Search

Background During inhalational induction of anaesthesia for children, severe respiratory events can occur but can be rapidly treated once intravenous access is in place. Reducing the time to successful cannulation during inhalational induction for children with poor vein visibility would improve safety. Objective To study the effectiveness of a near-infrared (NIR) vascular imaging device (Veinviewer) to facilitate intravenous cannulation. Design A prospective, multicentre, randomised, open clinical trial. Setting The operating rooms of three paediatric hospitals in Paris, France, from 1 October 2012 to 31 March 2016. Patients Children up to the age of 7 years, with poor vein visibility requiring general anaesthesia. Intervention Inhalational anaesthesia was initiated and intravenous cannulation was performed with the standard approach or with the Veinviewer Vision. Main outcome measures The primary outcome was the time to successful intravenous cannulation. A secondary outcome was the proportion of successful first attempts. Results The mean time to successful intravenous cannulation was 200 (95% CI, 143 to 295) seconds in the Veinviewer and 252 (95% CI, 194 to 328) seconds for the control group: hazard ratio 1.28 (1.02 to 1.60) (P = 0.03). The adjusted hazard ratio for known predictive factors was 1.25 (0.99 to 1.56) (P = 0.06). Success at the first attempt was 64.6% (102/158) in the 'Veinviewer' group vs. 55.6% (85/153) in the 'control' group (P = 0.10). Conclusion The Veinviewer has limited value in reducing the time to successful intravenous cannulation during inhalational anaesthesia for young children with poor vein visibility. However, there is a strong trend to reducing the delay in some cases and, given its absence of side effects, it could be part of a rescue option for a difficult venous-access strategy. Clinical trial registration NCT01685866 (http://www.clinicaltrials.gov).

International audience; Objectives: To provide an update to the 1999 French guidelines on “Muscle relaxants and reversal in anaesthesia”, a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. Methods: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. Results: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. Conclusion: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

International audience; Background: It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. Methods: In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. Results: Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean +/- SD, 36 +/- 31 vs. 39 +/- 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., -00:19] [95% CI, -0:38 to 0] and mean difference, 9 min [95% CI, -0:18 to -0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. Conclusions: The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach.

Objective We hypothesised that videolaryngoscopy modifies practice of tracheal intubation. Design Randomised single-blinded study (video and no-video groups). Setting Three institutions: one academic, one non-profit and one profit. Participants Patients >18 years, requiring orotracheal intubation, without predicted difficult intubation. Non-inclusion criterion was patients requiring a rapid-sequence intubation. 300 patients were included, 271 randomised, 256 analysed: 123 in the no-video and 133 in the video groups. Intervention Tracheal intubation using a McGrath Mac videolaryngoscope, the sequence being video recorded. Primary and secondary outcome measures The primary outcome was the proportion of intubations where assistance is necessary on request of the operator. Secondary outcomes included intraoperative variables (intubation difficulty scale and its components, percentage of glottic opening score, oesophageal Intubation, duration of intubation, removal of the screen cover in the no-video group, global evaluation of the ease of intubation, bispectral index, heart rate and blood pressure), intraoperative and postoperative complications (hoarseness or sore throat) and cooperation of the anaesthesiology team. Results Requirement for assistance was not decreased in the Video group: 36.1% (95% CI 27.9 to 44.9) vs 45.5% (95% CI 36.5 to 54.7) in the no-video group, p=0.74; OR: 0.7 (95% CI 0.4 to 1.1) and absolute risk: 0.10 (95% CI −0.03 to 0.22). Intubation difficulty scale was similar in both groups (p=0.05). Percentage of glottic opening score was better in the Video group (median of 100 (95% CI (100 to 100) and 80 (95%CI (80 to 90) in the no-video group; p Conclusion In patients without predicted difficult intubation, videolaryngoscopy did not decrease the requirement for assistance to perform intubation. Trial registration number NCT02926144; Results.

Resume A ce jour, plus de 50 % des evenements critiques perioperatoires de l’enfant sont d’origine respiratoire. La bonne gestion des voies aeriennes de l’enfant lors d’une anesthesie generale fait partie des preoccupations majeures des anesthesistes-reanimateurs. Les objectifs de ces recommandations formalisees d’experts etaient d’apporter une modification ou amelioration des pratiques cliniques repondant aux evolutions techniques dans la gestion des voies aeriennes superieures de tout enfant, mais egalement de valider au niveau national des connaissances reconnues dans la litterature ou aupres de societes savantes internationales. Par ailleurs, un point particulier a aborde la gestion des VAS de l’enfant enrhume, potentiel facteur de risque en anesthesie pediatrique. Parmi les recommandations, les experts recommandent l’utilisation preferentielle des dispositifs supraglottiques lors des interventions superficielles de courte duree avec monitorage de la pression du coussinet si possible. L’utilisation de sonde a ballonnet est preferable lors de l’intubation tracheale avec monitorage de la pression du ballonnet. L’intubation doit etre systematique pour une chirurgie d’amygdalectomie chez l’enfant. La place des videolaryngoscopes est precisee lors de l’intubation difficile. L’utilisation des curares est redefinie que ce soit durant l’induction a sequence rapide ou lors d’une anesthesie classique avec intubation orotracheale. Pour l’enfant enrhume, les experts recommandent l’utilisation preferentielle, si possible, du masque facial compare a la sonde d’intubation ou dispositif supraglottique et, pour l’enfant de moins de 6 ans, la nebulisation de salbutamol avant l’anesthesie generale. Le but final de ces recommandations est d’envisager une diminution de la morbi-mortalite respiratoire de l’anesthesie des enfants par une amelioration des pratiques cliniques quotidiennes.

