Evaluation of the efficacy of a forced-air warmer (Bair Hugger) during spinal surgery in children.

STUDY OBJECTIVE: To evaluate the efficacy of a forced-air warmer during spinal surgery for correction of scoliosis in children. DESIGN: Prospective randomized study (group allocation based on the availability of the warming device). SETTING: Children's teaching hospital. PATIENTS: 51 ASA physical status I and II children (mean age, 15 years; mean weight, 45 kg) scheduled for posterior spinal fusion with general anesthesia. INTERVENTIONS: Study group (warmed; n = 26)--legs covered with the forced-air warmer (Bair Hugger, Augustine Medical, Inc., Eden Prairie, MN) after installation of the patient in prone position--versus control group (n = 25)--400W heat lamp placed over the head during surgery as is usually done in our institution. MEASUREMENTS AND MAIN RESULTS: Rectal temperature was taken every 15 minutes during surgery and during the first 2 hours in the recovery room. Time required for the wake-up test, time to extubation, and blood loss also were noted. Temperature profiles were very different in the 2 groups. In the control group, rectal temperature decreased during the first 180 minutes to a minimum of 34.8 degrees C +/- 0.6 degrees C, followed by a slow rewarming phase. In the warmed group, the lowest temperature (35.6 degrees C +/- 0.5 degrees C) was recorded 45 minutes after placement of the forced-air warmer, followed by an effective warming phase. At the end of surgery, temperature was significantly higher in the warmed group than in the control group (36.5 degrees C +/- 0.8 degrees C vs. 35.4 degrees C +/- 0.9 degrees C). However, time required for the wake-up test, time to extubation, and blood loss did not differ between groups. CONCLUSION: The forced-air warmer (Bair Hugger) is effective during spinal surgery, although only about 20% of body surface area can be covered.

[Value of deliberate normovolemic hemodilution associated with a capillary vasoconstrictor, ornipressin, in surgery of the spine]. / Intérêt de l'hémodilution normovolémique intentionnelle associée à un vaso-constricteur capillaire, l'ornipressine, dans la chirurgie du rachis.

This study of sixty-seven children divided in two groups compared the blood loss and the amount of blood transfused during and after the operation. The operations were carried out without haemodilution nor the local injection of vasoconstrictor (twenty-four patients) and following haemodilution and the local injection of vasoconstrictor (forty-three patients). The blood loss during operation was 344 +/- 455 ml per vertebra in the first group, and 151 +/- 54 ml in the second. The blood loss in the post operative period did not seem to be modified by haemodilution, as the level of hemoglobulin was virtually the same in the two groups eleven days after the operation. A mean of seven units of blood were transfused to the first group, whilst only three in the second group. In the post-operative period, both groups received a mean of one unit each. Associating haemodilution and a vasoconstrictor, ornipressin, reduced very significantly the need for homologous blood.

[Intravenous iron in the treatment of postoperative anemia in surgery of the spine in infants and adolescents]. / Le fer intraveineux dans le traitement des anémies postopératoires dans la chirurgie du rachis de l'enfant et de l'adolescent.

PURPOSE OF THE STUDY: Spinal fusion surgery often leeds to massive bleeding responsible for anemia in the postoperative period. The aim of this study was to compare the effect of IV iron III hydroxide sucrose complex (Venofer) versus oral iron fumarate administration in postoperative anemia. The efficacy of both treatments was evaluated by comparing hemoglobin level in the postoperative period. METHODS: Two groups of sixteen patients, scheduled for anterior and/or posterior spinal fusion, were compared. Group 1, historical, was treated by supplementation of 10 mg/kg/day oral iron fumarate. Administration was started when hemoglobin level fell below 9 g/100 ml. Group 2 was treated by intravenous iron sucrose complex using same criteria as in group 1 for starting administration. The dosage of iron was individually adapted according to a target hemoglobin level of 13 g/100 ml and to the actual lowest hemoglobin level measured. The total iron deficit was calculated with the following formula: total iron deficit (mg) = 0.24 x body weight (kg) x (target Hb-actual Hb)(g/l). The patients were supplemented by 3 mg/kg/day until the calculated iron deficit was compensated. RESULTS: Both groups were identical regarding age and lowest hemoglobin level reached in the postoperative period. Hemoglobin increased by 0.25 g/day in group 1, and by 0.36 g/day in group 2. In others words, the beneficial effect of IV iron versus oral iron administration was as high as 45 per cent (p = 0.003). CONCLUSION: Intravenous iron therapy as ferric sucrose complex is a new and more effective form of iron therapy than oral iron therapy to restore postoperative hemoglobin after spinal surgery in children.

[Erythrocytapheresis a few weeks before surgery: an alternative to erythropoietin treatment in programmed autologous transfusion]. / L'érythrocytaphérèse quelques semaines avant l'intervention: une alternative au traitement par érythropoïétine en transfusion autologue programmée.

