[Haemorrhagic shock after severe abdominal trauma in children: knowing when to change from conservative to surgical management]

Abdominal vascular injuries following a serious falling out are quite rare in children. They can lead to haemorrhagic shock whose etiological diagnosis may be difficult in children in case of multiple trauma. The current management of abdominal injuries in the child is usually conservative, surgery being indicated in haemodynamically unstable patients. We report the case of a 7-year-old girl who presented with abdominal trauma with rupture of the hepatic artery and shredding of the splenic vein following a falling out of 10 meters. Aggressive resuscitation associated with early laparotomy for haemostasis, contrary to usual practices advocated in such a context, have helped control the hemorrhagic shock and stabilize the haemodynamic status of the child. The subsequent evolution was favourable, with full recovery. While a conservative attitude usually prevails in the management of traumatic intra abdominal bleeding in children an interventional attitude with emergency surgery must be sometimes considered.

[What non invasive haemodynamic assessment in paediatric intensive care unit in 2009?]

The haemodynamic assessment of the patients is a daily activity in paediatric intensive care unit. It completes and is guided by the clinical examination. The will to develop the least invasive possible coverage of the patients is a constant concern. The haemodynamic monitoring, all the more if it is invasive, ceaselessly has to put in balance the profit and the risk of beginning this technique at a fragile patient. In the last three decades, numerous non-invasive haemodynamic tools were developed. The ideal one must be reliable, reproducible, with a time of fast, easily useful answer, with a total harmlessness, cheap and allowing a monitoring continues. Among all the existing tools (oesophageal Doppler ultrasound method, transthoracic echocardiography, NICO, thoracic impedancemetry, plethysmography, sublingual capnography), no one allies all these qualities. We can consider that the transthoracic echocardiography gets closer to most of these objectives. We shall blame it for its cost and for the fact that it is an intermittent monitoring but both in the diagnosis and in the survey, it has no equal among the non-invasive tools of haemodynamic assessment from part the quality and the quantity of the obtained information. The learning of the basic functions (contractility evaluation, cardiac output, cardiac and the vascular filling) useful for the start of a treatment is relatively well-to-do. We shall miss the absence of training in this tool in France in its paediatric and neonatal specificity within the university or interuniversity framework.

Paediatric intracranial empyema: differences according to age

No recent studies are available which consider the epidemiology and outcome of paediatric intracranial empyema (PICE). We retrospectively studied all PICE cases admitted in our institution from 1993 to 2006. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 24 months. Aetiology, clinical features, therapeutic considerations and risk factors of poor outcome were analysed according to age. Data from 38 patients were studied; 33/38 presented with subdural empyema (SDE) and 5/38 with extradural empyema (EDE); 10/38 were infants <1 year of age with SDE, all related to bacterial meningitis; 28/38 were children, with 23/28 showing SDE and 5/28 EDE. Oto-sinogenic infections were the main causes in children. All infants recovered completely as did children with EDE. However, two out of 23 children with SDE had permanent neurological deficit, already detected on admission, and one out of 23 died. Thirty-three out of 38 were operated; 16 of which underwent multiple surgical procedure because of recurrence. Burr hole was performed in six infants and craniotomy in one, while 21/23 children underwent burr hole or craniotomy. Burr hole was more often associated with recurrence. In children with SDE, factors associated with poor outcome were neurological deficit (p = 0.002) and cerebral herniation on CT scan (p = 0.02) on admission. In this study, we gained further insights into modern epidemiology of PICE by highlighting age-related aetiology, symptoms, treatment strategy, and outcome differences. Meningitis was the main aetiology in the infants and sinusitis was prevalent in children. Finally, early diagnosis by neuro-imaging investigations and timely and appropriate multidisciplinary treatment may offer the best chance of recovery.

Evaluation of cuffed tracheal tube size predicted using the Khine formula in children

BACKGROUND

The correct size of cuffed endotracheal tube (CET) limits the risk of postintubation tracheal damage. The aim of this study was to compare the size of the CET used in children with the size predicted by the Khine formula [age (years)/4 + 3].