Resume Les voies aeriennes se modifient considerablement avec l’âge. Le nourrisson et le nouveau-ne constituent une population a fort risque d’evenement respiratoire du fait de leurs caracteristiques anatomiques et physiologiques. Chez ces jeunes enfants, l’infection des voies aeriennes superieures, l’inexperience de l’anesthesiste et l’intubation tracheale sont les principales causes d’evenements respiratoires. La prise en compte de ces risques et la connaissance des traitements des evenements respiratoires sont determinants pour diminuer la morbidite respiratoire en anesthesie pediatrique.

BACKGROUND AND OBJECTIVE Serious adverse cardiorespiratory events complicate super selective ophthalmic artery chemotherapy for retinoblastoma in anesthetized children. Their mechanism remains unclear but may be attributed to an autonomic nervous reflex induced by the catheter close to the ophthalmic artery. Inadequate depth of anesthesia during catheter stimulation might be an aggravating factor. Thus, we tested whether deep general anesthesia reduced the incidence of serious cardiorespiratory events. METHODS Children were prospectively included in this observational study. Standardized deep general anesthesia with sevoflurane, rocuronium, and sufentanil was administered. Sevoflurane MAC was kept between 1.5 and 1.7 and additional sufentanil administered. Serious cardiorespiratory event criteria were predefined and included arterial hypotension, bradycardia, and severe decrease in lung compliance. They were recorded and the factors influencing their occurrence were investigated. RESULTS One hundred fifteen procedures were performed on 32 children. The median MAC of sevoflurane was 1.5 and median BIS value was 44. Serious cardiorespiratory events occurred in 20% of procedures and were mainly severe decrease in lung compliance (83% of events). All of them required active treatment. One procedure was aborted due to cardiorespiratory compromise and required an epinephrine infusion. All severe decreases in lung compliance occurred within 2 minutes after catheter insertion in the ophthalmic artery. No recorded demographic and endovascular characteristics were associated with serious cardiorespiratory events. CONCLUSION Serious cardiorespiratory events occur commonly during super selective ophthalmic artery chemotherapy. Standardized deep anesthesia with analgesia did not appear to be protective. No predictive factors were identified, but these events systematically arose within 2 minutes after ophthalmic artery catheter insertion. Anesthetists and neuroradiologists should be prepared to manage these serious complications and parents should be informed of the risks.

Resume La prise en charge anesthesique d’un enfant souffrant d’un trouble envahissant du developpement (ou autisme) implique de prendre contact a l’avance avec les parents ou l’equipe soignante de l’enfant pour savoir de quelle categorie d’autisme il s’agit et pour definir quels troubles de la communication, du comportement et de la sensibilite il presente. Cela permettra de preparer l’enfant a son passage a l’hopital, y compris la consultation d’anesthesie, en utilisant le langage des signes ou des pictogrammes. Le jour de l’intervention (idealement en ambulatoire), tout doit etre fait pour eviter les sources de stress (attente, phobies specifiques, changement d’habits, nombreux intervenants etc.) et assurer la presence d’elements rassurants. Une premedication medicamenteuse est souvent necessaire. Le but est d’obtenir une induction calme sans contention et un reveil paisible.

Muscle relaxation for tracheal intubation during paediatric anaesthesia remains a subject of debate.The aim of the current meta-analysis was to investigate the effect of muscle relaxants (MR) compared with opioids on intubation conditions in children.Meta-analysis of randomised controlled studies.Exhaustive literature analysis.Clinical trials, with no high-risk bias, that examined the effect of MR in comparison with opioids on intubation conditions (excellent: primary outcome, acceptable: secondary outcome) in children were included.Excellent intubation conditions were not significantly different in their occurrence between children receiving MR or opioids, risk ratio [95% Confidence Interval] = 1.17 [0.96, 1.43], I = 36%, number of studies = 5, number of patients = 226. However, trial sequential analysis indicated the lack of power of this result and the need for more trials to provide certainty for this outcome (81 patients needed in future trials). Acceptable intubation conditions were more frequent when administering MR, risk ratio = 1.25 [1.06, 1.47], I = 70%, number of studies = 6, number of patients = 362. This effect was confirmed using the trial sequential analysis. Grading of Recommendations Assessment, Development and Evaluation analysis found a low and moderate quality of evidences for excellent and acceptable intubation conditions, respectively.The current meta-analysis shows that the use of MR during tracheal intubation might improve the quality of intubation conditions. Further studies, including at least 81 children, are required to confirm this and determine the impact of MR on complications related to intubation.

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.

