Addition of droperidol to prophylactic ondansetron and dexamethasone in children at high risk for postoperative vomiting. A randomized, controlled, double-blind study.

BACKGROUND: : The combination of dexamethasone (DEX), ondansetron (OND) and droperidol (DRO) is efficacious in preventing postoperative nausea and vomiting in adults, but has not been well assessed in children. METHODS: : Children undergoing elective surgery under general anaesthesia and considered at high risk for postoperative vomiting (POV) were randomly assigned to receive a combination of DEX, OND and placebo (Group A) or a combination of DEX, OND and DRO (Group B). The primary outcome was the incidence of POV during the first 24 hours after surgery. We hypothesized that the addition of DRO to the standard antiemetic prophylaxis would provide a further 15% reduction in the residual risk for POV. The secondary outcome considered was any adverse event occurring during the study. RESULTS: : One hundred and fifty-three children, aged three to 16 years, were randomized to Group A and 162 to Group B. The overall incidence of POV did not differ significantly between the two groups, with 16 patients in Group A (10.5%) and 18 in Group B (11.1%) presenting with one or more episodes of POV, P =0.86. Fewer patients presented with adverse events in Group A (2%) compared with Group B (8%), P =0.01. Drowsiness and headache were the principal adverse events reported. CONCLUSIONS: : The addition of DRO to a combination of OND and DEX did not decrease POV frequency below that obtained with the two-drug combination in children at high risk of POV, but increased the risk of drowsiness. The combination of DEX and OND should be recommended in children with a high risk of POV. CLINICAL TRIAL REGISTRATION.: NCT01739985.

[Endotracheal intubation with the GlideScope®, the Airtraq®, the McGrath® videolaryngoscope and direct laryngoscopy: a comparative study on an infant manikin]. / Comparaison de 3 vidéo-laryngoscopes à la laryngoscopie directe: une étude expérimentale sur mannequin nourrisson.

OBJECTIVE: The primary purpose of this experimental study was to compare intubation times for direct laryngoscopy with a Miller blade and for 3 VL: GlideScope® videolaryngoscope, Airtraq®, and McGrath®. METHODS: Seventy-seven operators, with various experience of pediatric tracheal intubation (from none to expert), performed 10 attempts of orotracheal intubation with each device on an infant manikin. The main outcome was intubation time and secondary outcome was failure rate. RESULTS: There was a significant decrease in intubation time from the first to the 10th intubation attempt with all devices (P<0.05). This decrease was no more significant following the third attempt with VL and following the fifth attempt with DL. At the time of the 10th attempt, intubation time was significantly shorter with Airtraq® as compared with all the other devices (P<0.05), but the differences were tight. Failure was significantly more frequent with DL. CONCLUSION: In this infant manikin model, the learning curve of the different VL was 3 attempts and the Airtraq® VL appears the airway device enabling the quickest orotracheal intubation. These experimental results need to be confirmed by clinical studies in infants and children.

Is the sitting or the prone position best for surgery for posterior fossa tumours in children?

BACKGROUND: The aim of this study was to compare complications in children operated for posterior fossa tumours in the sitting position with those in the prone position. METHODS: We retrospectively assessed the perioperative course of posterior fossa tumour (PFT) surgery according to the operating position. Sixty children were operated in the sitting position (SP) and 19 in the prone position (PP). Preoperative data were not different between groups. RESULTS: Patients in the PP group received a larger median (95% confidence interval) volume of intraoperative blood transfusion than patients in the SP group [200 (20-325) versus 0 (0-80) ml, P=0.04]. Intraoperative complications, as well as severe perioperative complications were more frequent in the PP group (P=0.01). The median duration of tracheal intubation [20 (18-24) versus 36 (18-72) h, P=0.037], of ICU stay [2 (2-3) versus 4 (2-5) days, P=0.02] and of hospital stay [11 (9-12) versus 14 (10-20) days, P=0.02] was longer in the PP group compared with the SP group. CONCLUSIONS: PFT surgery in the sitting position in children is not associated with an increased number or severity of perioperative complications, while the postoperative course appears better in this position.

Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation.

A postal survey of the use of cuffed or uncuffed tracheal tubes for tracheal intubation in children and infants was performed to investigate the criteria used for deciding the choice of tube and the manner of inflating the cuff in the case of use of a cuffed tracheal tube (CTT). From 200 questionnaires despatched, replies were received from 130 paediatric anaesthesiologists (response rate 65%). In paediatric practice, the CTT was routinely used by 25% of respondents for more than 80% of their patients, while more than 37% of respondents use them in less than 20% of the cases. The three main criteria used for inflating a cuff were: (i) the presence of a leak, (ii) the type of surgery associated with the presence of a leak and (iii) the patient's age associated with the type of surgery and the presence of a leak. These criteria were specified, respectively, by 32%, 24% and 18% of the respondents. The cuff was inflated in response to a leak in 18% of the cases and as a response to a pressure manometer in 15% of the cases. Few paediatric anaesthesiologists use a cuffed tracheal tube routinely for tracheal intubation in children, and fewer actually use a pressure monitoring device, while it is suggested that the cuff pressure should be monitored in case of CTT.

