François-Pierrick Desgranges

Pupillary reflex dilatation and analgesia nociception index monitoring to assess the effectiveness of regional anesthesia in children anesthetised with sevoflurane

Pupillary diameter (PD) monitoring and Analgesia Nociception Index (ANI) (Metrodoloris, Lille, France), an online wavelet transform‐based heart rate variability index, have been used in the assessment of pain.

Respiratory variation in aortic blood flow peak velocity to predict fluid responsiveness in mechanically ventilated children: a systematic review and meta-analysis.

Dynamic indices of preload have been shown to better predict fluid responsiveness than static variables in mechanically ventilated adults. In children, dynamic predictors of fluid responsiveness have not yet been extensively studied.

Changes in qualitative and quantitative ultrasound assessment of the gastric antrum before and after elective caesarean section in term pregnant women: a prospective cohort study.

Ultrasound measurement of the antral cross‐sectional area allows a quantitative estimate of gastric contents in non‐pregnant adults, but this relationship may be affected by compression of the stomach exerted by the gravid uterus during pregnancy. This study aimed to assess differences in quantitative (Perlas score) and qualitative (antral cross‐sectional area) ultrasound assessments of the gastric antrum performed immediately before and after caesarean section. Forty‐three women having elective caesarean section performed under spinal anaesthesia were studied in the semirecumbent and semirecumbent‐right lateral positions. Thirty‐nine women showed no change in stomach contents using the Perlas score between the two measurement periods; four women showed a change, but by one grade only. The median (IQR [range]) antral cross‐sectional area was 323 (243–495 [103–908]) mm2 before, and 237 (165–377 [112–762]) mm2 after, caesarean section in the semirecumbent position (p = 0.001); the comparable values in the semirecumbent‐right lateral position were 418 (310–640 [161–1238]) mm2 and 362 (280–491 [137–1231]) mm2 (p = 0.09). The distance between the skin and the antrum, and the aorta and the antrum, decreased significantly in both positions after surgery. We suggest that our results indicate that stomach contents remain largely unchanged in women having elective caesarean section, but antral cross‐sectional area decreases, especially in the semirecumbent position, related to a change in the position of the stomach within the abdomen. This implies that the relationship of antral cross‐sectional area to volume of stomach contents, which has been determined for non‐pregnant subjects, may not apply in term pregnant women.

Determination of a cut-off value of antral area measured in the supine position for the fast diagnosis of an empty stomach in the parturient A prospective cohort study

BACKGROUND Ultrasound measurement of the antral cross-sectional area of the stomach, performed in the supine position, has been described for preoperative assessment of gastric content in the adult, but, to date, no study has determined the cut-off value of the antral area for the diagnosis of an empty stomach in the parturient. Nevertheless, previous studies in parturients have reported that the use of a simple qualitative grading scale (0 to 2) was reliable for the estimation of the gastric fluid volume. However, this qualitative grading score requires turning the parturient into the right lateral decubitus position for the ultrasound examination, something which may not be easily feasible, particularly in the case of an obstetric emergency. OBJECTIVE To calculate the cut-off value of the antral area, measured in the supine position during established labour, for the diagnosis of ‘empty’ stomach. DESIGN A prospective cohort study. SETTING Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France. PATIENTS Seventy-three women in established labour. INTERVENTIONS For each parturient, ultrasound assessment of gastric contents was performed in the supine and right lateral decubitus position and scored 0 to 3 on a qualitative grading scale. This assessment was followed by ultrasound measurement of the antral cross-sectional area in both the supine and right lateral positions. MAIN OUTCOME MEASURES To assess the performance of the antral area measured in the supine position for the diagnosis of an ‘empty’ stomach (gastric antrum grade 0), a receiver operating characteristic curve was plotted, and the area under the receiver operating characteristic curve was calculated. RESULTS Data from 73 women were analysed. For the diagnosis of grade 0, the cut-off value for the antral area measured in the supine position was 381 mm2 (sensitivity, 81%; specificity, 76% and negative predictive value, 80%). CONCLUSION With a parturient lying in the supine position, a single assessment of the antral cross-sectional area may be used for the fast diagnosis of an empty stomach. This tool could be useful in assessing the risk of aspiration for parturients who require emergency anaesthesia during labour.

