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Resume Comment accueillir et accompagner au mieux les naissances de nouveau-nes prematurissimes, c’est-a-dire nes avant 25 semaines d’amenorrhee ? Enfant mort-ne, ne vivant mais decedant tres rapidement, enfant viable ou non ? Quelle prise en charge clinique et ethique serait optimale ? Il n’existe pas de consensus ni de protocole national sur ce sujet. Force est de constater que ces prises en charge sont equipes medicales dependantes (sensibilite, disponibilite). Les sages-femmes, parfois seules face a ces situations, sont alors placees dans une position delicate, sans droit de prescription pour ces enfants. Afin de repondre a ces nombreuses questions, l’Equipe Ressource Regionale de Soins Palliatifs Pediatriques (ERRSPP) a alors mis en place un groupe pluriprofessionnel en 2017 qui s’est reuni une dizaine de fois. Au cours de ces reunions, ont ete evoques differents aspects : medicaux, juridiques et ethiques. Ces echanges auront suscite des questionnements, notamment face aux limites juridiques et au questionnement ethique, permettant ainsi de faire evoluer et converger les positions de chacun. Au final, de nouveaux outils (procedures ecrites detaillees et logigrammes d’actions) ont vu le jour pour chacun des deux groupes d’enfants prematures que nous avons dissocies, c’est-a-dire les enfants nes strictement avant 24 semaines d’amenorrhee (SA) d’une part et les enfants nes entre 24 SA et 24 SA + 6 j d’autre part. Ils sont le reflet d’un souhait d’amelioration, d’harmonisation des pratiques et de soutien aux soignants, chaque situation restant bien evidemment singuliere. Ces procedures, toujours a parfaire, ont ouvert la voie a de nouvelles reflexions sur l’accompagnement.

Resume Les soignants en unite COVID ont tous rencontre des difficultes. Leurs paroles doivent etre entendues et analysees pour mieux comprendre leurs ressentis en ces periodes de drame sanitaire. Notre equipe est allee a la rencontre des unites COVID d’un CHU pendant deux mois en mars et avril 2020. Nous proposons ici le resultat d’un questionnaire donne aux membres de ces equipes et les preconisations qu’ils nous ont confiees afin de mieux vivre les semaines suivantes.

This study was designed to assess the ability of the stroke volume respiratory variation (ΔrespSV) determined by oesophageal Doppler monitoring (ODM) to predict the response to volume expansion (VE) during pneumoperitoneum. The predictive value of ΔrespSV was evaluated according to the concept of the 'grey zone'.Patients operated on laparoscopy and monitored by ODM were prospectively included. The exclusion criteria were frequent ectopic beats or preoperative arrhythmia, right ventricular failure, and spontaneous breathing. Haemodynamic parameters and oesophageal Doppler indices [stroke volume (SV), peak velocity (PV), cardiac output (CO), corrected flow time (FTc), respiratory variation of PV (ΔrespPV) and SV (ΔrespSV)] were collected before and after VE. Responders were defined as a ≥15% increase in SV after VE.Thirty-eight (64%) of the 59 patients were responders. A cut-off of14% ΔrespSV predicted fluid responsiveness with an area under the ROC curve (AUC) of 0.92 [95% confidence interval (CI): 0.82-0.98, P0.0001]. The grey zone of ΔrespSV ranged between 13 and 15%. With an AUC of 0.71 (95% CI: 0.56-0.83, P=0.005), ΔrespPV fairly accurately predicted fluid responsiveness. FTc was unable to accurately predict fluid responsiveness.ΔrespSV and ΔrespPV predicted fluid responsiveness during laparoscopy under strict physiological conditions. FTc was not predictive of fluid responsiveness during laparoscopy.

Operant conditioning of the electroencephalographic rhythm (EEG biofeedback) is argued to be an effective method for treating children with ADHD. This study was designed to evaluate whether this method, compared to methylphenidate, achieves an equally effective outcome. Participants were 39 children aged between 7 - 12 years. Thirteen children with attention-deficit/hyperactivity disorder (ADHD) were trained to enhance the amplitude of the beta1 activity (15 - 18 Hz) and decrease the amplitude of the theta activity (4 - 8 Hz), and 13 of which were treated with methylphenidate alone. Thirteen healthy children did not receive intervention. Several behavioral, neuropsychological and experimental tests were administered before and after intervention. While behavioral measures were improved by both types of method, methylphenidate was significantly more effective than EEG biofeedback. Response inhibition was improved only by EEG biofeedback. Both EEG biofeedback and methylphenidate were associated with improvements on the variability and accuracy measures of computerized tests. Intellectual ability increased also by both methods. Although averaged effect size for methylphenidate seems to be greater than for EEG biofeedback, the difference was not significant. In conjunction with other studies, these findings demonstrate that EEG biofeedback can significantly improve several behavioral and cognitive functions in children with ADHD, and it might be an alternative treatment for non-responders or incomplete responders to medication as well as for those their parents favor a non-pharmacological treatment.

