Hypnosis as an alternative to general anaesthesia for paediatric superficial surgery: a randomised controlled trial.

BACKGROUND: Reducing perioperative anxiety and controlling pain in children are essential to optimise recovery and outcomes for both children and their parents. By acting on sensory and affective modulation of anxiety and pain, hypnosis is widely used in medical care, especially in anaesthesia. This randomised controlled clinical trial was designed to compare general anaesthesia and intraoperative hypnosis support for perioperative management of children undergoing superficial surgery. METHODS: Children aged 7-16 yr scheduled for day-case superficial surgery were included and randomly assigned to one of the following two groups: general anaesthesia group or hypnosis group. The primary outcome was length of hospital stay. Child and parent anxiety, child pain, and the occurrence of postoperative negative behavioural changes were also evaluated. RESULTS: Sixty children of mean age 10.3 (standard deviation: 2.6) yr were enrolled in the study. Hypnosis was successful in all but one case. The median (25th-75th percentile) length of hospital stay was shorter in the hypnosis group (120 [95-145] vs 240.5 [218-275] min; P<0.001). The general anaesthesia group was associated with a greater incidence of high levels of preoperative anxiety in children (30 vs 11%; P=0.001) and parents (55 vs 30%; P=0.05). Pain scores did not differ between groups. No negative postoperative behavioural changes were reported. CONCLUSIONS: In children aged 7-16 yr, hypnosis appears to be feasible and accepted. The quality of the perioperative experience and the rapid recovery support the use of hypnosis as an effective and safe alternative to general anaesthesia for paediatric superficial surgery. CLINICAL TRIAL REGISTRATION: NCT02505880.

Enhanced recovery after surgery (ERAS) for adolescent idiopathic scoliosis: Standardisation of care improves patient outcomes.

INTRODUCTION: Adolescent idiopathic scoliosis (AIS) surgeries are major paediatric procedures requiring multidisciplinary management. Enhanced recovery after surgery (ERAS) programs, with proven benefits in adults, remain poorly developed in paediatrics. The main objective of this Before/After study was to evaluate the impact of an ERAS program implementation for AIS on length of stay (LOS) and postoperative recovery. METHODS: The ERAS protocol included intrathecal morphine, standardised multimodal analgesia and multidisciplinary measures for early recovery. Retrospective data from adolescents operated between 2015 and 2017 ("Before ERAS" group) were compared with data from patients benefiting from the ERAS program ("After ERAS" group). Patients treated for neuromuscular scoliosis were not included. After a descriptive analysis, a propensity score matching defined two comparable populations. The main outcome was the LOS. The time to first solid food intake, first ambulation, first bowel movement and Foley removal were also analysed. RESULTS: During the "Before ERAS" period, 73 underwent PSF for AIS. Thereafter, 65 patients benefited from the ERAS protocol, including 35 for AIS. After propensity score application, 32 patients of the "After ERAS" group were matched with 32 patients of the "Before ERAS" group. The ERAS implementation was associated with 25% reduction in LOS (2.10 ± 1.60 days p < 0.001). All other enhanced recovery criteria were significantly reduced after ERAS implementation. CONCLUSION: These results confirm the expected benefits of ERAS program in AIS with a significant impact on postoperative recovery and LOS. Patient adherence and the involvement of all caregivers are essential to the success of such a program.

A follow-up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study.

ABSTRACT: In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children younger than 18 years scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort through a smartphone App using the Parents' Postoperative Pain Measure-Short-Form (PPPM-SF). Children older than 6 years could also provide self-assessments of pain using a numerical rating scale (NRS)-11. Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variances (ANOVAs) were used to compare the self-assessments and hetero-assessments of pain. Eleven centers participated in the study, and 1573 patients were recruited. Forty-nine percentage of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for 4 main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least 1 episode of pain ≥4/10 during the first 48 postoperative hours. Although these findings indicated that postoperative pain management seems to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients provides useful information. A continuous report regarding pain and adverse events over a 10-day postoperative period by a self-reporting or parent's contribution is possible. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.

