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Objectives: To evaluate the benefits of training sessions for pelvic examination using anatomic models., Material and Methods: The medical students (MS) registered in their 5th year of medical studies at Angers University Hospital had to complete two anonymous questionnaires; one at the beginning of the workshop and one at the end. Every procedure which included pelvic exam (PE), vaginal sample (VS), smear test (ST), insertion of a speculum and insertion of intra-uterine device (IUD) was evaluated., Results: Seventy-one MS answered both questionnaires. They were very satisfied or satisfied with the outcomes of the workshop in 91 % of the cases. At the beginning of the workshop, 28 %, 52 %, 30 %, 25 % and 3 % reported a low level of difficulty to carry out, respectively, a PE, VS, ST, insertion of a speculum, insertion of an IUD. At the end of the session, there were respectively 55 %, 83 %, 76 %, 66 % and 16 % of MS to report a low level of difficulty of these same procedures. For all of these procedures, there were a significant (P<0.05) number of MS who estimated the procedure's level of difficulty as being low at the end of the session., Conclusion: The level of technical difficulty of all procedures was significantly decreased at the end of the workshop., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Simulation training is gradually being integrated into the curriculum for caregivers in intensive care units. There are few training programs on communication with families., Goal: This pilot-study evaluated the impact of a training protocol on professional practices including a protocol for the reception of the parents of a child admitted to a pediatric intensive care unit., Materials and Methods: The training program lasted 3 months and included three parts: a theoretical contribution, a simulation session with debriefing, and a focus group. During the simulation session, a multi-professional team of three healthcare providers (physician, nurse, assistant nurse) must apply a protocol for the reception of the parents of a child who had just been admitted. The protocol lasted 35 min and included three sequences: reception and dressing by the assistant nurse, medical meeting conducted by the physician and the nurse, support of the parents in the room by the nurse and the assistant nurse. The child was simulated by a manikin (SimBaby™, Laerdal) and the parents were prepared actors. The main objective of the pilot-study was to measure the rate of change in professional practices 1 year after the end of training., Results: One year later, all healthcare providers (n=15) declared they had changed their professional practices and felt that half of these changes were due to the pilot-study. New practices such as receiving parents in pairs in a dedicated room or managing a short interview with the parents before supporting the child were applied "always" or "if possible"., Conclusion: The pilot-study showed that the training program induced half of the changes of professional practices for welcoming the parents of a child admitted to pediatric intensive care unit 1 year later., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area., Methods: A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP"., Results: Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much., Conclusion: Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications., (Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objective: Update on simulation-based education and its evolution in North America., Data Sources: Main articles including those published within the last five years and indexed in Medline, and unpublished data from the Royal College of Physicians and Surgeons of Canada have been analyzed., Data Synthesis: After a review of historical development of simulation in North America, this article draw the place of simulation in healthcare, for medical education, research and assessment. Funding and accreditation of simulation centres are also discussed., Conclusion: Simulation is fully integrated in healthcare in North America and represents one of the main elements for healthcare professional education. Simulation is also a symbol of excellence for health and teaching institutions. The evolution of simulation in North America is likely to inform the future of simulation in France., (Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Introduction: The Airtraq optical laryngoscope (Vygon, Écouen, France) is a new intubation device designed to provide a view of the glottis without alignment of the oral, pharyngeal and laryngeal axes. In recent literature, the efficiency of the Airtraq even in difficult intubation and its short learning curve were characterized. The goal of our study is to evaluate Airtraq efficiency when use by inexperienced physicians in anticipated difficult intubation adult patients., Methods: The patients showing at least one of the four difficult intubation predictors (history of difficult intubation, thyromental distance less than 60mm, mouth opening less than 35 mm and Mallampati class 3 or 4 were included. Before induction of anaesthesia, the inexperienced physicians participating the study received a short oral formation on the use of the Airtraq. For each intubation manoeuvres, the participant were supervised by an expert in Airtraq handling. The Cormack and Lehane grade of direct laryngoscopy view, the duration times to best glottis view and to intubate the trachea, the success or failure of tracheal intubation, the drop in arterial oxygen saturation of below 95%, the need for external manipulation, and the difficulties met by the operators were noted., Results: Twenty patients were included over a month period. Thirteen had a history of difficult intubation, eight a thyromental distance less than 60mm, nine a mouth opening less than 35 mm and 12 patients were classified as Mallampati IV. The success rate of tracheal intubation with the Airtraq laryngoscope was 80%. Times to best glottis view and to complete tracheal intubation were 28 and 47 s, respectively. Four tracheal intubation failures were encountered. The LMA Fastrach and the flexible fiberoscope were used respectively in one and three patients., Discussion: In the majority of the cases, the insertion of the Airtraq, the visualization of the glottis and the subsequent intubation were easy and rapid, without arterial oxygen desaturation. However, the four tracheal intubation failures associated with prolonged tracheal intubation times in some patients highlight the fact that the Airtraq laryngoscope requires a clinical training process particularly in case of anticipated difficult airway management situations., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia., Methods: In this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded., Results: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8+/-11.6, lidocaine 12.4+/-9.7; and saline 16.2+/-11.5, P=0.08)., Conclusion: For the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia., (2009 Elsevier Ltd. All rights reserved.)