Perioperative blood salvage during surgical correction of craniosynostosis in infants.

Surgical correction of craniosynostosis in infants is a very haemorrhagic procedure. The aim of this study was to determine whether the perioperative use of the continuous autotransfusion system (CATS) would reduce homologous transfusion during repair of craniosynostosis. Two groups of patients were studied according to the availability of the CATS in our hospital. The control group had surgery before the system was introduced and the study group had operations subsequently. Use of CATS was associated with a significant decrease in the median (95% confidence interval) volume of homologous blood transfused [413 (250-540) ml in the control group versus 317 (150-410) ml in the CATS group, P = 0.02] and in the median (95% confidence interval) number of packed red cell units transfused [2 (1-2) in the control group versus 1 (1-2) in the CATS group, P = 0.04] in the perioperative period. Use of CATS is associated with a reduction in homologous transfusion during the surgical correction of craniosynostosis in infants.

Emergency management of deeply comatose children with acute rupture of cerebral arteriovenous malformations.

PURPOSE: To assess the impact of emergency management on mortality and morbidity of acute rupture of cerebral arteriovenous malformations resulting in deep coma in children, and the factors predicting outcome. METHODS: Retrospective chart review of 20 children with a Glasgow Coma Scale < or = 8 with acute hemorrhagic stroke from a cerebral arteriovenous malformation rupture was conducted. Protocol included: early resuscitation with tracheal intubation and ventilation after induction of anesthesia with sufentanil, and benzodiazepine, and mannitol 20% or hypertonic saline 7.5% infusion for life-threatening brain herniation. Radiological exploration was limited to contrast-enhanced CT scan preceding immediate surgical decompression. Postoperatively, children were deeply sedated and intracranial pressure monitoring allowed titration with osmotherapy, vasopressors, hyperventilation or barbiturate coma to control cerebral perfusion pressure. Analysis used stratification of the type of hemorrhage (supra or infra tentorial), location (intraparenchymal and subarachnoid, intraparenchymal and intraventricular or intraventricular alone) and relationship between presentation, evolution with resuscitation, type of cerebral lesion, and outcome. RESULTS: Patients had a severe initial presentation (median Glasgow Coma Scale five), eight had unilateral and eight bilateral third nerve palsy. Compressive hematoma in supratentorial localisation represented 75% of the cases. Global mortality was 40%. Persistence of mydriasis after resuscitation increased mortality to 75%. Massive intraventricular flooding was associated with increased mortality. Good functional outcome was achieved in survivors. CONCLUSION: Acute rupture of an AVM can result in rapidly progressing coma. Emergency management with early resuscitation, minimal radiological exploration before rapid surgical decompression results in a mortality rate of 40%, but a good functional outcome can be expected in the survivors.

Non-invasive aortic blood flow measurement.

Invasive monitoring is rarely used for children undergoing routine anaesthesia, whereas usual non-invasive haemodynamic measurements such as heart rate and blood pressure monitoring are unable to detect cardiovascular changes rapidly and precisely. In contrast, oesophageal aortic blood flow echo-Doppler is an easy, non-invasive and accurate method to monitor cardiac performance properly and continuously. Therefore, it could represent a useful addition to peri-anaesthetic monitoring techniques, particularly in infants and small children.

Predictive factors of outcome in severely traumatized children.

UNLABELLED: To identify risk factors associated with death in traumatized children, we prospectively studied 507 consecutive patients (7+/-4 yr) admitted to a level I pediatric trauma center over a 3-yr period. Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS) were calculated. Age, injury mechanism, injury pattern, and initial critical care were recorded. Univariate and multivariate analyses were performed for potential risk factors associated with mortality. Receiver operating characteristic curves were used to determine threshold values of variables identified by univariate analysis. Most children suffered from blunt trauma (99.6%), and head trauma was noted in 85%. Median values (range) of GCS scores, PTS, and ISS were 10 (3-15), 7 (-4 to 12), and 16 (3-75), respectively. The mortality rate was 12%. Using multivariate analysis, death was significantly associated with an ISS > or = 25 (odds ratio [OR] 22.2, 95% confidence interval 2.8-174.9), GCS score < or = 7 (OR 4.77, 1.8-12.7), emergency blood transfusion > or = 20 mL/kg (OR 4.3, 2.1-9.1), and PTS < or = 4 (OR 3.7, 1.4-9.7). An ISS > or = 25, GCS score < or = 7, immediate blood transfusion > or = 20 mL/kg, and PTS < or = 4 were significant and independent risk factors of death in an homogenous population of severely injured children. The probability of traumatic death was therefore 0 (95% confidence interval 0-0.0135) in children with no one of these threshold values in the four predictive factors and 0.63 (95% confidence interval 0.47-0.76) in those children with all the threshold values. IMPLICATIONS: Methods used for evaluating outcome of trauma patients have essentially been derived from adult series, and attempts to apply them to children have usually been inaccurate. Univariate and multivariate analyses were performed to identify risk factors associated with death in severely traumatized children, and Receiver operating characteristic curves were used to determine threshold values.

