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The prescription of preoperative complementary tests aims to decrease morbidity and mortality associated to the perioperative period.To assess the practice and the financial cost of the systematic prescription of preoperative tests.This was a retrospective study including all patients older than three years, scheduled for elective surgery from November 2018 to January 2019. Two attendings analyzed the data collected during the pre-anesthetic assessment and evaluated the usefulness of the ordered preoperative tests. The overall cost of prescribed preoperative tests and the cost generated by inappropriate prescriptions were also estimated.This study included 1006 patients. The average age was 46.9 ± 22.05 years old. Five hundred and twenty three of them (51.98%) have no medical history. Among the planned procedures, 6.46% had an intermediate or major bleeding risk. Preoperative prescriptions were ordered by surgeons in 99% of cases. Prescriptions were justifiable in only 9.42% of cases. Abnormal findings were noted in 4.98% of the patients. The total cost was almost 80992 Dinars (≈ 24543 €). Complying the guidelines would save 70245 Dinars (≈ 21286 €) during the three months' study.The routine prescription of preoperative complementary tests results in a significant additional economic cost. Developing national guidelines would change this attitude of unnecessary prescription.

Spinal anesthesia (SA) is being increasingly used in infants to avoid the potential negative neurocognitive effects of general anesthesia (GA). However, SA has been reported to provide a relatively short duration of surgical anesthesia. We retrospectively reviewed SA cases for surgical procedures lasting more than 60 min in children up to 3 years old. All patients received bupivacaine 0.5% (1 mg/kg up to 7 mg) with clonidine 1 µg/kg ± epinephrine. The primary outcome was success of SA without subsequent conversion to GA. Thirty-five patients met inclusion criteria (all males, age 7 ± 5 months, weight 8 ± 2 kg). Procedures included male genital, groin and multiple site surgeries. Average surgical duration was 71 ± 12 min (range 60–111 min). SA was successful in 31 of 35 patients (89%; 95% confidence interval 78, 99%). The cause of failure was rarely due to the duration of surgery (1 of 4 patients). Six patients with successful SA required sedation with dexmedetomidine ± fentanyl. Differences in procedure duration and patient characteristics were not statistically significant between successful and failed SA. SA is a highly successful technique and may offer an alternative to GA in children undergoing appropriate surgery expected to last as long as 60–100 min.

Hyper-immunoglobulin M syndrome is an X-linked primary immunodeficiency disease caused by mutations in the CD40 ligand gene. The CD40 ligand has been recently highlighted as playing a key role in the pathogenesis of primary biliary cholangitis. In the present study, we assessed an extensive set of serum autoantibodies in a series of well-defined patients with hyper-immunoglobulin M syndrome. Serum, liver-related and liver-not-related autoantibodies IgG, IgM and IgA were tested by ELISA and standard indirect immunofluorescence in HEp-2 cells in 13 Tunisian patients (8 males and 5 females, aged 1–12 years) with hyper-immunoglobulin M syndrome during 1995–2012 and, as controls, 21 age- and gender-matched blood donors. The level of IgM antibody against MIT3 was significantly higher in patients than in controls (35.8 vs 10.7, P=0.002). Half of the hyperimmunoglobulin M syndrome patients were found to be anti-MIT3 IgM positive vs none of the controls (P

Objective Interleukin 12 receptor beta 1 (IL-12Rβ1) deficiency is a primary immunodeficiency that exposes affected individuals to an augmented risk of intracellular pathogen-mediated infections. The paradoxical presence of autoimmune manifestations in immune-deficient patients has been recognized, but the basis of this phenomenon is unclear, with the role of frequent infections being a possible trigger to break tolerance. Our study aimed to analyze extensively a profile of autoantibodies in a clinically well-defined case series of patients with IL-12Rβ1 deficiency. Methods Eight patients with IL-12Rβ1 deficiency referred to Children's Medical Center in Tunis, Tunisia, during 1995-2012 were enrolled in the study. Sixteen age- and gender-matched blood donors served as controls. Serum, liver-related autoantibodies immunoglobulin (Ig)G, IgM, IgA were tested by ELISA and by standard indirect immunofluorescence on Hep-2 cells. Results We found a significant prevalence of liver autoantibodies in the study group. Regarding primary biliary cholangitis (PBC), two of eight patients were positive for MIT3 autoantibodies, both confirmed by immunofluorescence, and one patient was positive for PBC-specific antinuclear antibodies, sp100. Moreover, two patients had significantly increased gamma-glutamyltransferase levels and one had IgM levels twice the upper limit of normal. Intriguingly two patients were positive for anti-actin antibodies; a typical feature of autoimmune hepatitis type 1, along with a significant increase in IgG levels. Conclusions This is the first report of a serological analysis in patients with an IL-12Rβ1 deficiency. Despite the difficulty in interpreting the role of the IL-12, the evidence of liver-specific autoantibodies confirms the importance its signal in liver autoimmunity.

