Chrystelle Sola

Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study

Background:  Bilateral suprazygomatic maxillary nerve blocks approach improves pain relief after palate surgery. We report the feasibility and efficiency of ultrasound‐guided suprazygomatic maxillary nerve blocks in cleft palate repair in children.

Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children: a prospective, randomized, double-blind study versus placebo.

Background:The authors investigated the efficacy of bilateral suprazygomatic maxillary nerve block (SMB) for postoperative pain relief in infants undergoing cleft palate repair. Methods:In this prospective, double-blind, single-site, randomized, and parallel-arm controlled trial, 60 children were assigned to undergo bilateral SMB with general anesthesia with either 0.15 ml/kg of 0.2% ropivacaine (Ropi group) or 0.15 ml/kg of isotonic saline (Saline group) on each side. The primary endpoint was total postoperative morphine consumption at 48 h. Pain scores and respiratory- and SMB-related complications were noted. Results:The overall dose of intravenous morphine after 48 h (mean [95% CI]) was lower in the Ropi group compared with that in the Saline group (104.3 [68.9 to 139.6] vs. 205.2 [130.7 to 279.7] &mgr;g/kg; P = 0.033). Continuous morphine infusion was less frequent in the Ropi group compared with that in the Saline group (1 patient [3.6%] vs. 9 patients [31%]; P = 0.006). Three patients in the Saline group had an episode of oxygen desaturation requiring oxygen therapy. There were no technical failures or immediate complications of the SMB. Intraoperative hemodynamic parameters, doses of sufentanil, pain scores, and postoperative hydroxyzine requirements were not different between the two groups. Conclusion:Bilateral SMB is an easy regional anesthesia technique that reduces total morphine consumption at 48 h after cleft palate repair in children and the use of continuous infusion of morphine and may decrease postoperative respiratory complications.

Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study

Preoperative anxiety management receives special attention in pediatric anesthesia. Different pharmacological and nonpharmacological techniques can be employed. This study was designed to assess three different strategies for childhood preoperative anxiolysis: midazolam premedication, midazolam in combination with portable Digital Video‐Disk player, or video distraction strategy alone.

Children with challenging airways: What about GlideScope® video-laryngoscopy?

BACKGROUND GlideScope® video-laryngoscopy is becoming increasingly used, including in paediatrics. However, to date, very few data are available on efficiency during situations involving difficult intubation. Our objective was to describe the usefulness of the GlideScope® in children with presumed challenging airway criteria. METHODS In this observational study, all children with predicted criteria of potential difficult intubation and requiring general anaesthesia with tracheal intubation were prospectively enrolled over a 12-month period. The Cormack and Lehane (CMK) grade was first assessed by direct laryngoscopy. In case of a CMK≥3, the same experienced anaesthesiologist scored the CMK scale under GlideScope® videoscopy. Data related to GlideScope® use under difficult intubation conditions were analysed. RESULTS Out of the sixty-one patients (median [25th-75th interquartile range] age of 12 [4-37] months) included, 37 (62%) patients have confirmed a high probability of difficult intubation. Compared to direct laryngoscopy, GlideScope® video-laryngoscopy was significantly associated with an improved CMK grade (P<0.001). Tracheal intubation with the GlideScope® was successful after the first attempt in almost one half of cases and ultimately in 100% of patients. The median time required for successful GlideScope® intubation was 42.5 [30-60] s. No per procedure complications were recorded. CONCLUSION In children with challenging airways, GlideScope® video-laryngoscopy resulted in a significant improvement of the glottic view with an excellent success rate and satisfactory time to intubation. How these devices are to be positioned in difficult airway management algorithms and guidelines remain to be defined.

Ultrasound-guided tranversus abdominis plane block for herniorrhaphy in children: what is the optimal dose of levobupivacaine?

