Clonidine in preterm-infant caudal anesthesia may be responsible for postoperative apnea.

OBJECTIVE: Regional anesthesia without adjunctive general anesthesia or sedation has been recommended for preterm infants to decrease the risk of postoperative apnea. Single-dose caudal local anesthetic has a limited duration, which may be insufficient for long surgery. Addition of clonidine to local anesthetics has been shown to prolong the duration of surgical analgesia. However, respiratory depression related to clonidine may occur in adults. Respiratory depression has not been reported after caudal administration of clonidine in preterm infants. Here we report a case of early postoperative apnea in a waking preterm infant after caudal anesthesia performed with lidocaine, bupivacaine, and clonidine. CASE REPORT: A male infant, 39 postconceptual weeks old, was administered a single-injection caudal anesthesia without sedation with 5 mg/kg lidocaine plus 2.5 mg/kg bupivacaine and 1.25 microg/kg clonidine for bilateral inguinal hernia repair, and had early postoperative apneic events. Except for gestational age, the patient showed no apparent risk factors for postoperative apnea. The infant was monitored 24 hours in a neonatal intensive care unit, and no other apnea was recorded. CONCLUSIONS: Our report suggests that clonidine may be responsible for postoperative apnea in a preterm neonate. Further studies are required to determine the useful safe dose of clonidine for single-injection caudal anesthesia in those infants.

Evaluation of caudal anaesthesia performed in conscious ex-premature infants for inguinal herniotomies.

Ex-premature infants, before 45 weeks postconceptional age, are at high-risk of apnoea after surgery. General anaesthesia increases the risk of apnoea. We evaluated the tolerance and the efficiency of caudal anaesthesia performed in 25 consecutive conscious ex-premature infants for inguinal herniotomies. N2O/O2 and EMLA cream are used to facilitate caudal puncture. Anaesthesia procedure, patient comfort and complications following the 24 postoperative hours were studied. We report good anaesthesia conditions without compromising the baby's comfort and few perioperative complications. Only two infants with a prior history of apnoea or bronchopulmonary dysplasia had apnoea during and after surgery. A total spinal anaesthesia was the major complication in one infant and prolonged surgery requiring general anaesthesia was the main limitation of this technique in another child. The principal advantage of the procedure is to facilitate and simplify the postoperative management of the babies. The anaesthetic technique does not alter surgical conditions. Caudal epidural anaesthesia performed in awake high-risk preterm infants is beneficial for these infants but requires experienced operators.

Postoperative infectious complications in paediatric liver transplantation: a study of 48 transplants.

We studied, retrospectively, postoperative infectious complications following paediatric liver transplantation at a single university centre. The objectives were to characterize the epidemiology of infection and to determine the associated risk factors during the early postoperative period, either the first postoperative month or the entire duration of paediatric intensive care unit (PICU) stay. Forty-eight liver transplants were performed on 46 patients. Sixty-three infections occurred in 32 patients who underwent 34 liver transplantations (1.36 infection/patient); 47 were bacterial, 6 fungal and 10 viral. The most common sites of infection were bloodstream (36.5%) and abdomen (30%). Gram-positive bacteria (78%) predominated over gram-negative bacteria (22%). Initial analysis revealed infection risk factors to be age <1 year, body weight <10 kg, extrahepatic biliary atresia, intraoperative transfusion > 160 ml x kg(-1), mechanical ventilation > 8 days and PICU stay > 19 days. After stratified analysis, the main risk factor for infection was low body weight of the recipient.

High frequency oscillatory ventilation during repair of neonatal congenital diaphragmatic hernia.

We evaluated the use of high frequency oscillatory ventilation (HFOV) during congenital diaphragmatic hernia repair. After preoperative stabilization, 22 newborn infants were ventilated with HFOV during surgery. Ventilatory settings, blood gas values and oxygenation index were recorded before, during and after surgical repair. No differences were noted for these variables. No complications related to ventilation were recorded. According to the surgeon, diaphragmatic repair during HFOV is facilitated. This study confirms that CDH can be safely repaired using HFOV during anaesthesia.

[Deep venous thrombosis and severe burns]. / Thromboses veineuses profondes et brûlures graves.

Deep venous thrombosis (DVT) is a frequent and potentially serious complication in severely burned patients. We report the case of a burned patient (40% of total body surface burned), who had right femoral deep venous thrombosis and severe pulmonary embolism, although a prophylaxis was conducted with low molecular weight heparin, graduated compression stockings and rotating bed. This case shows that DVT early diagnosis and prophylaxis is difficult in severely burned patients. Systematic screening of DVT by duplex scan is possible only for femoral veins, which renders duplex scan more suitable for femoral catheter follow up than for systematic DVT screening. Computed tomography venography seems to be a valuable tool in the diagnosis of proximal thrombosis. Prophylaxis is best achieved with the use of preventive low molecular weight heparins, graduated compression stockings, and early mobilisation when possible. However, the place of low molecular weight heparins at high doses and external pneumatic calf compression needs to be evaluated by prospective studies.