This study was designed to assess the association between volume of fluid challenge (FC) and predictability of respiratory variation of stroke volume (ΔrespSV) in the operating theater. Patients undergoing intermediate/high-risk surgery and monitored by esophageal Doppler monitoring (EDM) were prospectively included. All patients were under general anesthesia and mechanically ventilated. Exclusion criteria were frequent ectopic beats or preoperative arrhythmia, right ventricular failure, and spontaneous breathing. Hemodynamic parameters and esophageal Doppler indices (SV, cardiac output, ΔrespSV) were collected before, after infusion of 250 mL, and after infusion of 500 mL of crystalloid solution. Responders were defined by a >15% increase of stroke volume after FC at each step. After infusion of a 250 mL FC, 41 patients (32%) were classified as fluid responders (R250). After infusion of a 500 mL FC, 80 patients (63%) were classified as fluid responders (R500). The predictability of ΔrespSV was fair with an area under the curve (AUC) of 0.79 (95% CI 0.71–0.86, P 15% increase of SV in response to a 500-mL FC.

Background The objective of this study was to determine whether assessment of stroke volume (SV) and measurement of exhaled end-tidal carbon dioxide E ′ CO 2 during an end-expiratory occlusion (EEO) test can predict fluid responsiveness in the operating theatre. Methods Forty-two subjects monitored by oesophageal Doppler who required i.v. fluids during surgery were studied. Haemodynamic variables [heart rate, non-invasive arterial pressure, SV, cardiac output (CO), respiratory variation of SV (ΔrespSV), variation of SV during EEO, and E ′ CO 2 ] were measured at baseline, during EEO (Δ EEO ), and after fluid expansion. Responders were defined by an increase in SV over 15% after infusion of 500 ml of crystalloid solution. Results Of the 42 subjects, 28 (67%) responded to fluid infusion. A cut-off of >2.3% ΔSV EEO predicted fluid responsiveness with an area under the receiver-operating characteristic (AUC) curve of 0.78 [95% confidence interval (95% CI): 0.63–0.89, P =0.003]. The AUC of ΔrespSV was 0.89 (95% CI: 0.76–0.97, P P =0.07), Δ E ′ CO 2EEO was poorly predictive of fluid responsiveness. Conclusions ΔSV EEO and Δ E ′ CO 2 were unable to accurately predict fluid responsiveness during surgery.

During abdominal surgery, the use of protective ventilation with a low tidal volume, positive expiratory pressure (PEEP) and recruitment maneuvers (RMs) may limit the applicability of dynamic preload indices. The objective of the present study was to establish whether or not the variation in stroke volume (SV) during an RM could predict fluid responsiveness. We prospectively included patients receiving protective ventilation (tidal volume: 6 mL kg−1, PEEP: 5–7 cmH2O; RMs). Hemodynamic variables, such as heart rate, arterial pressure, SV, cardiac output (CO), respiratory variation in SV (ΔrespSV) and pulse pressure (ΔrespPP), and the variation in SV (ΔrecSV) as well as pulse pressure (ΔrecPP) during an RM were measured at baseline, at the end of the RM, and after fluid expansion. Responders were defined as patients with an SV increase of at least 15% after infusion of 500 mL of crystalloid solution. Thirty-seven (62%) of the 60 included patients were responders. Responders and nonresponders differed significantly in terms of the median ΔrecSV (26% [19–37] vs 10% [4–12], respectively; P

The objective of this study was to test whether non-invasive assessment of respiratory stroke volume variation (ΔrespSV) by oesophageal Doppler monitoring (ODM) can predict fluid responsiveness during surgery in a mixed population. The predictive value of ΔrespSV was evaluated using a grey zone approach.Ninety patients monitored using ODM who required i.v. fluids to expand their circulating volume during surgery under general anaesthesia were studied. Patients with a preoperative arrhythmia, right ventricular failure, frequent ectopic beats, or breathing spontaneously were excluded. Haemodynamic variables and oesophageal Doppler indices [peak velocity (PV), stroke volume (SV), corrected flow time (FTc), cardiac output (CO), ΔrespSV, and respiratory variation of PV (ΔrespPV)] were measured before and after fluid expansion. Responders were defined by a15% increase in SV after infusion of 500 ml crystalloid solution.SV was increased by ≥15% after 500 ml crystalloid infusion in 53 (59%) of the 90 patients. ΔrespSV predicted fluid responsiveness with an area under the receiver-operating characteristic (AUC) curve of 0.91 [95% confidence interval (95% CI): 0.85-0.97, P0.0001]. The optimal ΔrespSV cut-off was 14.4% (95% CI: 14.3-14.5%). The grey zone approach identified 12 patients (14%) with a range of ΔrespSV values between 14% and 15%. FTc was not predictive of fluid responsiveness (AUC 0.49, 95% CI: 0.37-0.62, P=0.84).ΔrespSV predicted fluid responsiveness accurately during surgery over a ΔrespSV range between 14% and 15%. In contrast, FTc did not predict fluid responsiveness.

Sighs are important components of normal breathing. They occur isolated or associated with respiratory pauses. Functional residual capacity and lung compliance increase after sighs. Sighs have been shown to be part of an arousal reaction in infants and to induce heart rate modifications. We investigated the influence of sighs on the autonomic balance in infants. METHODS: 107 sighs (a single breath of at least twice the amplitude of the preceding breaths, not followed by an apnea) from 23 term infants were selected. The selection was made in conditions known not to interfere with spontaneous HR variability (quiet sleep,absence of movements, apnea or false detections of QRS during the 2 preceding and following minutes. Spectral analysis of RR variability was performed on the 2 minutes preceding and the 2 minutes following the sigh. To study the role of the ANS in the development of a sigh, spectral analysis of the period just before the sigh and of the 2 preceding minutes were compared. RESULTS: The 2 minutes following the sigh were characterized by an increased RR interval (p 0.001), an increased total power (p