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.

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.

Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.

BACKGROUND: Preoperative anxiety management receives special attention in pediatric anesthesia. Different pharmacological and nonpharmacological techniques can be employed. This study was designed to assess three different strategies for childhood preoperative anxiolysis: midazolam premedication, midazolam in combination with portable Digital Video-Disk player, or video distraction strategy alone. METHODS: In this prospective randomized study, children aged 2-12 years were assigned to one of the three study groups. The primary outcome was a change in preoperative children's anxiety, from baseline (before transfer to the preanesthetic holding area) to separation from parents, assessed by the Modified Yale Preoperative Anxiety Scale (mYPAS) and the Visual Analog Anxiety Scale (VAS-Anxiety). Delirium emergence, postoperative pain, and parental satisfaction were also collected. RESULTS: One hundred and thirty-five patients were enrolled. The three preventive strategies allowed control of preoperative distress. Within the three study groups, no significant change was objectified in the anxiety level from baseline to separation from parents (mean change in mYPAS midazolam group: 2.4 95% CI [-1.7 to 6.3]; midazolam+Digital Video-Disk group: -1.0 95% CI [-5.9 to 3]; and Digital Video-Disk group: 1.4 95% CI [-4 to 6.7]). Comparison of change in preoperative children's anxiety between the groups did not show any difference. Emergence delirium, postoperative pain scores, and analgesic consumption were similar between the groups and parents' satisfaction was excellent. CONCLUSION: Both pharmacological premedication and video distraction are effective strategies for controlling preoperative childhood anxiety. The combination of midazolam and Digital Video-Disk player was not better than either alone.

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.

Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo.

BACKGROUND: The authors investigated the efficacy of bilateral suprazygomatic maxillary nerve block (SMB) for postoperative pain relief in infants undergoing cleft palate repair. METHODS: In this prospective, double-blind, single-site, randomized, and parallel-arm controlled trial, 60 children were assigned to undergo bilateral SMB with general anesthesia with either 0.15 ml/kg of 0.2% ropivacaine (Ropi group) or 0.15 ml/kg of isotonic saline (Saline group) on each side. The primary endpoint was total postoperative morphine consumption at 48 h. Pain scores and respiratory- and SMB-related complications were noted. RESULTS: The overall dose of intravenous morphine after 48 h (mean [95% CI]) was lower in the Ropi group compared with that in the Saline group (104.3 [68.9 to 139.6] vs. 205.2 [130.7 to 279.7] µg/kg; P = 0.033). Continuous morphine infusion was less frequent in the Ropi group compared with that in the Saline group (1 patient [3.6%] vs. 9 patients [31%]; P = 0.006). Three patients in the Saline group had an episode of oxygen desaturation requiring oxygen therapy. There were no technical failures or immediate complications of the SMB. Intraoperative hemodynamic parameters, doses of sufentanil, pain scores, and postoperative hydroxyzine requirements were not different between the two groups. CONCLUSION: Bilateral SMB is an easy regional anesthesia technique that reduces total morphine consumption at 48 h after cleft palate repair in children and the use of continuous infusion of morphine and may decrease postoperative respiratory complications.

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.

Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study.

BACKGROUND: Bilateral suprazygomatic maxillary nerve blocks approach improves pain relief after palate surgery. We report the feasibility and efficiency of ultrasound-guided suprazygomatic maxillary nerve blocks in cleft palate repair in children. METHODS: Twenty-five children scheduled to undergo surgical cleft palate repair were included. Ultrasound-guided suprazygomatic maxillary blocks were performed according to landmarks previously defined. The ultrasound probe was located optimally over the maxilla and under the zygomatic bone to visualize the pterygopalatine fossa. 0.15·ml·kg(-1) of 0.2% ropivacaine was injected bilaterally. Feasibility of block, spread of local anesthetic, pain scores and side effects were noted. RESULTS: Fifty ultrasound-guided suprazygomatic maxillary nerve blocks were performed in 25 children. The needle movement was seen in all cases using an out-of-plane approach. The spread of LA was clearly observed in 94% (47/50) of cases. A poor ultrasound imaging was found in 4% (2/50), and the spread of LA was not identified in 2% of case (1/50). The median time to perform the block was 56 s (35-120 s). The median pain scores and consumption of nalbuphine were low during the study period. 80% of patients did not require continuous opioid infusion. No complication related to maxillary blocks was reported. CONCLUSION: With a very low technical failure rate and a good clinical success rate, ultrasound appears to be a useful and simple tool to aid suprazygomatic maxillary nerve block in children.

Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study.

BACKGROUND: Surgical correction of craniosynostosis in children is associated with substantial intraoperative bleeding. Tranexamic acid (TXA) decreases intraoperative blood loss during cardiac or orthopedic surgery in children. We hypothesized that intraoperative TXA would reduce blood transfusion relative to placebo in patients pretreated with erythropoietin. METHODS: Forty consecutive children, American Society of Anesthesiologists status 1 or 2, scheduled to undergo surgical correction of craniosynostosis were randomly assigned to receive either intravenous TXA or saline, 0.9%, intraoperatively. All children received preoperative erythropoietin (600 U/kg once a week for 3 weeks before surgery). Perioperative blood loss, number and volume of transfusions, percentage of children who underwent transfusion, and side effects were noted after surgery and at the end of the study. Surgeon satisfaction and cost of treatment were also recorded. RESULTS: There was no significant difference between groups in demographic or surgical data. In the TXA group, the volume of packed erythrocytes transfused was significantly reduced by 85% (from 11 to 1.6 ml/kg) intraoperatively and by 57% (from 16.6 to 7.2 ml/kg) throughout the study period (P < 0.05). Compared with the placebo group, the percentage of children requiring blood transfusion was lower in the TXA group during surgery (9 [45%] of 20 vs. 2 [11%] of 19 children; P < 0.05) and during the whole study period (14 [70%] of 20 vs. 7 [37%] of 19; P < 0.05). Preoperative and postoperative hematologic parameters were comparable in both groups. There were no adverse events. CONCLUSION: In children undergoing surgical correction of craniosynostosis and pretreated with erythropoietin, intraoperative TXA reduces the transfusion requirement.

A new approach for peri-operative analgesia of cleft palate repair in infants: the bilateral suprazygomatic maxillary nerve block.

BACKGROUND: Congenital cleft palate (CP) is a common and painful surgical procedure in infants. CP repair is associated with the risk of postoperative airway obstruction, which may be increased with administration of opioids, often needed for analgesia. No described regional anesthesia technique can provide adequate pain control following CP repair in infants. The primary aim of this prospective and descriptive study was to observe the effectiveness of bilateral maxillary nerve blocks (BMB) using a suprazygomatic approach on pain relief and consumption of rescue analgesics following CP repair in infants. Analgesic consumption was compared to retrospective data. Complications related to this new technique in infants were also reviewed. METHODS: The landmarks and measurements recently defined in a three-dimensional study using computed tomography in infants were used. After general anesthesia, a BMB was performed bilaterally with 0.15 ml x kg(-1) 0.2% ropivacaine in infants scheduled for CP repair. Postoperative analgesia, administration of rescue analgesics, adverse effects, and time to feed were recorded in the 48-h period following surgery and compared to retrospective data. RESULTS: Thirty-three children, mean age 5 +/- 1.8 months and weight 8.3 +/- 1.2 kg, were studied. Eighteen patients out of 33 (55%) did not require additional opioids intra-operatively, vs two out of 20 (10%) without block. None needed morphine postoperatively, and intravenous nalbuphine was required in only six children (18%), vs 16 (80%) without block. Median time to feed was 8 h (range 2-24 h), vs 13 h (4-25) without block. No technical failure or complication related to the BMB was reported. CONCLUSION: BMB using a suprazygomatic approach seems to improve pain relief, to decrease peri-operative consumption of opioids, and to favor early feeding resumption after CP repair in infants.

The perioperative validity of the visual analog anxiety scale in children: a discriminant and useful instrument in routine clinical practice to optimize postoperative pain management.