The usual methods like hypotension, isovolaemic haemodilution, autologous transfusion and peri-operative blood salvage may significantly reduce the need for homologous blood transfusion in haemorrhagic surgery and also the risk of transmitting infectious agents. Erythropoietin (EPO) is now available and is used to stimulate red cell regeneration in pre-operative autologous blood donation. In acute anaemia, many studies have shown that the stimulation of endogenous erythropoietin production could be very high and accelerate red blood cell production. Taking higher quantities of blood than usual induces a secretion of endogenous erythropoietin, and could be an alternative for the utilization of exogenous EPO in autologous blood donation.

[Prophylactic antibiotic therapy using oxacillin (Bristopen) in pediatric orthopedic surgery]. / Antibiothérapie prophylactique par oxacilline (Bristopen) en chirurgie orthopédique infantile.

The aim of this study was to evaluate the efficiency of oxacillin in the prophylaxis of bone infections in orthopaedic surgery in children. Staphylococcus is the usual pathogen in orthopaedics. This is the reason of our choice: oxacillin. 420 patients are included: 195 control patients did not receive any prophylactic antibiotherapy; 225 patients received oxacillin. The oxacillin treatment started at anaesthetic induction and was carried on for 72 hours. In the control group, 7 superficial and 4 deep infections were observed, while a single superficial infection was noted in the oxacillin-treated group. This easy and inexpensive prophylactic treatment gave excellent results. We think that it should be systematically administered in orthopedic surgery to ensure as little complication as possible to the child.

Development of two mobile laboratories for a routine and accident monitoring of internal contamination.

To provide medical surveillance of workers exposed to risk of internal contamination, IRSN (French Institute for Radiological Protection and Nuclear Safety) has developed two mobile laboratories for on-site monitoring. The laboratories are unique in Europe. They meet the new radiation protection requirements for nuclear medicine departments and radiological emergency response. Details of the design, calibration procedures and performance characteristics of these systems in measurements of various types of organs (thyroid, lung and whole body) are described. The sensitivity of the measurements is very close to that achieved in a heavily shielded stationary laboratory.

Reflex pupillary dilatation in response to skin incision and alfentanil in children anaesthetized with sevoflurane: a more sensitive measure of noxious stimulation than the commonly used variables.

BACKGROUND: Estimation of analgesia in anaesthetized children is often imprecise, and consequently, anaesthesiologists commonly evaluate children's response to surgical stimulation by movement or haemodynamic changes. In adults reflex pupillary dilatation has been demonstrated to be a very sensitive measure of noxious stimulation, correlated with opioid concentrations. The autonomic nervous control changes with age, raising the hypothesis that mechanisms involved in pupillary autonomic functions regarding both sympathetic and parasympathetic components may also differ between adults and children. In this pilot study, we tested the hypothesis that the pupillary reflex dilatation might allow assessment of noxious stimulation and analgesic effect of alfentanil in children under sevoflurane anaesthesia, as an alternative to haemodynamic and bispectral measures. METHODS: After sevoflurane induction, 24 children were maintained in steady-state conditions at 1.5 MAC of sevoflurane in O(2)-N(2)O (50-50). An intense noxious stimulation was provided by standardized skin incision on the lower limb. A bolus of alfentanil (10 microg kg(-1)) was administered either 1 min (n=16) or 2 min (n=8) after skin incision. Haemodynamic values, bispectral index (BIS) and pupillary diameter (PD) were recorded just before stimulation and at 30-60 s intervals during 4 subsequent minutes. RESULTS: In all children PD increased significantly after noxious stimulation [+200 (40)%, at 60 s]. In contrast, mean heart rate and blood pressure increased only 11 (7)% and 10 (8)% respectively, 60 s after stimulation. BIS did not change significantly. In all children, alfentanil injection induced a rapid decrease of PD and restored pre-incision values in 2 min. CONCLUSION: PD is a more sensitive measure of noxious stimulation than the commonly used variables of heart rate, arterial blood pressure and BIS in children anaesthetized with sevoflurane.

[Oral pristinamycin therapy for bone and joint infections in children. A report of 50 cases (author's transl)]. / Traitement des infections osseuses et articulaires de l'enfant par la pristinamycine. A propos de 50 cas.

50 children with bone and joint infections (acute osteomyelitis, suppurative acute arthritis, osteoarthritis) were treated with pristinamycin. The responsible bacterium was most often but not exclusively Staphylococcus aureus; its sensitivity to various antibiotics is discussed. The value of biochemical tests for diagnosis and follow-up is emphasized; the potency of this drug avoids the need for intravenous therapy. A therapeutic protocol according to age, type of and sensitivity of the germs is proposed.

[Significance of hemodilution and deferred autotransfusions in spinal surgery in the child and the adolescent]. / Intérêt de l'hémodilution et des autotransfusions différées dans la chirurgie du rachis de l'enfant et de l'adolescent.

