Francis Veyckemans

Levosimendan in Congenital Cardiac Surgery: A Randomized, Double-Blind Clinical Trial

OBJECTIVE In this study, the authors used a continuous infusion of either levosimendan or milrinone as inotropic support after corrective congenital cardiac surgery. The hemodynamic and biochemical parameters were compared. DESIGN A prospective, randomized, double-blind clinical study. SETTING A university hospital. PARTICIPANTS Forty-one patients between 0 and 5 years old requiring inotropic support for corrective congenital heart surgery under cardiopulmonary bypass (CPB) were enrolled in this trial. Thirty-six patients completed the study. INTERVENTIONS Patients were randomized in a double-blind fashion to a continuous infusion of either levosimendan at 0.05 μg/kg/min or milrinone at 0.4 μg/kg/min started at the onset of CPB. Epinephrine was started at 0.02 μg/kg/min after aortic cross-clamp release in both groups. MEASUREMENTS AND MAIN RESULTS There was no significant difference between serum lactate levels of groups. The rate-pressure index (the product of heart rate and systolic blood pressure), which is an indicator of myocardial oxygen demand, was significantly lower at 24 hours and 48 hours postoperatively in the levosimendan group (p < 0.001) in comparison to the milrinone group. Although not significantly different, the troponin values in the levosimendan group were less at 1 hour (median [P(25)-P(75)]: 20.7 [15.3- 48.3] v 34.6 [23.8- 64.5] ng/mL and 4 hours postoperatively: 30.4 [17.3-59.9] v 33.3 [25.5-76.7] ng/mL). CONCLUSION Levosimendan is at least as efficacious as milrinone after corrective congenital cardiac surgery in neonates and infants.

Clinical practice: Analgesia in neonates

Effective management of pain remains an important indicator of the quality of care provided to neonates. Since the review of McIntosh in this journal over a decade ago, an extensive number of papers on assessment, prevention, and treatment of pain have been reported. In addition, preclinical insights into neurodevelopmental aspects of pain processing and the neuro-apoptotic effects of analgesics and sedatives were unveiled. Based on the newly collected evidence, the practice of “one-drug, one dose and one treatment fits all” became obsolete, necessitating a more individualized analgesia, based on non-pharmacological and pharmacological therapies and preventive strategies for effective management of neonatal pain. The progress made is impressive, but the current major challenge is to implement the available knowledge in clinical care. Future research should therefore focus on the evaluation of the effectiveness of non-opioid and moderately potent opioids compared to morphine and should also describe the methods to facilitate effective implementation. Finally, there is an extensive field of procedural techniques that need to be evaluated on their pain related response.

Caustic burns of the upper digestive and respiratory tracts.

In a series of 51 children presenting with an accidental caustic burn, symptoms were analysed for their predictive value of significant i.e. necrotizing oesophageal lesions (grade II or III). For the whole group, the incidence of significant oesophageal lesions was 37%. Vomiting and/or respiratory distress were associated with high incidence of significant oesophageal burn (84% and 75% respectively). The particular location of each caustic burn was analysed for its association with caustic burns at other anatomical sites. Of the 18 patients with a laryngeal burn, 72% also had a grade II or III oesophageal burn. The 19 patients with a grade II or III oesophageal burn and the 18 patients with a laryngeal burn, all had lesions at other sites. In the group of 19 patients with a caustic lesion limited to one site, only 1 patient showed mild oesophagitis (grade I) without late sequelae.

Cerebral NIRS and superior vena cava ScvO2 should not be compared

SIR—We thank Drs. Makkar and Singh for their interest in our published report (1). They asked whether there was perioperative analgesia in children with cerebral palsy. We precisely pointed out that ‘patients assigned to the control group received caudal blocks with the same dose of local anesthetics for postoperative analgesia at the end of surgery’ in the methods section. Indeed, the control group, who received caudal blocks at the end of surgery for ethical considerations and postoperative analgesia, did not require more analgesics than the caudal group in the postoperative care unit. Additionally, all patients in our study (caudal and controls) who were judged to be in pain [OPS (2) ‡ 4] by the anesthetist in charge of the postoperative care unit were administered rescue i.v. fentanyl (0.5– 1.0 lgÆkg). During the intraoperative phase, the control group must have been provided adequate intraoperative anesthesia with sevoflurane, while bispectral index (BIS) values were maintained between 45 and 55. Although opioids are superior to the inhalation anesthetic from an analgesic point of view, the inhalation anesthetic agent has not only hypnotic but also analgesic properties, like opioids. Although the aim of our study was to evaluate the effect of caudal block on sevoflurane requirement, excluding other analgesics, while maintaining adequate anesthesia using BIS, the control group was also provided with a caudal block at the end of surgery, because of ethical considerations.

Does Postoperative Cardiac Troponin-I Have Any Prognostic Value in Predicting Midterm Mortality After Congenital Cardiac Surgery?