Risk factors for intraoperative allogeneic blood transfusion during craniotomy for brain tumor removal in children.

Several clinical and surgical factors can influence the occurrence of allogeneic blood transfusion (ABT) during oncologic neurosurgery.

Continuous oblique subcostal transversus abdominis plane block: an alternative for pain management after upper abdominal surgery in children

SIR—Continuous epidural analgesia is the most common regional anesthetic method performed for pain management after major upper abdominal surgery in children. However, central neuraxial block is sometimes contraindicated. The classical posterior approach for TAP block produces reliable analgesia below the umbilicus (1). Recently, an oblique subcostal approach of transversus abdominis plane (TAP) block has been described (2). This single injection technique has been proposed for pain control after abdominal surgery above the umbilicus in children (3). Here, we reported first use of continuous TAP block with insertion of a catheter via the subcostal approach under ultrasound guidance in a child. A 4-year-old child weighing 15 kg underwent a portosystemic shunt, 3 years after liver transplantation for congenital biliary atresia complicated by venous portal thrombosis. Because heparin was necessary at the end of the surgery, epidural anesthesia was not performed. General anesthesia was induced and maintained with sevoflurane and remifentanil. After left subcostal nonmidline abdominal incision, surgery was performed uneventfully. Before the end of the surgery, the children received paracetamol (15 mgÆkg) and morphine (0.15 mgÆkg). After skin closure, a left unilateral TAP catheter was placed under ultrasound guidance using sterile technique, with a high frequency 13-6 MHz linear ultrasound probe (SonoSite Micromax; SonoSite Inc., Bothwell, WA, USA) directed parallel to the costal margin. The Tuohy needle (Plexolong Nanoline 18 G · 50 mm; Pajunk, Geisingen, Germany) was inserted via an in-plane approach. When the tip was visualized in the fascia dividing the transversus abdominis and the internal oblique muscles, a 0.25% levobupicacaine bolus of 7.5 ml (0.5 mlÆkg) was administered, and a catheter was inserted 1 cm under ultrasound guidance (Figure 1). The patient denied pain in the immediate postoperative period. A multimodal analgesia was initiated in the postanesthesia care unit and regular pain assessment was made every 4 h using the FLACC scale. Intravenous administration of paracetamol (15 mgÆkg per 6 h) was started. The patient received also 0.125% levobupivacaine continuous infusion at a rate of 1.5 mlÆh via the TAP catheter. Intravenous nalbuphine (0.15 mgÆkg per 4 h) was added as rescue if FLACC > 4/10. Based on this drug regimen, analgesia was assessed as inadequate over the first twelve postoperative hours and the child received two injections of nalbuphine. For this reason, addition of 1.5 ml boluses of 0.125% levobupivacaine through the TAP catheter with lockout interval of 1 h were prescribed, in addition to background infusion of 1.5 mlÆh. In the subsequent 36 h, the child did not receive any other additional analgesic, and maximal pain score recorded was 3/10 on the FLACC scoring system. The TAP catheter was removed 48 h after the end of surgery. There is only one case report reporting the placement of TAP block catheters using the posterior approach in two children (4). Although the insertion of a catheter via the oblique subcostal approach for continuous TAP block has been proposed in adults (1), we describe the first use of this approach in a child.

Neurotoxicity of intrathecal 6% hydroxyethyl starch 130/0.4 injection in a rat model

Epidural blood patch is the gold standard treatment for post‐dural puncture headache, although hydroxyethyl starch may be a useful alternative to blood if the latter is contraindicated. The aim of this experimental study was to assess whether hydroxyethyl starch given via an indwelling intrathecal catheter resulted in clinical or histopathological changes suggestive of neurotoxicity. The study was conducted in rats that were randomly allocated to receive three 10‐μl injections on consecutive days of either saline or hydroxyethyl starch administered via the intrathecal catheter. Eight rats were given injections of saline 0.9% and 11 were given 6% hydroxyethyl starch 130/0.4 derived from thin boiling waxy corn starch in 0.9% sodium chloride (Voluven®). Daily clinical evaluation, activity measured by actimetry and neuropathological analysis of the spinal cord were subsequently performed to assess for signs of neurotoxicity. No clinical or actimetric changes were observed in either group following intrathecal saline or hydroxyethyl starch administration. Histopathological examination showed non‐specific changes with no differences between the two groups. This experimental study in the rat suggests that repeated intrathecal injection of hydroxyethyl starch is not associated with neurotoxicity.