BACKGROUND: Because children's anxiety influences pain perception, perioperative anxiety should be evaluated in clinical practice with a unique, useful, and valid tool to optimize pain management. In this study, we evaluated psychometric properties of the visual analog scale (VAS)-anxiety for children and to study its perioperative relevance in clinical practice. METHODS: One hundred children scheduled for elective surgery and general anesthesia were included. VAS-anxiety was measured at four timepoints and compared with both versions of State Spielbergers' questionnaires (State-Trait Anxiety Inventory for Youth [STAIY] and State-Trait Anxiety Inventory for Children [STAIC]) and the modified Yale Preoperative Anxiety Scale. Children's pain, parents' anxiety, and parents' proxy report of children's anxiety were evaluated using VAS. RESULTS: The correlation between STAIC and VAS-anxiety was significant on the day of discharge. Moreover, changes over time were not significant with STAIC, whereas VAS-anxiety was significantly sensitive to changes over time in the two groups of age (7-11 yr and 12-16 yr). A receiver operating characteristic curve, using modified Yale Preoperative Anxiety Scale as reference, determined a VAS-anxiety cutoff at 30 to identify high-anxiety groups. Pain levels were significantly higher when children were anxious (VAS > or = 30) in the postoperative period. Moreover, children's anxiety and pain were higher when parents were anxious. CONCLUSION: VAS-anxiety is a useful and valid tool to assess perioperative anxiety in children aged 7-16 yr. The influence of children's and parents' anxiety on children's postoperative pain suggests that VAS-anxiety should be recommended routinely for postoperative clinical practice to optimize anxiety and pain management.

Continuous peripheral nerve blocks for postoperative analgesia in children: feasibility and side effects in a cohort study of 339 catheters.

INTRODUCTION: Perioperative continuous peripheral nerve blocks (CPNB) are increasingly being used in children. Only one previous study has reported adverse events of CPNB in a high number of pediatric cases. We evaluated the indications, block efficacy, and adverse events related to CPNB in children. METHODS: All CPNBs that were performed in children for postoperative analgesia over a 5-year period at the Montpellier University Hospital in France were included in this study. The first bolus dose and the continuous doses of local anesthetic were not standardized. In the postoperative period, demographic data, quality of analgesia, amount of rescue analgesic medication, child/parent satisfaction, and adverse events were recorded in our Departmental Regional Anesthesia registry. RESULTS: A total of 339 catheters were evaluated in 292 children ASA physical status I to III. The median age was 8 yr (0.6-17 yr) and the median weight was 28 kg (7-116 kg). The main surgical indications were hip, femoral, or tibial osteotomies (44.5%) and club foot repair (27.4%). The local anesthetics used were either bupivacaine or ropivacaine. The mean volume of the local anesthetic bolus dose was 0.49 +/- 0.16 mL . kg(-1), and the mean regimen of local anesthetic continuous infusion was 0.11 +/- 0.04 mL . kg(-1) . hr(-1). The median duration of CPNB was 61.6 hr (range 0-264 hr). Pain relief, which was evaluated with the children at rest, was considered optimal in the majority of patients throughout the study period. The Children and Infants Postoperative Pain Scale (CHIPPS) was used in children age 0-6 yr and the Visual Analog Pain Scale (VAS) was used in children 7 yr and older. There were no major adverse events. There were 211 minor adverse events recorded in 153 CPNBs (45.1%). The most frequently reported complication (20.1%) involved mechanical problems with the catheter, followed by nausea and vomiting (14.7%). CONCLUSION: CPNBs are indicated after orthopedic surgery in children. Our results demonstrate that CPNBs are feasible in the pediatric setting, and in skilled hands, they promote prolonged analgesia in the majority of patients without major adverse events. The most common minor adverse events are catheter-related mechanical problems and postoperative nausea and vomiting.

Continuous infusion of ropivacaïne: an optimal postoperative analgesia regimen for iliac crest bone graft in children.

