Efficacy of Intraoperative Dexmedetomidine Compared with Placebo for Postoperative Pain Management: A Meta-Analysis of Published Studies

INTRODUCTION: Dexmedetomidine (Dex) has sedative, analgesic, and anesthetic-sparing effects. This meta-analysis examines demonstrated intraoperative and postoperative effects of intraoperative Dex administration during pediatric surgery. METHODS: A search for randomized placebo-controlled trials was conducted to identify clinical trials examining intraoperative Dex use in children, infants, and neonates. Primary outcome was postoperative opioid consumption; secondary outcomes were: postoperative pain intensity and postoperative nausea and vomiting (PONV). RESULTS: Fourteen randomized controlled trials performed during painful procedures were analyzed. Intraoperative Dex administration was associated with significantly reduced postoperative opioid consumption in the postanesthesia care unit [PACU; risk ratio (RR) = 0.31 (0.17, 0.59), I (2) = 76%, p < 0.0001 and cumulative z score using trial sequential analysis], decreased pain intensity in PACU [standardized mean difference (SMD) = -1.18 (-1.88, -0.48), I (2) = 91%, p < 0.0001] but had no effect upon PONV incidence [RR = 0.67 (0.41, 1.08), I (2) = 0%, p = 0.48]. Subgroup analyses found administering Dex during adenotonsillectomy and using a bolus <0.5 µg/kg (irrespective to the use of a continuous administration) without effects on studies outcomes. Heterogeneity was high among results and a high suspicion of publication bias was present for all analyzed outcomes. CONCLUSIONS: This meta-analysis shows that intraoperative Dex administration in children reduces postoperative opioids consumption and postoperative pain in PACU. According to our results, optimal bolus dose was found to be ≥0.5 µg/kg. Future studies have to explore this particular point and the postoperative analgesic effects of Dex during longer periods

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Facteurs prédictifs de l'utilisation de la récupération de sang intra-opératoire au cours de la chirurgie de la scoliose pédiatrique

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Ecologie bactérienne des infections de site opératoire du rachis de l'enfant (étude descriptive de la cohorte de Robert Debré)

L incidence, la gravité et le coût des infections du site opératoire justifient leur étude. En pédiatrie, un facteur de risque clairement identifié d infection du rachis est l étiologie neuromusculaire de la scoliose. De plus, les scolioses idiopathiques forment un groupe homogène de patients qui se distinguent des autres étiologies de déformation rachidienne. Les caractéristiques des infections et des patients infectés en fonction de l étiologie n ont pas été étudiées.Les cas d infections du rachis sur matériel sur une période de 5 ans ont été recueillis rétrospectivement dans un seul centre de 2007 à 2011. Ont été collectées les informations sur les caractéristiques des patients, de leurs prises en charge anesthésique et chirurgicale, et des infections. Les données ont été analysées en fonction de l étiologie de la déformation rachidienne idiopathique ou non-idiopathique .50 cas d infections précoces sont rapportée (incidence 9,1 %). 67 germes ont été identifiés, 14 infections sont pluri microbiennes, 33 mono microbiennes dans deux cas aucun germe n a été retrouvé. S. aureus est le pathogène le plus fréquemment retrouvé (43,1 %), suivi des bacilles gram négatif (24,6 %) et des anaérobies (15,4 %, dont 60 % de cocci gram positif anaérobies). La présence de bacilles gram négatif était significativement associée à l appartenance à la catégorie non-idiopathique , risque relatif 7,73 IC95 (1,11-53,6). Les patients non atteints de scolioses idiopathiques de l adolescent s infectaient préférentiellement à bacilles gram négatif. Les cocci gram positifs anaérobies ont une incidence plus importante qu attendue.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Effets des agents anesthésiques sur la phosphorylation de FAK et ERK 1 & 2 (mécanismes et implications de ces protéines dans les effets de ces agents)

PARIS-BIUSJ-Thèses (751052125) / SudocPARIS-BIUSJ-Physique recherche (751052113) / SudocSudocFranceF

Effets de la position genu-pectorale sur l index cardiaque et les besoins en propofol durant la chirurgie du rachis guidée par indice bispectral