METHODS

After ethical committee approval, 204 children aged 1 day-15 years were included prospectively in the study. The choice of the size of the CET was made at the discretion of the attending anesthesiologist. The main criterion of judgment was the comparison of the leak before and after inflating the cuff at a pressure of 20 cm.H(2)O. Demographic data, tracheal tube size used and that predicted by Khine's formulae and side-effects were recorded.

RESULTS

Overall, 21% of the CET were in accordance with the size predicted by the Khine formula. In the remaining patients, 72% were oversized and 7% undersized. In 12 cases, the size of CET chosen initially was modified: for a larger size in eight children and for a smaller size in four others. Six children (2.9%) presented with minor postoperative complications.

CONCLUSIONS

Our data suggest that Khine's formula for predicting the appropriate tracheal tube size underestimates optimal size by 0.5 mm. We therefore recommend the use of the following formula: internal diameter of the CET = [age/4 + 3.5] in children >1 year of age which may be applied without increased risk of complications. The rate of tracheal reintubation as well as the detected leaks supports these recommendations.

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures

OBJECTIVE

To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock.

DESIGN

Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII.

SETTING

Neurosurgical anesthesia and critical care unit of a pediatric university hospital.

PATIENTS/SUBJECTS

Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis.

INTERVENTIONS

Intravenous administration of recombinant activated factor VII (100 microg/kg).

RESULTS

Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery.

CONCLUSIONS

These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures

OBJECTIVE:: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN:: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING:: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS:: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS:: Intravenous administration of recombinant activated factor VII (100 mug/kg). RESULTS:: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS:: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Particularités pédiatriques de l'information préopératoire. Le point de vue de l'anesthésiste–réanimateur

Medical information is mandatory before any medical procedure, including pediatric anesthesia. Preoperative information covers many aspects, including medico-psychologic and judicial aspects. When the patient is a child, information must be delivered to the parents in priority. However, the French law has given a particular attention to the opinion of the child. In 70% of the cases, preoperative anxiety of the parents is more related to anesthesia than to the surgical procedure itself. We have to explain the most frequent adverse effects, as well as the more severe and well known complications to the parents, even though they are very infrequent. The only cases where preoperative information is not required are: emergency cases and refusal of the patient or the parents to be informed. While information is necessarily oral, it may be completed using a written document. The quality of the preoperative information directly influences the quality of the psychological preoperative preparation of the parents, and thereafter of the child. Preoperative preparation programs have been developed, but controversial results have been observed. The great majority of the studies on preoperative programs were performed in the USA, where the demand for preoperative information is very important. It is far from sure that the results of all these studies may be extrapolated to French parents, and French studies are needed.

Chocs hémorragiques au cours de dérivation interne du liquide céphalorachidien. Faut-il revoir la pratique anesthésique ou chirurgicale ?

We report two cases of perioperative haemorrhagic shock after accidental puncture of trunc vessels, during emergency shunt procedures in children who suffer of severe intracranial hypertension. In both cases it's the peritoneal internalization of the shunt with Portnoy trocar which is responsible of these deep vascular wounds. Evolution was favourable in both cases with cardiovascular resuscitation, transfusion and surgical haemostatic correction. Few days later, an internal shunt was performed in the second patient, while the first patient did not need shunt anymore. These two accidents lead to the discussion of the surgical procedure with surgeons, in order to have a better prevention against this complication. We also discuss our anaesthesiological practice from preoperative to perioperative period of this usually non-haemorrhagic surgical procedure.

Combined high cervical spine and brain stem injuries: a complex and devastating injury in children

BACKGROUND

In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions.

METHODS

Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale < 8).

RESULTS

Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 +/- 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery.

CONCLUSIONS

Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.

Surgical evacuation of acute subdural hematoma improves cerebral hemodynamics in children: a transcranial Doppler evaluation

OBJECTIVE

The objective was to evaluate cerebral hemodynamics in young children with acute subdural hematoma (SDH) and the impact of surgical treatment using transcranial Doppler (TCD).