OBJECTIVES This study evaluated the prognostic value of postoperative cardiac troponin-I (cTnI) in predicting all-cause mortality up to 3 months after normothermic congenital cardiac surgery. DESIGN Prospective observational study. SETTING University hospital. PARTICIPANTS All children ages 0 to 10 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS cTnI was measured after the induction of anesthesia but before the surgery, at the pediatric intensive care unit arrival, and at 4, 12, and 24 hours postoperatively. Follow-up was extended up to 6 months. Overall, 169 children were analyzed, of whom 165 were survivors and 4 were nonsurvivors. cTnI levels were significantly higher in nonsurvivors only at 24 hours (p = 0.047). Children undergoing surgery with cardiopulmonary bypass (CPB) had significantly higher cTnI concentrations compared with those without CPB (p<0.001). Logistic regression analysis was performed on the 146 children in the CPB group with the following predictive variables: CPB time, postoperative cTnI concentrations, the presence of a cyanotic malformation, and intramyocardial incision. None of the variables predicted mortality. Postoperative cTnI concentrations did not predict 6 months׳ mortality. Only cTnI at 24 hours predicted the length of stay in the pediatric intensive care unit. CONCLUSIONS This study did not find that postoperative cTnI concentration predicted midterm mortality after normothermic congenital heart surgery. (ClinicalTrials.gov identifier: NCT01616394).

Douleurs chroniques et anesthésie locorégionale chez l'enfant

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patients blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

Anesthetic management of a child with Ullrich myopathy

To the Editor: A 9-year-old boy was scheduled for surgery to correct bilateral fixed plantar flexion. Because muscular weakness had been observed early in childhood, a muscle biopsy had been performed (result: myopathy), but a skin biopsy finally established the diagnosis of Ullrich’s myopathy (UD), a congenital muscle dystrophy. Preoperative physical examination showed a child with weight of 24 kg and height of 131 cm. Cervical spinal mobility was slightly limited; micrognathism and prominent incisive teeth were present. Creatinine phosphokinase (CK) level was at the upper limit of normal values for our laboratory. Cardiac and pulmonary function tests were normal. The patient had already undergone one general anesthesia in the past (for the muscle biopsy) consisting of total intravenous anesthesia (TIVA) with alfentanil and propofol. After careful positioning, standard monitoring was applied. Peripheral venous was obtained while the patient breathed O2 and N2O (50–50 %) by mask. Induction of anesthesia was performed with sufentanil (0.1 lg/kg) and propofol (3 mg/kg), followed with manual ventilation with sevoflurane. Orotracheal intubation was performed at first attempt (Cormack–Lehane stage 3). Surgery lasted 2 h. A tourniquet was used for each site successively. Core body temperature and capnography remained normal; no significant increase in expired CO2 was noticed when the tourniquets were released. In this surgery, as in the previous one, no muscle relaxant was used. Postoperative analgesia consisted of IV ketorolac, acetaminophen, and piritramide in the pediatric acute care unit (PACU). The postoperative evolution was satisfactory. No clinical signs of rhabdomyolysis (e.g., dark urine) were observed. No significant elevation in the CK levels was observed. The CK increased from 407 U/l before the surgery to 440 U/l after the surgery; the upper normal value of our laboratory is 400 U/l. The clinical diagnosis of UD is based on general muscle weakness, contractures of multiple joints, hyperextensibility of distal joints, and other orthopedic and systemic signs [1, 2]. There is no evidence of cardiac dysfunction, but the diaphragm is often involved early. Tracheal intubation may be difficult because of the combination of micrognathism and contracture of the temporomandibular muscles. When planning anesthesia for a child with a muscle disease, one of the anesthesiologist’s concerns is to limit the risk of inducing a malignant hyperthermia (MH) crisis or rhabdomyolysis. In this case, the risk of MH was estimated to be not greater than in the general population because the familial history was negative and the gene mutations for UD are different and distant from the known mutations of the RYR1 and CACNL1A3 genes associated with MH [3–5]. In conclusion, this case, in addition to the other published cases, shows that halogenated agents can be used safely in children with UD as well as in other congenital muscle dystrophies. I. Grosu (&) D. Truong S. Teodorescu M. Mousny F. Veyckemans Service d’Anesthésiologie, Departments of Anesthesiology and Orthopedics, Cliniques Universitaires Saint Luc, 10 Avenue Hippocrate, 1200 Brussels, Belgium e-mail: irina.grosu@uclouvain.be

Evaluation of the Explorer Endoscopy Mask(©) for esogastroduodenoscopy in children: a retrospective study of 173 cases.

The aim of this study was to evaluate the usability and safety of the Explorer Endoscopy Mask® (EM) as an alternative to endotracheal intubation in children undergoing elective esogastroduodenoscopy (EGD) under general anesthesia (GA).

Technical description of a modified jet ventilation injector for airway laser surgery in neonates and infants: retrospective analysis of 20 cases

INTRODUCTION The authors modified an adult jet ventilation injector (Hunsaker Mon-Jet Ventilation Tube(®)) to be able to provide transglottal high-frequency jet ventilation (HFJV) in small children undergoing laryngeal procedures with CO2 laser. METHODS AND MATERIAL Retrospective review of the anesthetic records of all children younger than 2years undergoing transglottal HFJV for CO2 laser laryngeal procedures using this modified adult injector between 2006 and 2013. RESULTS Nine children (5 boys, 4 girls) were identified who underwent a total of 20 procedures. Mean age was 7.4 ± 6.9months, and mean weight was 6 ± 2.8 kg. No complications were observed with the use of HFJV or this modified injector. CONCLUSION In experienced hands, this modified injector ensures excellent visibility and field access to the surgeon as well as adequate ventilation during laryngeal laser surgery in infants.

Lord, deliver us from pain

Pain is a word every human being can understand. Except those with congenital insensitivity to pain there is probably no human being that has completely escaped the perception of pain. Pain is an unpleasant feeling related to a physical aggression compromising the integrity of the body. It also has an emotional component that may be weak or strong. The fear of pain may be as disturbing as pain itself, as many a torturer knows and uses.