Objective To provide French guidelines about "Airway management during paediatric anaesthesia". Design A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Societe Francaise d’Anesthesie-Reanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthesistes Reanimateurs Pediatriques d’Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. Methods The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. Results The SFAR Guideline panel provides 17 statements on “airway management during paediatric anaesthesia”. After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts’ opinions. No recommendation could be provided for 3 questions. Conclusions Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.

Resume Le surpoids et l’obesite se determinent chez l’enfant en reportant la valeur du BMI sur la courbe de corpulence de reference selon le sexe. La prevalence estimee du surpoids etait de 18 % en 2006 chez les enfants de 3 a 17 ans, la plupart des obesites sont communes ou primaires. L’obesite est associee a une morbidite cardiorespiratoire et metabolique. Les complications respiratoires sont plus frequentes en perioperatoire chez l’enfant obese. Les agents anesthesiques sont administres la plupart du temps sur la base du poids ideal sauf la succinylcholine et la dose d’entretien du propofol qui le sont sur la base du poids total. La meilleure adaptation est basee sur le monitorage de l’anesthesie.

Resume La mise en place d’un abord veineux est une des procedures les plus courantes en medecine. Malgre son apparente simplicite, ce geste technique peut rapidement devenir difficile et sa realisation frustrante et chronophage notamment chez les enfants. Afin de limiter les risques d’echec, il est interessant de depister les enfants a risque d’abord veineux difficile, a l’aide d’un score. Differentes methodes autres que l’experience de l’operateur existent pour tenter de faciliter la pose de la voie veineuse : 1) augmenter la veinodilatation en utilisant un garrot, en surbaissant le membre, en utilisant une source de chaleur locale ou des patchs de derives nitres et en evitant la douleur (patch d’Emla, melange equimolaire d’oxygene et de protoxyde d’azote [meopa]) ; 2) ameliorer la visualisation des veines en utilisant des dispositifs infrarouges ou avec l’echographie. Enfin si l’ensemble de ces methodes echoue, un catheter central ou une aiguille intraosseuse peuvent etre mis en place. Dans tous les cas, definir au prealable une strategie de gestion de l’echec est essentiel afin de ne pas etre pris au depourvu en cas de difficulte.

Bayesian forecasting has been shown to improve the accuracy of pharmacokinetic/pharmacodynamic (PK/PD) models by adding measured values to a population model. It could be done in real time for neuromuscular blockers (NMB) using measured values of effect. This study was designed to assess feasibility and benefit of Bayesian forecasting during a rocuronium target-controlled infusion (TCI). After internal review board (IRB) approval and informed consent, 21 women scheduled for breast plastic surgery were included. Anesthesia was maintained with propofol, alfentanil, and controlled ventilation through a laryngeal mask. Rocuronium was delivered in TCI with Stanpump software and the Plaud population model. The target effect was 50% blockade until insertion of breast prosthesis; thereafter it was set to 0%. Response to train of four (TOF) at adductor pollicis was recorded using a force transducer. In ten patients, drug delivery was based on the population model. In the others, repeated measures values were entered in the software, and the PK model was adjusted to minimize the error in predicted effect. Model precision was compared between groups using mean prediction error and mean absolute prediction error. At target 50%, model accuracy was not improved with Bayesian adjustments; conversely, post-infusion errors were significantly decreased. The first two measures had the most influence on the model changes. Below clinical utility, such adjustments may be used to explore cofactors influencing interindividual and intraindividual variability in NMB dose-response relationship. Similar tools may also be developed for drugs in which a quantitative effect is available, such as electroencephalography (EEG) for hypnotics. Real-time Bayesian forecasting combining measured values of effect with a population model is suitable to guide NMB-agent delivery using Stanpump software.

Resume Le traitement des malformations arterioveineuses (MAV) intracrâniennes associe chirurgie, radiotherapie et traitement endovasculaire. L’embolisation implique une navigation endovasculaire complexe puis l’injection supraselective de materiel d’embolisation au sein du nidus de la MAV. Les modifications de debit provoquees par l’embolisation au sein de la MAV et dans les territoires vasculaires adjacents exposent les patients a des complications. Les risques respectifs d’hypertension intracrânienne, hemorragie cerebrale et ischemie cerebrale sont variables en fonction de l’etendue de l’embolisation et des evenements propres a chaque procedure. Une attention particuliere est indispensable pendant la procedure et doit etre suivie d’une surveillance de plusieurs jours en unite de soins continus pour depister les complications qui peuvent etre tardives. En cas de complication hemorragique, les objectifs de la neuroreanimation sont une pression arterielle et une pression intracrânienne basses pour preserver la pression de perfusion cerebrale tout en limitant le risque de recidive hemorragique directement lie au niveau de la pression arterielle systemique.