BACKGROUND Regional anaesthesic techniques are commonly used for the management of pain following lower abdominal surgery in children. The transversus abdominis plane (TAP) block has shown promise for perioperative analgesia, but data on the optimal dose regimen are limited. OBJECTIVE To evaluate the optimal dose of levobupivacaine for successful ultrasound-guided TAP block in children. DESIGN A dose finding prospective study using Dixons up-and-down sequential method. SETTING University Hospital Paediatric Anaesthesia Unit. PATIENTS Twenty-seven consecutive children aged 1 to 5 years scheduled for day-case elective herniorrhaphy. INTERVENTION After standardised induction of general anaesthesia, ultrasound-guided TAP block was performed with a fixed volume of 0.2 ml kg−1 of levobupivacaine solution. The dose of levobupivacaine was determined by Dixons up-and-down method starting from 0.5 mg kg−1 with an interval of 0.1 mg kg−1. Block failure was defined as a 20% increase in heart rate or mean arterial pressure from baseline. Rescue analgesia consisted of intravenous remifentanil infusion during surgery and intravenous nalbuphine in the postanaesthetic care unit (PACU). Patients were assessed using the FLACC (face, legs, activity, cry and consolability) pain scale, the rescue analgesic consumption in the PACU and day-case unit and the postoperative pain measure for parents score at home. MAIN OUTCOME MEASURES The mean effective dose of levobupivacaine resulting in an effective TAP block in 50% of cases (ED50) obtained by using Dixons up-and-down sequential method. The ED50 and ED95 were further estimated by bootstrapping. RESULTS The ED50 according to the up-and-down staircase method was 0.22 mg kg−1 [95% confidence interval (CI) 0.19 to 0.25]. Bootstrap replicates of the original dataset resulted in ED50 and ED95 estimates of 0.16 mg kg−1 (95% CI 0.11 to 0.24) and 0.43 mg kg−1 (95% CI 0.30 to 0.57), respectively. CONCLUSION As part of a multimodal analgesia strategy, ultrasound-guided TAP block with 0.2 ml kg−1 of 0.2% levobupivacaine provides successful peroperative analgesia in 95% of children who underwent herniorrhaphy.

Management of mediastinal syndromes in pediatrics: a new challenge of ultrasound guidance to avoid high‐risk general anesthesia

Adverse events associated with anesthetic management of anterior mediastinal masses in pediatrics are common. To avoid an extremely hazardous general anesthesia, the use of real‐time ultrasonography offers an effective alternative in high‐risk cases. We report the anesthetic management including a light sedation and ultrasound guidance for regional anesthesia, surgical node biopsy, and placement of a central venous line in two children with an anterior symptomatic mediastinal mass. For pediatric patients with clinical and/or radiologic signs of airway compression, ultrasound guidance provides safety technical assistance to avoid general anesthesia and should be performed for the initial diagnostic and therapeutic procedures.

Ultrasound-guided pudendal nerve block in children: A new technique of ultrasound-guided transperineal approach.

Transperineal pudendal nerve block guided by nerve stimulator is used in pediatric anesthesia as an alternative to caudal analgesia in perineal surgery. The risk of rectal puncture or intravascular injection is inherent to this blinded technique. We described a new technique of transperineal pudendal nerve block, with ultrasound guidance, to improve safety of the technique.

Acute Pain Management in a Child: A Case Report of 46-Days of Popliteal Sciatic Nerve Catheter