Objective: To present the effective applications of paediatric medical simulation in terms of education, evaluation, density, development, goals and constraints., Study Design: Survey realized within 38 paediatric simulation centres (PSC) in Europe, identified by Web search and through the Society in Europe for Simulation Applied to Medicine (SESAM., Results: Twenty centers answered the questionnaire (52%). Ninety-four percent of the PSC had beforehand acquired an experience of adult medical simulation, 94.6% of the PSC were created before 2006. Ninety percent of the PSC owned at least one high-fidelity pediatric simulator. The 80% of the PSC indicated multiple funding sources. Eighty percent of the PSC had at least one specific instructor for the paediatric simulation (average=2.7 paediatric instructors per centre). The PCS reported to get onto various topics: neonatology (25% of the PCS), prehospital medicine (36.8%), paediatric anaesthesiology (74%) and paediatric intensive care (89%). Simulation allowed 70% of the centers to lead some research project. Ninety-five percent of the centers agreed about an European collaboration on research projects or about the mutualization of the created scenarios., Conclusion: The material, financial and human means of the interviewed centres are consequential but heterogeneous in Europe. MSP offers numerous and various application fields and generates some research activity.

There is a strong prevalence of sleep apnoea syndrome in general population. Cardiac arrhythmia and conduction disturbances during sleep may complicate this syndrome. We report the case of a 73-year-old patient to whom the sleep apnoea syndrome was diagnosed after varied heart blocks during the sleep. A treatment by continuous positive airway pressure (CPAP) permitted to correct these conduction disturbances and to avoid pacemaker implantation.

Objectives: To analyse the results of delayed evaluation of European teaching sessions using a questionnaire provided by the French College of Anaesthesiologists., Study Design: Open evaluation., Material: Questionnaires were completed 3-6 months after European courses provided in November-December 1999., Method: The types of professional exercise and the medical practice as well as the theme of the courses were pointed out. The evaluation included six items noted from 1 to 10: usefulness of the abstract book, discussion with colleagues, discussion with a manager, decision to modify medical practice, application of that decision, own objectives fulfilled. The global mean score for each item was calculated. Results were compared according to the professional mode of exercise and the theme of the course., Results: 5/7 centres provided information. 91/239 questionnaires were returned to the organizers. The participants were working in different structures (private clinic: 25, university hospital: 31, general hospital: 27, PSPH: 8). The main exercise was anaesthesiology (75/77 answers). Means scores affected to the different items were around 7 for all but one of them. The mean score concerning discussion with a manager was significantly decreased to 3.5 +/- 3.2. Decision to modify their own practise was higher in private clinics compared to PSPH. The abstract book was more consulted after the first course (respiration and thorax)., Conclusion: 3-6 months following the FEEA courses the participants thought to have fulfil their objectives and declared to have modify their medical practise. The lack of discussion with a manager should be analysed.

