Adverse effects of regional anaesthesia in children.

True complications of regional block procedures pertain to the performance of the block technique and the local anaesthetic. Such complications include lesions caused by the device used, and many of these complications can be avoided by using specifically designed devices.Complications related to the local anaesthetic solution mainly consist of local and systemic complications. Local toxicity has mainly been reported in adults following spinal administration of 5% lidocaine (lignocaine), a drug that is not usually used in children. Systemic toxicity consists of CNS and cardiovascular complications, methaemoglobinaemia and allergic reactions. Systemic toxicity has special features in children, especially in those <1 year old. Infants have a much higher free serum concentration of local anaesthetics than older children and adults, and are more prone to the deleterious effects of local anaesthetics. Additionally, as regional blocks are usually performed under general anaesthesia in children, signs of CNS toxicity may be concealed. Because of their higher heart rate, newborns and infants are thought to be more prone to the phasic block produced by tertiary amine agents such as bupivacaine than are adults. Serum concentrations at which bupivacaine (and etidocaine) exert cardiac toxicity seem to be similar to those producing CNS toxicity. As there is an increased threshold for CNS toxicity in infants plus an increased (or equal) sensitivity to bupivacaine cardiotoxicity, cardiac signs may not be preceded by any sign of CNS toxicity. Cardiac complications include: (i) arrhythmias with high degree conduction block, major QRS widening, torsade de pointes, and ventricular tachycardia related to re-entry phenomena; and (ii) major vascular collapse favoured by a concomitant decrease in the myocardial contractile force. Other complications of regional block procedures result from poor selection of agent, and inadequate safety precautions and monitoring of the patient, especially during the postoperative period. There are 2 other groups of disorders often reported as complications of regional anaesthetics: (i) effects that were not anticipated by the anaesthetist because of a lack of knowledge of all the consequences of the technique used; and (ii) complications attributed to a concomitant regional block procedure but with no established, sometimes even improbable, causal link with the regional technique. The overall morbidity of regional anaesthesia in children is low. Sound selection of local anaesthetics, insertion routes and block procedures, together with appropriate and careful monitoring, should prevent any major undesirable effects and enable regional anaesthesia to be a well tolerated and effective tool to overcome pain associated with minimal morbidity.

Cerebrospinal fluid enzymology: creatine kinase, lactate dehydrogenase activity and isozyme pattern as a brain damage index.

Blood serum and cerebrospinal fluid from a 4.5-year-old girl suffering from convulsive episodes of toxic origin were investigated for lactate dehydrogenase (LDH) and creatine kinase (CK) activities. Elevated levels of both enzymes were found. Furthermore CK was higher in the CSF (680 I.U./1) than in blood serum (160 I.U./1). The CSF activity was demonstrated mainly as the BB form (96%) for CK and H4 (63%) was the predominant form for LDH. Identical investigations were performed 45 h later and results compared with the first set. These data provide an additional example of interest in CSF enzymatic studies as a brain damage index.

Evaluation of infectious episodes in neonates using a new procedure for the nitroblue tetrazolium test.

A new procedure for the NBT slide test for peripheral blood neutrophils has been tested. 255 neonates were studied of which 63 served as control cases. Among the 114 term infants, 37 were patently infected, 30 suspicious and 47 non-infected. The latter did not significantly differ from control cases, whereas suspicious and infected infants were credited with significantly higher NBT scores. 78 infants were preterm, 31 of which were patently infected, 22 suspicious and 25 non-infected. NBT scores of infected and suspicious infants were significantly higher than those of non-infected infants, but, as previously reported, scores of preterm infants were systematically and significantly lower than those of full-term infants of the same bacteriological class. Threshold values are suggested; they could represent an accurate diagnostic aid in the early differentiation of healthy infants from high-risk infants regarding bacterial infections.

Intrathecal morphine for spinal fusion in children.

