How to replace codeine after tonsillectomy in children under 12 years of age? Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL).

The authors present the guidelines of the French Oto-rhino-laryngology--Head and Neck Surgery Society (SFORL) regarding pain management in children and adults following tonsillectomy. A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as professional agreement in decreasing order of level of evidence. At home, non-steroid anti-inflammatory drugs (NSAIDs) are recommended in association with paracetamol in elevated respiratory risk and especially obstructive sleep apnea syndrome; in elevated hemorrhagic risk (hemostasis disorder, surgical problems, etc.), tramadol is recommended. Two other treatment schedules (modified NSAIDs and corticosteroids) have not undergone dedicated study and should be assessed. Management of post-tonsillectomy pain in children is founded on individual risk/benefit analysis.

Guidelines (short version) of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL) for the management of post-tonsillectomy pain in adults.

OBJECTIVES: The present clinical practice guidelines cover the entire field of management of post-tonsillectomy pain. Given the French and European regulatory restrictions on the use of codeine, an update appears necessary to clarify the management of post-tonsillectomy pain in adults. METHOD: A work group approached the issue of pain management, following the chronological pathway from initial consultation to postoperative period. As exhaustive a study of the literature as possible assessed the pain impact of the various surgical techniques and the efficacy of the various analgesia schedules. RESULTS: Guidelines on the management of post-tonsillectomy pain in adults were drawn up and graded, based on the levels of evidence of selected articles and on work group consensus. The guidelines stress the importance of patient information and seek to harmonize practice, reduce the risk of postoperative complications and above all improve control of post-tonsillectomy pain in adults.

[Role of isotopic imaging in intensive care]. / Place de l'imagerie isotopique en réanimation.

The real place of isotopic imaging in intensive care patients remains still unclear. This review aimed to consider the indications of isotopic imaging for improved diagnosis and therapy and to specify its place among the other techniques of exploration. Pulmonary perfusion and ventilation scintigraphies are valuable for the diagnosis of pulmonary embolism (PE). A "high probability" scintigraphy of the lungs ascertains the diagnosis of PE and allows to start a specific treatment without requiring a pulmonary angiography. This is not the case in the presence of a history of previous PE or if the arguments for a PE are only weak. A normal lung scintigraphy eliminates the diagnosis of a clinically significant PE all the more as an exploration of good quality of the lower limb veins remains negative. In the opposite a "non diagnostic" scintigraphy justifies a pulmonary angiography in intensive care patients. The diagnosis of myocardial contusion is made uneasy as the clinical symptoms, the ECG, the cardiac enzymes and the chest X-ray are only of limited value. Isotopic explorations of the heart could provide additional valuable data or be an alternative for 2 D echocardiography. The comparison of CPK-MB concentrations with a myocardial scintigraphy using thallium 201 is given as being very reliable, with positive and negative predictive values higher than 80%. An exploration restricted to the cardiac ejection fractions is only of limited value. In the future, an improvement will perhaps be obtained with tracers such as MIBI labelled with technetium 99m, which allow the simultaneous assessment of myocardial perfusion and the ventricular ejection fractions as well. The localisation of centres of infection, especially when intra-abdominal, remains difficult in intensive care patients. Isotopic imaging, especially the scintigraphies with labelled polynuclears, could allow in combination with conventional imaging techniques (computed tomography and 2 D echocardiography) to prevent from errors in diagnosis. An array of arguments is essential for ascertaining the presence of an abscess. Scintigraphies with leucocytes labelled with indium 111 or technetium 99m are qualified as having a sensitivity and a specificity greater than 90%. The conventional techniques of measurement of the cerebral blood flow (CBF) using xenon 133 require a special equipment or are invasive. Other cerebral tracers, such as cyclic amines (HMPAO) labelled with technetium 99m and administrable by i.v. route, allow the use of a standard tomo-gamma camera, and could be of help in various pathological conditions.(ABSTRACT TRUNCATED AT 400 WORDS)

[Autologous transfusion in heart surgery (apropos of 74 patients)]. / Transfusion autologue en chirurgie cardiaque (a propos de 74 patients).

The present study uses three techniques of autotransfusion in heart surgery under ECC: peroperative and post-ECC transfusion of blood removed after induction of anaesthesia (group I: 25 patients); postoperative transfusion of extravasated thoracic blood (group II: 24 patients) and a combination of the two (group III: 25 patients). Postoperative bleeding was comparable in all groups; A subset likely to haemorrhage made up of patients who had lost more than one litre of blood was isolated and demonstrated a reduction in the number of homologous red cell concentrates needed for the autotransfused population in comparison with the controls (2.4 +/- 2.6 vs 5.7 +/- 3.5 red cell concentrates, p less than 0.05) and was particularly marked in Group II patients who received 1.9 +/- 2.2 homologous red cell concentrates. None of the techniques caused any side-effects. Combination of the two autotransfusion techniques in heart surgery does not secure any additional advantages compared with postoperative autotransfusion alone.

[Effects of propofol on intraocular pressure in surgery of strabismus in children]. / Effets du propofol sur la pression intraoculaire dans la chirurgie du strabisme de l'enfant.

Propofol was assessed for eye surgery in 20 children. ASA group I or II, 2-14 year-old, randomly assigned to 2 equal groups. Premedication, analgesia and muscle paralysis were similar in both groups. Group P patients were given an induction dose of 4 mg.kg-1 propofol, followed by an infusion of 15 mg.kg-1.h-1 for the first half hour, and then 10 mg.kg-1.h-1 to maintain anaesthesia. Group C patients were given 10 mg.kg-1 thiopentone for induction and halothane for maintenance. The quality of anaesthesia was assessed by monitoring adverse effects, heart rate, blood pressure, the length of anaesthesia, the delay of the first spontaneous breath and eye opening, and extubation. Intraocular pressure was measured before and 3 min after intubation, and 5 min after extubation. The quality of anaesthetic induction and maintenance were very similar in both groups. Pain occurred more frequently at the injection site with propofol (p less than 0.01). Children in group P recovered more quickly, and extubation was possible much earlier in this group (p less than 0.05). However, restlessness was significantly more frequent in group P (n = 9) than in group C (n = 1) (p less than 0.01). Systolic, diastolic blood pressure and heart rate were significantly lower in group P (p less than 0.05; 0.001; 0.001 respectively). No significant decrease in intraocular pressure in both groups was observed. The use of propofol for eye surgery in children is acceptable, despite some restlessness during recovery.