Predicting fluid responsiveness in mechanically ventilated children under general anaesthesia using dynamic parameters and transthoracic echocardiography.

BACKGROUND: Dynamic variables are accurate predictors of fluid responsiveness in adults undergoing mechanical ventilation. They can be determined using respiratory variation in aortic flow peak velocity (▵Vpeak), arterial pulse pressure [▵PP and pulse pressure variation (PPV)], or plethysmographic waveform amplitude [▵POP and pleth variability index (PVI)]. These indices have not been validated in children. We studied the ability of these variables to predict fluid responsiveness in mechanically ventilated children. METHODS: All results are expressed as median [median absolute deviation (MAD)]. Thirty mechanically ventilated children were studied after undergoing general anaesthesia. Mechanical ventilation was maintained with a tidal volume of 10 ml kg(-1) of body weight. ▵PP, PPV, ▵POP, PVI, ▵Vpeak, and aortic velocity-time integral were recorded before and after volume expansion (VE). Patients were considered to be responders to VE when the aortic velocity-time integral increased more than 15% after VE. RESULTS: VE induced significant changes in ▵PP [13 (MAD 4) to 9 (5)%], PPV [15 (5) to 9 (5)%], ▵POP [15 (10) to 10 (6)%], PVI [13 (6) to 8 (5)%], and ▵Vpeak [16 (9) to 8 (3)%] (P<0.05 for all). Differences in ▵PP, ▵POP, PPV, and PVI did not reach statistical significance. Only ▵Vpeak was significantly different between responders (R) and non-responders (NR) to VE [22 (3) vs 7 (1)%, respectively; P<0.001]. The threshold ▵Vpeak value of 10% allowed discrimination between R and NR. CONCLUSIONS: In this study, ▵Vpeak was the most appropriate variable to predict fluid responsiveness.

[Evaluation of the clinical benefit of decompression hemicraniectomy in intracranial hypertension not controlled by medical treatment]. / Evaluation du bénéfice clinique de l'hémicraniectomie décompressive dans l'hypertension intracranienne non contrôlée par le traitement médical.

Through the findings in the literature on the basis of 9 personal cases, we review the indications and value of decompressive hemicraniectomy with plasty of the dura mater in cases of medically uncontrolled and decompensated intracranial hypertension. Seven patients had a pseudo-tumoral brain infarction. Five patients survived and their functional recovery is consistent with an autonomous daily life. Another patient with acute traumatic sub-dural haemorrhage died. The ninth patient had presuppurative encephalitis and recovered with no disability. At the time of surgery, all the patients were comatose with herniation of the mesencephalon (n = 3), uncal transtentorial herniation which was either unilateral (n = 4) or bilateral (n = 2). ICP was between 25 and 60 mmHg before the operation. After flap removal, ICP decreased by 15% and, after opening of the dura, it fell a further 70%. In 6 patients we were able to carry out continued post-operative monitoring of ICP, which stayed below 50% of initial values. Decompressive hemicraniectomy is an effective means of treating ICH caused by carotid cerebrovascular accidents with a high degree of edema, where mortality rises to 70-85% when only medical treatment is administered. No haemorrhagic complications, which can occur during hemispherectomies, were observed during decompression.

[A prospective study of 180 percutaneous catheterizations of the axillary vein during resuscitation]. / Etude prospective de 180 cathétérismes percutanés de la veine axillaire en réanimation.

Central venous catheterization via the axillary vein was performed in 180 comatose patients with a success rate of 91%. The scarcity of serious nervous (none), thrombotic (6%), hemorrhagic (9.4%), infectious (1.8%), or thoracic (none) complications, the preservation of cerebral venous drainage, a longer distance between puncture site and tracheostomy or intubation tube make this safe and easy procedure perfectly convenient for comatose patients.

[A comparative study of CPK during spinal surgery in the knee-chest position. Apropos of 93 patients]. / Etude comparée des CPK au cours de la chirurgie du rachis en position génupectorale. A propos de 93 patients.

A number of severe rhabdomyolysis with acute renal failure have been reported following spine surgery in knee chest position. CPK were measured postoperatively in 93 patients (A group), comparatively with two groups in which respectively neurosurgery without any muscle stretching (B group) and abdominal surgery with aid of retractors (C group) were performed. CPK were significantly and similarly increased in A and C groups only. This postoperative increase of CPK appears to be related more to the muscle stretching than to the posture itself. Intraoperative low blood pressure and an operating time longer than 4 hrs contribute probably to rhabdomyolysis. No renal failure was observed in our series. Low limb vascular insufficiency is the main contra-indication of knee chest position. Postoperative diuresis surveillance is mandatory in all cases, CPK analysis is not.

