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There has been an exponential increase in the frequency of immune deviations in young children. Consequently, research investigating environmental causes for this increase has become a Public Health priority. We have summarized the experimental observations and epidemiological data that could link repeated acetaminophen and ibuprofen exposure in early infancy to this increase. Recent observations on the maturational immunity of the intestinal sub-mucosal lamina propria underscore indeed the importance of prostaglandins (PGE2s). PGE2 appearing at this sub-mucosal level is a product of arachidonic acid metabolism mediated by type-2 cyclooxygenase (COX-2) situated on the membrane of many immune cells. Moreover, it seems that acetaminophen - like ibuprofen - also carries a non-selective inhibitory action on peripheral COXs, besides its central action. This inhibitory action of acetaminophen on COX2 only relates to physiological, low arachidonic acid concentrations. This explains the difference in anti-inflammatory effects. The impact of repeated inhibition of mucosal PGE2 synthesis due to COX-inhibitor exposure on maturational immunity has been demonstrated in animal experiments. Repeatedly exposed young animals do not develop tolerance to food antigens and exhibit autoimmune deviations. Several recent epidemiological studies have also reported on the magnitude of acetaminophen and ibuprofen exposure in children and the increase in immune deviations, it is important to better understand the potential negative impact of repeated inhibitions of prostaglandin synthesis by COX2s during infancy. Since acetaminophen and ibuprofen are commonly administered analgesics and antipyretics, a well-designed prospective strategy for pharmacovigilance and -epidemiology of COX-inhibitor exposure in infancy is urgently needed. [ABSTRACT FROM AUTHOR]

Abstract: The real place of tramadol in the armatarium of postoperative analgesics in children remains to be defined. This paper presents a synthetic review of the present knowledge regarding the efficacy, dosage and possible routes of administration of tramadol to children in the postoperative period. The intravenous and oral routes are the most used. The perinervous routes (epidural, around peripheral nerves, skin infiltration) are controversial. Tramadol is a good alternative to NSAIDs and to morphine for moderate pain but its efficacy is variable due to the genetic polymorphism of its metabolism and possible drug interactions. [Copyright &y& Elsevier]

Background: Central venous cannulation in infants remains challenging even for experienced paediatric anaesthesiologists. Ultrasound (US)-guidance techniques are proven to be safer for internal jugular vein catheterization. But the subclavian vein (SCV) is often the preferred site for long-term central venous catheterization in children. We describe a novel US-guided approach for SCV cannulation in infants and children.Methods: The principle of this technique is to place the US probe at the supraclavicular level to obtain a longitudinal view of the SCV, and to gain access to the vein via the usual infraclavicular route to cannulate it under ultrasonic control. Details and pitfalls of this technique are described. The prospectively collected results of our first 25 punctures are reported.Results: Patients' weight and age range were 2.2-27 kg and 1 day to 9 yr, respectively: 76% of the children weighed less than 10 kg. The success rate at the first attempt was 84% and 100% after two attempts. An asymptomatic thrombus in the SCV could also be detected with this technique.Conclusions: This US-guided approach of the SCV offers a new possibility for central venous catheterization in children. This technique seems promising for children less than 10 kg and probably also for older children. It provides good quality needle guidance and allows to check the vessel patency before puncture. [ABSTRACT FROM AUTHOR]

We report a case of respiratory distress in the post anesthesia care unit following general anaesthesia for a dilatation and curettage related to miscarriage in a 32-year-old woman. The preoperative physical examination showed no abnormalities except for the presence of dry cough during the preceding two or three days. A few minutes after her arrival in the PACU, the patient developed hyperthermia till 40.6 °C, cough, polypnea and oxygen desaturation (SpO2: 82% on FiO2: 40%). A thoraco-abdominal angioscanner showed pulmonary basal condensations and a thrombosis of the right ovarian vein. The patient had to be transferred to the intensive care unit where she remained intubated and ventilated during 13 days because of a Haemophilus influenzae pneumonia. [Copyright &y& Elsevier]

Abstract: The anaesthetic management of a child with a known metabolic disease is always a challenge. It should be a multidisciplinary process based upon the experience of all medical specialists involved and on a thorough review of the information available in the literature and in specialized up to date websites. The authors propose a list of questions to be addressed when dealing with such a case and provide two clinical examples. [ABSTRACT FROM AUTHOR]

Background: Critical respiratory events are common in children in the peri-anaesthetic period and are caused by airway and ventilation management difficulties. We aimed to analyse current European paediatric airway management practices and identify the incidence and potential consequences of difficult airway management.Methods: We performed a secondary analysis of airway and ventilation management details of the European multicentre observational trial (Anaesthesia PRactice in Children Observational Trial, APRICOT) of children from birth to 15 yr of age. The primary endpoint was the incidence of difficult airway management. Secondary endpoints were the associations between difficult airway management, known pre-existing respiratory risk factors, and the occurrence of critical respiratory events.Results: Details for 31 024 anaesthetic procedures were available for analysis. Three or more tracheal intubation attempts were necessary in 120 children (0.9%) and in 40 children (0.4%) for supraglottic airways insertions. The incidence (95% confidence interval) for failed tracheal intubation and failed supraglottic airway insertions was 8/10 000 (0.08%; 0.03-0.13%) and 8.2/10 000 (0.08%; 0.03-0.14%) children, respectively. Difficulties in securing the airway increased the risk for a critical respiratory event for tracheal tube (2.1; 1.3-3.4) and supraglottic airway (4.3; 1.9-9.9) placement. History of pre-existing respiratory risk factors was significantly associated with critical respiratory events independently of the airway device used.Conclusions: Airway management practices vary widely across Europe. Multiple airway device insertion attempts and pre-existing respiratory risk factors increase the likelihood of critical respiratory events in children and require further stratification during preoperative assessment and planning. This study highlights areas where education, research, and training may improve perioperative care.Clinical Trial Registration: NCT01878760. [ABSTRACT FROM AUTHOR]

