Jean Camboulives

Continuous Fascia Iliaca Compartment Block in Children: A Prospective Evaluation of Plasma Bupivacaine Concentrations, Pain Scores, and Side Effects

We sought to determine the plasma concentrations of bupivacaine and its main metabolite after continuous fascia iliaca compartment (FIC) block in children. Twenty children (9.9 ± 4 yr, 38 ± 19 kg) received a continuous FIC block for either postoperative analgesia (n = 16) or femoral shaft fracture (n = 4). A bolus dose of 0.25% bupivacaine (1.56 ± 0.3 mg/kg) with epinephrine was followed by a continuous administration of 0.1% bupivacaine (0.135 ± 0.03 mg · kg−1 · h−1) for 48 h. Plasma bupivacaine levels were determined at 24 h and 48 h by using gas liquid chromatography. Heart rate, arterial blood pressure, respiratory rate, side effects, and pain scores were recorded at 4-h intervals during 48 h. No significant differences were found between mean plasma bupivacaine levels at 24 h (0.71 ± 0.4 &mgr;g/mL) and at 48 h (0.84 ± 0.4 &mgr;g/mL) (P = 0.33). FIC block provided adequate analgesia in most cases. No severe adverse effects were noted. We conclude that the bupivacaine plasma concentrations during continuous FIC block in children are within the safety margins. FIC block is well tolerated, and provides satisfactory pain relief in most cases.

Double-lung transplantation in mechanically ventilated patients with cystic fibrosis☆

Many lung transplant programs consider ventilator dependence as a contraindication for transplantation. Among 54 patients in whom bilateral lung transplantations for cystic fibrosis were performed by the Joint Marseille-Montreal Lung Transplant Program, 10 were ventilator dependent. Three of them died in the early postoperative period (30%): 2 as a result of cerebral anoxia and sepsis, 1 of Pseudomonas cepacia pneumonia. Two patients died at 15 and 19 months after transplantation of obliterative bronchiolitis and secondary bacterial pneumonitis. Another 2 patients in whom obliterative bronchiolitis developed underwent retransplantation with a heart-lung block; 1 of those was operated on at 12 months and is well at 29 months after his initial transplantation; the second was operated on at 34 months and died of primary graft failure. Three other patients are alive and well at 3, 11, and 14 months after transplantation. Actuarial survival at 1 year was 70%. The postoperative course and the infectious and rejection complications were no different from those in patients who underwent transplantation while spontaneously breathing. Obliterative bronchiolitis developed in 66% of patients at risk (2 of 6 patients surviving more than 6 months). We conclude that transplantation in mechanically ventilated patients with cystic fibrosis is not associated with an increase in morbidity or mortality after bilateral lung transplantation. Long-term survival, as in patients who undergo transplantation while spontaneously breathing, is limited by the development of obliterative bronchiolitis.

EMLA versus nitrous oxide for venous cannulation in children.

We compared EMLA cream with nitrous oxide (N2O) for providing pain relief during venous cannulation in children. In a prospective, double-blinded, randomized study, 40 children, 6–11 yr, ASA status I or II, undergoing scheduled surgery received either EMLA cream and inhaled air and oxygen (Group EMLA) or a placebo cream and inhaled 70% N2O in oxygen (Group N2O) before venous cannulation. Pain was evaluated with a visual analog scale and the Objective Pain Scale. The ease of venous cannulation and the observer’s assessment of its efficacy for preventing pain were assessed. Heart rate, blood pressure, respiratory rate, and oxygen saturation were compared before and after venous cannulation. Visual analog scale scores (4.4 ± 7.5 vs 3.9 ± 9.3 mm, P = 0.85), Objective Pain Scale scores (median 0 [0–6] vs 0 [0–1], P = 0.61), efficacy (median 0 [0–1] vs 0 [0–1], P = 0.59), and ease of venous cannulation (0 [0–2] vs 0 [0–1], P = 0.84) were not different between EMLA and N2O groups, respectively. There was no statistical difference between the groups for the physiologic variables. Minor side effects were significantly more common in the N2O group (11 of 20) than in the EMLA group (7 of 20) (P = 0.0248). We conclude that both techniques provided adequate pain relief during venous cannulation, as demonstrated by the low pain scores.

Double-lung transplantation in children: A report of 20 cases

In the last 3 1/2 years, we have performed 20 double-lung transplantations in children between 7 and 16 years old (mean age, 13 years). One patient had primitive bronchiolitis obliterans and the other 19, cystic fibrosis. Eight patients were operated on in an emergency situation, 7 of them requiring ventilator support before transplantation. The procedures were en bloc double-lung transplantation in the first 11 patients with separate bronchial anastomoses in 10, and sequential bilateral lung transplantation in the later 9 patients. There were no operative deaths. Two patients died in the hospital on postoperative days 37 and 73, and there were four late deaths, which were due to infection, rejection, and bronchiolitis obliterans. The acceptable incidence of airway complications, the improvement in lung function of survivors, and the acceptable midterm survival make double-lung transplantation an acceptable alternative to heart-lung transplantation in children. However, in very small children, heart-lung transplantation may be preferable because of the size of the airway anastomoses at risk.