[Place of neuroleptics in neurosurgical anesthesia-resuscitation]. / Place des neuroleptiques en anesthésie-réanimation neuro-chirurgicale

The interest of neuroleptics in neurosurgery should be examined in the light of physiopathological and pharmacological data concerning cerebral circulatory autoregulation and intracranial pressure. The fairly favourable conclusions permit one to consider their wide use justified, especially, by the feeble hypnogenic effects, without any marked disturbance of the E.E.G., associated with an anticatecholaminergic and stabilizing effect on the autonomic nervous system. They therefore occupy a place of choice, in particular during induction of anesthesia in high risk patients, during operations requiring neurological or continuous E.E.G. investigations, in surgery of intracranial aneurysm and, finally, to obtain sedation and post-operative autonomic control.

Intracystic chemotherapy with bleomycin in the treatment of craniopharyngiomas.

OBJECT: Since bleomycin has not yet been used very frequently in the treatment of patients with craniopharyngioma, it seemed important to document the course of a series of such patients treated with this preparation. METHODS AND RESULTS: Local chemotherapy with bleomycin was performed in 24 patients (20 children and 4 adults), 16 of whom presented with cystic or mixed (solid/cystic) craniopharyngioma and 8, with recurrent cystic craniopharyngioma. The drug was administered through an Ommaya reservoir, which was placed either by using a direct surgical approach (6 patients) or a stereotactic approach (16 patients), or with endoscopic assistance in patients with hydrocephaly (2 patients). Injection of bleomycin was always preceded by a water-tightness test. Each patient received a 3-mg dose of bleomycin every other day. The total dose of bleomycin injected ranged from 28 mg to 150 mg. Most patients (17, or 70%) were treated only with intracystic chemotherapy. Chemotherapy was followed by surgery in 7 patients. Five were operated on at the beginning of our study, and 2 required surgery because chemotherapy yielded poor results. A toxic dose was injected in 1 patient only: a severe complication, i.e. blindness, was observed. The follow-up period ranged from 2 years to 10 years. CONCLUSION: Our results show that bleomycin can be an alternative in the treatment of cystic craniopharyngiomas or cystic recurrences, as it reduces surgical morbidity and improves clinical results.

[Hemodynamic study of acute neurogenic pulmonary edema in children]. / Etude hémodynamique de l'oedème pulmonaire aigu neurogène chez l'enfant.

Acute neurogenic pulmonary edema (NPE) can dramatically complicate a serious brain injury. From bibliographic data and four personal cases documented by and haemodynamical study, the authors analyse the pathophysiological mechanisms and the haemodynamical changes resulting from massive sympathic outflow, the main mechanism of NPE being haemodynamical rather than lesional. This rare complication needs to be recognized in order to undergo an intensive care treatment generally leading to a favourable evolution. This treatment lies on circulatory and ventilatory supports with positive and expiratory pressure in order to maintain an optimal oxygenation and an optimal cerebral perfusion pressure. With this treatment the outcome of NPE is usually favourable with complete recovery within 2 to 5 days.

[Cranio-cerebral gunshot wounds in civilian practice in children]. / Plaies cranio-cérébrales par balle en pratique civile chez l'enfant.

The circumstances and the prognosis of six gunshot craniocerebral wounds in civilian children are presented. The cause is a suicide in two cases and an accident in four cases. In three out of these four cases, another person is responsible for this accident, an adult two times, a child in one case. When the accident is due to a child, it is always by play and one time the accident is the autofact of a 2-year-old boy. In all cases, the fire arm was loaded and an adult's imprudence is present. The mortality is important (4/6). More than the initial clinical state, the seriousness of which is not a pejorative indice, the prognosis is subordinated to the CT scan aspect about the missile tract, and to the initial value of the intracranial pressure.

[Monitoring of intracranial pressure in children. Prospective fiber optic study of an intraparenchymatous system]. / Monitorage de la pression intracrânienne chez l'enfant. Etude prospective d'un système intraparenchymateux à fibre optique.

The authors studied the reliability and tolerance of a new intra-parenchymatous fiberoptic device for intracranial pressure monitoring in 20 neurosurgical children. The system proved to be reliable, and the measures were well correlated with clinical evolution, CT scan lesions, and the abolition of the cerebral perfusion pressure in the case of brain death. There was a minimal shift of the electric 0 after 15 days of monitoring. The tolerance was good and no hemorrhagic, infectious or epileptic complications were observed.