Bilateral mandibular block improves pain relief and morphine consumption in mandibular osteotomies: a prospective, randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: The sensory innervation of the lower jaw mainly depends on the third root of the trigeminal nerve, the mandibular nerve (V3). The aim of this single-center, prospective, randomized, double-blind, placebo-controlled study was to evaluate the effectiveness of bilateral V3 block for postoperative analgesia management in mandibular osteotomies. METHODS: 107 patients undergoing mandibular surgery (75 scheduled osteotomies and 32 mandible fractures) were randomized in two groups. A bilateral V3 block was performed in each group, either with ropivacaine 0.75% (block group, n=50) or with a placebo (placebo group, n=57). A postoperative multimodal analgesia was equally provided to both groups. The primary outcome was the cumulative morphine consumption at 24 hours. Secondary outcomes were the occurrence of severe pain and the incidence of postoperative nausea and vomiting (PONV) in the first 24 hours. Data were analyzed on an intention-to-treat basis. RESULTS: The cumulative morphine consumption at 24 hours was significantly lower in the block group (median 8.0 mg (IQR 2.0-21.3) vs 12.0 mg (IQR 8.0-22.0), p=0.03), as well as the incidence of severe pain during the 24 hours of follow-up (4.0% vs 22.8%, p<0.01). The mandibular block had no impact on the incidence of PONV. CONCLUSION: Bilateral V3 block for mandibular osteotomies is an effective opioid-sparing procedure. It provided better postoperative analgesia in the first 24 hours, and it did not affect PONV incidence. TRIAL REGISTRATION NUMBER: NCT02618993.

Facial expressions of pain in daily clinical practice to assess postoperative pain in children: Reliability and validity of the facial action summary score.

BACKGROUND: Behavioural pain scales are recommended to assess postoperative pain for children who are too young to use self-report tools. Their main limitation is underestimation of pain in the days following an intervention. Although relevant, facial expression is not used in daily clinical practice. This prospective study aimed to assess the validity and reliability of the Facial Action Summary Score (FASS), a five-item scale, to assess postoperative pain until hospital discharge in children <7 years. METHODS: Assessments of pain and anxiety of 123 children using FASS and validated scales were used to study the psychometric validity of the FASS in clinical practice. RESULTS: The content validity was previously investigated in a development study. The internal validity of the FASS was high with excellent reliability (intraclass coefficient = 0.94) and a high Cronbach α (0.89). Convergent validity with pain scales (FLACC [Face, Legs, Activity, Cry, Consoling] and FPS-R [Faces Pain Scale - Revised]) was high (r > 0.8). Sensitivity to change was verified by a significant decrease in the score after rescue analgesia. For a threshold of 2/5, the FASS shows excellent specificity (97%) and sensitivity (82%). The low number of false negatives is the main strength of this tool. CONCLUSIONS: This work highlights the interest in using facial expression in daily clinical practice to manage postoperative pain. The FASS is easy to use with excellent psychometric properties and is particularly sensitive to measure pain in the days following surgery. SIGNIFICANCE: The aim of this study was to prove that facial expression of pain can be used in clinical practice to measure postoperative pain in children. The reduced number of false negatives is the main strength of this tool.

Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic Profile.

BACKGROUND: The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. METHODS: This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. RESULTS: Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds. CONCLUSIONS: In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.

Management of the child's airway under anaesthesia: The French guidelines.

OBJECTIVE: To provide French guidelines about "Airway management during paediatric anaesthesia". DESIGN: A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. METHODS: The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. RESULTS: The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.

Peri-operative respiratory adverse events in children with upper respiratory tract infections allowed to proceed with anaesthesia: A French national cohort study.

BACKGROUND: Peri-operative respiratory adverse events (PRAEs) in paediatric patients with upper respiratory tract infections (URTIs) remain inadequately explored in patients allowed to proceed to anaesthesia and surgery. OBJECTIVE: To determine the incidence and risk factors of PRAE in children with URTI allowed to proceed to anaesthesia. DESIGN: Multicentre cohort study performed over 6 months in France. SETTING: Sixteen centres with dedicated paediatric anaesthetists. PATIENTS: Eligible patients were aged from 0 to 18 years with URTI symptoms on admission or a history of such over the preceding 4 weeks. MAIN OUTCOMES: The primary outcome of the study was to determine predictors of PRAE. Secondary outcomes were: predictors of peri-operative arterial desaturation and of the decision to proceed with anaesthesia and surgery in children with URTI. RESULTS: Overall, 621 children were included and 489 (78.7%) anaesthetised. Of those anaesthetised, 165 (33.5%) and 97 (19.8%) experienced PRAE and arterial desaturation, respectively. Factors predictive of PRAE included patient age, tracheal intubation and the absence of midazolam premedication. Factors predictive of peri-operative arterial desaturation included patient age, anaesthetist experience, endoscopic procedures and the presence of other PRAE. Factors predicting proceeding to anaesthesia in the context of URTI included anaesthetist experience, emergency procedures and the absence of severe URTI symptoms. CONCLUSION: The risk of PRAE in patients anaesthetised in the presence of URTI was similar to previous publications - close to 30%. In the light of our findings, first, current rescheduling indications should be questioned, and second, further medical and organisational strategies should be investigated to reduce PRAE in children with URTI. TRIAL REGISTRATION: The study was registered in the European Networks of Centers for Pharmacoepidemiology and Pharmacovigilance (EUPAS16436).

Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach.

BACKGROUND: Transperineal pudendal nerve block guided by nerve stimulator is used in pediatric anesthesia as an alternative to caudal analgesia in perineal surgery. The risk of rectal puncture or intravascular injection is inherent to this blinded technique. We described a new technique of transperineal pudendal nerve block, with ultrasound guidance, to improve safety of the technique. AIMS: The first goal of this study was to describe this new technique and to test its feasibility. The second objective was to evaluate intra operative effectiveness and postoperative pain control. METHODS: After parental and children consent, this prospective descriptive study included children aged 1-15 years, ASA status I-III, scheduled for general anesthesia associated with bilateral pudendal nerve block for an elective perineal surgery. After standardized general anesthesia, the anesthesiologist performed pudendal nerve block under ultrasound guidance with "out of plane" approach and evaluated the visualization of anatomical structures (ischial tuberosity, rectum, and pudendal artery), of the needle and of the local anesthetic spread. Pudendal nerve block failure was defined as an increase in mean arterial blood pressure or heart rate more than 20% compared to baseline values after surgical incision. In the postoperative period, the need for rescue analgesia was noted. RESULTS: During the study period, 120 blocks were performed in 60 patients, including 59 boys. Quality of the ultrasonographic image was good in 81% of blocks, with easy visualization of ischium and rectum in more than 95% of cases. Localization of the tip of the needle was possible for all pudendal nerve blocks, directly or indirectly. The spread of local anesthetic was seen in 79% of cases. The block was effective in 88% of cases. CONCLUSION: The new technique of ultrasound-guided pudendal nerve block, described in this study, seems to be easy to perform with a good success rate, and probably improves safety of the puncture and of the injection by real-time visualization of anatomical structures and local anesthetic spread.

Pupillometry-guided Intraoperative Remifentanil Administration versus Standard Practice Influences Opioid Use: A Randomized Study.

BACKGROUND: Pupillometry has shown promising results for assessing nociception in anesthetized patients. However, its benefits in clinical practice are not demonstrated. The aim of this prospective randomized study was to evaluate the impact of intraoperative pupillometry monitoring on perioperative opioid consumption in major gynecologic surgery. METHODS: After receiving ethics committee approval and written consent of patients, American Society of Anesthesiologists status I to II women undergoing gynecologic surgery were included in this single-blinded, prospective, parallel-arm randomized study. General anesthesia was standardized with propofol-remifentanil target-controlled infusion. Patients were randomly assigned into two groups. In the pupillometry group, remifentanil administration was guided by pupillary diameter changes. In the standard group, remifentanil administration was left to the discretion of the anesthesiologist. The primary outcome was intraoperative remifentanil consumption. RESULTS: Fifty-five patients were analyzed. Remifentanil consumption was markedly decreased in the pupillometry group (3.8 [3.4 to 4.8 µg · kg · h] vs. 7.9 µg · kg · h [6.5 to 9.0 µg · kg · h] in the standard group; difference = 4.2 µg · kg · h [95% CI, 3.0 to 5.3 µg · kg · h]; P < 0.001). Cumulative 0- to 12-h morphine consumption was reduced in the pupillometry group (two-way repeated measures ANOVA 0.3 ± 0.1 vs. 0.4 ± 0.2 mg/kg; P = 0.048). A telephone survey 3 months after surgery revealed that 15 of 29 patients in the standard group still experienced procedure-related pain versus 3 of 23 in the pupillometry group (chi-square P = 0.037). No adverse events associated with pupillometry were observed during the study. CONCLUSIONS: The use of pupillometry to guide intraoperative analgesia reduced intraoperative remifentanil consumption and postoperative morphine requirements. The possible consequences of decreasing intraoperative remifentanil in terms of chronic pain require further investigation.