Intrathecal morphine (0.025 mg/kg) was administered preoperatively to 20 children undergoing major surgery of the rachis, ie, either posterior (16 cases) or anterior (4 cases) spinal fusions. During the surgical procedure, hemodynamic control was easily maintained. Blood loss was slightly less than 50% of blood volume and the mean infusion rate of blood was 6.3 +/- 4.5 ml/kg/hour for the duration of surgery. The technique did not significantly interfere with wake-up tests, and memory of awakening was only observed in one case. The postoperative course was also positively affected. The children could be extubated within the 30 minutes following completion of surgery, and they could perform effective breathing exercises early on. High degree and long duration (36 to 72 hours) of pain relief were obtained in every case. No major adverse effect was observed. Thus, the administration of intrathecal morphine prior to spinal fusion appears to be safe, easy, and reliable. We think it should be recommended for major surgery of the rachis.

Spontaneous perforation of Meckel's diverticulum in a neonate.

A case of a male newborn infant with spontaneous perforation of Meckel's diverticulum is reported. The clinical course consisted of delayed occlusive disorders and bloody stools following 36 h of normal gastrointestinal transit, without pneumoperitoneum and infection. Pathogenesis of the perforation is discussed and the importance of early diagnosis, especially in maternity hospitals, is emphasized.

Cerebrospinal fluid cytomorphology in neonates.

A prospective cytologic study of cerebrospinal fluids from 57 full-term neonates confirmed the previously reported cellular polymorphism. The cells were classified as (1) exogenous cells, (2) blood and bone-marrow cells, (3) histiomonocytes, (4) cell aggregates and (5) "free" cells. Histiomonocytes were a constant feature in these fluids and were the cause of neonatal pleiocytosis. Various degrees of activation could be recognized. The so-called inactive forms were closely related to brain damage. Identification of erythrophages and siderophages had diagnostic significance. The presence of fat in macrophages (lipophages) suggested a serious developmental disorder. The free cells were incompletely identified, as were the cell aggregates, which probably originate in the meningeal lining. Both require further study.

Severe farm machinery injuries to children--a report on 15 cases.

Fifteen children with 24 farm injuries were admitted to our institution during a 12 years period. Ten accidents occurred in boys and five in girls. They ranged in age from 1 to 15. The cause of fatal and non-fatal injury was farm machinery and especially tractor in 9/15. Fractures, lacerations and amputations were the most common injuries requiring multiple reconstructive surgical procedures. The magnitude of the problem requires emergency management in rural areas. However, educational programs with an emphasis on prevention by physicians, family members, educators and legislators is necessary to reduce the incidence of farm accidents.

[Nitroblue tetrazolium test. Neonatal infections and antibiotic therapy]. / Test au nitrobleu de tétrazolium. Infections néonatales et antibiothérapie.

The authors report the results of a prospective test of NBT carried out by an original method already described, and now used for seventy newborn babies. Eleven of them (group I) were tested by simultaneously taken samples from the cord and the heel in the labour ward. The levels obtained according to the position from which the samples were taken showen no significant difference. In 59 other infants (group 2) three successive tests were carried out in the first two weeks of life. These results were classified according to whether the children were: infected, perhaps infected and non-infected. The results confirm correlations between raised levels and infections. Giving antibiotic therapy does not alter significantly the levels in non-infected babies, nor the high positive scores in infected babies that were revealed in the four days after the start of treatment. Following this delay, levels of infected babies' blood did drop significantly, which was a probable indication of the efficacy of the antibiotic therapy.

[Rapid screening for neonatal infection by employing new techniques for the use of the nitroblue tetrazolium test (NBT) (author's transl)]. / Dépistage rapide de l'infection néonatale par le test au nitrobleu de tétrazolium réalisé selon des modalités nouvelles.

A new method for carrying out the nitroblue tetrazolium test (NBT) has been used on micro-specimens taken from 116 newborn infants for the purpose of carrying out a prospective enquiry into neonatal infection. 44 children aged from 1 to 6 days were selected at random from a population that was said to be normal in the maternity unit and were the control group. 72 children of less than 48 hours of age were made to object of a prospective study of neonatal infection, an enquiry that allowed them to be divided into 3 groups: non-infected, infected and suspect. The study showed a very strong correlation between raised scores (higher than 100) and the presence of an infection, whereas scores in the controls and the non-infected infants were low. This test, which is hardly invasive and easy to introduce as a routine when carried out early is a good screening test for infection and can be best used on the newborn population in a maternity unit.