[Intracerebral hematoma caused by rupture of intracranial angioma. Analysis, prognosis and clinical course of 35 comatose patients admitted to intensive care units]. / Hématome intra-cérébral par rupture d'angiome intracrânien. Analyse, pronostic et évolution à propos de 35 comateux admis en réanimation.

The outcome of 35 patients in deep coma (GSS less than 7) due to an intracerebral hematoma following ruptured arteriovenous malformation (AVM) and admitted to a neurosurgical intensive care unit is reviewed. Eighty percent of these patients had a cerebral AVM and 20% had an AVM in the posterior fossa. All had a medical treatment of increase intracranial pressure (ICP). Twenty-four patients or 68.6% had an early surgical treatment or some days further and 13 had a good outcome, six had a persistent coma or a residual neurological deficit and five died. Four patients or 11.4% had an endovascular embolisation therapy and three had no satisfactory results and one died; all had a new intracranial hemorrhage with hematoma. Seven patients were not treated: four died before 48 hours of hospitalisation, one is in persistent coma and two are waiting an endovascular embolisation, alive but with a neurological deficit. The results suggest that neurosurgical treatment are a safe and effective means for treatment of these AVM with compressive intracranial hematoma.

[Blood coagulation disorders in intracerebral hematoma caused by rupture of intracranial angioma. Incidences on hemorrhagic recurrence]. / Troubles de l'hémostase au cours des hématomes intra-cérébraux par rupture d'angiome intracrânien. Incidences sur la récidive hémorragique.

In 34 patients admitted in Neurological Intensive Care Unit, for a cerebral hematoma by ruptured arterio-venous malformation, are present in 26 patients, on the first day. In many cases, the APTT is increased and this can be respected. These disorders do not seem to modify the incidence of delayed hemorrhage, except for the severe perturbances, related to a DIC or an hepatic deficiency. In these cases, the delayed hemorrhage must be prevented by transfusions of platelets and/or freeze fresh plasma.

[Treatment of ischemic cerebral edema with intracranial hypertension after neurosurgery of intracranial aneurysms]. / Traitement de l'oedème cérébral ischémique avec hypertension intracranienne après neurochirurgie des anévrysmes.

Ischemic cerebral edema frequently develops after aneurysm surgery and may lead to severe intracranial hypertension. Of prime importance are reducing the level of ICP and preserving oligemic areas from becoming infarcted. Besides correction of factors known to worsen intracranial hypertension, several therapeutics may be of value: external CSF drainage, perfusion of mannitol, induced arterial hypertension and use of anesthetic agents with cerebral vasoconstricting capability. Hyperventilation is not recommended. Arterial hypotension and hypovolemia certainly contribute to aggravate cerebral ischemia and must be corrected. Cerebral ischemia may be reduced by two specific approaches: by improving cerebral oxygen transport in ischemic areas using arterial hypertension and calcium blockers rather than hemodilution or hypervolemia; by reducing cerebral metabolic rates with heavy anesthesia under the cover of a complete cardiovascular monitoring. In view of the large heterogenicity in cerebral lesions and physiopathological stages, a therapeutical trial appears suitable in each individual case. Criteria allowing to know if any therapeutic, used alone or in association, is beneficial include increase in blood flow in ischemic areas, reduction of ICP level and normalizing of indices like CSF or venous jugular blood lactate.

Craniocerebral injury resulting from transorbital stick penetration in children.

OBJECTS: Two children were admitted to hospital for treatment of craniocerebral injury with transorbital penetration. METHODS: One child aged 6 years and 6 months had poked a chopstick in his orbit. There was no report of either a palpebral or an ocular wound. He had subsequently developed a meningeal syndrome with a cerebral abscess managed by needle aspiration biopsy and intravenous antibiotics. The other child, aged 4, had fallen onto a metal rod. He presented with a palpebral wound, motor disorders and coma, all due to a frontal intracerebral hematoma. There was an improvement in outcome without complications of an infectious nature or motor sequelae. CONCLUSIONS: Such head injuries are rare. Clinical, radiological and ophthalmological investigations must be performed, including computed tomography (CT) scan or cerebral magnetic resonance imaging (MRI) with antibiotic treatment for suspected microorganisms.

[Adequate intrathecal diffusion of teicoplanin after failure of vancomycin, administered in continuous infusion in three cases of shunt associated meningitis]. / Diffusion intrathécale efficace de la teicoplanine aprés échec de la vancomycine, administrées en perfusion continue, dans trois cas de méningite sur shunt.