Peri-operative management of overweight and obese children and adolescents.

Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.

Effectiveness of Epidural Analgesia, Continuous Surgical Site Analgesia, and Patient-Controlled Analgesic Morphine for Postoperative Pain Management and Hyperalgesia, Rehabilitation, and Health-Related Quality of Life After Open Nephrectomy: A Prospective, Randomized, Controlled Study.

BACKGROUND: There is no widely recognized effective technique to optimally reduce pain scores and prevent persistent postoperative pain after nephrectomy. We compared continuous surgical site analgesia (CSSA), epidural analgesia (EA), and a control group (patient-controlled analgesic morphine) in patients undergoing open nephrectomy. METHODS: Sixty consecutive patients were randomized to be part of EA, CSSA, or control groups postoperatively for 72 hours. All patients received patient-controlled analgesic morphine, if needed. Hyperalgesia was assessed on the first, second, and third postoperative days. Chronic pain characteristics and quality of life were analyzed at 1 and 3 months. The primary outcome was the pain score at 24 hours. Secondary outcomes were morphine consumption, postoperative rehabilitation, hyperalgesia, chronic pain incidence, and quality-of-life parameters. RESULTS: At 24 hours, mean ± standard deviation pain values at rest (2.4 ± 1.7, 2.2 ± 1.2, and 4.2 ± 1.2, respectively, in EA, CSSA, and control groups, P <.001) and during coughing was lower in the EA and CSSA groups. Total morphine consumption was higher in the control group. Rehabilitation parameters improved sooner in the EA and CSSA groups. Median values of area of hyperalgesia differed at 48 hours between the EA group and the control group (36.4 cm) and (52 cm) (P = .01) and at 72 hours among the EA group, CSSA group, and the control group (40 cm, 39.5 cm, and 59 cm, respectively; P = .002). CSSA reduced the severity of pain and hyperalgesia at 1 month and optimized quality of life 3 months after surgery (role physical scores, P = .005). CONCLUSIONS: CSSA and EA significantly improve postoperative analgesia, reduce postoperative morphine consumption, area of wound hyperalgesia, and accelerate patient rehabilitation after open nephrectomy. CSSA significantly reduces the severity of residual pain 1 month after surgery and optimizes quality-of-life parameters 3 months after surgery.

Children with challenging airways: What about GlideScope® video-laryngoscopy?

BACKGROUND: GlideScope® video-laryngoscopy is becoming increasingly used, including in paediatrics. However, to date, very few data are available on efficiency during situations involving difficult intubation. Our objective was to describe the usefulness of the GlideScope® in children with presumed challenging airway criteria. METHODS: In this observational study, all children with predicted criteria of potential difficult intubation and requiring general anaesthesia with tracheal intubation were prospectively enrolled over a 12-month period. The Cormack and Lehane (CMK) grade was first assessed by direct laryngoscopy. In case of a CMK≥3, the same experienced anaesthesiologist scored the CMK scale under GlideScope® videoscopy. Data related to GlideScope® use under difficult intubation conditions were analysed. RESULTS: Out of the sixty-one patients (median [25th-75th interquartile range] age of 12 [4-37] months) included, 37 (62%) patients have confirmed a high probability of difficult intubation. Compared to direct laryngoscopy, GlideScope® video-laryngoscopy was significantly associated with an improved CMK grade (P<0.001). Tracheal intubation with the GlideScope® was successful after the first attempt in almost one half of cases and ultimately in 100% of patients. The median time required for successful GlideScope® intubation was 42.5 [30-60] s. No per procedure complications were recorded. CONCLUSION: In children with challenging airways, GlideScope® video-laryngoscopy resulted in a significant improvement of the glottic view with an excellent success rate and satisfactory time to intubation. How these devices are to be positioned in difficult airway management algorithms and guidelines remain to be defined.

One year of anaesthesia in France: A comprehensive survey based on the national medical information (PMSI) database. Part 2: Out-hospital patients.