DESIGN

The design was a prospective study of infants with SDH requiring surgical evacuation.

SETTING

The setting was the neuro intensive care unit of a university hospital.

INTERVENTIONS

Indications for surgical evacuation were based upon clinical and radiological arguments. Surgery included emergency needle aspiration followed by external or/and internal shunting as required. A TCD evaluation was performed before needle aspiration, and after each surgical drainage procedure. It included a pressure provocation test to assess cerebral compliance. Preoperative and postoperative middle cerebral artery (MCA) velocities, Gosling pulsatility (PI) and Pourcelot resistivity (RI) indexes and compliance were compared with Student's t-test, or Fisher's exact test as indicated.

MEASUREMENTS AND MAIN RESULTS

Out of 26 infants, 23 (88%) had injuries that had possibly been inflicted, and 3 had accidental injuries. Initial TCD evaluation demonstrated intracranial hypertension with decreased diastolic velocity, increased PI and RI, and decreased compliance. Surgical evacuation resulted in statistically significant improvement in cerebral hemodynamics (diastolic velocity: 17.2+/-10 cm/s vs. 31.1+/-10 cm/s, p<0.0015, PI: 2.5+/-1.3 vs. 1.4+/-0.8, p<0.002, RI: 0.8+/-0.2 vs. 0.6+/-0.1, p<0.005) in all but 3 infants, who eventually died. Surgical drainage (primary shunting or external drainage) was needed in 23 infants and resulted in further improvement in cerebral hemodynamics. Finally, 73% of the infants made a good recovery.

CONCLUSIONS

Children with acute bilateral HSD have a high incidence of increased intracranial pressure as assessed by TCD. Surgical evacuation improves cerebral hemodynamics. TCD could be used for assessing the need for, and the efficiency of surgical drainage.

[Postnatal maturation of the diaphragm muscle: ultrastructural and functional aspects]

OBJECTIVE

In the diaphragm muscle, postnatal maturation is associated with major histological and biochemical modifications, as well as a progressive development of the sarcoplasmic reticulum (SR), which in turn are responsible for the progressive postnatal improvement in diaphragmatic contractility. However, the mechanisms by which postnatal maturation induces this improvement in diaphragmatic contractility remain poorly understood and controversial. The aim of this review is to analyze the data from the literature regarding the process involved in the postnatal improvement in diaphragmatic contractility.

DATA SOURCES

References obtained from Pubmed((R)) databank using keywords (diaphragm muscle, postnatal maturation, contractility, muscular fatigue, cross-bridge).

DATA SYNTHESIS

From a cytological point of view, the postnatal development of the diaphragm muscle is processed in two successive generations of fiber types, corresponding to the progressive adaptation of the diaphragm muscle to its physiological function. Indeed, the proportion in type I (slow, aerobic) and type IIB fibers (fast, anaerobic) progressively increases with postnatal maturation, while the proportion in type IIA fibers (fast, intermediate) progressively decreases. The histochemical classification of the type of fiber corresponds to the expression of the different isoforms of myosin heavy chains (MHC). Two types of MHC: MHC embryologic (MCH-emb) and MHC neonatal (MCH-neo), and one type of myosin light chains (MLC) are expressed in the foetal skeletal muscles, then are progressively eliminated during postnatal maturation. For many authors, this progressive transition from immature MHC (MCH-emb and neo) to adult MHC (by chronological order of appearance: MHC-2A, MHC-lente, MHC-2X, MHC-2B) could be responsible for the progressive improvement in postnatal diaphragmatic contractility. This transition could be modulated by external factors, mainly including neural and hormonal stimuli. For others, this transition in MHC expression do not play a major role, and other factors, including the postnatal maturation of the ryanodine receptor (RyR) or developmental changes in cross-bridges (CB) properties should play a central role. The most recent hypotheses proposed included the possibility of a postnatal transition in the expression of structural proteins, which are playing a major role in the maintenance of the stability of the sarcomer, and therefore in force generation.

