthésie péridurale par voie caudale chez l'enfant. Etude des variations endocriniennes.

Changes in serum levels of corticotrophin (ACTH), immunoreactive beta-endorphin, antidiuretic hormone and cortisol were compared in children undergoing minor surgery under either general anaesthesia with halothane or epidural anaesthesia by the caudal route. A rapid and major increase in hormone levels was observed under general anaesthesia but not under epidural anaesthesia.