A case of intestinal gas explosion during the course of carcinologic surgery in a 51-year-old patient is reported. This accident, often dramatic, has become exceptional since the use of mannitol for colonic preparation has disappeared. This incident occurred during the course of a total pelvic exenteration performed under general anaesthesia with inhalation of both a mixture oxygen-nitrous oxide and volatile agents. The colon incision with an electrocautery was contemporaneous with a violent deflagration accountable for organic lesions. This case report reminds us that the risk of a dangerous explosion persists in relation with surgical, anaesthetic and individual risk factors.

Objectives: To evaluate what could be the benefit in terms of alarm suppression, of a new syringe pumps system, which allows automatic relay without alarms., Patients and Methods: We have prospectively recorded the nature and the mode of relay of all syringe pumps for administration of drugs to patients in two ICU. The perfusion regimen was studied in 61 patients over the complete duration of their stay in two ICU. Alarms were also recorded in one ICU room, over 13 days consecutive. The records were processed off-line with an automatic detection-recognition system in order to assess the origin of each alarm. Accordingly, the amount of alarm corresponding to monitor, ventilator and syringe pumps was computed., Results: We found that syringe pumps, which would provide automatic relays without alarm, would suppress 17% of alarms in ICU and automatize 65% of the relay procedures, which are usually performed often in emergency, on response to the end of perfusion alarm., Conclusion: New syringe pumps allow both reduction of alarms in ICU and a better management of nurse workload. Indeed syringe relay can be planned in advance.

As in the case of adults, there are three main goals in the monitoring of severe head trauma in children: to prevent or minimize the apparition of secondary lesions, to optimize treatment, to help make precise prognosis. The basic monitoring is composed of repeated clinical examinations, brain radiological imaging and control of vital parameters (blood pressure, temperature, PaO2 (SpO2), PaCO2 (FETCO2), haemoglobin, haematocrit. On the other hand, during specific brain monitoring, the brain perfusion (TCD, intracranial pressure), the electrical activity of the brain and sometimes the brain oxygenation (SvjO2) are controlled. The data obtained from the brain monitoring must always be interpreted carefully. A child with a severe head trauma, in ICU, always requires constant and competent medical attention.

The authors report a case of subdural haematoma (HSD), which occurred following epidural analgesia for labour, complicated by post dural puncture headache (PDPH). A 26-year-old woman displayed a typical PDPH following epidural anaesthesia. On the sixth day, she was given a blood patch (BP), which was partially efficacious. Because of worsening of the headache, of disappearance of the postural characteristics, and of vomiting without focal neurological signs on the 9th day, a CT-scan was done. The CT-scan showed a small hemispheric subdural haematoma. The recovery was complete with only medical treatment. HSD is a rare serious complication of dural puncture. When the characteristics of PDPH change, HSD should be evoked even without focal neurological signs. An early diagnosis and the small size of the haematoma may allow HSD to be treated medically and avoid surgical evacuation.

Objective: To study electroencephalographic (EEG) changes in children during induction of anaesthesia with 8% sevoflurane., Patients: Twenty patients were consecutively included (ASA I-II; aged: 13-101 months)., Material and Method: Prospective study; approved by the Ethics Committee; written informed consent obtained from parents; anaesthesia induced with 8% sevoflurane in oxygen; no premedication was given; to collect the EEG data, non-invasive electodes were installed before induction; EEG was recorded continuously and stored on a computer for later analyses (descriptive analysis)., Results: Myoclonics movements were observed during induction of anaesthesia in two boys. Myoclonics movements stopped spontaneously without therapy. Epileptiform EEG activity (spikes and poly-spikes, burst suppression) was observed. In the 18 others cases, during sevoflurane induction, EEG changed rapidly with an increase in the range of beta activity (> 13 Hz) (n = 15) and in slow (< 8 Hz) and delta activity (< 4 Hz). In 14 patients, at time of laryngoscopy, the EEGs showed monophasic slow data activity (sharp high-voltage slow waves). Periods of EEG isoelectrical (burst suppression) were seen without spikes in four cases., Conclusion: At 2 MAC, epileptiform EEG activity has been observed during sevoflurane anaesthesia. In a short group of patients, this raises the question of avoiding sevoflurane in patients who have a history of epilepsy.