Non-invasive aortic blood flow measurement in infants during repair of craniosynostosis.

We have assessed the potential clinical benefit of a new echo-Doppler device (Dynemo 3000) which provides a continuous measure of aortic blood flow (ABF) using an aortic flowmeter and a paediatric oesophageal probe, during repair of craniosynostosis in infants under general anaesthesia. The data recorded included: ABFi (i = indexed to body surface area), stroke volume (SVi), systemic vascular resistance (TSVRi), pre-ejection period (PEP), left ventricular ejection time (LVET), mean arterial pressure (MAP), heart rate (HR) and central venous pressure (CVP). Data were collected: before (T1) and 3 min after skin incision (T2), at the time of maximal haemorrhage (T3) and at the end of the procedure (T4). Twelve infants (aged 7.0 (range 6-12) months) were included. ABFi, MAP and CVP were significantly lower at T3 compared with T1 (2.0 (0.8) vs 3.0 (0.8) litre min-1 m-2, 46.1 (5.8) vs 65.2 (8.9) mm Hg and 2.8 (1.6) vs 5.2 (2.1) mm Hg; P < 0.05). PEP/LVET ratio was significantly lower at T2 compared with T1 (0.25 (0.05) vs 0.30 (0.06)) and increased at T4 (0.36 (0.04); P < 0.05). These preliminary results suggest that this non-invasive ABF echo-Doppler device may be useful for continuous haemodynamic monitoring during a surgical procedure associated with haemorrhage in infants.

End-tidal carbon dioxide during out-of-hospital cardiac arrest resuscitation: comparison of active compression-decompression and standard CPR.

STUDY OBJECTIVES: To compare the maximal end-tidal carbon dioxide pressure (ETCO2 peak) values obtained during standard (S-CPR) and active compression-decompression CPR (ACD-CPR) during prolonged resuscitation in out-of-hospital cardiac arrest. DESIGN: Prospective, randomized crossover study. SETTING: City with a population of 3.5 million, served by an emergency medical service system providing advanced cardiac life support. PARTICIPANTS: Patients with nontraumatic out-of-hospital cardiac arrest. INTERVENTIONS: Patients were randomly assigned to receive first, for a period of 3 minutes, either ACD-CPR or S-CPR; then the two methods were alternated. ETCO2 was continuously monitored and computed. MEASUREMENTS AND RESULTS: Sixteen patients (48 +/- 20 years old) were included; in 12, return of spontaneous circulation was achieved, and 5 were admitted alive to the hospital. A statistically significant increase in ETCO2 peak was obtained with ACD-CPR (27.6 +/- 3 mm Hg) compared with S-CPR (15.6 +/- 2.2 mm Hg). No major adverse effect possibly related to ACD-CPR was observed. CONCLUSION: This prospective study suggests that ACD-CPR may improve cardiac output compared with S-CPR.

Transesophageal echocardiographic assessment of left ventricular function during apnea testing for brain death.

The effects of apnea testing-induced respiratory acidosis on left ventricular function (LVF) are still controversial. The aim of the study was to assess LVF during apnea testing using transesophageal echocardiography (TEE). Twenty consecutive patients suspected of brain death, hemodynamically stable, and considered as potential organ donors were prospectively studied. A 20-min apnea test was performed after obtaining a PaCO2 > 35 mmHg and 20 min of FIO2 1 ventilation. LVF was assessed using TEE with a CFM 750 (Diasonic) connected to a 5 MHz probe. Heart rate (HR), mean arterial pressure (MAP), left ventricle end-diastolic and systolic area (LVEDA, LVESA), and LVF assessed by fractional area changes (FAC), systolic wall motion (SWM) scores, and blood gases were recorded at baseline, and after 5, 10, 15, and 20 min of apnea testing. In 19 patients, no spontaneous respiratory movement occurred during the standard 20-min period. In one patient (No. 15), the apnea test had to be stopped after 10 min because of hypoxia. HR, LVEDA, LVESA, and SWM were not significantly modified during the study. There was a progressive statistically significant decrease in MAP during apnea (from 77 +/- 10 to 63 +/- 11 mmHg), associated with a statistically significant increase in FAC at 20 min (from 48 +/- 13 to 56 +/- 8%). PaCO2 progressively rose (from 40 +/- 3 to 95 +/- 11 mmHg), associated with a decrease in pH (from 7.42 +/- 0.06 to 7.09 +/- 0.08). At the same time, PaO2 decreased slightly in all patients, but values remained well above hypoxic levels, except for one patient. Despite severe respiratory acidosis the increase in FAC suggests that apnea testing is well tolerated for brain death assessment.