Background: The use of perineural catheter for more than 72 hours is rare in perioperative practice, but was especially reported for chronic pain, oncologic related pain or palliative care. The main concern remains the risk of neurological or infectious complication. No guideline clearly specifies the maximum duration of perineural catheter maintenance and the safety of long-term catheters is discussed. Case report: We described the case of an 11-year-old boy who suffered a serious injury on his foot. An ultrasound guided sciatic nerve block was performed, with placement of a non-tunneled perineural catheter. The catheter could be used for 46 days with an excellent efficiency both for analgesia (continuous infusion) and anesthesia (additional bolus for surgical procedure). No infectious or neurological related complication to regional anesthesia was notified. Conclusion: This case demonstrates all the benefits that can be expected by long-term perineural catheter, even if it should be managed with great caution and after careful assessment of the risk-benefit balance. number of days before removal of the catheter with an increased risk after 3 days of catheter maintenance [2]. But only few transient and no major neurologic complications were reported [2]. In pediatric, PNBC are often used for postoperative analgesia after orthopedic or general surgery and are typically removed after only 2-3 days. Long term used of PNBC have yet been described for control of chronic pain, oncologic related pain or palliative care in young adults and children [3-5]. We present the case of a child who required the use of a PNBC over a long period of 46 days for perioperative pain management. The child and his family consented to the anonymous publication of this case. Description of the Case An 11-years-old boy, weighting 38 kg, without medical or surgical history, was admitted to our unit after a motor vehicle-pedestrian trauma. The child presented a faciocranial trauma with an initial loss of consciousness but a Glasgow score of 14 at the arrival of medical assistance. A fracture of the right horizontal branch of the mandibular corpus was diagnosed and treated by surgical osteosynthesis. Moreover, there was a severe injury with a large soft tissue defect extending from the internal malleolus to the second phalangeal of the right hallux and musculotendinous and osseous exposure. No vascular compromise was noted and the limited initial neurological exam was not able to objectify significant nerve injury or deficit. The patient complained of diffuse pain. However, shocked by the accident, it was not possible to assess the level of his pain. It was decided to treat him by sedation-analgesia with ketamine. Surgical CASe RePoRt

Transversus Abdominal Plane Block in Children: Efficacy and Safety: A Randomized Clinical Study and Pharmacokinetic Profile.

BACKGROUND: The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. METHODS: This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg−1 levobupivacaine as either HVLC (0.2 mL·kg−1 of 0.2% levobupivacaine) or LVHC (0.1 mL·kg−1 of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. RESULTS: Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29–1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference −0.60 (95% CI, −1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL−1, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL−1, remained far below theoretical toxic thresholds. CONCLUSIONS: In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg−1 administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.BACKGROUND The transversus abdominis plane (TAP) block has become a common regional anesthesia technique for pain management in a wide variety of abdominal procedures. Evidence to support any particular local anesthetic regimen as well as pharmacokinetic and systemic toxicity risks of TAP block remain insufficiently studied in children. The aim of this study was to compare the analgesic effects and investigate pharmacokinetic profile of levobupivacaine after ultrasound-guided TAP block using a low volume/high concentration (LVHC) or a high volume/low concentration (HVLC) solution in children. METHODS This prospective randomized study included children scheduled for day-case inguinal surgery. Children were randomized to receive TAP block using 0.4 mg·kg levobupivacaine as either HVLC (0.2 mL·kg of 0.2% levobupivacaine) or LVHC (0.1 mL·kg of 0.4% levobupivacaine). The primary outcome was the number of children who required opioid rescue analgesia postoperatively. Pharmacokinetic profile study of levobupivacaine was also performed. RESULTS Seventy patients were equally randomized, and 65 were included in the final analysis. Seventy-one percent of patients did not require any postoperative opioid analgesia. The number of patients who received rescue analgesia was 12 (35%) in the LVHC group and 7 (23%) in the HVLC group (relative risk, 0.64; 95% confidence interval [CI], 0.29-1.42; P = .26). Mean pain scores (FLACC [faces, legs, activity, cry, and consolability]) at postanesthesia care unit discharge did not differ between LVHC and HVLC groups, respectively, 0.39 ± 0.86 and 1 ± 1.71 with mean group difference -0.60 (95% CI, -1.27 to 0.06; P = .08). The pharmacokinetic profile of levobupivacaine was comparable in the 2 groups: the mean total and free levobupivacaine peak concentrations were 379 ± 248 and 3.95 ± 3.16 ng·mL, respectively, occurring 22.5 ± 11 minutes after injection. The highest total and free levobupivacaine concentrations collected, respectively, 1360 and 15.1 ng·mL, remained far below theoretical toxic thresholds. CONCLUSIONS In children, quality of postoperative pain control provided by TAP block using levobupivacaine 0.4 mg·kg administered as either HVLC or LVHC did not differ and was associated with a very low risk of local anesthetic systemic toxicity.