Objectives: To assess the individual activity of anaesthetists in paediatric anaesthesia (PA), and collect their wishes about continuing education and recommendations in PA., Study Design: Transversal, prospective study., Methods: A questionnaire of 33 items, sent to 4,360 anaesthetists, spread over 15 health districts, working in a public or private institution., Results: We gathered 1,526 replies (35%) of which 34% university hospitals, 32% public institutions and 31% private institutions. 943 physicians (63%) had no specific structure, and 1,119 (87%) considered a specialized nurse to be essential for PA. 1,127 physicians (74%) had undertaken a specific session during their formation. The practice of PA depends upon age and context. Above 1 year old, the surgery that is performed weekly was ENT (38%), abdominal and urologic surgery (28%). Mask induction was performed by 60% of the physicians in children under 5 years. 63% of the anaesthetists dreaded a laryngospasm during induction. 625 physicians undertook regional anaesthesia in children under 5 years (87% caudal anaesthesia, 48% peripheral nerve blocks). 1,029 physicians (67%) wished for recommendations in PA in children under 12 months., Conclusions: This survey showed that most of the anaesthetists wished for recommendations in their paediatric anaesthesia practice.

Objective: To evaluate the changes in transfusion practices during craniosynostosis surgery in children, with consideration of the transfusion-associated risks., Study Design: Retrospective study., Patients: The study included 64 consecutive craniosynostosis repairs by the same neurosurgical and anaesthetic team, over a period of 17 years., Methods: The children were allocated into two groups. In group I (1980-1991), blood loss was compensated precisely from scalp incision on. In group II (1992-1996), transfusion was only started when blood loss crossed a calculated limit considered as acceptable. The mean criterion of judgment was the quantity of transfused blood in comparison with the theoretical blood volume. Mean preoperative and postoperative haemoglobin concentrations, estimated blood losses, volume of replaced blood and number of transfused patients were compared between the two groups with a two tailed Student's t test., Results: The rate of non transfused children increased from 6% before 1991 to 39% after 1992%; conservely the rate of postoperative transfusions increased from 3 to 39%., Conclusion: The risks of blood transfusion favoured the development of new of more restrictive transfusion practices, even in haemorrhagic surgery. To limit blood transfusion in craniosynostosis surgery, a harmonious cooperation between surgeons and anaesthetists is essential and blood replacement must be based on a definite determination of the acceptable blood losses.

Case report of a 25-year-old primigravida who sustained a necrosis of the anterior pituitary gland after a haemorrhagic Caesarean section. The diagnosis was delayed, as the early symptoms (apathy, anorexia, nausea, orthostatic hypotension and hypoglycaemia) were imputed to more usual causes.

We report a case of a probable interaction between sufentanil and naltrexone, an oral long acting opioid antagonist, prescribed for maintenance of abstinence in alcoholics and opioid addicts. The interaction resulted in an antagonisation of the effects of sufentanil and the necessity to increase the dosage. Anaesthetists should be aware of this potential drug interaction.

Objective: To assess in children with a transcranial Doppler the effect on cerebral blood flow velocities of desflurane, whose cerebral vasodilator effects have been studied in animals and in adults with intracranial lesions., Study Design: Prospective clinical study., Patients: Ten healthy children, mean age: 3.4 yr, ASA physical class 1, undergoing minor urologic surgery, were included in this study., Method: Induction was obtained with atropine 10 micrograms.kg-1, fentanyl 3 micrograms.kg-1 and propofol 3 mg.kg-1. Endotracheal intubation was facilitated by atracurium 0.3 mg.kg-1. Mechanical ventilation, with a 50% air/oxygen mixture was adjusted to achieve an end-tidal CO2 (PETCO2) level of 38 +/- 2 mmHg. Monitoring included measurement of mean arterial blood pressure (MAP), heart rate, PETCO2, SpO2 and end-tidal desflurane concentrations (FETDes). Mean blood flow velocities (Vmean) were measured in the middle cerebral artery using a bi-directional 2 MHz TCD system (EME-TC 2000 S). A first TCD measurement followed intubation (T1). Thereafter, desflurane was adjusted to 1 MAC. Six other TCDs were recorded each minute until FETDes reached the inspired fraction (T2-T7). Thereafter, CO2 reactivity was assessed with a hypocapnia test, induced by hyperventilation. Measures were done at T8 (PETCO2: 33 +/- 1 mmHg), T9 (PETCO2: 29 +/- 1 mmHg), and T10 (initial PETCO2: 38 +/- 1 mmHg). All these measurements were made before starting surgery. Analysis of variance (ANOVA) was used to analyse the data (P < 0.05 was considered as significant)., Results: The Vmean and heart rate increased significantly with increasing concentrations of desflurane (Vmean from 68 +/- 27 to 106 +/- 30 cm.s-1 and heart rate from 109 +/- 17 to 136 +/- 15 b.min-1 between T1 and T7). During hypocapnia, Vmean decreased to 68 +/- 23 cm.s-1 at T9, and returned to normal values with PETCO2 at 38 mmHg at T10. SpO2 remained unchanged. Mean arterial pressure was stable from T1 to T7, but decreased significantly at T9 and T10., Conclusion: Desflurane elicits a dose-dependent increase in cerebral blood flow velocities and heart rate, but does not change mean arterial pressure, suggesting that its cerebrovascular action is independent of its systemic vascular action. CO2 reactivity is maintained at one MAC. The results in children are similar to those seen in adults.

