Evaluation of the analgesia nociception index for monitoring intraoperative analgesia in children.

BACKGROUND: Intraoperative analgesia is still administered without guidance. Anaesthetists decide upon dosing on the basis of mean population opioid pharmacological studies and in response to variations in haemodynamic status. However, those techniques have been shown to be imprecise. We assessed the diagnostic value of monitoring the analgesia nociception index (ANI) to detect surgical stimulation in children. METHODS: This was an observational study of 2- to 12-yr-old patients 5 min before and after surgical incision. Hypnosis was maintained with sevoflurane and guided by bispectral index. Intraoperative analgesia was administered as a remifentanil infusion titrated to variations in haemodynamic parameters, and ANI monitor values were recorded. ANI parameters assessed included instantaneous ANI (ANIi), mean ANI (ANIm), and the relative change of ANIi to ANIm (DeltaANI=ANIi-ANIm/ANIm). Statistical analyses were performed using receiver-operating-characteristic analysis with determination of the area under the receiver operating characteristic (AUROC) curve and the grey zone. RESULTS: Overall, 49 subjects were included in this study. The AUROC was 0.755 (0.738-0.772), 0.771 (0.755-0.787), and 0.756 (0.738-0.774) for ANIi, ANIm, and DeltaANI, respectively. The threshold of ANI parameters indicating the presence of noxious surgical stimuli was ≤53%, ≤56%, and ≤-13.3% for ANIi, ANIm, and DeltaANI, respectively. The percentage of subjects in the inconclusive zone was 41%, 51%, and 33% for ANIi, ANIm, and DeltaANI, respectively. CONCLUSIONS: ANI has diagnostic value for detecting surgical stimuli in children.

Acute chest syndrome after laparoscopic splenectomy in children with sickle cell disease: operative time dependent?

BACKGROUND: Laparoscopic splenectomy remains a technically demanding procedure. On patients with sickle cell disease (SCD), a post operative acute chest syndrome (ACS) can occur. The aim of the study was to look for predictive factors of post operative ACS. PATIENTS AND METHOD: It's a retrospective study on patients with SCD, who underwent a laparoscopic splenectomy in Robert Debré hospital, Paris, France, between March 2008 and December 2013. Diagnosis of ACS was done if the patient developed hypoxemia associated with fever above 38.5 °C and an infiltrate on chest x ray during the post operative course. Pre-, post- and operative factors were studied. Descriptive statistics were compared using the Mann-Whitney test or the exact Fisher test. A p inferior to 0.05 was considered as significant. RESULTS: 52 patients with SCD underwent a laparoscopic splenectomy. Twelve patients presented a post operative ACS (23%) (mean age at surgery 4 years old) while forty did not (mean age 5.25 years old). Neither previous episode of ACS nor any factors reflecting SCD severity were significant. The shorter the operative time was, the greater the risk of developing an ACS (p < 0.05). CONCLUSION: ACS is an important complication following laparoscopic splenectomy in patients with SCD. The immediate post operative management, in the absence of predictive factors for ACS, should be carefully followed in a high dependency unit at least for 48 h for all patients.

Premedication with clonidine is superior to benzodiazepines. A meta analysis of published studies.

BACKGROUND: Premedication is considered important in pediatric anesthesia. Benzodiazepines are the most commonly used premedication agents. Clonidine, an alpha2 adrenoceptor agonist, is gaining popularity among anesthesiologists. The goal of the present study was to perform a meta-analysis of studies comparing premedication with clonidine to Benzodiazepines. METHODS: A comprehensive literature search was conducted to identify clinical trials focusing on the comparison of clonidine and Benzodiazepines for premedication in children. Six reviewers independently assessed each study to meet the inclusion criteria and extracted data. Original data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), 95% confidence intervals [95% CI] and statistical heterogeneity were accessed. RESULTS: Ten publications fulfilling the inclusion criteria were found. Premedication with clonidine, in comparison with midazolam, exhibited a superior effect on sedation at induction (OR=0.49 [0.27, 0.89]), decreased the incidence of emergence agitation (OR=0.25 [0.11, 0.58]) and produced a more effective early post-operative analgesia (OR=0.33 [0.21, 0.58]). Compared with diazepam, clonidine was superior in preventing post-operative nausea and vomiting (PONV). DISCUSSION: Premedication with clonidine is superior to midazolam in producing sedation, decreasing post-operative pain and emergence agitation. However, the superiority of clonidine for PONV prevention remains unclear while other factors such as nausea prevention might interfere with this result.