The management of children presenting with an anterior mediastinal mass (AMM) is challenging for anesthesiologists. AMMs are a heterogeneous collection of primary or secondary, benign or malignant tumors. Severe and life-threatening complications related to airway obstruction and/or cardiovascular compression can occur in a patient with an AMM during anesthesia, even in an asymptomatic patient. It is important for the anesthesia provider to understand the pathophysiology of symptoms and complications and the current evidence regarding perioperative management of children with AMM. This chapter explores the pathophysiology of AMM symptoms and of AAM and anesthesia. Perioperative management of AMM patients, including preoperative evaluation and induction and maintenance of anesthesia, is also discussed.

Mehdi Trifa,1,2 Dmitry Tumin,1,3 Hina Walia,1 Kathleen L Lemanek,4 Joseph D Tobias,1,3 Tarun Bhalla1,3 1Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 2Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; 3Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA; 4Department of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital, Columbus, OH, USA Background: The use of complementary and alternative medicine (CAM) therapies has increased in children, especially in those with chronic health conditions. However, this increase may not translate into acceptance of CAM in the perioperative setting. We surveyed caregivers of patients undergoing surgery to determine their knowledge and acceptance of hypnotherapy, acupuncture, and music therapy as alternatives to standard medication in the perioperative period. Materials and methods: An anonymous, 12-question survey was administered to caregivers of children undergoing procedures under general anesthesia. Caregivers reported their knowledge about hypnotherapy, music therapy, and acupuncture and interest in one of these methods during the perioperative period. CAM acceptance was defined as interest in one or more CAM methods.Results: Data from 164 caregivers were analyzed. The majority of caregivers were 20–40 years of age (68%) and mothers of the patient (82%). Caregivers were most familiar with acupuncture (70%), followed by music therapy (60%) and hypnotherapy (38%). Overall CAM acceptance was 51%. The acceptance of specific CAM modalities was highest for music therapy (50%), followed by hypnotherapy (17%) and acupuncture (13%). In multivariable logistic regression, familiarity with music therapy was associated with greater odds of CAM acceptance (odds ratio=3.36; 95% CI: 1.46, 7.74; P=0.004).Conclusion: Overall CAM acceptance among caregivers of children undergoing surgery was 51%, with music therapy being the most accepted CAM method. Familiarity with music therapy was the only factor that was independently associated with accepting CAM in the perioperative period. The low acceptance for acupuncture and hypnosis in the perioperative situation may be related to insufficient parental knowledge and information. Keywords: complementary and alternative medicine, perioperative, children, caregiver, hypnotherapy, acupuncture, music therapy

Introduction The aim of this review was to evaluate the current evidence regarding the use of dexmedetomidine as an adjuvant to local anesthetic agents (LAA) for caudal blockade anesthesia and analgesia in children. Evidence acquisition A literature search was performed of the Medline, Embase, and CINAHL databases using the keywords "dexmedetomidine" and "caudal". We included all studies that used caudal dexmedetomidine as an adjuvant to a LAA in children, excluding case reports, reviews, expert opinions, and animal studies. Evidence synthesis Twenty-one publications met the inclusion criteria and included 1590 children. Fourteen compared the efficacy of adding dexmedetomidine to a LAA alone and seven compared dexmedetomidine to other adjuvants in combination with a LAA. The duration of postoperative analgesia was significantly longer in patients receiving a caudal epidural block with a LAA plus dexmedetomidine when compared to a LAA alone. Only one study demonstrated improved analgesia with a dose of dexmedetomidine ≥1 µg/kg. Dexmedetomidine provided longer postoperative analgesia than fentanyl and morphine, while the quality of postoperative analgesia was similar to dexamethasone or clonidine. Although higher sedation scores were associated with caudal dexmedetomidine in the majority of the trials, postoperative behavior scores were improved in these children. There were no reports of respiratory depression. Significant hemodynamic effects were uncommon, and occurred most commonly in patients receiving a higher dose of caudal dexmedetomidine (2 µg.kg-1). Conclusions There is sufficient evidence to recommend the addition of caudal dexmedetomidine to the LAA in patients undergoing lower extremity and infra-umbilical surgical procedures.