Objective: To assess the development and the current practice of predeposit autologous blood transfusion (PABT) in children in France., Study Design: Nationwide survey with a questionnaire., Method: Survey conducted in January 1995, including 121 blood transfusion centres (BTC) out of which 101 replied., Results: Initiated in 1979, PABT is practiced at present in 66% of BTC. This figure increased by 12% from 1993 to 1994. Orthopaedic surgery was the main indication. Other indications included bone marrow harvesting for allogenic transplantation. Concerning the inclusion criteria, the lower limit of age was 9 +/- 4 years and weight 26 +/- 10 kg. The youngest child was one-year-old and his body weight was 8 kg., Conclusion: The production of codified protocols would probably favour the development of PABT in children and increase its safety and its efficiency.

Background: Pyknodysostosis is characterized by post-natal onset of short-limbed short stature and generalized hyperostosis. It must be differentiated from osteopetrosis with precocious manifestations in which hyperostosis may crowd the marrow cavity with extramedullary hematopoiesis., Case Reports: A boy, born from consanguineous parents presented with classical features of pyknodysostosis: short-limbed stature, large skull, frontal bossing, wide anterior fontanelle and tendency to fracture. His sister had the same features at the age of 3 months; she had hepatosplenomegaly at the age of 5 months with anemia, erythroblastosis (13%), myelemia and, at 10 months, thrombocytopenia., Conclusion: Hyperosostis can be complicated by development of such severe hematological manifestations as classically seen in osteopetrosis. Differential diagnosis between both entities is based upon radioclinical investigation.

Magnesium (Mg), a cofactor in numerous enzymatic reactions, is often ignored by clinicians, as the symptomatology of Mg depletion is not specific and usually associated with that of the cause of the depletion. Furthermore, the plasma Mg concentration (0.8 to 1.1 mmol.L-1) is only equivalent to one percent of the total body content. A Mg deficit may exist while plasma Mg concentration is normal. Therefore other techniques for Mg assessment, such as the repletion test, as well as red blood cell and lymphocyte concentrations have been used. A renewed interest for Mg occurred as numerous studies have shown the therapeutic efficiency of Mg and as the mechanisms of its haemodynamic effects have been recognized. Mg regulates Na-K-ATPase activity, K channels activity and, most of all, it is a natural calcium channel blocking agent. These properties explain its important place in electrophysiology of myocardial cells and the effects on the tension of smooth muscles, resulting in a vasodilation and a bronchodilation respectively. The antagonistic effect of Mg on calcium decreases the presynaptic release of acetylcholine at the neuromuscular junction and the release of epinephrine at the peripheral sympathetic nerves and the adrenals. Mg potentiates the effect of non-depolarizing muscle relaxants. A Mg deficiency occurs often in ICU patients, in alcoholics and during use of diuretics. Simultaneous administration of Mg is often required for treatment of potassium deficiency. Mg has an anti-arrhythmic effect towards digoxin-mediated dysrhythmias and torsades de pointes, and can be efficient in other arrhythmias. Systematic use of Mg seems to decrease mortality of acute myocardial infarction and is justified during cardiac surgery, often associated with hypomagnesemia, because of vasodilation of coronary arteries and in order to prevent occurrence of arrhythmias. Mg, because of its calcium channel blocking properties and as it lowers the release of epinephrine, is indicated for surgery of pheochromocytoma. In eclamptic and pre-eclamptic patients, the use of Mg is valuable, but not as an anti-epileptic agent. Other clinical uses of Mg have been proposed, but they are either anecdotal or of uncertain efficiency.