INTRODUCTION: Epidemiological data on French ambulatory anaesthesias are restricted. The aim of this study was to perform an epidemiological analysis of this activity for the year 2010. METHODS: Using the national database program for medical information systems (the PMSI), we have listed all institutions in France and her overseas territories performing ambulatory anaesthesia. We have assessed the number and nature of anaesthetic procedures, in terms of type of institution, age and surgeries. These results were correlated with French general demographics. RESULTS: Ambulatory anaesthetic procedures represented 44.4% of all anaesthesias, excluding childbirth, (n=4644,791 ambulatory acts), among which 88% were performed on adults and 12% on minors. The "65-74 years" age group had the highest annual relative rate of ambulatory anaesthesia. Rate of ambulatory anaesthesia was higher in children compared to adults (60% versus 42.8%, respectively). Outpatient surgery was mainly developed in Private Clinics as compared to public institutions. CONCLUSION: Ambulatory anaesthesia has dramatically increased over fourteen years. It represents almost half of all anaesthetic acts, and its development is promising, especially in University Hospitals and adult populations.

One year of anaesthesia in France: A comprehensive survey based on the national medical information (PMSI) database. Part 1: In-hospital patients.

UNLABELLED: Anaesthesia has evolved in France since the last epidemiologic survey in 1996. The national database program for medical information systems (the PMSI) can be used to track specific knowledge concerning anaesthesia for a selected period of time. The goal of this study was to perform a contemporary epidemiological description of anaesthesia in France for the year 2010. METHODS: The data concerning private or public hospital stays were collected from the national PMSI database. All surgical/medical institutions performing anaesthesia in France and French Overseas Departments and Territories were queried concerning the number of anaesthesias, patient age, sex ratios, institution characteristics, hospitalization types, the duration of hospital stays, and the surgical procedures performed. RESULTS: In 2010, the number of anaesthesia procedures performed was 11,323,630 during 8,568,630 hospital stays. We found that 9,544,326 (84.3%) anaesthetic procedures were performed in adults (> 18 years of age; excluding childbirth), 845,568 (7.5%) were related to childbirth and 933,736 (8.2%) were acts in children (up to 18 years of age). The mean duration of hospital stay was 5.7±8.2 days. 56.5% of adults and 39.5% of children were managed as inpatient hospital stays. The male/female sex ratio and mean age were 42/58 and 54±19 years, respectively. In adults, anaesthesia was predominantly performed for abdominal surgery (24.5%), orthopaedics (16.7%), gynaecology (10.3%), ophthalmology (9.7%) and vascular surgeries (7.1%). For paediatric populations, the main surgical activities were Ear-Nose-Throat surgery (43.1%), orthopaedic surgery (15.1%) and urological surgeries (12.8%). DISCUSSION: The number of anaesthesias performed in France has dramatically increased (42.7%) since the last major epidemiological survey. Anaesthesia in the 21th century has been adapted to associated demographic changes: an older population with more comorbidities and fewer in-hospital procedures.

Effects of pressure support ventilation mode on emergence time and intra-operative ventilatory function: a randomized controlled trial.

UNLABELLED: We tested the hypothesis that pressure-support ventilation (PSV) allows a reduction in emergence time and laryngeal mask airway (LMA) removal time after general anesthesia compared to volume-controlled mechanical ventilation (CMV). Because spontaneous breathing (SB) is often used with LMA under general anesthesia, patients were allocated randomly to three groups (CMV, SB and PSV). Thirty-six consecutive ASA I-II patients scheduled for knee arthroscopic surgery under general anesthesia with a LMA and breathing throughout the ventilator circuit were included. Hemodynamic and ventilatory variables were recorded before and 10-min after general anesthesia-induction, at the surgical incision, at the end of anaesthetic drugs infusion and when the patient was totally awake (which defines emergence time). LMA removal time, drug consumption were recorded at the end of the surgical procedure. Leak fraction around the LMA was also evaluated. LMA removal time was significantly higher in the CMV-group (18 ± 6 min) compared to both SB (8 ± 4 min) and PSV (7 ± 4 min, P < 0.05) groups as well as for emergence time: CMV-group (32 ± 12 min), SB (17 ± 7 min) and PSV (13 ± 6 min, P < 0.05) groups. Total propofol consumption was significantly lower in the PSV-group (610 ± 180 mg) than in both CMV (852 ± 330 mg) and SB (734 ± 246 mg, P < 0.05) groups. Air leaks around the LMA was significantly higher in the CMV-group than in the SB and PSV groups (16% vs 3% and 7%, all P<0.05). In conclusion, in knee arthroscopic surgery, in comparison to CMV, PSV use during general anesthesia in unparalyzed patients decreases LMA removal time, propofol consumption and leaks around LMA while improving ventilatory variables without adverse effects. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN17382426.

