Alain Rochette

Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study.

Background:Surgical correction of craniosynostosis in children is associated with substantial intraoperative bleeding. Tranexamic acid (TXA) decreases intraoperative blood loss during cardiac or orthopedic surgery in children. We hypothesized that intraoperative TXA would reduce blood transfusion relative to placebo in patients pretreated with erythropoietin. Methods:Forty consecutive children, American Society of Anesthesiologists status 1 or 2, scheduled to undergo surgical correction of craniosynostosis were randomly assigned to receive either intravenous TXA or saline, 0.9%, intraoperatively. All children received preoperative erythropoietin (600 U/kg once a week for 3 weeks before surgery). Perioperative blood loss, number and volume of transfusions, percentage of children who underwent transfusion, and side effects were noted after surgery and at the end of the study. Surgeon satisfaction and cost of treatment were also recorded. Results:There was no significant difference between groups in demographic or surgical data. In the TXA group, the volume of packed erythrocytes transfused was significantly reduced by 85% (from 11 to 1.6 ml/kg) intraoperatively and by 57% (from 16.6 to 7.2 ml/kg) throughout the study period (P < 0.05). Compared with the placebo group, the percentage of children requiring blood transfusion was lower in the TXA group during surgery (9 [45%] of 20 vs. 2 [11%] of 19 children; P < 0.05) and during the whole study period (14 [70%] of 20 vs. 7 [37%] of 19; P < 0.05). Preoperative and postoperative hematologic parameters were comparable in both groups. There were no adverse events. Conclusion:In children undergoing surgical correction of craniosynostosis and pretreated with erythropoietin, intraoperative TXA reduces the transfusion requirement.

Continuous epidural block versus continuous popliteal nerve block for postoperative pain relief after major podiatric surgery in children: a prospective, comparative randomized study.

Foot and ankle surgery in children is very painful postoperatively. Adverse effects from opioids and continuous epidural block (CEB) limit their use in children. Continuous popliteal nerve blocks (CPNB) have not been studied for this indication in children. In this prospective, randomized study we evaluated the effectiveness and adverse events of CPNB or CEB in children after podiatric surgery. Fifty-two children scheduled for foot surgery were separated into four groups by age and analgesia technique. After general anesthesia, 0.5 to 1 mL/kg of an equal-volume mixture of 0.25% bupivacaine and 1% lidocaine with 1:200000 epinephrine was injected via epidural or popliteal catheters. In the postoperative period, 0.1 mL·kg−1·h−1 (group CPNB) or 0.2 mL·kg−1·h−1 (group CEB) of 0.2% ropivacaine was administered for 48 h. Niflumic acid was routinely used. Adverse events were noted in each treatment group. Postoperative pain during motion was evaluated at 1, 6, 12, 18, 24, 36, and 48 h. Requirement for rescue analgesia (first-line propacetamol 30 mg/kg 4 times daily or second-line 0.2 mg/kg IV nalbuphine), and motor blockade were recorded. Parental satisfaction was noted at 48 h. Twenty-seven patients were included in the CEB groups and 25 in CPNB groups. There were 32 children 1 to 6 yr of age (CPNB = 15; CEB = 17) and 20 children 7 to 12 yr of age (CPNB = 10; CEB = 10). The demographic data were comparable among groups. Postoperative analgesia was excellent for the two continuous block techniques and in the two age groups. Motor block intensity was equal between techniques. Adverse events (postoperative nausea or vomiting, urinary retention, and premature discontinuation of local anesthetic infusion in the 1- to 6-yr-old group) were significantly more frequent in the CEB group (P < 0.05). Eighty-six percent of the parents in the CEB groups and 100% in the CPNB groups were satisfied. We conclude that although both CEB and CPNB resulted in excellent postoperative analgesia in this study, CPNB was associated with less urinary retention and nausea and vomiting. Therefore, we recommend CPNB as the ideal form of postoperative analgesia after major podiatric surgery in 1- to 12-yr-old children.

Developmental pharmacology of tramadol during infancy : ontogeny, pharmacogenetics and elimination clearance

Aims and objectives:  To illustrate the complex interaction between ontogeny, i.e., age‐dependent maturation, genetic polymorphisms and renal elimination clearance during infancy, based on developmental disposition of intravenous tramadol during infancy.

A review of pediatric regional anesthesia practice during a 17-year period in a single institution

Background:  There is anecdotal evidence of changes in pediatric regional anesthesia (RA) practice. We performed a retrospective review of prospective data on pediatric RA over 17 years in our institution.