Objective: To evaluate the hypothesis that magnesium sulphate (SO4Mg), usually administered for protecting the myocardium and decreasing the rate of arrhythmias in cardiac surgery, was able to control the hypertensive peaks occurring during cardiopulmonary bypass (CPB), as efficiently as nicardipine (N)., Study Design: Randomized controlled trial., Patients: Forty patients were allocated into two groups when hypertensive peaks occurred during CPB. The patients of the N group were then given nicardipine 0.016 mg.kg-1 and those of the SO4Mg group received magnesium sulphate 50 mg.kg-1., Methods: Anaesthesia technique was identical and during normothermic CPB the flow remained constant at 2.4 L.min-1, during the 10 min following N or SO4Mg administration. The usual haemodynamic variables were monitored., Results: Both N and SO4Mg decreased significantly the MAP and the SVR over the 9 min following their administration. The decrease was more marked after SO4Mg. As the flow of the pump was unchanged after their injection the decrease can be attributed to the relaxing effect of these agents on the smooth vascular muscles., Conclusions: SO4Mg permits to treat hypertensive peaks occurring during CPB as efficiently as N. Three grammes of SO4Mg have an hypotensive effect equivalent to that of 1 mg of nicardipine. However repetitive injections of SO4Mg cannot be recommended because of the risk for hypermagnesemia.

Due to the action of the drugs and the position of the patient, general anaesthesia in a child with a mediastinal tumor can complete the obstruction of the trachea and/or the main bronchi and possibly result in irreversible respiratory failure. The risk is directly linked to the degree of lumen amputation of the trachea, usually evaluated by CT-scan: there is a risk of accident if the degree of lumen amputation is greater than 30%. The case reports underline the value of the flexible fibreoptic bronchoscopy under local anaesthesia. This examination, as well as the CT-scan, allows to evaluate the degree of tracheal compression. Moreover, it carries a lower risk than the CT-scan which requires, in a small child, either general anaesthesia or heavy premedication which could lead to asphyxia. Total obstruction most often occurs with anterior mediastinal tumors. However, even posterior or lateral tumors can extend to an anterior position, especially in the young child. If the obstruction of the lumen is greater than 30% and if general anaesthesia is required, the fibreoptic bronchoscopy allows endotracheal intubation under local anaesthesia before general anaesthesia. We report 5 cases which illustrate the risk of tracheal compression during general anaesthesia in patients with a mediastinal tumor and substantiate the advantages of a flexible fibreoptic bronchoscope in the management of these patients before and during general anaesthesia.

The shaken baby syndrome is a relatively recent concept concerning mishandled children and characterized by cerebral lesions (subarachnoid haemorrhage, oedema, axonal injuries). A case is reported of a 11-month-old female infant, who was admitted in a paediatric intensive care unit with clinical signs of brain death after cardiopulmonary resuscitation. The CT scan showed subdural haemorrhage. Pathological examination confirmed the major blunt head trauma. The father admitted that he had shaken his daughter as "she cried too often". The mechanism of the lesions is a combination of several factors, especially the large size of infant's head and the weakness of the neck muscles. It is possible to recognize still in the perinatal period children at risk of mishandling, allowing an efficient prevention of the shaken baby syndrome.