Repair of a Type IV Laryngotracheoesophageal Cleft with Cardiopulmonary Bypass

Laryngotracheoesophageal clefts (LTECs) are rare congenital defects of variable severity depending on the extent of malformation. Management of a complete LTEC represents a major surgical and anesthetic challenge. The main problems are achieving adequate operative exposure and maintaining ventilatory support during and after the operation. We describe correction of a type IV LTEC extending down to the carina in an infant who had respiratory distress at birth. Surgical repair was achieved in a single stage by an anterior sternotomy approach on the 11th day of life. The procedure was facilitated by cardiopulmonary bypass. After the operation, the infant was intubated, mechanically ventilated, and sedated. Nissen fundoplication and gastrostomy were carried out on the 11th postoperative day. The child was extubated on the 12th postoperative day. The rationale for this method and its advantages in comparison with other surgical approaches are discussed.

Acute myopathy of intensive care in a child after heart transplantation

Purpose: Acute myopathy of intensive care has been described infrequently in children and never after organ transplantation. We report a case of acute myopathy of intensive care in a child after heart transplantation.Clinical features: An II-yr-old girl, with no previous medical history, developed acute cardiomyopathy leading to cardiac shock. Family history revealed four cases of unidentified myopathy and/or cardiomyopathy. Preoperatively, while muscle biopsy was near normal, myocardial biopsy revealed non specific mitochondrial disorders. A few days after heart transplantation, she developed acute hypotonia and flaccid quadriplegia, consistent with the diagnosis of acute myopathy of intensive care. Nerve conduction studies were normal, electromyography showed myopathic changes and a new muscle biopsy from quadriceps femoris showed severe loss of myosin filaments and ATPase activity in type 2 fibres. A large laboratory screening failed to demonstrate a metabolic disease or a known myopathy. Muscle strength recovered progressively in three weeks allowing home discharge. A few months later, she was free of symptoms and muscle biopsy showed full histopathological recovery.Conclusion: Acute myopathy of intensive care can occur in children after heart transplantation. It should be suspected in the presence of muscle weakness and difficulty in weaning from ventilatory support. Electromyography confirmed a myogenic process and muscle biopsy allowed diagnosis. Full clinical and histopathological recovery usually occur within three weeks.RésuméObjectif: La myopathie aiguë de réanimation a été rarement décrite en pédiatrie, et jamais après transplantation d’organe chez l’enfant. Nous rapportons un cas pédiatrique de myopathie aiguë de réanimation après transplantation cardiaque.Éléments cliniques: Une enfant de II ans, sans antécédent, est hospitalisée pour choc cardiogénique sur cardiomyopathie aiguë. Dans sa fratrie, on note l’existence de myopathies et de cardiomyopathies non déterminées. La biopsie musculaire préopératoire est normale et la biopsie myocardique montre des anomalies mitochondriales non spécifiques. Quelques jours après une transplantation cardiaque, elle présente une hypotonie globale avec tétraplégie flasque. Une myopathie aiguë de réanimation, évoquée devant des vitesses de conduction nerveuses normales et un tracé électromyographique montrant une atteinte musculaire, est confirmée par une biopsie musculaire montrant une perte des fibres de myosine par dépolymérisation, avec perte de l’activité ATPasique dans les fibres de type 2. La recherche élargie d’une myopathie chronique ou d’une maladie métabolique est négative. En quelques semaines, l’enfant a progressivement récupéré sa force musculaire. Une biopsie musculaire, réalisée à distance, montre une architecture musculaire et une activité enzymatique normales.Conclusion: Une myopathie aiguë de réanimation peut se développer chez le transplanté pédiatrique, puisque des facteurs favorisants sont utilisés pour l’immunosuppression. Elle doit être évoquée devant une faiblesse musculaire et des difficultés de sevrage de la ventilation artificielle. L’électromyogramme objective un processus myogénique et c’est la biopsie musculaire qui permet le diagnostic. La récupération de la force musculaire et histopathologique est obtenue en quelques semaines.

Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency.