Resume La baisse brutale d’acuite visuelle apres chirurgie est un sujet sur lequel l’attention a ete recemment attiree. La comprehension de l’importance de son diagnostic, des facteurs de risque et par la suite de methodes de prevention, ne date que de quelques annees. Les lesions corneennes ont une incidence encore trop elevee bien qu’elles soient faciles a prevenir. Les sequelles fonctionnelles sont importantes lorsqu’elles siegent dans l’axe visuel. Les complications ischemiques par obliteration de l’artere centrale de la retine ou par neuropathie optique ischemique sont principalement liees a une augmentation de la pression intraoculaire, de mecanismes divers, associee ou non a une diminution de la pression arterielle. La recuperation fonctionnelle est quasiment nulle. Enfin, l’atteinte cerebrale corticale, de pronostic pejoratif, s’apparente par son mecanisme et sa prevention aux complications cardiovasculaires. Le pronostic de baisse brutale d’acuite visuelle postoperatoire etant mauvais dans la majorite des cas, la prevention est primordiale. Elle repose sur l’absence de compression orbitaire lors l’installation des patients et le maintien de la pressions de perfusion systemique et du taux d’hemoglobine, notamment chez les patients a risque cardiovasculaire.

Resume Le traitement endovasculaire des anevrismes intracrâniens se fait par deploiement de coils dans le sac anevrismal par la methode du remodeling. De plus en plus souvent cette technique est associee au deploiement de stent dans la lumiere du vaisseau porteur. Cela induit un risque ischemique, thrombose de stent ou embols distaux. Ces complications sont prevenues par une anticoagulation a fortes doses associee a une preparation par aspirine et clopidogrel. Il existe en contrepartie un risque hemorragique qui doit etre anticipe a la consultation d’anesthesie en depistant des hemorragies occultes, digestives en particulier, et preparer une eventuelle transfusion. En cas de rupture d’anevrisme pendant le traitement, le role de l’anesthesiste reanimateur est central dans le diagnostic et la prise en charge. Pour le traitement endovasculaire des anevrismes rompus la regle est la stabilite hemodynamique a tous les temps de l’anesthesie pour eviter un resaignement en cas d’hypertension arterielle et une ischemie cerebrale en cas d’hypotension.

The aim of this study was to confirm that emergency platelet transfusion effectively restores platelet function to patients receiving antiplatelet therapy (APT) with aspirin and/or clopidogrel.This was a prospective observational case report series conducted between January 1, 2009, and January 1, 2012. All responder patients according to the Verify Now device requiring emergency platelet transfusion because of a potentially life-threatening hemorrhage or before emergency neurosurgery were included. Aspirin or P2Y12-specific tests were used as appropriate for patients under aspirin or clopidogrel. Patients who were responders to aspirin had an aspirin reaction unit of less than 550, and patients who were responders to clopidogrel had an inhibition percentage of more than 20%. The Verify Now test was performed again after platelet transfusion. Pretransfusion and posttransfusion test results were compared.During the 36-month period, 25 patients met the inclusion criteria. Of these patients, 4 were receiving dual APT, 8 were receiving clopidogrel only, and 13 were receiving aspirin only. The average platelet transfusion dose was 0.12 UI/kg (range, 0.10-0.14 UI/kg). For patients under clopidogrel, the inhibition percentage lowered significantly after transfusion (median 54 [range, 31-69] before and 25 [range, 18-50] after transfusion; p0.005) but remained above the 20% threshold. Our patients were still responsive to clopidogrel after platelet transfusion. This result is conflicting with the existing literature. The median aspirin reaction unit of aspirin users before and after transfusion were 420 (range, 400-470) and 630 (range, 610-640), respectively (p = 0.001). The efficacy of platelet transfusion to restore aspirin-mediated disaggregation is confirmed by our case series.Platelet transfusion does not restore platelet function in patients under clopidogrel, but it is efficient for patients under aspirin. This sheds new light on previous large-scale studies that have been unable to show any effectiveness of emergency platelet transfusion in patients under APT. Emergency platelet transfusion may only be indicated in aspirin users who are responders and not in all patients under APT as is actually recommended.

Background: Because of the renewed interest in intubation in children without relaxants, over a period of 1 month, the anaesthesiologists of five paediatric universitary teaching hospitals were asked to complete a questionnaire each time they performed a tracheal intubation without muscle relaxant. Methods: Intubating conditions were assessed with five items. Each item was graded on a four-point scale. Intubating conditions were judged acceptable when all items scored 2 or less. Episodes of oxygen desaturation and failed intubations were noted. Data are expressed as mean ± SD (extremes). Results: Five hundred and two questionnaires were completed during the study period. Children were aged 61 ± 50 (1–180) months old. Induction of anaesthesia was performed with sevoflurane for 62.6% of the children (endtidal concentration 5.9 ± 1.5%) and propofol for 28.9% (dose 5.8 ± 4.2 mg·kg–1). Opioids were associated with these hypnotics in 53.2% of the children. Tracheal intubation was successful in 87.1% of the children. Sevoflurane produced better intubating conditions than propofol. Sevoflurane requirements for tracheal intubation may be higher in infants aged less than 6 months old than in older children. A severe decrease in SpO2 (≤ 90%) was observed in 15.9% of the infants aged less than 1 year old and in 1.7% of the children, respectively (P

Transient left ventricular apical ballooning also called Takotsubo cardiomyopathy is a recently described cardiac syndrome. It often affects postmenopausal women having an acute physical or emotional stress, but it have also been described after convulsive status epilepticus. Although this association is rare and left ventricular function often recovers, it would be useful to the neurologist to be aware of the signs leading to this diagnosis, to improve the cardiac later care. Here we report a patient with partial status epilepticus in whom the diagnosis of transient left ventricular apical ballooning was made. We describe the diagnostic criteria and the potential complications that should be monitored.