Prise en charge périopératoire de la sténose du pylore en France en 1999 : résultats d’une enquête postale

OBJECTIVE

The aim of this postal survey was to know how were treated infants with hypertrophic pyloric stenosis in France in 1999.

METHODS

A questionnaire was sent to all French members of the Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (Adarpef).

RESULTS

Half the cases of pyloric stenosis treated in France in 1999 were related by the survey. Preoperative management was short lasting (24 h) while the advised guidelines regarding biologic criteria for operation were poorly followed. Nevertheless, crush induction was only performed in 80%.

CONCLUSION

The management of infants with pyloric stenosis must be improved, at least to obtain the generalization of crush induction.

Recommandations concernant la mise en place, la gestion, l’utilisation et l’évaluation d’une salle d’accueil des urgences vitales pédiatriques

The pediatric resuscitation room is the place where children suffering from vital distress are cared for in the emergency unit. Recommendations for its organization, functioning and evaluation have been ruled on by experts from six medical societies involved in these emergencies. They concern all the hospital's physicians, nurses and administrative directors.

Antithrombin Phe229Leu: a new homozygous variant leading to spontaneous antithrombin polymerization in vivo associated with severe childhood thrombosis

There is increasing evidence that serpin conformational alteration caused by single point mutations can be responsible for protein deficiency associated with human diseases. A typical example is the alpha1-antitrypsin deficiency caused by the Z variant carrying a Glu342Lys substitution. Only a few cases of "conformational disease" involving other serpins have been described so far. We investigated a severe antithrombin deficiency in a 13-month-old child with fever and cerebral venous thrombosis. The infant was found to be homozygous for a new antithrombin gene mutation (7396T>C, predicting a Phe229Leu antithrombin variant), and heterozygous for the factor V Leiden mutation. Mild atypical antithrombin deficiency was found in both parents, who were first cousins, asymptomatic, and heterozygous for the same antithrombin gene mutation. The Phe229Leu variant, which does not readily fit into the current classification of antithrombin deficiency, was shown to be a thermolabile antithrombin that spontaneously polymerized in the proband's circulation. This points to a key role for the conserved Phe at position 229, which is near the reactive site loop in a region critical for serpin function and stability. Molecular modeling suggested how the mutation might destabilize this region of the protein and thereby favor reactive site loop insertion and polymerization. This study provides the first direct evidence of antithrombin polymerization in vivo causing antithrombin deficiency and severe thrombotic disease.

[Acute dyspnea in children]

Diagnosis of an acute obstructive dyspnea in children is very difficult, especially in the prehospital setting, because there are many possible causes. However, some of them may rapidly become life-threatening and therefore require a rapid prehospital management by a team staffed by a physician. The main causes of acute dyspnea in children usually include: obstructive dyspnea (acute laryngitis, foreign body aspiration, bronchiolotis, acute asthma), pulmonary infections and cardiac dyspnea, as well as dyspnea from other origins (cardiovascular collapse, hyperthermia, acidosis, intoxication, deshydratation). Following the assessment of the severity of the illness, the prehospital management should aimed at restoring an optimal oxygenation, before initiating a treatment adapted to the cause of the disease.

Effects of halogenated anaesthetics on diaphragmatic actin-myosin cross-bridge kinetics

BACKGROUND

The effects of halogenated anaesthetics on cross-bridge (CB) kinetics are unclear. As halogenated anaesthetics do not markedly modify the intracellular calcium transient in the diaphragm, we used an isolated rat diaphragm preparation to assess the effects of halothane and isoflurane on CB kinetics.

METHODS

The effects of halothane and isoflurane (1 and 2 minimum alveolar concentration (MAC)) on rat diaphragm muscle strips were studied in vitro (Krebs-Henseleit solution, 29 degrees C, oxygen 95%/carbon dioxide 5%) in tetanus mode (50 Hz). From the force-velocity curve and using A. F. Huxley's equations, we determined the main mechanical and energetic variables and calculated CB kinetics.

