Lessons from 1100 pediatric caudal blocks in a teaching hospital.

METHODS. The demographic and technical data of all the pediatric caudal blocks (CBs) performed from August 1986 to September 1989 in our teaching hospital were prospectively collected on a computerized protocol. Except for 22 high-risk ex-premature infants, all CBs were performed under halothane or isoflurane anesthesia, after premedication with atropine. Moreover, they were performed using local anesthetic solutions containing 1:200,000 epinephrine. A total of 1100 CBs were performed in children younger than 7 years; 203 patients weighed 5 kg or less; 260, 5.1-10 kg; 300, 10.1-15 kg; and 337, more than 15.1 kg. The CBs were also analyzed according to the anesthesiologist's experience with CB: 184 were performed by anesthesiologists who had performed fewer than 10 CBs (Group A); 210, 10-20 CBs (Group B), and 704, more than 20 CBs (Group C). RESULTS. We found difficult landmarks in 11.2% of our patients. Moreover, it was significantly more frequent (p = 0.0004) if the patients weighed less than 10 kg, because of poor anatomy or obesity. There were 76 bloody taps (BTs, 6.9%); although there was a statistically insignificant trend toward a lower incidence of BTs in the 5.1-10-kg group, experience seemed to influence the incidence of BTs, as it decreased from 11.4% in Group A to 8.9% and 5.4% in Groups B and C, respectively (p less than 0.05). There were eight systemic reactions (i.e., brisk onset of tachycardia during or shortly after the CB), which were all short-lived and responded quickly to hyperventilation with oxygen. Two occurred despite repositioning the needle after a previous BT, but six occurred with no previous evidence of blood and were thus called "concealed" BTs. Moreover, all occurred in children weighing 10 kg or less. There was only one dural tap. Only nine CBs (0.81%) failed to provide effective intraoperative anesthesia, and 93% of the patients left the recovery room without having required narcotic or non-narcotic analgesics. CONCLUSIONS. Our results confirm that CB is a reliable technique, easy to perform by beginners. It should be stressed, however, that small infants are at increased risk of concealed BTs

Guillain-Barre syndrome after obstetrical epidural analgesia.

Guillain Barre Syndrome (GBS) occurred 24 hours post-partum following an obstetrical epidural anesthetic (OEA) procedure. Clinical diagnosis was confirmed by cerebrospinal fluid (CSF) findings and nerve conduction velocity studies. GBS is an immune mediated process. Because of short latency between the onset of symptoms and the performance of the epidural block, a cause and effect relationship between epidural block and GBS in this patient is unlikely

Management of upper gastrointestinal bleeding due to esogastric variceal hemorrhage in childhood

L'hémorragie du tractus digestif supérieur constitue une menace vitale pour l'enfant cirrhotique. Cet événement peut s'accompagner de choc hypovolémique, d'insuffisance hépatique, de sepsis et conduire au décès. La sclérose des varices en urgence peut être réalisée par voie endoscopique. Le contrôle du saignement est obtenu par cette technique dans plus de 90% des patients traités. La sclérothérapie itérative est ensuite nécessaire pour obtenir l'occlusion variqueuse et prévenir la récidive hémorragique. Lorsque la sclérothérapie ne contrôle pas les saignements, la mise en place transjugulaire d'une prothèse porto-systémique hépatique (TIPSS) peut réduire l'hypertension portale même chez le petit enfant. Enfin, les enfants souffrant d'une affection hépatique très décompensée sont programmés en vue d'une transplantation hépatique, ce qui procure un taux de survie à long terme de l'ordre de 80 %. L'association de ces divers moyens thérapeutiques diminue à présent de façon considérable la mortalité associée au saignement aigu sur varices chez cette catégorie de patient

Anaesthetic considerations in progressive familial intrahepatic cholestasis (Byler's disease).

Progressive familial intrahepatic cholestasis (PFIC) or Byler's disease is one of the most common forms of intrahepatic cholestasis of metabolic and genetic origin. Affected children progress to terminal cirrhosis before adulthood and at present the only curative treatment of PFIC is orthotopic liver transplantation (OLT). We present a retrospective review of 40 general anaesthetics administered in our hospital to 22 patients with PFIC undergoing various procedures. The clinical features of PFIC and the anaesthetic implications of chronic cholestasis in children (malnutrition, cirrhosis, portal hypertension, chronic hypoxaemia) are reviewed