BACKGROUND: Postoperative analgesia of iliac crest (IC) donor site can be performed by on site infiltrations of local anesthetics (LA) or morphine. Single injections or continuous infusions of LA proved their efficacy in adults, but was not reported in children. We prospectively evaluated the interest of a continuous infusion of 0.2% ropivacaïne at the IC donor site in terms of postoperative pain relief and rescue analgesics consumption. METHODS: Sixteen consecutive patients, aged from 4 to 16 years scheduled for maxillar alveolar graft with IC bone, were included. After IC bone graft surgery under general anesthesia, they received a 0.2-0.4 ml x kg(-1) bolus of 0.2% ropivacaïne through the IC catheter; then a continuous infusion of 0.2% ropivacaïne at 0.125 ml x kg(-1) x h(-1) was administrated for 48 h with disposable elastomeric pumps. Children systematically received paracetamol (15 mg x kg(-1) four times a day) and niflumic acid (40 mg x kg(-1) twice a day). Postoperative pain was evaluated using a Visual Analog Scale (>7 years old) or Children and Infants Postoperative Pain Score (between 4 and 7 years old) every 4 h until H48. Doses of rescue analgesics and adverse events (LA toxicity, catheter's removal, nausea-vomiting) were also noted. Three months after surgery a blinded clinical research assistant reviewed all children and assessed functional recovery, neuropathic chronic pain symptoms or local complications. RESULTS: The median value of IC graft pain scores was 0 during whole studied period. Of the patients, 31.2% did not require any rescue analgesics and 43.8% needed only once. No adverse events related to LA and no removal of catheter were noted. One child had nausea in the 48-h postoperative period, and one child had neuropathic pain symptoms at 3 months at the donor site. CONCLUSION: Continuous infusion of 0.2% ropivacaïne through an IC catheter is an optimal and safe technique of regional postoperative analgesia after bone graft harvest in children.

A prospective comparison of post-surgical behavioral pain scales in preschoolers highlighting the risk of false evaluations.

Four behavioral rating scales (BRS) (CHEOPS, CHIPPS, FLACC and OPS) assessing postoperative pain in children aged 1-7 years were studied to compare their psychometric properties, sensitivity and specificity. One hundred and fifty children included in this prospective longitudinal study were videotaped to analyze retrospectively peri-operative behaviors. Pain and anxiety were evaluated by children or by their parents prospectively. At the end of the study, four observers rated the peri-operative videos using the four BRS. Because self-reporting cannot be used for all the children, facial expression of pain was analyzed from the videos to create a Facial Action Summary Score (FASS) which was considered as a reference for the study of validity of the four BRS. Internal validities were excellent but external validities were mixed. The FLACC seems to be better adapted to assess post-surgical pain in children between 1 and 7 years old. Nevertheless, it was significantly correlated with anxiety measures. Moreover, the analysis of sensitivity and specificity using both self-reporting of pain and FASS showed that some children were still under-evaluated. The multivariate analysis underlines silence as a high risk factor of misevaluating postoperative pain. In conclusion, this study highlights the difficulty of discriminating pain intensity from anxiety when using the four BRS and that postoperatively, nearly one child in 10 was misevaluated.

Changing trends in paediatric regional anaesthetic practice in recent years.

PURPOSE OF REVIEW: Regional anaesthesia has come to a substantial position in paediatric anaesthesia. Time has now come to assess what has reached significant acceptance in daily practice and try to clear possible ways up for the next steps to come. RECENT FINDINGS: Epidemiologic data produced in the last 2 years provide useful information about the place taken by regional anaesthesia as a whole and by the most popular blocks nowadays. Significant series seem to open a track in the field of postoperative pain management at home. Ultrasound guidance takes a great part in recent publications. The most relevant, according to the location of blocks and in the scope of security, are presented. Change in anatomical background that ultrasonography demands is questioned. Finally, most recently described approaches and their potential advantages have been looked at. SUMMARY: Lessons can be drawn from epidemiologic data now available and possible ways for changes in a near future can be anticipated. Ultrasonology brings clear advantages in abdominal wall blocks. Its use in place of nerve stimulation is claimed forcefully but not yet widely used for the blocks of the limbs in children. This switch requires profound changes in the practice of regional anaesthesia which will probably not take place immediately. Blocks of the face appear innovating and promising, according to recent literature.

