Alpha-2 adrenoceptor agonists as adjuncts to peripheral nerve blocks in children: a meta-analysis.

BACKGROUND: Adult meta-analyses have verified that adjunct use of alpha-2 adrenoceptor agonists (A2AA) together with local anesthetics (LA) will prolong the duration of peripheral nerve blocks. The standard use of A2AAs for peripheral nerve blockade has recently been recommended also in children, but the evidence base in support of this suggestion has to date been equivocal. The purpose of this meta-analysis was to produce evidence-based data regarding the effect in children. METHODS: Following a thorough literature search, five randomized controlled trials were included in a meta-analysis. Raw data from all studies were gathered and aggregated into patients randomized to receive plain LA (Group PLA) or LA mixed with either adjunct clonidine or dexmedetomidine (Group ADJ). The main outcome parameter was block duration (time to first administration of supplemental analgesic based on predetermined pain scores) analyzed by survival statistics. The total number of supplemental analgesic doses during the first 24 postoperative hours and serious side effects were included as secondary outcomes. RESULTS: Pooling of the study data generated 141 patients in Group PLA and 142 patients in Group ADJ (overall n = 283; age: 0.8-13 years; weight 8-47 kg). Block duration was significantly prolonged (9.75 h vs 3.75 h) compared to the use of plain LA. Survival statistics verified a beneficial effect of using adjunct A2AAs [the log rank (Mantel-Cox) test (P = 0.0078), Gehan-Breslow-Wilcoxon test (P = 0.0027), and hazard ratio (1.653; 95% CI: 1.142 to 2.395)]. The number of patients that needed ≥ 2 doses of supplemental analgesics was higher in Group PLA (n = 19) compared to Group ADJ (n = 6) (P = 0.0088). No serious side effects were reported. CONCLUSION: This meta-analysis provides evidence-based support for the use of adjunct alpha-2 adrenoceptor agonists when performing peripheral nerve blocks in children.

Epidemiological and bacteriological profiles in children with burns.

OBJECTIVES: The aim of our study is to determine the most prevalent bacteria responsible for nosocomial infection (NI) in burned children. MATERIALS AND METHODS: A prospective analytic study was conducted over a period of 30 months at the Children's Hospital of Tunisia. All burned children were enrolled. RESULTS: A total of 185 children were hospitalised during the study period. The mean age was 30 months (interquartile range, IR:18; 48). The gender ratio of the study population was 1.3 (104 males and 81 females). The mean total body surface area burned (TBSA) was 10% (IR:6; 16). The incidence rate of NI was 39.1 NIs per 1000 patient-days and two-thirds of the infections were polymicrobial. The most common isolated micro-organisms were methicillin-susceptible Staphylococcus aureus (MSSA, 57.7%), wild-type Pseudomonas aeruginosa (35.9%) and wild-type Enterobacter cloacae (26.9%). The case fatality rate was 5.9% corresponding to a crude death rate of 1.32 deaths per year. Septic shock with multiple organ failure was the leading cause of death. CONCLUSION: The most common micro-organisms responsible for NI in our series were of the wild-type phenotype. Thus, on suspicion of sepsis, empiric antibiotic treatment combining piperacillin, oxacillin and gentamicin can be proposed until identification of the causative microorganism is available.

Gastric perforation in the newborn.

BACKGROUND: Gastric perforation in neonates is an uncommon condition. It could be spontaneous but a contributing cause should be sought. AIM: To review our experience of treating 8 neonates with gastric perforation over the past 20 years. METHODS: We reviewed the records of all newborns admitted to our hospital between 1990 and 2010 with regard to gender, age at admission, contributing factors, associated anomalies, site of perforation, type of operation, and outcome. RESULTS: Of the eight neonates, five were female and three male. The average weight was 2130 g. Four babies were premature. Three infants were ventilated for respiratory difficulty. Five patients had associated anomalies. Perforation occurred in the lesser curvature in 4, at the greater curvature in 3, and at the anterior antrum surface in 1. All patients were treated with gastrorrhaphy. Four neonates required additional gastrostomy. Mortality was 75% (6 infants). CONCLUSION: Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation.

Ropivacaine 0.2% versus Bupivacaine 0.25% in para-umbilical block in children.

BACKGROUND: Para-umbilical block was an old block that regains a new interest. No study was available using Ropivacaine in this block. AIM: To compare quality of analgesia after using Ropivacaine 0.2% to Bupivacaine 0.25% in para-umbilical blocks. METHODS: In a prospective randomized double blind study we included one to six years old children, scheduled for umbilical herniorrhaphy. The children were randomized in two groups to receive in para-umbilical block by side: Ropivacaine 0.2%: 0.2 ml.kg-1 (group GR) or Bupivacaine 0.25%: 0.2 ml.kg-1 (group GB). RESULTS: The data of 75 children (GR= 38; GB= 37) were analyzed. The groups were comparable regarding the demographics' characters. The scores of Children's Hospital of Eastern Ontario Pain Scale in different postoperative times were comparable between the two groups. No difference was noted in the time of the first analgesic request. The two groups were comparable regarding the peroperative analgesia. No complication was recorded in this study. CONCLUSION: Ropivacaine 0.2% is equivalent to the Bupivacaine 0.25% concerning postoperative and peroperative analgesia in the para-umbilical block for umbilical herniorrhaphy.