Homologous blood transfusions may involve immunological risks, as much as the risk of transmitting viral bacterial or parasitic illnesses. 140 children and adolescents having been operated for scoliosis were evaluated in order to compare hemodilution plus deferred auto-transfusion against standard transfusion techniques. By combining hemodilution and deferred autotransfusion, pre and post-surgery transfusions drop from 2725 to 370 ml of homologous blood, on the average. The combined use of these two techniques thus reduces the need for new homologous blood most significantly.

Epiphyseal vascularization during growth: the upper limb.

Sixty fetal, newborn and child cadavers were injected with India ink and plastic material (Batson's technique) via the subclavian artery. The arterial and capillary intracartilaginous and intraosseous networks of the physes of the long bones of the upper limb were then studied by microdissection of the vascular sources and serial epiphyseal sections in different planes. Already present in the third week of fetal life and present all during the rest of life, this circulation plays a fundamental role not only in the ossification of the epiphyseal cartilage but also in the trophicity of the bone that supports the cartilaginous articular surfaces. Like those of the lower limb, the epiphyses of the upper limb present a typical vascular pattern consisting of three entries, with the exception however of the inferior extremity of the ulna.

Analgesic effect of low-dose intrathecal morphine after spinal fusion in children.

BACKGROUND: This study was designed to assess the postoperative analgesic effect of low-dose intrathecal morphine after scoliosis surgery in children. METHODS: Thirty children, 9-19 yr of age, scheduled for spinal fusion, were randomly allocated into three groups to receive a single dose of 0 (saline injection), 2, or 5 microg/kg intrathecal morphine. After surgery, a patient-controlled analgesia device (PCA) provided free access to additional intravenous morphine. Children were monitored for 24 h in the postanesthesia care unit. RESULTS: The three groups were similar for age, weight, duration of surgery, and time to extubation. The time to first PCA demand was dose-dependently delayed by intrathecal morphine. The first 24 h of PCA morphine consumption was 49 +/- 17, 19 +/- 10, and 12 +/- 12 mg (mean +/- SD) in the saline, 2 microg/kg morphine, and 5 microg/kg morphine groups, respectively. Pain scores at rest were significantly lower over the whole study period after 2 and 5 microg/kg intrathecal morphine than after saline, but there was no difference between intrathecal doses. Pain scores while coughing and the incidence of side effects were similar in the three groups. CONCLUSIONS: These data demonstrate that low-dose intrathecal morphine supplemented by PCA morphine provides better analgesia than PCA morphine alone after spinal fusion in children. The doses of 2 and 5 microg/kg seem to have similar effectiveness and side-effect profiles, whereas a reduction of intraoperative bleeding was observed in patients who received 5 microg/kg but not 2 microg/kg intrathecal morphine.

The analgesic efficacy of an injectable prodrug of acetaminophen in children after orthopaedic surgery.

The analgesic efficacy and safety of propacetamol, an injectable prodrug of acetaminophen, (paracetamol) were studied in 87 children (36 boys, 51 girls; age 6-13; mean age 9.5 years) immediately after limb surgery. Using a double-blind, randomized, parallel group design, the effects of a single IV infusion of 30 mg.kg-1 propacetamol (i.e. 15 mg.kg-1 acetaminophen) were compared with a single injection of placebo (PL). Efficacy was assessed on pain scores rated on a four-point verbal scale, a five-point visual scale (faces) and on a four-point relief verbal scale before administration (T0) and 0.25, 0.5, 1, 2, 3, 4, 5, 6 h after administration. At the end the global efficacy was rated by the physician on a five-point verbal scale. Propacetamol was statistically superior to placebo on all assessment criteria. Seven side-effects were recorded: five in the propacetamol group and two in the placebo group. 30 mg.kg-1 propacetamol provided a significantly greater analgesic effect than placebo in children after orthopaedic surgery.

[Thromboembolic complications in pediatric orthopedics. Multicentric collection of 33 case reports]. / Complications thromboemboliques en orthopédie pédiatrique. Recueil "multi-centrique" de 33 observations.

We report 33 cases of venous thrombosis of the limb, in children aged 15 years or less (average age is 10 years old): 22 acute thrombophlebitis have been treated, 11 children shown post-phlebitic disease. The thrombus was found, most of the time, in the iliac and/or femoral vein. Acute complications were seen in 30% of our cases, and 25% treated children reviewed, had post-phlebitic sequelae. Congenital disease of hemostasis (deficiency of antithrombin III, protein C or S) must be detect before anticoagulant start, because such deficiency influence the treatment and the prognosis. There is non indication for preventive treatment, because of the rarity of spontaneous thrombophlebitis by children. Nevertheless, we can draw an "high risk" population: antecedent of phlebitis, antecedent of congenital disease of hemostasis, antecedent of thrombophlebitis by parents below 40 years old, thrombogenic disease (homocystinuria), vertebral arthrodesis.