C. Mottolese

Predicting fluid responsiveness in mechanically ventilated children under general anaesthesia using dynamic parameters and transthoracic echocardiography

BACKGROUNDnDynamic variables are accurate predictors of fluid responsiveness in adults undergoing mechanical ventilation. They can be determined using respiratory variation in aortic flow peak velocity (▵Vpeak), arterial pulse pressure [▵PP and pulse pressure variation (PPV)], or plethysmographic waveform amplitude [▵POP and pleth variability index (PVI)]. These indices have not been validated in children. We studied the ability of these variables to predict fluid responsiveness in mechanically ventilated children.nnnMETHODSnAll results are expressed as median [median absolute deviation (MAD)]. Thirty mechanically ventilated children were studied after undergoing general anaesthesia. Mechanical ventilation was maintained with a tidal volume of 10 ml kg(-1) of body weight. ▵PP, PPV, ▵POP, PVI, ▵Vpeak, and aortic velocity-time integral were recorded before and after volume expansion (VE). Patients were considered to be responders to VE when the aortic velocity-time integral increased more than 15% after VE.nnnRESULTSnVE induced significant changes in ▵PP [13 (MAD 4) to 9 (5)%], PPV [15 (5) to 9 (5)%], ▵POP [15 (10) to 10 (6)%], PVI [13 (6) to 8 (5)%], and ▵Vpeak [16 (9) to 8 (3)%] (P<0.05 for all). Differences in ▵PP, ▵POP, PPV, and PVI did not reach statistical significance. Only ▵Vpeak was significantly different between responders (R) and non-responders (NR) to VE [22 (3) vs 7 (1)%, respectively; P<0.001]. The threshold ▵Vpeak value of 10% allowed discrimination between R and NR.nnnCONCLUSIONSnIn this study, ▵Vpeak was the most appropriate variable to predict fluid responsiveness.

Craniocerebral injury resulting from transorbital stick penetration in children.

Abstractu2002Objects: Two children were admitted to hospital for treatment of craniocerebral injury with transorbital penetration. Methods: One child aged 6 years and 6 months had poked a chopstick in his orbit. There was no report of either a palpebral or an ocular wound. He had subsequently developed a meningeal syndrome with a cerebral abscess managed by needle aspiration biopsy and intravenous antibiotics. The other child, aged 4, had fallen onto a metal rod. He presented with a palpebral wound, motor disorders and coma, all due to a frontal intracerebral hematoma. There was an improvement in outcome without complications of an infectious nature or motor sequelae. Conclusions: Such head injuries are rare. Clinical, radiological and ophthalmological investigations must be performed, including computed tomography (CT) scan or cerebral magnetic resonance imaging (MRI) with antibiotic treatment for suspected microorganisms.

Delayed rupture of traumatic aneurysm after civilian craniocerebral gunshot injury in children

BackgroundThere are few published large series on civilian craniocerebral gunshot injuries in children. Traumatic intracranial aneurysms (TICAs) are rare and highly unstable lesions. They represent less than 1% of all aneurysms and can either rupture within minutes after formation or remain quiescent for several weeks or years, manifesting with delayed hemorrhage and neurologic deterioration.Case historyWe report the case of a 10-year-old girl who was referred for coma after high-velocity craniocerebral gunshot wound and neurological deterioration 7xa0days after the initial injury. A massive right posterior occipital hematoma caused by the rupture of an unsuspected right posterior cerebral artery TICA was discovered. TICA was treated by coil embolization, with a good neurological recovery at 6-month follow-up.DiscussionWe discuss the pathogenesis and the management of TICA in a child after civilian craniocerebral gunshot injuries.ConclusionsTICAs should be suspected in patients with civilian craniocerebral gunshot injuries, presenting with secondary neurological deterioration, to carry out emergent CT scan and angiographic exploration before contemplating definitive endovascular treatment. Endovascular management may be a prompt safe-to-use technique and a valuable option, especially when surgery is highly risky.

Ventriculostomie du troisième ventricule et diabète insipide

Resume Nous rapportons le cas dun enfant de deux ans, ayant eu un diabete insipide definitif apres une ventriculostomie du troisieme ventricule pour hydrocephalie par malformation de Dandy-Walker. Cette technique, utilisee dans le traitement de lhydrocephalie non communicante, peut etre source de complications, dont le diabete insipide. Celui-ci a ete rarement decrit et il est le plus souvent transitoire. Cette eventualite impose une surveillance postoperatoire attentive, notamment chez le petit enfant.