Clonidine added to bupivacaine in neonatal spinal anesthesia: a prospective comparison in 124 preterm and term infants.

Background:  Spinal anesthesia (SA) remains the ‘gold standard’ in neonatal anesthesia for inguinal herniorrhaphy but its short duration impedes its usefulness. We previously demonstrated that clonidine prolongs neonatal SA without immediate side effects.

A new approach for peri-operative analgesia of cleft palate repair in infants: the bilateral suprazygomatic maxillary nerve block.

Background:  Congenital cleft palate (CP) is a common and painful surgical procedure in infants. CP repair is associated with the risk of postoperative airway obstruction, which may be increased with administration of opioids, often needed for analgesia. No described regional anesthesia technique can provide adequate pain control following CP repair in infants. The primary aim of this prospective and descriptive study was to observe the effectiveness of bilateral maxillary nerve blocks (BMB) using a suprazygomatic approach on pain relief and consumption of rescue analgesics following CP repair in infants. Analgesic consumption was compared to retrospective data. Complications related to this new technique in infants were also reviewed.

A prospective comparison of post-surgical behavioral pain scales in preschoolers highlighting the risk of false evaluations.

ABSTRACT Four behavioral rating scales (BRS) (CHEOPS, CHIPPS, FLACC and OPS) assessing postoperative pain in children aged 1–7 years were studied to compare their psychometric properties, sensitivity and specificity. One hundred and fifty children included in this prospective longitudinal study were videotaped to analyze retrospectively peri‐operative behaviors. Pain and anxiety were evaluated by children or by their parents prospectively. At the end of the study, four observers rated the peri‐operative videos using the four BRS. Because self‐reporting cannot be used for all the children, facial expression of pain was analyzed from the videos to create a Facial Action Summary Score (FASS) which was considered as a reference for the study of validity of the four BRS. Internal validities were excellent but external validities were mixed. The FLACC seems to be better adapted to assess post‐surgical pain in children between 1 and 7 years old. Nevertheless, it was significantly correlated with anxiety measures. Moreover, the analysis of sensitivity and specificity using both self‐reporting of pain and FASS showed that some children were still under‐evaluated. The multivariate analysis underlines silence as a high risk factor of misevaluating postoperative pain. In conclusion, this study highlights the difficulty of discriminating pain intensity from anxiety when using the four BRS and that postoperatively, nearly one child in 10 was misevaluated.

Changing trends in paediatric regional anaesthetic practice in recent years.

Purpose of review Regional anaesthesia has come to a substantial position in paediatric anaesthesia. Time has now come to assess what has reached significant acceptance in daily practice and try to clear possible ways up for the next steps to come. Recent findings Epidemiologic data produced in the last 2 years provide useful information about the place taken by regional anaesthesia as a whole and by the most popular blocks nowadays. Significant series seem to open a track in the field of postoperative pain management at home. Ultrasound guidance takes a great part in recent publications. The most relevant, according to the location of blocks and in the scope of security, are presented. Change in anatomical background that ultrasonography demands is questioned. Finally, most recently described approaches and their potential advantages have been looked at. Summary Lessons can be drawn from epidemiologic data now available and possible ways for changes in a near future can be anticipated. Ultrasonology brings clear advantages in abdominal wall blocks. Its use in place of nerve stimulation is claimed forcefully but not yet widely used for the blocks of the limbs in children. This switch requires profound changes in the practice of regional anaesthesia which will probably not take place immediately. Blocks of the face appear innovating and promising, according to recent literature.

Continuous infusion of ropivacaïne: an optimal postoperative analgesia regimen for iliac crest bone graft in children

Background:  Postoperative analgesia of iliac crest (IC) donor site can be performed by on site infiltrations of local anesthetics (LA) or morphine. Single injections or continuous infusions of LA proved their efficacy in adults, but was not reported in children. We prospectively evaluated the interest of a continuous infusion of 0.2% ropivacaïne at the IC donor site in terms of postoperative pain relief and rescue analgesics consumption.

Transpulmonary thermodilution hemodynamic monitoring for pheochromocytoma surgery in a child with complex congenital heart disease

Hemodynamic alterations related to pheochromocytoma surgery may lead to decompensation with an associated cardiac malformation. Moreover, they are incompletely described in children because of potential hazards of invasive monitoring. We report transpulmonary thermodilution hemodynamic monitoring during pheochromocytoma surgery in a child with a complex congenital heart malformation. Comprehensive analysis of hemodynamic events was obtained that guided therapeutic decisions. Cardiac function was preserved and no complication occurred.