Jean-Michel Devys

A survey of practice of tracheal intubation without muscle relaxant in paediatric patients

Background: Because of the renewed interest in intubation in children without relaxants, over a period of 1 month, the anaesthesiologists of five paediatric universitary teaching hospitals were asked to complete a questionnaire each time they performed a tracheal intubation without muscle relaxant.

Is platelet transfusion efficient to restore platelet reactivity in patients who are responders to aspirin and/or clopidogrel before emergency surgery?

PURPOSE: The aim of this study was to confirm that emergency platelet transfusion effectively restores platelet function to patients receiving antiplatelet therapy (APT) with aspirin and/or clopidogrel. PATIENTS AND METHODS: This was a prospective observational case report series conducted between January 1, 2009, and January 1, 2012. All responder patients according to the Verify Now device requiring emergency platelet transfusion because of a potentially life‐threatening hemorrhage or before emergency neurosurgery were included. Aspirin or P2Y12‐specific tests were used as appropriate for patients under aspirin or clopidogrel. Patients who were responders to aspirin had an aspirin reaction unit of less than 550, and patients who were responders to clopidogrel had an inhibition percentage of more than 20%. The Verify Now test was performed again after platelet transfusion. Pretransfusion and posttransfusion test results were compared. RESULTS: During the 36‐month period, 25 patients met the inclusion criteria. Of these patients, 4 were receiving dual APT, 8 were receiving clopidogrel only, and 13 were receiving aspirin only. The average platelet transfusion dose was 0.12 UI/kg (range, 0.10–0.14 UI/kg). For patients under clopidogrel, the inhibition percentage lowered significantly after transfusion (median 54 [range, 31–69] before and 25 [range, 18–50] after transfusion; p < 0.005) but remained above the 20% threshold. Our patients were still responsive to clopidogrel after platelet transfusion. This result is conflicting with the existing literature. The median aspirin reaction unit of aspirin users before and after transfusion were 420 (range, 400–470) and 630 (range, 610–640), respectively (p = 0.001). The efficacy of platelet transfusion to restore aspirin‐mediated disaggregation is confirmed by our case series. CONCLUSION: Platelet transfusion does not restore platelet function in patients under clopidogrel, but it is efficient for patients under aspirin. This sheds new light on previous large‐scale studies that have been unable to show any effectiveness of emergency platelet transfusion in patients under APT. Emergency platelet transfusion may only be indicated in aspirin users who are responders and not in all patients under APT as is actually recommended. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Bilateral Angle Closure Glaucoma After General Anesthesia

Acute angle closure glaucoma is a rare complication of general anesthesia. However, in case of delayed diagnosis, it may lead to blindness. We present a case of bilateral acute angle closure glaucoma after cervical spine surgery under general anesthesia in a hypermetropic patient. In this case, the most likely trigger was the use of ephedrine, but nefopam administration and the prone surgical position are discussed as additional potential factors.

Cardiac rhabdomyomas in tuberous sclerosis patients: a case report and review of the literature.

Rhabdomyomas are the most common benign cardiac tumours. They are often associated with tuberous sclerosis and can be diagnosed antenatally and postnatally by echocardiography. Rhabdomyomas tend to regress spontaneously and are not usually operated upon, unless they become obstructive or cause severe arrhythmias. We describe the case of a child with tuberous sclerosis who was admitted for the resection of a subependymal giant cell astrocytoma, in whom cardiac rhabdomyomas in the right ventricular outflow tract were diagnosed. These two kinds of tumours are well known in the setting of tuberous sclerosis.

Development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients: the VPOP score

Few data are available in the literature on risk factors for postoperative vomiting (POV) in children.

Partial status epilepticus causing a transient left ventricular apical ballooning

Transient left ventricular apical ballooning also called Takotsubo cardiomyopathy is a recently described cardiac syndrome. It often affects postmenopausal women having an acute physical or emotional stress, but it have also been described after convulsive status epilepticus. Although this association is rare and left ventricular function often recovers, it would be useful to the neurologist to be aware of the signs leading to this diagnosis, to improve the cardiac later care. Here we report a patient with partial status epilepticus in whom the diagnosis of transient left ventricular apical ballooning was made. We describe the diagnostic criteria and the potential complications that should be monitored.