[Sub-capsular renal hematoma during severe preeclampsia: clinical case and review of the literature]. / Hématome sous-capsulaire du rein compliquant une prééclampsie sévère: cas clinique et revue de la littérature.

Renal haematoma during severe preeclampsia is a rare uneventful event. It is usually associated with other organ injury such as cerebral or liver haematoma. Imaging (ultrasound or tomodensitometry examination) plays an important role in detecting this complication and following its evolution. In the current case report, we describe an isolated renal haematoma during a severe preeclampsia complicated by a HELLP syndrome. This patient was managed with a conservative treatment (control of arterial pressure and induction of delivery) and an imaging follow-up.

[Opioid-sparing effect of ketamine during tonsillectomy in children]. / Effet d'épargne morphinique de la kétamine au cours de l'amygdalectomie chez l'enfant.

INTRODUCTION: In the adult population, Ketamine is currently used as an antihyperalgesic and opioid-sparing agent during the perioperative period. However, for doses of ketamine up to 0.5mg/kg, these effects have not been found in pediatric population. The aim of the present study was to evaluate the efficacy of a preoperative bolus of 1mg/kg of ketamine on postoperative pain intensity and morphine consumption in children undergoing tonsillectomy. METHODS: We have undertaken a retrospective comparison of 60 consecutive children operated for tonsillectomy in our institution before (first 30 patients) and after (last 30 patients) the introduction of a preoperative bolus of 1mg/kg of ketamine. Data collected were: age, ASA score, dose of intraoperative sufentanil, OPS score during PACU stay and the first postoperative day, morphine consumption during PACU stay and the first postoperative day, psychodysleptic manifestations, pain at first solid oral intake and postoperative respiratory complications or haemorrhage. RESULTS: No difference was found between the two groups in terms of demographic characteristics. Perioperative doses of sufentanil, postoperative opioid consumption or pain score in PACU or during 24hours were similar between the two groups. The two groups did not differ in terms of pain at first oral intake, or other adverse effects. CONCLUSION: These results suggest that 1mg/kg of ketamine administered right after anaesthesia induction in children undergoing tonsillectomy did not result in an opioid sparing effect.

[Aerobic bacteria associated with acute appendicitis in children]. / Bactéries aérobies associées aux appendicites aiguës de l'enfant.

OBJECTIVE: The aim of the study was to determine the microbiological profile of acute appendicitis in children. STUDY DESIGN: Prospective descriptive study including children hospitalized for acute appendicitis. METHODS: A specimen of the appendice and the peritoneal exudates (if exists) was performed intraoperatively for aerobe bacteriological examination. Anaerobic incubation was not possible in our study. RESULTS: Eighty children were included. The specimen culture isolated aerobic bacteria in 56 patients (70%). Polymicrobial infection was found in 14 children. Gram-negative bacilli were the most frequently isolated microorganisms (64/70). Escherichia coli was found in 48 children. The resistance rate to amoxicilline-clavulanic acid and to cefazolin was 35%. Pseudomonas aeruginosa susceptible to ticarcillin was detected in seven patients. CONCLUSION: In our study, the specimen culture found aerobic bacteria in 70% of cases, especially Gram-negative bacilli. Empiric antibiotherapy in acute complicated appendicitis in children should be efficient against these microorganisms.