Respiratory distress caused by migration of ventriculoperitoneal shunt catheter into the chest cavity.

Sirs: There are many reported complications related to the peritoneal catheters of ventriculoperitoneal shunt. We present a case of potentially life-threatening complication of ventriculoperitoneal shunting involving migration of the distal catheter into the pleural cavity. An 8-month-old boy was admitted because of rapidly increased head circumference associated with bulging anterior fontanel. Computed tomography demonstrated communicating hydrocephalus. A right ventriculoperitoneal shunt with a lowpressure valve system was inserted. The postoperative course was uneventful. On the first postoperative day radiography was performed of the head, neck, chest, and abdomen to verify correct catheter placement. These were considered to demonstrate excellent positioning of the various catheters. At 11 months of age the child was admitted with a 1-week history of labored breathing. His breath sounds were markedly diminished on the right. Chest radiography demonstrated coiling of the distal shunt catheter in the chest with a large right pleural effusion and mediastinal shift (Fig.1). A quantity of 600 ml clear fluid was drained from the right pleural cavity. The respiratory distress rapidly improved. At surgery the valve was replaced with a new distal intraperitoneal catheter. The postoperative course was uneventful and roentgenograms showed that the abdominal catheter remained in the peritoneal cavity. Numerous abdominal complications from ventriculoperitoneal shunts have been reported [1]. The thoracic complications are manifested as pleural effusion, bronchial perforation, pneumothorax, and pneumonia [2]. Potentially life-threatening complications occur with the migration of the abdominal catheter into the thorax. The migration may be supradiaphragmatic or transdiaphragmatic. In supradiaphragmatic migration the site of entry into the chest is incorrect subcutaneous passage during distal tunneling. The shunt can be inadvertently passed into and out of the pleural cavity, probably in the supraclavicular fossa, during the distal tunneling procedure. Negative inspiratory pressure and increased patient movement can slowly draw the entire distal shunt catheter into the chest, with the tip entering the chest last. Transdiaphragmatic migration is possible by two routes [2]. A possible anchoring effect, caused by fibrous encasement of the peritoneal catheter as a result of inflammation, may result in repeated pressure by its tip at a fixed point on the diaphragm surface, eventually leading to perforation [2]. Another possible route is through the congenital defect in the diaphragm, Morgagnis or esophageal hiatus [3], or other small defects. In our case the route of migration of the catheter seems to have been the right xiphocostal margin at the anatomical point beneath the rectus abdominis muscle where the superior epigastric vessels perforate the diaphragm. In the infant and children younger than 5 years of age, respiratory insufficiency is more severe because the pleura cannot absorb sufficient CSF [4, 5]. Therefore, in this case, the peritoneal catheter probably migrated into the thoracic cavity shortly before the respiratory distress occurred. This case demonstrates the need for careful and complete assessment of all patients with ventriculoperitoneal shunts who present with symptoms and signs initially thought to be unrelated to their shunts.

Ultrasonographic anatomic variations of the major veins in paediatric patients

BACKGROUNDnThe aim of our study was to describe the anatomic relationships in internal jugular (IJV), subclavian (SCV), and femoral (FV) vein sites.nnnMETHODSnOne hundred and forty-two children had a two-dimensional (2D) ultrasound (US) evaluation of IJV, SCV, and FV sites. They were enrolled according to their age: 0-1 month old (n=9), 1 month old to 2 yr old (n=61), 2-6 yr old (n=22), 6-12 yr old (n=32), and 12-18 yr old (n=18).nnnRESULTSnWe found about 7.7% variation for the IJV. The most common anatomic variations were a lateral (nine children) or anterior (nine children) position of the IJV to the carotid artery. Regardless of the age category, about 9.8% of the anatomic variations were found for the FV. The most common anatomic variation in our study was that the FV ran anteromedially to the femoral artery (17 children). Anatomic variation of the SCV, regardless of age category, was about 7.4%. The most common anatomic variation was the SCV, which ran medially (10 children) to the subclavian artery.nnnCONCLUSIONSnThe relevant percentages of anatomic variations obtained for all these areas support at least a systematic US screening before attempting to obtain central venous access, ideally using a US-guided technique.