Acute angle closure glaucoma is a rare complication of general anesthesia. However, in case of delayed diagnosis, it may lead to blindness. We present a case of bilateral acute angle closure glaucoma after cervical spine surgery under general anesthesia in a hypermetropic patient. In this case, the most likely trigger was the use of ephedrine, but nefopam administration and the prone surgical position are discussed as additional potential factors.

Summary Background Few data are available in the literature on risk factors for postoperative vomiting (POV) in children. Objective The aim of the study was to establish independent risk factors for POV and to construct a pediatric specific risk score to predict POV in children. Methods Characteristics of 2392 children operated under general anesthesia were recorded. The dataset was randomly split into an evaluation set (n = 1761), analyzed with a multivariate analysis including logistic regression and backward stepwise procedure, and a validation set (n = 450), used to confirm the accuracy of prediction using the area under the receiver operating characteristic curve (ROCAUC), to optimize sensitivity and specificity. Results The overall incidence of POV was 24.1%. Five independent risk factors were identified: stratified age (>3 and 13 years: adjusted OR 2.46 [95% CI 1.75–3.45]; ≥6 and ≤13 years: aOR 3.09 [95% CI 2.23–4.29]), duration of anesthesia (aOR 1.44 [95% IC 1.06–1.96]), surgery at risk (aOR 2.13 [95% IC 1.49–3.06]), predisposition to POV (aOR 1.81 [95% CI 1.43–2.31]), and multiple opioids doses (aOR 2.76 [95% CI 2.06–3.70], P

Introduction La chimiotherapie in situ par catheterisme de l’artere ophtalmique fait partie des nouveaux traitements du retinoblastome [1] . Cette procedure, realisee sous anesthesie generale (AG), se complique d’evenements cardiorespiratoires severes (ECRS) qui necessitent un traitement en urgence et dont le mecanisme est mal connu [2,3] . Le peu d’etudes sur le sujet est retrospectif. L’objectif de notre etude etait d’analyser ces ECRS et d’en rechercher les facteurs predictifs. Materiel et methodes Etude prospective observationnelle monocentrique realisee sur 15 mois apres accord du comite d’ethique local et information des parents. Etaient inclus les enfants consecutifs ayant une AG pour chimiotherapie in situ par catheterisme de l’artere ophtalmique. La technique d’anesthesie etait standardisee et incluait une analgesie au sufentanil 0,2 μg/kg a l’induction plus un bolus de 0,1 μg/kg lors du catheterisme femoral et un entretien par sevoflurane a 1,5 MAC pour un objectif de BIS 30 % de la valeur post-induction ; la bradycardie a une baisse de la frequence cardiaque > 30 % ; le bronchospasme a une augmentation de la pression de crete > 30 %. Les donnees recueillies incluaient les caracteristiques des enfants, les donnees de l’anesthesie et du catheterisme et les parametres hemodynamiques et respiratoires dont ceux enregistres toutes les minutes de la montee du catheter de l’artere femorale jusqu’a l’artere ophtalmique. Les facteurs de risque d’ECRS etaient recherches en analyse univariee. Les resultats sont exprimes en mediane et interquartiles. Resultats Ont ete enregistrees 104 procedures, realisees chez 29 enfants âges de 20 [13–26] mois et pesant 12 [9–14] kg, avec une mediane de 3 [1–4] procedures par enfant. La duree de catheterisme jusqu’a l’ostium etait de 20 [16–23] min. Des ECRS ont complique 23 procedures (22 %) realisees chez 14 enfants (dont 2 ont eu 3 procedures avec ECRS). Il s’agissait de 3 hypoPA isolees, 3 hypoPA avec bradycardie et 17 bronchospasmes avec desaturation Discussion La chimiotherapie in situ par catheterisme de l’artere ophtalmique est une procedure a haut risque d’ECRS. Ils apparaissent juste apres le catheterisme de l’ostium, sont surtout des bronchospasmes et necessitent un traitement specifique. Ils surviennent de facon non previsible, malgre une anesthesie standardisee, ne permettant pas la mise en place de mesures preventives.