RESULTS

At 1 and 2 MAC, isoflurane and halothane induced no significant inotropic effects. Whatever the concentrations tested, halothane and isoflurane did not significantly modify the CB number, the elementary force per CB, the attachment and detachment constants, the duration of the CB cycle and mean CB velocity.

CONCLUSION

In the rat diaphragm at therapeutic concentrations, halogenated anaesthetics do not significantly modify CB mechanical and kinetic properties.

Effects of halothane and isoflurane on the contraction, relaxation and energetics of rat diaphragmatic muscle

BACKGROUND

The inotropic effects of halogenated anaesthetics on diaphragmatic muscle remain a matter of debate. Their effects on its relaxation are poorly understood, although diaphragmatic relaxation is recognized as an important physiological process that may interfere with diaphragmatic performance, fatigue and arterial blood flow.

METHODS

The effects of halothane and isoflurane (1 or 2 x minimum alveolar concentration [1 or 2 MAC]) on contraction and relaxation of rat diaphragm muscle strips (n = 40) were studied in vitro from force-velocity curves obtained at various loads from isotonic to isometric conditions. From these curves we determined the peak power output and the curvature. Data are mean (SD) percentage of baseline values.

RESULTS

At I MAC, isoflurane and halothane induced no significant inotropic and lusitropic effects. At 2 MAC, isoflurane induced a negative inotropic effect (active force, 93(5)% of baseline). Halothane and isoflurane induced a significant decrease in the peak power output at 2 MAC (88(8) and 86(9)% of baseline; P < 0.05), without significant changes in the curvature of the force-velocity curve. At 2 MAC isoflurane under high loads and halothane under low loads induced moderate negative lusitropic effects.

CONCLUSION

Halothane and isoflurane induced very moderate inotropic and lusitropic effects, suggesting that the decrease in diaphragm function observed in vivo is not related to a direct effect on diaphragmatic contractility.

Effects of postnatal maturation on energetics and cross-bridge properties in rat diaphragm

The effects of maturation on cross-bridge (CB) properties were studied in rat diaphragm strips obtained at postnatal days 3, 10, and 17 and in adults (10-12 wk old). Calculations of muscle energetics and characteristics of CBs were determined from standard Huxley equations. Maturation did not change the curvature of the force-velocity relationship or the peak of mechanical efficiency. There was a significant increase in the total number of CBs per cross-sectional area (m) with aging but not in single CB force. The turnover rate of myosin ATPase increased, the duration of the CB cycle decreased, and the velocity of CBs decreased significantly only after the first week postpartum. There was a linear relationship between maximum total force and m (r = 0.969, P < 0.001), and between maximum unloaded shortening velocity and m (r = 0.728, P < 0.001). When this study in the rat and previous study in the hamster are compared, it appears that there are few species differences in the postnatal maturation process of the diaphragm.

[Anesthetic management for craniosynostosis]

Surgical procedures for correction of craniosynostosis are performed in young infants with a small blood volume and represent major surgery with extensive blood loss. An accurate determination and a precise restoration of blood losses represent the major concern for the anaesthetist during this surgery. The preoperative assessment of these patients is usually simple, except in the cases where the craniosynostosis is associated with other congenital malformations. The anaesthetist should keep in mind that intracranial hypertension may be associated with craniosysnostosis, which modify the anaesthetic management, especially the induction of anaesthesia. Even though the psychological impact of a craniosynostosis should be taken into consideration, surgery is most often indicated for functional considerations, therefore parents should be informed of the risks related to the procedure. During the postoperative period the major concerns are related to the possibility of a persistent bleeding, which usually decreases and disappears over the first 12 hours.