We describe a case of osteomyelitis, in a 7-month-old boy, caused by S. pneumoniae involving the pelvic bone with a purulent collection in the adductor muscle. Osteomyelitis diagnosis was suspected using ultrasound and CT scan investigations. This showed a periosteal elevation in the Case Study Ben Marzouk et al.; IJMPCR, 3(3): 68-72, 2015; Article no.IJMPCR.2015.038 69 pelvis and an abscess of the adductor muscle. Culture of the perioperative specimens isolated serotype 19A S. pneumoniae with reduced susceptibility to penicillin and macrolides. The patient was treated successfully with amoxicillin-clavulanate during five weeks, associated with gentamicin during the first week.

Le test ultime au lit du malade (TULM) est obligatoire en Tunisie (circulaire: 32/15) avant toute transfusion erythrocytaire et engage directement la responsabilite du medecin prescripteur. Il se fait en melangeant le serum du malade avec les globules rouges a transfuser ou en controlant l’epreuve globulaire pour le patient et le concentre de globules rouges (CGR). Ce travail a pour but d’evaluer la pratique du TULM chez les medecins. Nous rapportons les resultats de deux enquetes: la premiere(mars–novembre 2011) a concerne 80 medecins de differentes specialites exercant dans des structures hospitalo-universitaires du grand Tunis. La deuxieme(mai a juin 2014) a cible tous les medecins anesthesistes-reanimateurs (MAR) exercant dans le secteur prive du grand Tunis. Le moyen d’evaluation est un questionnaire anonyme a choix multiples se rapportant a la modalite pratique de realisation du test direct de la compatibilite: sang total malade + globules rouges du CGR ou serum du malade + globules rouges du CGR ou globules rouges malade + globules rouges du CGR. Soixante-quinze pour cent ont accepte de participer a l’enquete. Parmi les participants aux deux etudes, 37,5 % et 22 % pratiquent correctement le test dans le premier et le deuxieme groupe respectivement. Soixante et un et soixante et onze pour cent le pratiquent en melangeant le sang total du patient avec les globules rouge a transfuser. Ce travail devoile une large meconnaissance de la technique de realisation du TULM. Une formation medicale continue portant sur la pratique et l’interpretation au lit du malade est indispensable.

Introduction: Anesthesiologists use sugammadex to reverse neuromuscular blockade (NMB) produced by rocuronium and vecuronium. Its mechanism involves encapsulation of the neuromuscular blocking agent. Sugammadex dosing is based on the depth of NMB, assessed by measuring the train-of-four (TOF). Methods: We retrospectively reviewed procedures under general anesthesia in patients older than 1 year of age if they included sugammadex reversal of rocuronium-induced NMB. Documentation of TOF monitoring before and after reversal was noted, along with the dose of sugammadex administered. TOF was considered correctly documented if the anesthesia provider recorded the number of twitches before and after NMB reversal, or if they recorded 4 twitches before NMB reversal. We defined appropriate sugammadex dosing if it was within 10% of the recommended dose for the depth of NMB. We repeated this review after staff education and creating a reminder in the electronic health record system. Results: We included 100 patients in the preintervention analysis, of whom 30% had correct TOF documentation. Among patients with TOF assessment before sugammadex administration, the dose was appropriate in 34 of 40 cases. In the postintervention analysis, we reviewed 75 cases and found that correct documentation improved to 45% (P = 0.024). Among postintervention cases with TOF documented before sugammadex administration, sugammadex dosing was appropriate in 62 patients. Conclusion: Documentation of TOF was low (30%) before intervention and improved to only 45% after the interventions, suggesting that additional interventions are needed. Even before the intervention, with or without TOF documentation, the dose of sugammadex was generally consistent with recommendations.