[Acute pain in children and its treatment]. / La douleur aiguë de l'enfant et son traitement.

Pain in paediatrics has long been underestimated. The numerous scientific studies carried out during the last decade show that its existence can no longer be doubted: in fact, pain already exists during the neonatal period, and probably throughout the last trimester of gestation as well. Pain pathways mature during the embryonic period and peripheral receptors develop between the 7th and 20th week. A-delta and C fibers, as well as spinal roots and nerves, are completely differentiated before the end of the second month. The development of specific neurotransmitters and thalamic and cortical dendritic branching occurs later on; it is well enough developed to allow perception of painful stimuli (slow or protopathic component) from the beginning of the foetal period onwards. The discriminative rapid component develops in parallel to myelinisation, and the psycho-affective component, which requires a long and complex learning process, will not be fully operative until the end of puberty. Assessing pain, already a difficult task in the adult, is all the more so in children because of lesser verbal communicative capabilities, difficulty in handling abstract concepts, lack of experience of painful stimuli to make comparisons, and ignorance of their body image. In the very young child, diagnosing pain relies on suggestive circumstances, and an altered behaviour, knowing that no one symptom in pathognomonic. As the child grows up, methods for self-assessment of pain become usable, such as coloured scales and simplified verbal scales. However, behavioural tests remain the mainstay until the prepubertal period. The treatment of acute pain requires a reasoned approach which takes into account the state of the child, that of the aetiological investigations, the likely course of the lesions, as well as the patient's analgesic requirements. Therapeutic means do not differ from those for adult patients; however, the differences of distribution of body water, the small possibilities of linking with plasma proteins, and limited conjugation with glucuronate must be taken into account, especially during the first months of life. Local and regional anaesthetic block techniques are of great interest in elective and emergency surgery, as well as in trauma: they can provide complete pain relief, mostly without having any effect on the patient's physiological state (haemodynamics and consciousness). Peripherally acting analgesic agents, which are well supported on the whole, as well as co-analgesics, have a great part to play, although there are less drugs available than for adults. The most useful ones are paracetamol, followed by the salicylates, propionic acid derivatives and non steroid anti-inflammatory drugs.(ABSTRACT TRUNCATED AT 400 WORDS)

[Regional anesthesia in pediatrics]. / L'anesthésie locorégionale en pédiatrie.

After having been virtually completely forgotten since the Second World War, paediatric regional anaesthesia has been undergoing a renewal in the last decade. This renewed interest in old techniques is due to several converging factors: a better knowledge of the pharmacology of local anaesthetic agents in the child, the availability of equipment adapted for children, the remarkable haemodynamic stability of the very young child during an epidural block, as well as the need to treat pain not just in the operative period. The child is not, or rather, is not only a small adult. Embryological development is not finished at birth. The incompletely myelinized nervous system as well as the incomplete skeletal ossification will influence local anaesthetic pharmacodynamics and the choice of anaesthetic technique and anatomical landmarks. Aponeurotic sheaths are only poorly attached to anatomical structures, especially nerves. This, together with the fact that epidural fat in the young child is very fluid, explains why some techniques are very efficient, but also why the volumes of required anaesthetic solution are proportionately much more important than in adults. The general pharmacology of local anaesthetic drugs is very close to adults. However, the very important regional blood flow rates, the different body water distribution, the immature neurovegetative system, the weak activity of some enzymes, and the relatively greater importance of the liver and brain by weight explain the differences found in pharmacokinetics, which are differences in degree and not in nature. The choice of the appropriate local anaesthetic agent depends on these factors. In France, the chosen drug will almost exclusively be an amide, mostly lignocaine and bupivacaine. The psychological immaturity of children makes any assessment of pain quite difficult. Moreover, body image has not yet been completely acquired in most cases, so reducing the possibility of conceptualization. The usefulness of techniques requiring an active patient participation, in particular the search for paraesthesia, is therefore rather reduced. Light general anaesthesia and peripheral nerve stimulators (for nerve blocks) are essential, and desirable at least, if not wished by most patients. Caudal anaesthesia is an important technique in the child. It is easy to perform, efficient, with small risk. Its ideal indication is surgery below the umbilicus in the infant and young child. Lumbar epidural anaesthesia requires greater experience as well as proper equipment, especially in the very young child. Peripheral nerve blocks are less used than in adults.(ABSTRACT TRUNCATED AT 400 WORDS)