[Severe head injuries in the young child: early management]

The initial management of severely head-injured patients, including infants and children, is aimed at preventing and treating secondary brain damage, which mainly result from systemic insults (hypoxaemia, hypercarbia, arterial hypotension). Orotracheal intubation, followed by continuous sedation-analgesia, is mandatory when the Glasgow Coma Scale score (GCS) is less than or equal to 8 (crush induction is recommended). The goal of mechanical ventilation is to maintain normoxaemia and normocarbia. Moreover, the maintenance of an optimal cerebral perfusion pressure, usually 50 mmHg in infants, requires volume loading (isotonic fluids and colloids), and catecholamines if arterial hypotension persists. Intravenous mannitol is used only in case of life threatening intracranial hypertension, keeping in mind the potential for aggravating an hypovolaemia. Cerebral tomodensitometry is the most relevant imaging procedure for diagnosing surgical brain lesion. However, it should be noted, that severe head trauma is frequently associated with extra-cranial traumatic injuries, which may be responsible for (avoidable) deaths if the diagnosis is not made or delayed. Therefore, infants and small children presenting with severe head trauma should be considered as multiple injured and treated accordingly. Adequate initial management of severely head-injured children may participate to improved neurological outcome.

[Anesthesia-resuscitation for intracranial expansive processes in children]

The most frequent space-occupying cerebral lesions in children are brain tumors, mostly posterior fossa tumors and haematoma resulting from arteriovenous malformation rupture. They result in intracranial hypertension, directly or by compression of the cerebrospinal fluid pathway resulting in hydrocephalus. Their localization and compressive effects are responsible for specific neurological deficits and general problems. Posterior fossa lesions carry a high risk of obstructive hydrocephalus, cranial nerves palsy and brain stem compression, pituitary and chiasmatic tumors a risk of blindness, pituitary deficiency and diabetes insipidus, and cortical tumors a risk of motor deficit and epilepsy. All these parameters must be analyzed before choosing anaesthetic protocols, and surgical techniques. In the presence of life-threatening intracranial hypertension, emergency anaesthetic induction, tracheal intubation and ventilation are life-saving. The specific treatment consists in either hydrocephalus derivation, initial medical treatment with osmotherapy, or rarely surgical removal. In other situations, surgical process requires a highly deep, stable anaesthesia with perfect control of cerebral haemodynamics. Surgical positioning is complex for these long lasting procedures and carries specific risks. The most common is venous air embolism in the sitting position that must be prevented by the use of specific measures. In the postoperative period, the risk of neurological and general complications commands close surveillance, fast track extubation must be adapted on an individual basis.

[Cardiac arrest in a traumatized child from an unusual cause: atlanto-occipital luxation]

We report the case of a trauma child who developed a cardiac arrest due to atlanto-occipital luxation of the cervical spine. The occurrence of a rapidly reversible cardiac arrest in a trauma patient should alert physicians about cervical trauma. Adequate resuscitation of these patients require endotracheal intubation with concomitant full immobilisation of the cervical spine, plasma expansion to prevent arterial hypotension and immobilisation of the cervical spine during transport. Thorough application of these resuscitation techniques should increase the survival rate on admission to trauma centres of paediatric patients presenting with such a severe condition. Nevertheless, atlanto-occipital luxation is a major cause of paediatric cervical trauma mortality and our patient did not survive this condition.

A survey of practice of tracheal intubation without muscle relaxant in paediatric patients

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 x 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 (< or = 90%) was observed in 15.9% of the infants aged less than 1 year old and in 1.7% of the children, respectively (P < 0.0001).

CONCLUSIONS

Sevoflurane is the most commonly used agent for tracheal intubation without relaxants with higher doses being required in infants aged less than 6 months. Propofol, even with opioids, was not so successful.

[A case of hepatic pseudoaneurysm treated with percutaneous embolization in a child with multiple trauma]

Hepatic artery pseudoaneurysms are rare complications of blunt abdominal trauma in children. Diagnosis is frequently delayed and made by splanchnic angiography. Most of the indications for surgical treatment have disappeared after the development of selective catheterization and embolization. We report a case in an 8-year-old pedestrian who was struck by a car and suffered a multiple trauma with a severe blunt abdominal trauma. A severe collapse upon admission commanded immediate laparotomy that depicted a liver fracture with associated jejunal and pancreatic lesions. Recovery was progressive until the 15th postoperative day where an abrupt haemobilia occurred. A CT-scan exploration was performed and revealed a vascular mass lesion in the left lobe of the liver. The performance of a selective angiography confirmed the diagnosis of left artery pseudoaneurysm, but because of technical difficulties, no embolization could be performed by this way. A direct percutaneous puncture and embolization of the aneurysm allowed a complete exclusion of the lesion. Eventually, recovery was complete. This percutaneous technique could be a valuable alternative to classical embolization and could avoid surgical treatment that still carries a high morbidity.