Postoperative analgesia for craniosynostosis reconstruction: Scalp nerve block or local anesthetic infiltration?

Sir–The postoperative pain management for craniosynostosis reconstruction is particularly challenging. Scalp nerve block and local anesthetic infiltration have never been compared for postoperative pain relief after craniosynostosis surgery. In our center, both techniques are usually performed to ensure postoperative analgesia, according to anesthesiologist practice and skill. This retrospective case-control comparative study aimed to assess whether postoperative morphine consumption was different when a block or an infiltration was performed in children undergoing craniosynostosis reconstruction. All consecutive children under 2 years of age undergoing craniosynostosis reconstruction between January 2014 and May 2015 were included. General anesthesia was performed with sevoflurane and remifentanil. Before skin incision, either a scalp block or local anesthetic infiltration was performed with 1 mL/kg of 0.25% levobupivacaine, associated with epinephrine (0.01 mg/mL) in case of infiltration. The infiltration (performed by the surgeon) covered a large coronal zone (incision zone). The scalp block was performed by an anesthetist with a practice of at least 10 scalp blocks, according to a previously described technique. Before the end of the surgery, intravenous paracetamol 15 mg/kg and morphine 0.1-0.2 mg/kg were administered. All children were transferred to the recovery room after extubation. Postoperative analgesia included intravenous morphine titration in the recovery room so that FLACC 3/10, followed after recovery room discharge by a systematic intravenous administration of paracetamol combined with oral morphine or intravenous nalbuphine as rescue if necessary. Two groups of patients were defined according to the analgesic technique performed, an infiltration or a block. Data were compared with student t test or Mann-Whitney U test or test or Fisher test. A multivariate analysis (backward regression) was performed to identify the potential predictors for morphine administration in recovery room. The variables considered for inclusion in the multivariate analysis were: age, gender, type of craniosynostosis, block or infiltration, duration of surgery, total intraoperative dose of remifentanil, use of methylprednisolone and ketamine during the intraoperative period, and total dose of morphine administered prior to extubation. A Pvalue <.05 was considered statistically significant. Data were analyzed from 81 children (mean age = 11 months). An infiltration was performed in 25 children and a block in 56 children. No adverse event was reported for either technique. All types of craniosynostosis were represented. The most frequent types were trigonocephaly (44%) and scaphocephaly (38%). The intraoperative anesthetic and surgical characteristics were similar between the 2 groups, apart for the duration of surgery longer in the infiltration group and the total dose of remifentanil infused greater in the infiltration group. The need for morphine for rescue analgesia and the total dose of morphine administered in the recovery room were significantly greater in the block group (Table 1). The pain scores in the recovery room were not statistically different between the 2 groups. The only independent risk factor for morphine administration in recovery room was the scalp block (odds ratio = 3.17 [95% confidence interval 1.18-8.55], P = .02). We found that patients managed with a local anesthetic infiltration instead of a preoperative scalp nerve block had a modest reduction in need for morphine in the early recovery period, with no differences in pain scores, in the context of craniosynostosis surgery. Because retrospective studies are subject to confounding by selection bias, these data should be confirmed by further prospective and ideally randomized studies.

Prevalence and prediction of higher estimated gastric content in parturients at full cervical dilatation: A prospective cohort study

Emergent obstetrical procedures may require general anaesthesia in parturients at full cervical dilatation or immediately after vaginal birth. This study aimed to determine the prevalence and the predictive factors of higher estimated gastric content in parturients at full cervical dilatation with epidural analgesia and allowed to drink during the labour, and to assess the ability of the antral area measured in the semirecumbent position (SR‐CSA) to identify higher estimated gastric content in this setting.