A review of pediatric regional anesthesia practice during a 17-year period in a single institution.

BACKGROUND: There is anecdotal evidence of changes in pediatric regional anesthesia (RA) practice. We performed a retrospective review of prospective data on pediatric RA over 17 years in our institution. METHODS: Data were collected from an electronic database for every anesthetic performed between 1989 and 2005. Type of RA, if any, and age of the patient were noted. Patients were divided into two groups:

Multicentric assessment of the safety of neonatal videosurgery.

BACKGROUND: Complex procedures for managing congenital abnormalities are reported to be feasible. However, neonatal videosurgery involves very specific physiologic constraints. This study evaluated the safety and complication rate of videosurgery during the first month of life and sought to determine both the risk factors of perioperative complications and the most recent trends in practice. METHODS: From 1993 to 2005, 218 neonates (mean age, 16 days; weight, 3,386 g) from seven European university hospitals were enrolled in a retrospective study. The surgical indications for laparoscopy (n = 204) and thoracoscopy (n = 14) were congenital abnormalities or exploratory procedures. RESULTS: Of the 16 surgical incidents that occurred (7.5%), mainly before 2001, 11 were minor (parietal hematoma, eventration). Three neonates had repeat surgery for incomplete treatment of pyloric stenosis. In two cases, the incidents were more threatening (duodenal wound, diaphragmatic artery injury), but without further consequences. No mortality is reported. The 26 anesthetic incidents (12%) that occurred during insufflation included desaturation (<80% despite 100% oxygen ventilation) (n = 8), transient hypotension requiring vascular expansion (n = 7), hypercapnia (>45 mmHg) (n = 5), hypothermia (<34.9 degrees C) (n = 4), and metabolic acidosis (n = 2). The insufflation had to be stopped in 7% of the cases (transiently in 9 cases, definitively in 6 cases). The significant risk factors for an incident (p < 0.05) were young age of the patient, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery. CONCLUSION: Despite advances in miniaturizing of instruments and growth in surgeons' experience, the morbidity of neonatal videosurgery is not negligible. A profile of the patient at risk for an insufflation-related incident emerged from this study and may help in the selection of neonates who will benefit most from these techniques in conditions of maximal safety.

Transpulmonary thermodilution hemodynamic monitoring for pheochromocytoma surgery in a child with complex congenital heart disease.

Hemodynamic alterations related to pheochromocytoma surgery may lead to decompensation with an associated cardiac malformation. Moreover, they are incompletely described in children because of potential hazards of invasive monitoring. We report transpulmonary thermodilution hemodynamic monitoring during pheochromocytoma surgery in a child with a complex congenital heart malformation. Comprehensive analysis of hemodynamic events was obtained that guided therapeutic decisions. Cardiac function was preserved and no complication occurred.

Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study.