Minimum alveolar concentration of volatile anesthetics in rats during postnatal maturation

BACKGROUND

Although neonatal rats have become widely used as experimental laboratory animals, minimum alveolar concentration (MAC) values of volatile anesthetics in rats during postnatal maturation remain unknown.

METHODS

We determined MAC values of volatile anesthetics in spontaneously breathing neonatal (2-, 9-, and 30-day-old) and adult Wistar rats exposed to increasing (in 0.1-0.2% steps) concentrations of halothane, isoflurane, or sevoflurane (n = 12-20 in each group), using the tail-clamp technique. MAC and its 95% confidence intervals were calculated using logistic regression and corrected for body temperature (37 degrees C).

RESULTS

In adult rats, inspired MAC values corrected at 37 degrees C were as follows: halothane, 0.88% (confidence interval, 0.82-0.93%); isoflurane, 1.12% (1.07-1.18%); and sevoflurane, 1.97% (1.84-2.10%). In 30-day-old rats, the values were as follows: halothane, 1.14% (1.07-1.20%); isoflurane, 1.67% (1.58-1.76%); and sevoflurane, 2.95% (2.75-3.15%). In 9-day-old rats, inspired MAC values were as follows: halothane, 1.68% (1.58-1.78%); isoflurane, 2.34% (2.21-2.47%); and sevoflurane, 3.74% (3.64-3.86%). In 2-day-old rats, inspired MAC values were as follows: halothane, 1.54% (1.44-1.64%); isoflurane, 1.86% (1.72-2.01%); and sevoflurane, 3.28% (3.09-3.47%).

CONCLUSION

As postnatal age increases, MAC value significantly increases, reaching the greatest value in 9-day-old rats, and decreases thereafter, and at 30 days is still greater than the adult MAC value.

[Pulmonary embolism in sclerotherapy for a venous malformation in a child under general anesthesia]

We report a case of pulmonary embolism associated with percutaneous sclerotherapy (absolute ethanol: 0.5 mL.kg-1) of a venous angioma, performed under general anaesthesia in a 13 year-old child. The diagnosis of pulmonary embolism, suspected on the clinical setting and symptoms, was supported by the pulmonary scintigraphy obtained 4 hours later, showing 3 minimal pulmonary defects. The outcome was rapidly favourable without sequelae under heparin administration and the pulmonary scintigraphy, performed on day 7, was normal. The role of absolute ethanol, for explaining the apparent contrast between the severity of the symptoms and the minimal obstruction noted on pulmonary scintigraphy is discussed. Also discussed are the prophylactic and curative therapeutic issues of this severe complication.

Validity of applying TRISS analysis to paediatric blunt trauma patients managed in a French paediatric level I trauma centre

OBJECTIVE

Using a weighted combination of the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the type of injury (blunt or penetrating) and patient age, the TRISS method is used to calculate the probability of survival (ps) in trauma patients. The goal of this study was to compare the ability of the American Major Trauma Outcome Study (MTOS) norm for adult blunt trauma patients (ADULT) and the specific norm for paediatric patients (PED) to estimate the ps of injured children using TRISS methodology.

DESIGN

Retrospective analysis using a paediatric trauma patient database.

SETTING

A French level 1 paediatric trauma centre.

PATIENTS

Four hundred seven consecutive paediatric blunt trauma patients, treated over a 3-year period.

