Surgical approach to the posterior fossa in children, including anesthetic considerations and complications: The prone and the sitting position. Technical note.

INTRODUCTION: Medulloblastoma (MB) in children is, in most cases, a midline lesion located in the posterior fossa, with a high tendency to invade the fourth ventricle (and sometimes its floor). METHODS: In this technical note, we present both the sitting and the prone position for children with medulloblastoma. These positions will be described together by deliberately deciding not to oppose one against the other. The park bench position, seldom used in pediatric neurosurgery is not described here. The latter procedure can be useful, however, for MB located more laterally or within the cerebellopontine angle. RESULTS: The aim of this technical note is to provide the reader with a step by step procedure (from installation to closure), at least from the author's point of view. A special focus regarding anesthetic considerations is also provided. This anesthesia requires perfect coordination and communication between both the anesthetic and surgical teams. Complications of posterior fossa surgery are mentioned as well. Some of the advantages and disadvantages of each positions are mentioned. CONCLUSION: Only careful installation, respect of certain surgical principles (careful attention of the vermis and dentate nuclei for example), knowledge of anatomy, closure and perioperative monitoring, screening and immediate correction of potentially devastating complications will enable surgeons to obtain the best results from their surgery.

[Acute pancreatitis caused by sodium valproate. Review of the literature apropos of a case in a child]. / Pancréatite aiguë au valproate de sodium. Revue de la littérature à propos d'un cas chez l'enfant.

The authors report on the case of a 12.5 and year-old epileptic boy with severe acute pancreatitis which appeared 39 months after starting treatment with sodium valproate (VAP) at a daily dosage of 26.6 mg/kg. Twelve days after hospitalization, a pseudocyst of the pancreas developed, leading to cystoduodenostomy 3 months later. Following VPA suppression, no recurrence of pancreatic symptomatology was observed. The pathophysiological mechanism of this adverse side-effect of VPA treatment remains unclear. The appearance of a painful epigastric syndrome and/or vomiting in a patient subjected to a VPA treatment indicates the possibility or acute pancreatitis, to be confirmed by blood and urinary determination of amylases and abdominal tomodensitometric examination. Finally, the fact that this side-effect may be severe even lethal, brings into question the prescription of this drug in the management of epilepsy.

[Early excision and grafting in the burned child. Apropos of 49 cases studied retrospectively 1986-1987]. / Excision greffe précoce chez l'enfant brûlé. A propos de 49 cas, étude rétrospective 1986-1987.

Early excision and grafting (EEG) is a commonly-used surgical technique which limits the risk of infection and improves healing. However, when used on children, their particular anatomic and physiological specificities must be taken into account. The authors present a retrospective investigation concerning 49 EEG performed on 45 patients from five months to nineteen years old, presenting a burnt skin surface of between 1% and 70%. This short operation (1 h 30) gives rise to an important and early haemorrhage induced by blood losses which are impossible both to stop and to evaluate. This explains the frequency and the severity of the peroperative complications (one cardiocirculatory deficiency, eleven low blood pressure/tachycardias) related to an underestimated blood loss. The post-operative period is characterized by hemodynamic, infectious and hypothermic complications. As regards operative results, they can be considered to be good or excellent in 80% of the cases both from a functional and an anaesthetic point of view. In order to decrease the important operative morbidity related to EEG in the case of children, the authors stress the necessity or taking certain precautions: During the operative period --Antibiotic prophylaxis against cutaneous bacteria when the excision is important and BSS greater than 20%; --ordering sufficient quantities of blood and plasma taking into account the estimated amount of blood losses during the per and post-operative period, and also with regard to the patient's weight and the excised (AE): During the operation --prevention of hypothermia by the permanent use of an infrared radiator, warming up the solutions before perfusion, using of a heating mattress...); --provision of two large diameter venous passages; --initiation of the transfusion before the first incision.(ABSTRACT TRUNCATED AT 250 WORDS)

[Continuous inflation of a leaking cuff of an intubation tube]. / Inflation permanente du ballonnet rompu d'une sonde d'intubation.

Perforation of the cuff of the endotracheal tube peroperatively is a very serious problem, especially when it occurs in a patient prone on an orthopaedic table. This is even more dramatic when the patient is not breathing spontaneously and he cannot be turned over to be reintubated. Given the unusual character of this situation, an apparatus has been designed to keep the cuff inflated permanently. It was a circuit consisting of a manual pressure valve, flexible tubing, a peripheral catheter and the cuff supply tube. The gas used was medical air at 3 bar pressure. This method proved perfectly safe and efficient, the operation having continued without reintubation.

[Zona after spinal anesthesia: coincidence or consequence?]. / Zona après rachianesthésie: coïncidence ou conséquence?

A case is reported of a herpes zoster infection occurring a few days after spinal anaesthesia in a man with severe cardiac disease who had undergone transurethral endoscopic resection of a prostatic epithelioma. The question as to whether there was a relationship between the two events had to be asked, all the more so as the rash seemed to be centered on the puncture wound. Others factors involved may have been the effect of anaesthesia on the body's defence mechanisms, the use of prophylactic antibiotics and the neoplasm.