[Epidemiology of pediatric traumatic brain injury at the Children's Hospital of Tunisia, 2007]. / Épidémiologie du Traumatisme Crânien à l'Hôpital d'Enfants de Tunis au cours de l'année 2007.

BACKGROUND: The traumatic brain injury is a major cause of morbidity and mortality in the paediatric population. Adequate knowledge of their epidemiology is necessary to develop targeted preventive campaigns, and to estimate the needs for care facilities. AIM: To specify the demographic and epidemiologic characteristics of paediatric traumatic brain injury. METHODS: Longitudinal retrospective study including children hospitalized for traumatic brain injury in the Hospital of Child of Tunis during the 1-year period (2007). RESULTS: Our study comprised 298 children with an average age of 5.9 ± 3.9 years and a sex-ratio with 2. Minor traumatic brain injury represented 92.6 % of the cases and severe traumatic brain injury represented 5.4 %. One child of 6 had another traumatism. Accidents at home were the most frequent causes (64.1 %). Traffic accidents represented 27.9 % of the mechanisms. In 90.6 % of the cases the transport was assured by clean means. The cerebral scanner, produced at 89.9 % of the patients, revealed cerebral lesions in 49.7% of the cases. Neurosurgical indications were carried in 5 children. The death rate was 2.1 %. At three months of the exit of the hospital, 97.2 % of the children had a good recovery. CONCLUSION: The paediatric traumatic brain injury is a frequent and serious pathology. The epidemiologic studies can contribute to the development of prevention program in order to decrease its incidence in the target population.

Time to extubation in infants undergoing pyloromyotomy -- isoflurane inhalation vs remifentanil infusion.

BACKGROUND: Infantile hypertrophic pyloric stenosis (IHPS) associated with metabolic alkalosis, could induce late anesthesia recovery, especially when opioids are used. The aim of this study was to compare the time of extubation and the quality of perioperative analgesia in infants scheduled for pyloromyotomy, receiving either isoflurane inhalation or remifentanil infusion. METHODS: Thirty full-term infants scheduled for pyloromyotomy were prospectively studied. A standardized anesthetic induction was performed. For maintenance of anesthesia, infants were randomly allocated to receive either isoflurane 0.75% of inspired concentration (GI n = 15), or remifentanil as a continuous infusion of 0.4 microg x kg(-1) x mn(-1) (GR n = 15). At the beginning of skin closure, the anesthetic was discontinued and 15 mg x kg(-1) of paracetamol administered. Non parametric tests were used in statistical analysis. RESULTS: The time to extubation was similar in both groups. The intraoperative heart rate was significantly lower in the GR group. CONCLUSION: Remifentanil provided better intraoperative analgesia than isoflurane in infants undergoing pyloromyotomy without increasing time to extubation.

The analgesic effects of ropivacaine in ilioinguinal-iliohypogastric nerve block in children--concentration or volume?

OBJECTIVES: The aim of the present study was to compare the analgesic effects of ripovacaine when used as high concentration/small volume, versus its use as high volume/low concentration, in ilioinguinal-iliohypogastric nerve block in children. METHODS: This is a prospective single-blind randomized study consisting of 72 children ASA I & II, 3-9 years of age, scheduled for outpatient elective surgery. Children were randomly assigned into two equal groups (36 each), to receive ropivacaine 0.8 mg.kg(-1), for ilioinguinal-iliohypogastsric block, either as: 1 mg.ml(-1) (0.8 ml.kg(-1)) G1 group, or 2 mg.ml(-1) (0.4 ml.kg(-1)) G2 group. The postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), at the end of surgery (H0), at one (H1), tow (H2), four (H4) and six (H6) postoperative hours. Parents were requested to record their child's pain every 6 hours during the first 24 postoperative hours, using the postoperative pain measurement for Parent Scale. RESULTS: CHEOPS score H0 was significantly lower in G2 as compared to G1 group (p = 0.03). Only 2 children in G2 as compared to 8 children in G1 group, required i.v. paracetamol administration after surgery (p = 0.04). In group G1, two children required paracetamol at home and three developed a postoperative transitory femoral nerve block (p = 0.23). CONCLUSIONS: Ropivacaine when used with high concentration/small volume is more efficient than when used a high volume/low concentration, for ilioinguinal-iliohypogastric nerve block in children.