PurposeMajor gastric distension in the left hemithorax can threaten life in patients with congenital diaphragmatic hernia (CDH) presenting after the neonatal period. After presentation of two paediatric cases, guidelines for the optimal care of these patients are given.Clinical featuresBoth children had respiratory and cardiocirculatory compromise on arrival. The diagnosis of late presenting CDH was made and the severity of symptoms was related to a voluminous distension of an intrathoracic stomach. Successful placement of an naso-gastric tube in the first patient, lead to a rapid clinical improvement, allowing surgical repair. In the second patient, oroor naso-gastric decompression was not possible and, while the lungs were mechanically ventilated and the patient was prepared for surgery, a sudden cardiocirculatory arrest was managed by external chest compressions and rescuscitation drugs. Transthoracic percutaneous decompression of the stomach was the sole treatment allowing spontaneous cardiac activity to reappear, and haemodynamic condition to normalize. However, the child died from brain death after this episode.ConclusionGastric decompression is the key for the treatment of patients with CDH who present respiratory and/or cardiocirculatory distress due to the intrathoracic distension of the stomach. If an oroor naso-gastric decompression is not possible, then radiologically directed percutaneous decompression under local anaesthesia is required. After decompression, the patient is prepared for surgery, with particular emphasis on fluids infusion, in order to correct the frequently associated hypovolaemia:RésuméButsLa dilatation aiguë de l’estomac dans l’hemithorax gauche est une urgence vitale chez les patients qui présentent une hernie diaphragmatique congénitale (HDC) à révélation tardive. Après la description de deux cas pédiatriques, des recommandations pour la prise en charge optimale de ces patients sont discutées.Présentation cliniqueLes deux enfants présentaient à la fois une détresse respiratoire et cardiocirculatoire à leur arrivée. Le. diagnostic de HDC était porté et la gravité du tableau mis sur le compte d’une dilatation gastrique importante, dans l’hémithorax gauche. La mise en place d’une sonde nasogastrique chez le premier patient a entraîné une amélioration clinique rapide, permettant la réparation chirurgicale. Pour le deuxième patient, la décompression de l’estomac par sonde oro ou naso-gastrique n’a pas été possible, et, alors que le patient était en ventilation contrôlée sous respirateur et préparé à l’intervention, un arrêt cardiocirculatoire brutal est survenu, immédiatement pris en charge par la réalisation d’un massage cardiaque externe et injection de drogues d’urgence. La décompression transcutanée de l’estomac a été la seule thérapeutique permettant la reprise d’une activité cardiaque spontanée et la normalisation progressive de l’état hémodynamique. Malheureusement, l’enfant devait décéder de mort cérébrale à la suite de cet épisode.ConclusionLa décompression gastrique est l’élément-clé du traitement des patients ayant une HDC à révélation tardive se présentant avec une détresse respiratoire et cardiocirculatoire liée à la dilatation gastrique intrathoracique. Si la décompression par l’intermédiaire d’une sonde gastrique n’est pas possible, il faut alors envisager la réalisation d’une décompression par ponction percutanée de l’estomac, avec l’aide d’une radioscopie, sous anesthésie locale. Après la décompression, le patient est préparé à l’intervention, avec une attention particulière sur l’expansion volémique qui vise à corriger une hypovolémie, très fréquente dans ce contexte.

Successful treatment of fungal right atrial thrombosis complicating central venous catheterization in a critically ill child.

A 9-year-old boy was admitted to our pediatric intensive care unit after multiple trauma. On the 17th day post trauma, he developed catheter-related sepsis with candidemia. After removal of the catheter and 6 days of unsuccessful intravenous antifungal therapy, conventional and transesophageal two-dimensional echocardiography was performed revealing a large right atrial thrombus. Surgical thrombectomy under cardiopulmonary bypass was performed and the patient recovered within a few days. Fungal right atrial thrombus is a rare, lifethreatening complication of central venous catheterization. Two-dimensional echocardiography is a simple and effective diagnostic technique that should be performed when candidemia is detected. The proper therapeutic response depends on the findings of this examination. For a symptomatic patient with a large, mobile thrombus, we strongly recommend thrombectomy. Surgery not only allows removal of the mass and thus elimination of the mechanical complication but is also a key to management of infection.

Le virus d'Epstein-Barr. Une cause inhabituelle de myocardite aiguë sévère chez l'enfant

UNLABELLED Epstein-Barr virus does not belong to the principal causative agents of acute myocarditis, whose diagnosis and pathogenesis are often difficult to determine. Treatment is also controversial regarding the use of anti-inflammatory or immunosuppressive therapy. CASE REPORT We describe a 13-month-old girl, admitted for acute heart failure, in whom cardiac catheterization with endomyocardial biopsy revealed an acute myocarditis. Acute viral titers indicated infectious mononucleosis caused by Epstein-Barr virus, and the virus genome was identified with a polymerase chain reaction in the patients serum. The patient had clinical improvement after corticosteroid administration. CONCLUSION The different diagnostic tools and the screening examinations to determine the causative agent of myocarditis are discussed. The frequency of Epstein-Barr virus in pathogenesis is also considered. The favorable outcome with immunosuppressive therapy suggests its administration in cases of acute myocarditis.

Une cause rare de défaillance cardiaque brutale chez le nourrisson : la cardiomyopathie histiocytoïde

Histiocytoid cardiomyopathy is a rare disease which occurs predominantly in the first two years of life, with a female preponderance. We report the cases of two girls (11 and 15-month-old) which were respectively referred to our institution for ventricular tachycardia and ventricular fibrillation without prodroma. Etiologic findings only showed mild cardiomyopathy. Autopsy and histologic examination led to the diagnosis of histiocytoid cardiomyopathy. Furthermore, in the first observation, agenesis of the corpus callosum was found.