Sugammadex is a novel pharmacologic agent, which reverses neuromuscular blockade (NMB) via a mechanism that differs completely from acetylcholinesterase inhibitors. By encapsulating rocuronium, sugammadex can provide recovery of neuromuscular function even when there is a profound degree of NMB. We report anecdotal experience with the use of sugammadex to reverse NMB to facilitate intraoperative neurophysiological monitoring (motor evoked potentials) in an adolescent with scoliosis during posterior spinal fusion. Its potential application in this unique clinical scenario is discussed, and potential dosing schemes are reviewed.

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

To determine the demographic, clinical, biological and bacteriological profile of acute community acquired hematogenous osteomyelitis (AHO) in children.Prospective study including children admitted for AHO. We noted the demographic parameters of patients and the clinical, biological and radiological characteristics of the infection. Blood cultures and local specimen in operated children were systematically performed.70 patients were included. The mean age was 7.7 years. The mean time between onset of symptoms and admission was 3.2 days. Distal tibia was the most frequent localization (18.66%). Fever higher than 38° on admission was found in 92.8% of patients. Creactive protein (CRP) was superior to 20 mg / L in 95.8% and ESR superior to 20 mm in the first hour in 92% of cases. A deep venous thrombosis was found in 7 patients and a pleuropulmonary Staphylococcus infection in 4 patients. A micro organism was isolated in 64.7% of cases. Staphylococcus aureus methicillin susceptible (SAMS) was the predominant germ. Staphylococcus aureus methicillin resistant (SAMR) accounted for 15.7% of staphylococcus aureus infections. The importance of CRP on admission and time to resolution of fever after the start of treatment were significantly higher in SAMR infections. The existence of deep venous thrombosis and a pleuropulmonary Staphylococcus infection and the need for surgical drainage were significantly more frequent in SAMR infections.The existence of a severe form of AHO should lead to a high suspicion of SAMR infection and prompt the prescription of an appropriate antibiotiotherapy.

The addition of clonidine to peripheral nerve blocks is controversial in children.The aim of our study was to evaluate the effect of clonidine added to ropivacaine in pediatric axillary brachial plexus block (ABPB).Children aged 1-6 years, scheduled to undergo forearm or hand surgery, were recruited into this prospective, double-blind controlled trial. Patients were randomly allocated to receive an ABPB either with ropivacaine 0.2% 0.4 ml · kg(-1) plus saline in 1 ml (RS) or ropivacaine 0.2% 0.4 ml · kg(-1) plus clonidine 1 μg · kg(-1) in 1 ml (RC). Primary endpoints were quality of postoperative analgesia as assessed by pain scores and total 24-h postoperative analgesia requirements. Secondary outcomes were time to first analgesia request and duration of motor blockade.Sixty patients were recruited (n = 30 per group) into the study. Pain scores were comparable throughout the first 24 h between the two groups. Ten children in the (RS) and six in (RC) groups required supplementary analgesia during the first 24 h (P = 0.24). Children who required further analgesia did so after 288 ± 94 min in the (RS) and 437 ± 204 min in the (RC) group (P = 0.06). There was no difference in the duration of motor block [186 ± 71 and 154 ± 56 min, P = 0.12 for (RS) and (RC), respectively].Ropivacaine (0.2% 0.4 ml · kg(-1) ) for ABPB provides sufficient postoperative analgesia in children scheduled for forearm or hand surgery. The addition of clonidine to ABPB does not improve overall postoperative analgesia but may increase the time to first analgesia request.

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

Stress fractures of the femoral neck are uncommon. They are caused by either excessive stress or bone fragility.To report a case of bilateral stress fracture of the femoral neck in a 15-year-old girl without any risk factorsWe report a case of bilateral stress fracture of the femoral neck in a 15-year-old girl in whom no risk factors were found. One of the fractures was displaced at first diagnosis and was successfully treated by closed reduction and valgus subtrochanteric osteotomy. The other fracture was initially undisplaced but displacement occurred later despite internal fixation with a dynamic hip screw.A high index of suspicion of stress fractures of the femoral neck must be kept in mind even without risk factors. Delays in diagnosis and displacement should therefore be avoided.

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

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