Diagnostic performance of computed tomography angiography compared with transesophageal echocardiography for the detection and the analysis of aortic atheroma.

Aortic arch atheroma is a major source of embolism (1,2). Transesophageal echocardiography (TEE) is the gold standard for the detection of aortic atheroma. However, we have witnessed in these recent years an increasing number of requests for computed tomography angiography (CT angiography) to assess the ascending aorta and the aortic arch. This study compared CT angiography and TEE performances for the detection of aortic arch atheroma. Among the 192 patients admitted to our hospital in 2008–2009 for acute ischemic stroke and in whom transthoracic echocardiography failed to identify a source of embolism, we have retrospectively selected the 47 patients who underwent both TEE and CT angiography. A scoring was established and resulted in the following (Table 1): No atheroma: 0 Plaque thickness < 4 mm: 1 Plaque thickness 4 mm (protrusive aortic atheroma): 2 Ulcerated plaque: 3 At risk atheroma: 2 or 3. Interobserver reproducibility for CT angiography (two readers) was found to be 57·45% for each score, with a kappa index of 0·4020. For at-risk plaques, interobserver reproducibility was 89·36% (kappa index 0·7403). The agreement between CT angiography and TEE for each score was 61·70%, with a Kappa index of 0·4816. For at-risk plaques, the agreement between the two techniques was of 74·47% (kappa index 0·4416). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CT angiography compared with TEE for the detection of at-risk plaques were calculated. The sensitivity was 52·60% (95% CI: 33·50–79·70%) and the specificity was 92·60% (95% CI: 75·70–99·10%). The PPV was 84·60% (95% CI: 54·60– 98·10%) and the NPV was 75·80% (95% CI: 57·70–88·90%). In conclusion, CT angiography is very specific but lacks sensitivity for the detection of at-risk aortic plaques.

Benign thymic hyperplasia: an unexpected cause of respiratory distress during inhalatory induction of anesthesia

of the intravenous cannula. Based on our experience and previous reports, we suggest the use of shorter acting agents like remifentanil and desflurane along with bispectral index monitoring to enable quick recovery. If LMA is left in situ, use of bite block is highly recommended. Alternatively, it may be removed under deep anesthesia on resumption of spontaneous respiration. Muscular dystrophy may be undiagnosed in patients with AS and it would be ideal to completely avoid muscle relaxants. If unavoidable, we suggest a significant reduction in the recommended dose and neuromuscular monitoring. The postoperative aggressive behavior could be explained by pre-and ⁄ or postoperative anxiety, a feature not uncommon in patients with learning disability, or was it sevoflurane emergence? Angelman syndrome is a rare syndrome and the average life expectancy in AS is known to be short. Given the limited literature in the perioperative anesthetic management of these patients, we hope that our experience along with the previous case reports will contribute to better anesthetic management of these children in the future. Jayaprakash J Patil Seema Sindhakar Department of Anaesthesia, Royal Gwent Hospital, Newport, UK (email: seema.sindhakar@gwent.wales.nhs.uk)

Prospective analysis of serious cardiorespiratory events in children during ophthalmic artery chemotherapy for retinoblastoma under a deep standardized anesthesia

Serious adverse cardiorespiratory events complicate super selective ophthalmic artery chemotherapy for retinoblastoma in anesthetized children. Their mechanism remains unclear but may be attributed to an autonomic nervous reflex induced by the catheter close to the ophthalmic artery. Inadequate depth of anesthesia during catheter stimulation might be an aggravating factor. Thus, we tested whether deep general anesthesia reduced the incidence of serious cardiorespiratory events.

Heparin-induced thrombocytopenia without thrombocytopenia in an intensive care unit

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