This prospective randomized single-blind study compared the efficacy of a combination of propacetamol (2 g) and a low dose of nalbuphine hydrochloride (10 mg) with nalbuphine hydrochloride (20 mg) alone, in a population of 152 white female patients after gynaecologic or obstetrical surgery, for alleviation of postoperative pain in recovery room. The drugs were administered intravenously in case of pain. The population was divided into two groups: group 1 received 20 mg of nalbuphine hydrochloride and group 2 received 2 g of propacetamol combined with 10 mg of nalbuphine hydrochloride. The pain intensity was studied with the visual analogue scale and comparisons use no parametric tests (Mann and Whitney test, Kruskall and Wallis test) and Chi2 test. Groups were similar for age, surgical and anaesthesia procedures and initial pain level. The propacetamol-nalbuphine hydrochloride 10 mg association provided a significantly better analgesia than nalbuphine 20 mg during the first two postoperative hours (p < 0.05). In group 1, the analgesia score decrease was respectively 28 +/- 25 mm (range: 33-75 mm) after 1 h and 31 +/- 25 mm (range: 26-84 mm) after 2 h. In group 2, the decrease was more important: 37 +/- 21 mm (range: 5-84 mm) after 1 h and 42 +/- 23 mm (range: 20-84 mm) after 2 h. Side effects were minimal and similar in both groups (nausea, drowsiness). It is concluded that a propacetamol-nalbuphine hydrochloride 10 mg association provides better analgesia than single dose of 20 mg of nalbuphine. This association convenient analgesia with a decreased dose of nalbuphine.

Acute epiglottitis is an infectious disease causing a severe respiratory distress. Any attempt to move the child in the horizontal position or to examine his throat can result in cardiac arrest. Diagnosis, endotracheal intubation as well as decision making of the optimal time for extubation are greatly facilitated by the use of a fiberoptic bronchoscope. The device is a paediatric model (external diameter 3.6 mm with an operating channel). It is inserted through the nare in the child in the sitting position. Oxygen is delivered through a nasal tube. The examination is performed under local anaesthesia (lidocaine 0.5%). Midazolam is sometimes added via the rectal or i.v. route. The clinical signs are monitored as well as the heart rate and SpO2. The diagnosis of epiglottitis as it is visual, is very easy and rapid once the epiglottis is observed through the fibreoptic bronchoscope. The advantage of the examination under fibreoptic bronchoscope is to allow visualization without aggression or stimulation of the pharyngolaryngeal structures and without modification of the child's position. Endotracheal intubation, which is always required, is facilitated as the child is breathing spontaneously. The expiratory flow blows bubbles of saliva, which guide the bronchoscope to the glottis. When the internal diameter of the endotracheal tube is larger than 4 mm, the bronchoscope is used as a guide. When it is less than 4 mm. the bronchoscope is inserted in the trachea with a guide wire slipped in the operating channel; the bronchoscope, but not the wire is withdrawn and the endotracheal tube is inserted over the guide wire.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcranial doppler ultrasonography (TCD) is a non invasive technique for the assessment of cerebral blood flow (CBF). The aim of this prospective study was to evaluate the benefit of TCD for the monitoring of major head trauma patients. Therefore 10 of such patients, aged 17 to 37 years, had a TCD at admission and subsequently at least twice a day. Following data were measured simultaneously at the site of the right and the left middle cerebral arteries: the systolic (SV), diastolic (DV) and mean (MV) blood velocity, the resistance index (RI) of Pourcelot (RI = SV-DV/SV) and the pulsatility index (PI) of Gosling (PI = SV-DV/MV). Simultaneously, the mean intracranial pressure (ICP) obtained with a subarachnoid probe, the PaCO2 and the mean arterial pressure (Pa) were measured. The cerebral perfusion pressure (CPP) was calculated with the formula: CPP = Pa-ICP. A total of 132 measures were analysed. There was a linear relation between RI and CPP (r = 0.566; p < 0.001), between RI and ICP (r = 0.822; p < 0.001), as well as between PI and CPP (r = 0.563; p < 0.001) and between PI and ICP (r = 0.837; p < 0.001). In the opposite there was no statistically significant relation between ICP and MV (r = 0.18) nor between CPP and MV (r = 0.23). However, a MV over 100 cm.s-1 was regularly associated with a ICP over 60 mmHg. The close correlation between RI, PI and ICP allows to use RI or PI to estimate ICP.(ABSTRACT TRUNCATED AT 250 WORDS)