[Diprivan and locoregional anesthesia in children over 3 years of age]. / Diprivan et anesthésie locorégionale chez l'enfant de plus trois ans.

Preparation for anaesthesia (at least 1 hour prior to surgery): Topical anaesthesia at venepuncture sites and at the site of the block. Possible premedication (rectal midazolam: 0.3 mg.kg-1). Anaesthetic induction: Insertion of venous cannula; i.v. injection of 3-4 mg.kg-1 propofol, mixed with 0.05% lidocaine; Control of child's ventilation conditions: tolerance of the face mask, Guedel airway, laryngeal mask; tracheal intubation would be easy if necessary and would not require muscle relaxants; In cases where the child is distressed or where venous access cannot be obtained, it is sometimes preferable to resort to inhalational induction with halogenated anaesthetics prior to venepuncture. Initial maintenance anaesthesia (performing the block): Propofol given as a continuous infusion of 13 mg.kg-1.h-1, after a bolus injection of 1.3 mg.kg-1 (alternative solution: maintaining anaesthesia using halogenated agents); Positioning of the patient and performing the block technique with relatively concentrated local anaesthetic solutions (to avoid differential blocks). Maintenance anaesthesia during the procedure: Propofol given as a continuous infusion in reduced doses: 2 to 5 mg.kg-1.h-1; Alternatively: halogenated anaesthesia at low concentrations (equivalent to 0.25 to 0.5 vol % of halothane). Recovery: Particularly rapid and pleasant recovery, with a minimum of side effects; In cases of day-case surgery, patient discharge has virtually never to be postponed.

[Pros or cons of accessory anesthetic circuits. I. Arguments for their use]. / Pour ou contre les circuits anesthésiques accessoires. I. Arguments pour leur utilisation.

In addition to the circle breathing system, which represents the main circuit of the anaesthetic machine, the use of an accessory breathing system (ABS), either a partial rebreathing system according to Mapleson's classification, or a system including a non-rebreathing valve, is appropriate for the anaesthetic management of many patients, depending on their physical status, age, indication and duration of surgery. The same safety rules, namely full checking procedure before use of the system and monitoring of inhaled gases and end-tidal CO2 must be applied as for the main circle system. Potential complications resulting from non compliance with these rules cannot be considered valuable reasons for denying the use of breathing systems that have safely been used for decades in millions of patients.

[Accessory anesthetic breathing systems: verification before use]. / Circuits anesthésiques accessoires: vérification avant utilisation.

Accessory or ancillary anaesthesia breathing systems can be defined as all those connected to the fresh gas outlet of the anaesthetic apparatus and used instead of the circle system associated with the ventilator, which is the main circuit. They include: the Mapleson systems, the systems with a nonrebreathing valve and the disposable systems with a carbon dioxide absorber. They can be a cause of major accidents when not checked before and monitored during use. This technical note describes techniques of preanaesthetic checking and monitoring during anaesthesia.

[Outcome of nonsurgically treated pseudoappendicular syndromes in children. Retrospective study of 479 cases]. / Le devenir des syndromes pseudo-appendiculaires non opérés de l'enfant. Etude rétrospective portant sur 479 cas.