Introduction : La position genu-pectorale (GP) est utilisée en chirurgie rachidienne. Elle peut engendrer une chute du débit cardiaque. De plus la pharmacocinétique du propofol est proportionnelle au DC. Notre objectif est de quantifier les modifications du DC et les modifications des besoins en propofol, lors du changement de position.Méthode: Vingt patients, ASA I-III bénéficiant d'un monitorage du débit cardiaque par doppler oesophagien et de la profondeur d'anesthésie par index bispectral, pendant une anesthésie à objectif de concentration par propofol-remifentanil ont été inclus de façon prospective. Les données suivantes étaient recueillies en décubitus dorsal (DD) puis en GP: index cardiaque (IC), volume d'éjection systolique (VES), pression artérielle moyenne (PAM), fréquence cardiaque (FC), deltaPP, concentrations plasmatiques cibles (CPC) de propofol. Seule les CPC du propofol étaient modifiée pour maintenir un BIS entre 40 et 50. Les données sont exprimées en moyenne +- écart type, sauf pour le deltaPP exprimé en pourcentages de patients avec un deltapp > 13. Résultats: L'IC, le VES, la PAM et la CPC de propofol ont diminués en position GP : 2,6 +- 0,03 à 1,7 +- 0,04 L.mn-1.m-2,p 13 % passait 0 à 18 (90 %) en GP (p 13 %. Results: Cardiac index, stroke volume, mean arterial pressure and propofol target concentration were significantly decreased from supine to KC position : 2,6 +- 0,03 to 1,7 +- 0,04 L.mn-1.m-2, p 13 % was 0 in the supine position and 18 (90 %) in the KC position (p<0,0001). Conclusion: Placing surgical patients in the KC position during BIS guided anaesthesia was associated with marked decrease in cardiac index and propofol requirements. These results suggest that monitoring intraoperative cardiac index via an oesophageal Doppler and depth of anaesthesia with the BIS may be useful in patients undergoing spine surgery in the KC positionPARIS12-CRETEIL BU Médecine (940282101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

PRISE EN CHARGE DE LA DOULEUR POSTOPERATOIRE (REVUE DE LA LITTERATURE ET EXPERIENCE DE L'HOPITAL BICHAT CLAUDE BERNARD)

PARIS-BIUM (751062103) / SudocCentre Technique Livre Ens. Sup. (774682301) / SudocSudocFranceF

Évaluation de l index de variabilité de la pléthysmographie (PVI) comme facteur prédictif de réponse au remplissage vasculaire chez l enfant sous anesthésie générale

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Description of practices and complications in the French centres that participated to APRICOT: A secondary analysis

International audienceIntroduction: Analysing national patients' profile and organisation of human resources are important for improving the perioperative quality of care. The aim of the current study was to achieve these goals using the French data from the APRICOT study.Material and methods: Data from the French centres that participated to the APRICOT study were extracted and analysed. The primary goal of the study was to describe patients' characteristics, procedures and perioperative anaesthetic management in France, and compare them to the results of the European APRICOT trial. Secondary outcomes were the description of major perioperative complications and the determination of human resources organisation possibly associated with these perioperative complications.Results: Overall 3535 procedures collected in 20 facilities (17 teaching hospitals, one community hospital and two private institutions) were analysed. Comparison between the French and European APRICOT cohorts found differences related to the more specialised French centres participating to the study. Overall complications (respiratory complications, haemodynamic instability, cardiac arrest, drug errors, and anaphylactic reactions) were observed in 6.4% [95% CI: 5.6; 6.3] of cases. Multivariate analysis identified the anaesthesiologist's experience of<15 years and the absence of an anaesthetic nurse as human factors independently associated with an increased risk for perioperative complications.Discussion: The current study identified some important differences between the French and the whole APRICOT cohort in terms of preoperative evaluation, surgical specialties involved, and monitoring of neuromuscular blockade. It confirms that, in France, the presence of an anaesthetic nurse and an experienced anaesthesiologist prevents anaesthetic complications.Trial registration: ClinicalTrials.gov NCT01878760