Introduction La crise myasthenique aigue (CMA) se caracterise par une decompensation de la maladie marquee par une atteinte respiratoire et des troubles de deglutition. Il est actuellement recommande d’intuber les patients ayant une capacite vitale (CV) inferieure a 20 mL/kg soit 33 % de la theorique, voire des 50 % [1] en attendant l’efficacite du traitement par immunoglobulines. L’utilisation de la ventilation non invasive (VNI) a ete rapportee pour eviter l’intubation, avec un taux de succes d’environ 50 % dans seulement 2 etudes retrospectives [2] , [3] . Nous rapportons notre experience de la VNI dans cette indication. Materiel et methodes Etude prospective observationnelle acceptee par le comite de protection des personnes de l’hopital (CPP). L’indication de VNI etait l’association d’une hospitalisation en reanimation pour CMA isolee, d’un score d’Osserman Les criteres d’echec de VNI etaient l’inhalation, l’hypoxemie et l’epuisement clinique. Ont ete releves quotidiennement les caracteristiques du patient, le score d’Osserman, la CV, les troubles de deglutition, le recours a l’intubation, les complications respiratoires, la duree de VNI, la duree de sejour en reanimation, et la duree de traitement par immunoglobulines. Les resultats sont exprimes en mediane (extremes). Resultats Huit patients ont ete inclus. L’âge median etait de 53 ans (16–81 ans). A l’arrivee, le score d’Osserman median etait de 50 (23–68) avec une CV de 38 % (22 %–43 %). Aucun patient n’a ete intube. La duree de VNI etait de 4 jours (2–10). La duree de sejour en reanimation etait de 7 jours (4–13). La duree de traitement par immunoglobulines, instituee a J0 des leur arrivee a dure 3–5 jours. Les 5 patients ayant des troubles de deglutition dus a une atteinte bulbaire n’ont pas presente de complication sous VNI ( Fig. 1 ). Discussion Dans notre cohorte observationnelle, la VNI a toujours permis d’eviter l’intubation contrairement aux etudes retrospectives publiees. La mise systematique sous VNI permet de limiter la fatigue musculaire induite par la CMA et evite ainsi l’aggravation respiratoire du patient. La VNI en service de reanimation nous parait une bonne alternative a l’intubation dans les CMA meme en cas de criteres de gravite.

Interpreting a Bispectral Index (BIS) of "0", corresponding to an isolelectric electroencephalography, can be difficult. After ruling out technical issues, such as leads disconnection, several possible causes for a decrease in the BIS persists, including deep anesthesia, hypothermia, decrease in the cerebral perfusion pressure and cerebral ischemia. We report a sudden transient decrease of the BIS to "0" in a patient that underwent a coil embolization of a ruptured intracranial aneurysm and suggest that the change in BIS values could provide useful information about the cerebral hemodynamic during aneurysm treatment and might provide indications of a serious cerebral event.

Introduction Le VeinViewer Vision (Christie Medical, VW) est un dispositif utilisant la lumiere infrarouge permettant de visualiser les veines superficielles ( [1] , [2] , [3] concernant l’apport de dispositifs comparables chez l’enfant ont ete recemment publies dans le cadre de la perfusion d’enfants eveilles. L’objectif de notre etude etait d’evaluer l’apport VeinViewer Vision pour diminuer le temps de pose, et le nombre de tentatives de VVP chez les enfants difficiles a perfuser, lors de l’induction inhalatoire. Materiel et methodes Cette etude prospective multicentrique a ete financee par le ministere de la Sante dans le cadre du PHRC-IR 2012. Apres accord du CPP, information et consentement des parents, les enfants de moins de 7 ans, devant beneficier d’une induction inhalatoire et presentant un DIVA score ≥ 4 ont ete inclus, et randomises en 2 groupes, perfusion aidee par le VW (groupe VW) et perfusion realisee a l’aveugle (groupe T). La pose de VVP etait effectuee par des anesthesistes seniors en anesthesie pediatrique et ayant plus de 10 utilisations du VW a leur actif. Le critere principal de jugement etait la duree de pose de perfusion (pose de garrot - VVP fonctionnelle). Le nombre de tentatives, les echecs (tentatives de perfusion > 30 min ou utilisant plus de 10 cathlons) etaient notes. A partir d’une etude preliminaire, il a ete defini que l’inclusion de 156 patients par bras permettrait de mettre en evidence, de facon statistiquement significative (au risque alpha 5 % pour une puissance de 80 %), une difference de 25 % du delai de perfusion avec le VW, reduction jugee cliniquement pertinente. Les variables quantitatives sont exprimees en mediane. Resultats Parmi les 322 enfants qui ont ete inclus, 158 sont dans le groupe VW et 154 dans le groupe T. Les groupes etaient comparables en termes d’âge (25 vs 22 mois), de poids (12,5 vs 12 kg), de proportion d’enfants a peau sombre (39 % vs 37 %) et de score DIVA (5 vs 5). La duree moyenne de perfusion n’etait pas differente entre les 2 groupes (VW : 6,3 vs T : 6,3 min, p = 0,5). On constatait une absence de difference dans la population a peau sombre aussi (VW : 6,2 vs T : 5,8 min, p = 0,23). Le nombre median de tentatives etait de 1 dans les 2 groupes. Le nombre d’echec etait respectivement de 2 et 3 dans les groupes VW et T. Discussion Dans le cadre de cette etude prospective multicentrique randomisee realisee chez des enfants anesthesies ayant un acces veineux difficile, le VeinViewer n’a pas permis de diminuer le temps de perfusion ni le nombre de tentatives.