Levobupivacaine scalp nerve block in children

I read with interest the comment to my recent editorial by Dr Stümpelmann. I believe that we agree in principle that a low-glucose containing solution that also includes a near normal level of sodium would be a very good ‘compromise’ that is a substantially better alternative than that currently available to most pediatric anesthetists. I believe that we also agree that the use of such a ‘golden compromise solution’ would significantly reduce the risks involved with the current practice of perioperative fluid management in children. However, how such a new intravenous formulation should be composed to be as near perfect as possible is of course a matter for discussion. In this regard I would like to clarify that I do not ‘recommend’ the French solution but I do believe that Murat et al. deserve recognition for being the first to both report this concept, as well as bringing it into an available product. My hope now is as stated in the editorial that some medical company will start to produce and market an intravenous solution specially designed for perioperative use in children and that this company will make it available world-wide since this will, in my opinion, reduce both morbidity and mortality in children undergoing surgery. Per-Arne Lönnqvist M D D E A A F R C A P h D Paediatric Anaesthesia & Intensive Care, Astrid Lindgrens Children’s Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden (email: per-arne.lonnqvist@ki.se)

Opioid consumption after levobupivacaine scalp nerve block for craniosynostosis surgery

BACKGROUND AND OBJECTIVESnCraniosynostosis surgery is considered a very painful procedure due to extended scalp and periosteal detachment, and is associated with prolonged postoperative consumption of opioids and their side effects. In this observational descriptive case series study, we investigated perioperative opioid consumption in children undergoing craniosynostosis repair under general anesthesia when scalp nerve block with levobupivacaine was involved.nnnMETHODSnAfter standard anesthesia induction, scalp nerve block with levobupivacaine 2 mg/kg plus epinephrine 1:800,000 was performed. Hemodynamic parameters and opioid consumption were noted. Patients were monitored in the recovery room. Requirements of additional analgesia, indicated by the Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) pain score of >9, and incidence of side effects (sedation, nausea, and vomiting) were recorded during the first 24 hours.nnnRESULTSnA total of 32 patients were recruited in this study; 88% of them needed morphine rescue in the recovery room because they had high CHEOPS scores. Trigonocephaly was the most frequent type of craniosynostosis (37.5%), requiring 50% more opioids in the postoperative period than other forms of craniosynostosis.nnnCONCLUSIONnScalp nerve block can be proposed as a complement to the routine craniosynostosis anesthetic protocol, because it is easy to perform, seems to reduce the need for supplementary opioids during the perioperative period, and can reduce the risk of developing acute opioid tolerance and chronic pain. In the event of trigonocephaly or craniofacial reconstruction, a complementary infraorbital nerve block can be added.

Conception et évaluation de la qualité d’une information écrite sur le scanner et l’imagerie par résonance magnétique en neuropédiatrie

INTRODUCTIONnWe designed written information concerning two medical imaging techniques: the computed tomography scanner and the magnetic resonance imaging (MRI), and we evaluated the quality of the information in particular its readability.nnnMETHODSnWritten information concerning scanner and MRI were elaborate starting from a reference frame based on a lexicon of the good practices. The written information sheets were initially reviewed by eight doctors, 45 nurses and by 26 couples of parents of hospitalized children, and finally by the communication and juridical services of our hospital. They were asked to improve the lexico-syntactic readability in order to increase the comprehension of the written information. Seventy-two couples of parents of hospitalized children who had not taken part of the protocol before evaluated the final version of the documents. The quality of the documents was evaluated using the scores of readability of Flesch and the Flesch-Kincaid, and a questionnaire of comprehension, managed before and after the delivery of written information.nnnRESULTSnA total of 144 persons participated in the study. The number of right answers after reading written information increased by 38 % and by 35 % for the scanner and MRI informations respectively. Flesch and Flesch-Kincaid scores were not improved in the revised version of the written information compared to the first version.nnnCONCLUSIONnAlthough readability scores for information sheets were low, our results suggest that they brought information, which contributed to a better understanding of these two medical imaging techniques by parents.