A retrospective study was conducted to assess outcome in 479 children admitted to a surgical pediatric department with pseudo-appendicular syndromes untreated by surgery. A precise diagnosis had been made during the first admission in 186 cases. At a later date, each child had been examined clinically and a detailed history taken, or a questionnaire was sent to the families or treating physician. Replies were received concerning 263 children, including 205 who had had no further episode of abdominal pain, 24 who had had similar atypical bouts of abdominal pain and 34 who had been operated upon at a later date (representing 12.9% of replies). These findings would appear to justify avoidance of surgery, after admission for observation, whenever the atypical symptomatology, negative results of paraclinical investigations and the progression towards total remission of the affection is observed.

[Lower limb blocks in children]. / Blocs du membre inférieur chez l'enfant.

Conduction blocks have important advantage over spinal blocks for unilateral low extremity surgery in children. The complexity of innervation compared with upper limb is more apparent than real and a good understanding of fascial diffusion spaces is as essential as it is of neural pathways. Useful techniques can be classified into two groups, proximal blocks and distal blocks. Beside emergency situations, proximal blocks are usually performed under light general anaesthesia, with the aid of a neurostimulation. The most used proximal blocks are the femoral block, the sciatic nerve block and to a lesser degree the lumbar plexus direct blockade. Distal blocks can complete a non quite satisfactory proximal block, or be effected so as to obtain analgesia in a limited area (in a cooperative vigil patient). Some of these consist of several anaesthetic subcutaneous infiltrations for which no costly material nor special dexterity are required. A judicious choice among the main available techniques allows an excellent analgesia with a very low cost and almost no risks.

[Practical methods of using propofol as a complement to loco-regional anesthesia in children]. / Modalités pratiques d'utilisation du propofol en complément de l'anesthésie loco-régionale chez l'enfant.

Propofol fulfills most of the requirements for the ideal intravenous agent usable in conjunction with regional anesthesia in children, especially for outpatient surgery. Some limitations are easily overcome by simple means such as contact anesthesia of the skin prior to venous puncture or addition of lidocaine (1 ml 1% lidocaine in 20 ml of propofol). In clinical practice, it is mandatory that the sites of puncture (venous line as well as block technique) be anesthetized by skin application of EMLA cream and that anxious children be given premedication (0.3 mg.kg-1 of rectal midazolam). Recommended induction dose of propofol is 3 to 4 mg.kg-1. Maintenance of anesthesia can be achieved either by continuous infusion of 2 to 5 mg.kg-1.h-1 of propofol or by inhalation anesthesia with low concentrations of halogenated agents. Spontaneous ventilation through a face mask or a laryngeal mask is usually made possible. Satisfactory conditions for performing the regional block technique are especially obtained when the skin at the site of puncture is anesthetized. Adverse effects are unusual and mainly consist of undesirable movements, the occurrence of which is favored by the existence of a differential sensory block. Propofol allows easy and complete post-anesthesia awakening and it has anti emetic and anxiolytic effects: due to these properties, it is remarkably suitable for use in association with regional anesthesia in children.

[Ventilation using jet-ventilation during fiber-optic bronchoscopy in children under 5 years old. Apropos of 100 case reports]. / Ventilation par jet-ventilation au cours des fibroscopies bronchiques chez l'enfant de moins de cinq ans. A propos de 100 observations.

The authors report an original procedure for respiratory assistance during flexible bronchoscopy in infants and toddlers. The injector is directly connected with the operating channel of the bronchoscope. Ventilation parameters are pre-regulated before introducing the fiberscope into the respiratory tree. Insufflation volumes are restricted to 5 ml/kg at the tip of the bronchoscope, on a basis of 40 to 60 cycles per minute, according to children's age. A venturi effect may occur as discrepancy between bronchi and the size of the fiberscope does exist. For evaluating this effect, gas flow is measured through tracheal tubes selected in accordance to the size of the respiratory tree of the infant. This evaluation demonstrates that tidal volumes are comprised within 5 and 10 ml/kg. The procedure of jet-ventilation was performed on 100 infants under general anaesthesia with curarization. Baro-traumatic accidents did not occur, despite poor physical conditions in many cases. The procedure was safe for the infants and convenient for the physicians. In this way, it could be recommended for flexible bronchoscopy in infants and toddlers with poor condition or when excessive duration of the examination could be required (diagnostic or therapeutic procedures associated).