Background The aim of this study was to compare intubating conditions and adverse events after sevoflurane induction in infants, with or without the use of rocuronium or alfentanil. Methods Seventy-five infants, aged 1–24 months, undergoing elective surgery under general anaesthesia were randomly assigned to receive 8% sevoflurane with either placebo (i.v. saline 0.5 ml kg −1 ), rocuronium (0.3 mg kg −1 ), or alfentanil (20 µg kg −1 ). The primary outcome measure was intubating conditions evaluated 90 s after test drug injection by an anaesthetist unaware of the patient's group. The secondary outcome criteria were respiratory ( S p O 2 , laryngospasm, closed vocal cords preventing intubation, bronchospasm) and haemodynamic adverse events (heart rate and mean arterial pressure variations ≥30% control value). Results Intubating conditions were significantly better in the rocuronium group, with clinically acceptable intubating conditions in 92%, vs 70% in the alfentanil group and 63% in the placebo group ( P =0.044). Adverse respiratory events were significantly less frequent in the rocuronium group: 0% vs 33% in the placebo group and 30% in the alfentanil group ( P =0.006). Haemodynamic adverse events were more frequent in the alfentanil group: 48% vs 7% in the placebo group and 16% in the rocuronium group ( P =0.0019). Conclusions In 1- to 24-month-old infants, the addition of 0.3 mg kg −1 rocuronium to 8% sevoflurane improved intubating conditions and decreased the frequency of respiratory adverse events. Alfentanil provided no additional benefit in this study.

Acute angle closure glaucoma is a rare complication of general anesthesia. However, in case of delayed diagnosis, it may lead to blindness. We present a case of bilateral acute angle closure glaucoma after cervical spine surgery under general anesthesia in a hypermetropic patient. In this case, the most likely trigger was the use of ephedrine, but nefopam administration and the prone surgical position are discussed as additional potential factors.

Introduction La transfusion plaquettaire est indiquee en neuro-anesthesie-reanimation pour corriger en urgence les anomalies plaquettaires, qui incluent les thrombopenies, definies par une numeration plaquettaire (NP) aires aux agents antiplaquettaires (AAP). Son efficacite a ete peu evaluee. Notre objectif etait d’evaluer si la transfusion plaquettaire permet de corriger ces deux types d’anomalies plaquettaires. Patients et methodes Etude retrospective monocentrique. Ont ete inclus les patients transfuses exclusivement en plaquettes pour une hemorragie intracrânienne ou une neurochirurgie urgente. Les donnees recueillies incluaient les caracteristiques des patients, l’indication et les modalites de la transfusion et les donnees biologiques. Les resultats sont en mediane et interquartiles. Resultats Soixante patients ont ete inclus : – vingt et un patients, âges de 57[47–66] ans, ont ete transfuses pour thrombopenie. La transfusion de 3,9[3,3–4,0] QPA (quantite de principe actif, en 10 11 plaquettes) a augmente la NP de 67[47–76] a 105[85–114] G/L. Seuls 52 % des patients passaient au-dessus de 100 G/L. Il n’y avait pas de difference de poids, de NP pretransfusion ou de QPA transfusee entre les groupes corriges ou non corriges. La dose transfusee etait inferieure a la dose prescrite dans 75 % des cas, et toujours inferieure a la dose minimale recommandee (= 0,5 × 10 11 plaq/7 kg de poids) ; – quarante patients âges de 57[46–69] ans ont ete transfuses pour neutraliser les AAP (aspirine n = 35, clopidogrel n = 17, dont bitherapie n = 13). La transfusion de 4 [3,8–4,4] QPA a augmente la NP de 237 [179–294] a 278 [233–323] G/L. La restauration des fonctions plaquettaires a ete evaluee en mesurant la reactivite plaquettaire par le test de Verifynow ® . Apres transfusion, 11 % des patients traites par aspirine avaient encore une inhibition plaquettaire, contre 75 % des patients initialement repondeurs au clopidogrel. Les patients corriges avaient recu plus de QPA, totale ou selon le poids, que les non corriges ( p = 0,46 et 0,013). Les non corriges avaient tous recu une QPA inferieure aux recommandations versus 64 % chez les corriges ( p = 0,12). Discussion Cette etude, retrospective, sur un faible effectif, montre que l’efficacite biologique de la transfusion plaquettaire est mediocre, pour corriger une thrombopenie ou pour neutraliser les AAP. La neutralisation des AAP est moins bonne lorsqu’il s’agit du clopidogrel ou que la QPA transfusee est inferieure aux doses recommandees. Les QPA delivrees par l’EFS sont inferieures aux doses prescrites et aux doses recommandees. L’augmentation des doses souleverait le probleme de la penurie de plaquettes.