MEASUREMENTS

The observed and expected survivals were compared, using the M, W and Z scores, with both ADULT and PED. The W score is the number of survivors more or less than expected from the MTOS predictions for 100 patients. A Z score, which measures the significance of W, between -1.96 and +1.96, indicates no significant difference between observed and expected survivors. A value of M less than 0.88 indicates a disparity in the severity match between the study group and the MTOS group. We calculated the standardised W score (Ws), which represents the W score that would have been observed if the case mix of severity was identical to that of the MTOS group. Accordingly, a standardised Z score (Zs) was also calculated. In addition, we calculated the area under the receiver operating curve (aROC) using both norms, while calibration was also assessed by calculation of the Hosmer-Lemeshow goodness-of-fit tests.

RESULTS

Using PED, the number of actual survivors (n = 364) was not significantly different from the MTOS (n = 358). The value of M, 0.65, indicated a disparity in the severity match between the study group and the MTOS group, due to a higher proportion of patients with lower ps (TRISS < 0.95, 52 vs 27%). We was +1.06% (95% confidence interval -0.34 to 2.08) and Zs was 1.48, indicating no significant difference from the MTOS. Using ADULT, the number of observed survivors (n = 364) was significantly higher than that expected (n = 354), with a W score of +2.70% (Z = +1.98, p < 0.05). There was a disparity in the severity match (M = 0.67) between the study group and the MTOS group, due to a higher proportion of patients with lower ps. Ws was +1.32% (95% confidence interval -0.12 to 2.37) and Zs = +1.79 (NS), indicating no significant difference from the MTOS. The Hosmer-Lemeshow statistics indicated that ADULT (Cg = 7.24, p = 0.51; Hg = 4.45, p = 0.81) and PED (Cg = 6.08, p = 0.64; Hg = 3.55, p = 0.90) provided sufficient goodness-of-fit. There was no significant difference in the aROC of the TRISS between the two norms (0.935 +/- 0.050 vs 0.936 +/- 0.050; NS).

CONCLUSION

Both adult and paediatric norms were equally good predictors of the probability of survival of injured children, provided that Ws and Zs are used when there is a disparity in the severity match between the study group and the MTOS group.

Effects of Dantrolene on Rat Diaphragm Muscle during Postnatal Maturation

Background

Dantrolene is the only known effective treatment for malignant hyperthermia. However, its effects on diaphragm muscle during postnatal maturation remain unknown.

Methods

The effects of dantrolene (10(-8) to 10(-4) M) were investigated in vitro on diaphragm muscle strips in adult rats and in postnatal rats aged 3, 10, and 17 days, and compared with those of ryanodine (10(-8) to 10(-6) M). The authors studied contraction and relaxation under isotonic and isometric conditions (29 degrees C, Krebs-Henseleit solution, tetanic stimulation at 50 Hz). Data are mean +/- SD.

Results

During postnatal maturation, the authors observed a progressive increase in active force developed per cross-sectional area (from 34 +/- 25 to 69 +/- 32 mN/mm2; P &lt; 0.05) and maximum shortening velocity (from 2.9 +/- 0.5 to 4.9 +/- 1.4 Lmax/s; P &lt; 0.05). Dantrolene induced a negative inotropic effect in diaphragm muscles in isotonic and isometric conditions in all groups, but this effect was significantly less marked in the 3-day-old rats compared with older rats. Dantrolene did not induce significant lusitropic effects during postnatal maturation. Developmental changes in the pharmacologic response to dantrolene were more rapid than those of ryanodine.

Conclusion

Dantrolene induced less pronounced negative inotropic effects on the diaphragm in neonatal rats as compared with adult rats. Our study suggests that developmental changes in the pharmacologic response to dantrolene are more rapid than those of ryanodine.

[Acute hemolysis following perioperative blood salvage in chldren operated for the surgical correction of craniosynostosis]

We report the case of a 6-month-old child, who suffered from acute haemolysis following transfusion of salvaged blood. This complication, of favourable outcome, was related to the accidental aspiration of benzalkonium chloride into the cell saver. This case emphasizes that any adjunction of antiseptic solution is contraindicated during blood saving. The use of a cell saver must be associated with written protocols, describing clearly the contraindications, precautions of use, and the different steps of use of this method of autologous blood transfusion.