Glycopeptides which have excellent in vitro activity against the Gram-positive causal agents of meningitis unfortunately have a poor CSF penetration. Vancomycin distribution into CSF is improved when administered by a continuous intravenous route and staphylococcal shunt related infection have been reported to be cured. Teicoplanin has good in vitro activity against a lot of staphylococci, and activity superior to vancomycin, against streptococci and is less toxic. In three children with shunt ventriculitis (S epidermidis 2, S. faecalis 1) despite a continuous infusion, vancomycin 15 mg/kg over 60 minutes onset, then 50 mg/kg/day was clinically and bacteriologically ineffective with very poor CSF levels even if high blood levels. After failure of vancomycin we used teicoplanin as a continuous i.v. infusion 6 mg/kg over 60 mn onset, then 12 mg/kg/day. This treatment was quickly effective and well tolerated.

Zero rate of shunt infection in the first postoperative year in children--dream or reality?

The rate of infectious complications following shunt implantations at the Pierre Wertheimer Hospital was 6.4% in 1992-1994. In order to improve this infection rate, new recommendations for surgery were applied and a new type of valve was used. The effects of these measures after a 1-year follow-up were analyzed in 70 patients. The rate of infection was zero, 2.8, and 4.3% at 2, 6, and 12 months, respectively. A case-control study did not reveal any significant risk factor among the patient and surgical factors analyzed.

[S. aureus neuromeningeal infection in 3 children with ventricular shunts without cytochemical changes in the lumbar cerebrospinal fluid]. / Infection neuroméningée à S. aureus chez trois enfants porteurs d'une dérivation ventriculaire, sans altération cytochimique du liquide céphalorachidien lombaire.

The authors report on three cases of staphylococcal cerebrospinal fluid (CSF) infection with normal white blood cell count and normal CSF glucose level in repeated lumbar CSF examination. All three children (2 months, 17 months and 4 years old) have been operated for neonatal hydrocephalus with setting of a ventriculo-peritoneal shunt one to two months before. Infection was suspected because of fever without evocative clinical signs. In two cases plasma C reactive protein level was increased, and in all three cases a leucocytosis was present. The diagnosis was made by bacteriological examination of the ventricular CSF. Both surgical and medical management were required and the bacteriological outcome was favourable. Since neurological sequellae may occur if the treatment is delayed such atypical infection needs to be promptly assessed.

[Hyperthermia in meningeal hemorrhage. Contribution of daily determination of inflammation proteins]. / Hyperthermie au cours des hémorragies méningées. Apport du dosage quotidien des protéines de l'inflammation.

This paper studies the causes of hyperthermias occurring after a subarachnoid hemorrhage by ruptured aneurysm in 54 patients, totalizing 66 febrils episodes. Only 29 episodes bacteriologically proved infections. The profile of thermic curve, the hemodynamical profile, and clinical examination are not convincing. The most convincing elements for the diagnosis of infection are the increasing number of the leucocytes counts, the increasing curve of CRP, and simultaneous decreasing curve of C4. The evolution of these parameters permit to follow the efficiency of antibiotics.

[Intracranial aneurysm and dysplasia of elastic tissue: pre- and postoperative problems]. / Anévrysme intracranien et dysplasie du tissu élastique: problèmes pré et post-opératoires.

From two cases of patients presenting a cerebral aneurysm associated with a dysplasia of elastic tissue, one a Marfan's syndrome, the other an anetoderma, this paper relate the post-operative, essentially cardio-vascularly and pulmonary complexities and define the elements of the pre-operative check-up.

[Neurogenic pulmonary edema, complication of meningeal hemorrhage: report of 4 cases]. / Oedème pulmonaire neurogénique, complication de l'hémorragie méningée: à propos de 4 observations.

Neurogenic pulmonary edema (NPE) observed in 4 patients admitted in Neurosurgical Intensive Care au SAH by ruptured a vascular malformation. This complication is unusual (1.9%) and has been observed in comatose patients. For 3 patients, NEP resorption was rapid, from 12 to 72 hours with a treatment by CCPV with a P.E.E.P. and with restoring the hemodynamical parameter. The drug must be discussed according to eventual deleterous side effects on cardiac output and systemic resistances. The early hemodynamical study argues for an essentially hemodynamical mechanism due to the brutal symphatic discharge created by cerebral lesions and increasing. ICP, more than a toxic lesionnal edema, as the Weidner's study shows it in ultrastructural analysis of sheep lungs.