Résumé: Il faut distinguer le retard de réveil et l’apparition de troubles neurologiques ou du comportement après une anesthésie, la phase d’agitation transitoire, ou délire du réveil, habituelle après une anesthésie à base d’agents halogénés, étant exclue. En dehors des fausses causes de retard de réveil que sont la curarisation résiduelle et la rachianesthésie totale, le retard de réveil est en général dû à un surdosage absolu ou relatif en agents anesthésiques. Pour ce qui concerne les troubles neurologiques et les troubles du comportement postopératoires, il est utile de distinguer les situations à risque, les patients à risque, l’iatrogénicité et les incidents imprévisibles tels que la maladie métabolique ou la tumeur cérébrale inconnue ou la réponse idiosyncrasique à un médicament. [ABSTRACT FROM AUTHOR]

Abstract: This paper critically reviews the new devices that can be used on the operating room to monitor the oxygenation and the haemodynamics of the child undergoing general anaesthesia. [Copyright &y& Elsevier]

Résumé: La douleur chronique est sous-estimée chez l’enfant car elle est mal connue et sa sémiologie est particulière. Outre la souffrance engendrée, la douleur chronique constitue un coût physique, psychologique, émotionnel, social et financier pour l’enfant et ses proches. Le praticien peut se trouver dans une situation d’échec avec épuisement des ressources médicales. Certains types de douleurs sont réfractaires aux traitements analgésiques systémiques et peuvent nécessiter le recours à l’anesthésie locorégionale. Les douleurs cancéreuses sont fréquentes chez l’enfant et leur prise en charge est parfois défaillante. Ce type de douleurs est accessible aux techniques d’anesthésie locorégionale centrales ou périphériques dans la mesure où leur localisation est couverte par un de ces blocs et où il n’y a pas de contre-indication à la réalisation du bloc. Le syndrome douloureux régional complexe de type 1 est une pathologie fréquente mais méconnue chez l’enfant et l’adolescent. L’anesthésie locorégionale peut contribuer au traitement de ce type de syndrome, principalement dans ses formes rebelles, permettant d’obtenir rapidement une analgésie et de mettre en place une physiothérapie intensive. Ces techniques ont également montré leur intérêt dans la douleur de membre fantôme après amputation, mais restent controversées pour les douleurs d’érythromélalgie ou les douleurs abdominopelviennes chroniques. Enfin, les céphalées dues à une brèche de l’arachnoïde peuvent être traitées par une injection péridurale du sang du patient, appelée blood-patch. Enfin, il faut noter l’importance de la multidisciplinarité (pédiatre, kinésithérapeute, psychologue, chirurgien, anesthésiste-réanimateur) afin de prendre en charge l’enfant et sa problématique dans leur globalité. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In order to reduce the risk of postoperative apnoea, awake spinal anaesthesia or awake caudal anaesthesia are recommended for hernia surgery in newborn babies and former premature infants aged less than 60 weeks of amenorrhoea. However, additional sedation is sometimes necessary. Our working hypothesis was that a general anaesthesia with a face mask (sevoflurane) with no opiates nor neuromuscular blocking agents, maintaining the infant''s spontaneous breathing and combined with a caudal anaesthesia, could provide a safe and effective alternative. Study design: The epidemiological and technical data about the patient and the anaesthesia, as well as any per- and postoperative complications, were collected prospectively and analysed retrospectively. Patients and methods: Ninety-eight infants undergoing hernia surgery were included during the period from 2003 to 2008. Results: Caudal anaesthesia proved successful at first attempt in 69% of the infants (term or premature). Three attempts were needed in 8% of the infants born at term and 2% of the infants born prematurely. One failure was recorded. Seven patients presented one episode of peroperative apnoea; they were easily taken care of by means of brief face mask ventilation. The follow-up of these seven infants did not reveal any reappearance of postoperative apnoea/bradypnoea. Conclusion: The technique proposed is an effective alternative to the awake locoregional anaesthesia techniques: it provides excellent conditions for surgery and presents similar perioperative morbidity and risk of postoperative apnoea. [Copyright &y& Elsevier]

Abstract: A 3-year-old boy of North African decent was seen in the anaesthetic preoperative clinic prior to a scheduled adenoidectomy. His history revealed that his older brother suffered from an unknown form of muscular dystrophy. On clinical exam, no signs of muscular dystrophy were present. However in light of the patient''s family history a blood sample for CPK was taken. This was found to be elevated and a neurological consultation was obtained. The patient was diagnosed with a deltasarcoglycanopathy, a rare form of limb girdle muscular dystrophy. A non triggering anaesthetic technique was used, avoiding halogenated anaesthetics and succinylcholine. The preoperative evaluation for a child with a suspected myopathy and the implications for its anaesthetic management are reviewed in this article. [Copyright &y& Elsevier]