Foot and ankle surgery in children is very painful postoperatively. Adverse effects from opioids and continuous epidural block (CEB) limit their use in children. Continuous popliteal nerve blocks (CPNB) have not been studied for this indication in children. In this prospective, randomized study we evaluated the effectiveness and adverse events of CPNB or CEB in children after podiatric surgery. Fifty-two children scheduled for foot surgery were separated into four groups by age and analgesia technique. After general anesthesia, 0.5 to 1 mL/kg of an equal-volume mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via epidural or popliteal catheters. In the postoperative period, 0.1 mL x kg(-1) x h(-1) (group CPNB) or 0.2 mL x kg(-1) x h(-1) (group CEB) of 0.2% ropivacaine was administered for 48 h. Niflumic acid was routinely used. Adverse events were noted in each treatment group. Postoperative pain during motion was evaluated at 1, 6, 12, 18, 24, 36, and 48 h. Requirement for rescue analgesia (first-line propacetamol 30 mg/kg 4 times daily or second-line 0.2 mg/kg IV nalbuphine), and motor blockade were recorded. Parental satisfaction was noted at 48 h. Twenty-seven patients were included in the CEB groups and 25 in CPNB groups. There were 32 children 1 to 6 yr of age (CPNB = 15; CEB = 17) and 20 children 7 to 12 yr of age (CPNB = 10; CEB = 10). The demographic data were comparable among groups. Postoperative analgesia was excellent for the two continuous block techniques and in the two age groups. Motor block intensity was equal between techniques. Adverse events (postoperative nausea or vomiting, urinary retention, and premature discontinuation of local anesthetic infusion in the 1- to 6-yr-old group) were significantly more frequent in the CEB group (P < 0.05). Eighty-six percent of the parents in the CEB groups and 100% in the CPNB groups were satisfied. We conclude that although both CEB and CPNB resulted in excellent postoperative analgesia in this study, CPNB was associated with less urinary retention and nausea and vomiting. Therefore, we recommend CPNB as the ideal form of postoperative analgesia after major podiatric surgery in 1- to 12-yr-old children.

Clonidine added to bupivacaine in neonatal spinal anesthesia: a prospective comparison in 124 preterm and term infants.

BACKGROUND: Spinal anesthesia (SA) remains the 'gold standard' in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects. METHODS: We conducted a prospective observational study of 124 infants undergoing herniorrhaphy under SA with bupivacaine and clonidine. Two cohorts, term (n = 57) and former preterm (n = 67) infants, were evaluated and compared with regard to episodes of apnea, desaturation, and bradycardia within 24 h of SA. RESULTS: In both groups, postoperative desaturation episodes were unchanged after SA, compared with the 12 preoperative hours, despite significantly increased apnea (P < 0.003 and <0.011 respectively). Transient bradycardias occurred in former preterm infants (P < 0.014): they spontaneously resolved in all cases. Mean arterial pressure did not vary during the study. Upper sensory level of SA, sedation on entering the postanesthesia care unit (PACU) and duration of stay in the PACU were similar in both groups. CONCLUSIONS: The clinical significance of short apneas, recovering spontaneously without desaturation, remains debatable. It is concluded that addition of clonidine to neonatal SA results in acceptable side effects. Side effects must be compared with the potential advantages before future recommendations.

Tolerance of laparoscopy and thoracoscopy in neonates.

OBJECTIVES: Video-surgery in neonates is recent. Data on the respiratory, hemodynamic, and thermic effects during the first month of life are still sparse. This study aimed to evaluate the tolerance of video-surgery in neonates and to determine the risk factors of per-operative complications. METHODS: From 1994 to 2004, 49 neonates (mean age: 11 days; weight: 3285 g) underwent 50 video-surgical procedures. Indications for laparoscopy were duodenal atresias, volvulus with malrotation, pyloric stenosis, gastroesophageal reflux, cystic lymphangiomas, ovarian cysts, biliary atresia, and congenital diaphragmatic hernias; indications for thoracoscopy were esophageal atresias and tracheoesophageal fistula. RESULTS: Median operative time was 79 minutes. Mean insufflation pressure was 6.7 mm Hg (range: 3-13). Oxygen saturation decreased, especially with thoracic insufflation or high-pressure pneumoperitoneum. Systolic arterial pressure, which decreased in 20% of the patients, was controlled easily with vascular expansion. Thermic loss (mean postoperative temperature: 35.6 degrees C) was proportional to the duration of insufflation. No surgical incident was noted. Ten anesthetic incidents occurred (20%), 3 of which required temporary or definitive interruption of insufflation (O2 saturation <70%). Risk factors for an incident were low preoperative temperature, high variation of end-tidal pressure of CO2, surgical time >100 minutes, thoracic insufflation, and a high oxygen or vascular expansion requirement at the beginning of insufflation. CONCLUSION: The neonate's high sensitivity to insufflation is an important limiting factor of video-surgery. The described profile of the neonate at risk may help to reduce the frequency of adverse effects of this technique and improve its tolerance.