Objective To determine the protective action of hyaluronidase on peribulbar anesthesia-related diplopia in patients undergoing cataract surgery. Design Single-center observational case series. Participants All patients undergoing elective phacoemulsification and intraocular lens implantation under peribulbar anesthesia between February 2001 and January 2003. Methods We compared the incidence of postoperative diplopia between 2 periods—February 2001 to January 2002 (P1) and February 2002 to January 2003 (P2)—which differed by the presence (P1) or absence (P2) of hyaluronidase in the anesthetic solution. Main Outcome Measures All patients were examined on the first and fifth postoperative days during both periods. When diplopia was diagnosed, we recorded the characteristics of the patient, peribulbar anesthesia, and diplopia (orthoptic examination, and magnetic resonance imaging in some cases). Results Seven thousand two hundred five patients were studied. During P1, 3582 patients received peribulbar anesthesia, and no cases of diplopia occurred. During P2, 3623 patients received peribulbar anesthesia, and 27 cases of diplopia occurred (incidence, 0.75%; P = 0.0002 vs. P1). Diplopia involved the inferior rectus (40%) and the external rectus (37%) muscles. Diplopia was persistent in 54% of the cases. Conclusions Peribulbar anesthesia-related diplopia was significantly more frequent when hyaluronidase was not added to the anesthetic solution.

We report the cases of five patients who have experienced postoperative diplopia after cataract surgery under peribulbar anaesthesia and in whom orbital Magnetic Resonance Imaging was performed immediately after the diagnosis. In four patients, the imaging study showed a T2 hyper‐intensity signal and swelling of one extraocular muscle that was interpreted as oedema. Therefore, these cases were most probably a result of an accidental i.m. injection of local anaesthetics. In the other patient, the imaging study revealed no abnormality.

To compare, over a 48-hr follow-up period, the analgesia and side-effects of patient controlled iv analgesia (PCA) with morphine alone vs combined intrathecal and PCA morphine (IT+PCA) in patients undergoing major abdominal surgery.Sixty adult patients undergoing abdominal surgery for cancer were randomly allocated to receive preoperative IT (0.3 or 0.4 mg) plus postoperative PCA morphine or postoperative PCA morphine alone. Postoperative analgesia was tested at rest and while coughing on a visual analogue pain scale and morphine consumption was recorded. Patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting and pruritus were also noted.Analgesia at rest and while coughing was significantly better in the IT+PCA morphine group (rest: P = 0.01; coughing: P = 0.005) on the first postoperative day only. IT+PCA morphine constantly provided adequate analgesia during this period. Morphine consumption was lower in the IT+PCA morphine group during this period also (IT+PCA: 9 (17) vs PCA: 40 (26); mg of morphine, mean (SD), P = 0.0001). No difference was found in pain relief and morphine consumption between the groups on the second postoperative day. Nausea and vomiting were more frequent with IT+PCA morphine on the first postoperative day. No respiratory depression occurred in either group. Satisfaction was high in both groups.IT+PCA morphine improves patient comfort constantly during the first postoperative day after major abdominal surgery. However, after the first postoperative day, IT+PCA morphine provides no additional benefit.

To describe negative pressure pulmonary edema due to biting of the laryngeal mask tube at emergence from general anesthesia.A healthy patient underwent general anesthesia using a laryngeal mask airway and mechanical ventilation. During recovery, the patient strongly bit the laryngeal mask and made very forceful inspiratory efforts until the mask was removed. Five minutes later, the patient developed dyspnea and had an hemoptysis of 50 ml fresh blood. Chest radiograph showed bilateral alveolar infiltrates. Pharyngo-laryngeal examination was normal. Bronchoscopy revealed no injury but diffuse pink frothy edema fluid. Clinical examination and chest radiograph became normal after 12 hr of nasal oxygen therapy confirming airway obstruction as the most available cause of this pulmonary edema.Airway obstruction due to biting of a laryngeal mask tube may result in negative pressure pulmonary edema.

Aortic arch atheroma is a major source of embolism (1,2). Transesophageal echocardiography (TEE) is the gold standard for the detection of aortic atheroma. However, we have witnessed in these recent years an increasing number of requests for computed tomography angiography (CT angiography) to assess the ascending aorta and the aortic arch. This study compared CT angiography and TEE performances for the detection of aortic arch atheroma. Among the 192 patients admitted to our hospital in 2008–2009 for acute ischemic stroke and in whom transthoracic echocardiography failed to identify a source of embolism, we have retrospectively selected the 47 patients who underwent both TEE and CT angiography. A scoring was established and resulted in the following (Table 1): No atheroma: 0 Plaque thickness < 4 mm: 1 Plaque thickness 4 mm (protrusive aortic atheroma): 2 Ulcerated plaque: 3 At risk atheroma: 2 or 3. Interobserver reproducibility for CT angiography (two readers) was found to be 57·45% for each score, with a kappa index of 0·4020. For at-risk plaques, interobserver reproducibility was 89·36% (kappa index 0·7403). The agreement between CT angiography and TEE for each score was 61·70%, with a Kappa index of 0·4816. For at-risk plaques, the agreement between the two techniques was of 74·47% (kappa index 0·4416). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CT angiography compared with TEE for the detection of at-risk plaques were calculated. The sensitivity was 52·60% (95% CI: 33·50–79·70%) and the specificity was 92·60% (95% CI: 75·70–99·10%). The PPV was 84·60% (95% CI: 54·60– 98·10%) and the NPV was 75·80% (95% CI: 57·70–88·90%). In conclusion, CT angiography is very specific but lacks sensitivity for the detection of at-risk aortic plaques.