Inguinal hernia in premature boys: should we systematically explore the contralateral side?

OBJECTIVE: Bilateral surgery has been largely advocated in premature boys with unilateral inguinal hernia owing to the high incidence of contralateral patent processus vaginalis. Recently, the potential morbidity of herniotomy in low birth-weight babies and the progress in pediatric anesthesia questioned this attitude. This study aims to evaluate the incidence of contralateral metachronous hernia in a large series of premature boys and to compare the morbidity of preventive versus elective surgery. METHODS: This retrospective multicenter analysis of 964 premature boys presenting with unilateral inguinal hernia operated from 1998 to 2012 included 557 infants who benefited from a unilateral herniotomy and 407 from a bilateral herniotomy (median follow-up 12months). RESULTS: Contralateral metachronous hernia after unilateral surgery occurred in 11% (n=60) without significant difference according to the initial symptomatic side (9.5% on right vs 13% on left, p>0.05). Postoperative morbidity on the contralateral side was higher after preventive surgery than elective surgery with metachronous hernia (2.45% versus 0.9%, p=0.05) especially for secondary cryptorchidism (1% vs 0%, p=0.03). Despite the risk of metachronous incarcerated hernia, elective surgery did not increase the rate of testicular hypotrophy on the opposite side (0.7%, vs 0.7%, p>0.05). CONCLUSION: Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a significant morbidity. Secondary surgery for metachronous hernia does not increase the risk of testicular lesion and even reduces the risk of secondary cryptorchidism. These results, along with the risk of hypofertility reported after bilateral surgery, may justify treating only the symptomatic side in premature boys.

Ultrasound-guided tranversus abdominis plane block for herniorrhaphy in children: what is the optimal dose of levobupivacaine?

BACKGROUND: Regional anaesthesic techniques are commonly used for the management of pain following lower abdominal surgery in children. The transversus abdominis plane (TAP) block has shown promise for perioperative analgesia, but data on the optimal dose regimen are limited. OBJECTIVE: To evaluate the optimal dose of levobupivacaine for successful ultrasound-guided TAP block in children. DESIGN: A dose finding prospective study using Dixon's up-and-down sequential method. SETTING: University Hospital Paediatric Anaesthesia Unit. PATIENTS: Twenty-seven consecutive children aged 1 to 5 years scheduled for day-case elective herniorrhaphy. INTERVENTION: After standardised induction of general anaesthesia, ultrasound-guided TAP block was performed with a fixed volume of 0.2  ml  kg(-1) of levobupivacaine solution. The dose of levobupivacaine was determined by Dixon's up-and-down method starting from 0.5  mg  kg(-1)with an interval of 0.1 mg   kg(-1). Block failure was defined as a 20% increase in heart rate or mean arterial pressure from baseline. Rescue analgesia consisted of intravenous remifentanil infusion during surgery and intravenous nalbuphine in the postanaesthetic care unit (PACU). Patients were assessed using the FLACC (face, legs, activity, cry and consolability) pain scale, the rescue analgesic consumption in the PACU and day-case unit and the postoperative pain measure for parents score at home. MAIN OUTCOME MEASURES: The mean effective dose of levobupivacaine resulting in an effective TAP block in 50% of cases (ED50) obtained by using Dixon's up-and-down sequential method. The ED50 and ED95 were further estimated by bootstrapping. RESULTS: The ED50 according to the up-and-down staircase method was 0.22  mg   kg(-1) [95% confidence interval (CI) 0.19 to 0.25]. Bootstrap replicates of the original dataset resulted in ED50 and ED95 estimates of 0.16  mg    kg(-1) (95% CI 0.11 to 0.24) and 0.43 mg  kg(-1)(95% CI 0.30 to 0.57), respectively. CONCLUSION: As part of a multimodal analgesia strategy, ultrasound-guided TAP block with 0.2  ml  kg(-1)of 0.2% levobupivacaine provides successful peroperative analgesia in 95% of children who underwent herniorrhaphy.