Transcranial Doppler sonography (TCD) is a non invasive technique whereby ultrasonic signals may be recorded from the basal cerebral arteries by using a low frequency probe. Three routes can be used: the transtemporal approach, which studies the anterior, middle and posterior cerebral arteries; the transorbital approach, which evaluates the ophthalmic artery and the carotid canal; and the sub-occipital approach, which assesses the basilar, posterior cerebral and intracranial vertebral arteries. Normal reference values for Doppler parameters have been established for these arteries. Many factors influence them, such as the diameter of the examined blood vessel, PaCO2, cerebral blood flow and cerebrovascular resistances. There are numerous clinical applications of TCD. In anaesthesia, monitoring with this method is useful during cardiopulmonary bypass, controlled hypotension, or carotid endarterectomy. After subarachnoid haemorrhage, the degree of vasospasm can be assessed by TCD. Monitoring cerebral blood flow velocities in intensive care provides important information for the treatment of patients suffering from meningitis, or experienced a head injury, or another ischaemic-anoxic disease. The field of clinical applications of TCD is increasing greatly, but the results must always be carefully interpreted, taking into account the data of other investigations.

A case of pseudo von Willebrand's disease occurring in a 26 year old pregnant woman is reported. The diagnosis was made during the 33rd week of pregnancy. The patient had excessive bleeding of minor wounds, and biological tests revealed a bleeding time exceeding 20 min, a greatly reduced level of Rco fraction of von Willebrand's factor (27%), the absence of high molecular weight von Willebrand's factor multimers, and a greatly increased platelet aggregation in small doses of ristocetin. The patient was allowed to give birth by the vaginal route, receiving 30 IU.kg-1 highly purified concentrated factor VIII, once cervical dilatation was complete. Uterine revision was carried out for safety's sake because of prolonged post-partum bleeding. Two red cell packs were transfused as haemoglobin concentration decreased from 106 g.l-1 to 80 g.l-1. The newborn also presented with biological signs of pseudo von Willebrand's disease, with a bleeding time exceeding 15 min, hypothrombocytopaenia, and a level of Rco fraction of von Willebrand's factor of 9%. Preoperative assessment should always include an investigation of primary haemostatic mechanisms. In case of pseudo von Willebrand's disease, platelet transfusion combined or not with the transfusion of highly purified factor VIII seems to be useful. Investigation of other family members for a pseudo von Willebrand's disease trait is essential.

The efficacy of transcutaneous pacing was studied in 33 patients during general anaesthesia. The temporary pacing was effective in all cases. Stimulation thresholds ranged from 85 to 150 mA (mean : 110 +/- 17). In all 33 patients, external pacing was effective in producing a pulse without significantly reducing arterial pressure. Stimulation thresholds were only influenced by electrode position; age, weight, thoracic diameter and cardiothoracic ratio did not have any effect on them. No adverse effects of transcutaneous pacing were recorded. Transcutaneous pacing can be an alternative to transvenous right ventricular endocardiac pacing in the operating room in some circumstances.

Three cases of acute adrenal haemorrhage complicating heparin induced thrombocytopaenia are described. The patients were 2 men and 1 woman, respectively 62, 74 and 76-year old. They all had orthopaedic problems requiring a treatment by subcutaneous calcium heparinate. Thrombocytopaenia occurred 7 to 10 days after the beginning of treatment, with a progressive return to normal of platelet count on stopping heparin. A syndrome suggestive of adrenal failure appeared on the 10 th to 12 th day consisting of abdominal pain, hyperpyrexia, arterial hypotension, asthenia, altered consciousness. Adrenal hormone levels were decreased. Abdominal scanography demonstrated adrenal haemorrhage in 2 patients. The third patient died before further investigations could be carried out. Hormonal replacement therapy brought things back to normal. Six other similar cases have already been published. The heparin induced thrombocytopaenia probably explains the two paradoxes of adrenal haemorrhage complicating heparin therapy: its occurrence in the absence of excessive anticoagulation, and adrenal venous thrombosis. The presence of abdominal pain, fever, collapse, or hyponatraemia with heparin induced thrombocytopaenia should suggest a possible adrenal haemorrhage. Adrenal CT scans should be carried out rapidly, so that hormone treatment can be initiated without delay.

The haemodynamic changes due to cross-clamping of the abdominal aorta below the renal arteries were studied in ten patients. Anaesthesia was induced with thiopentone and maintained with fentanyl and vecuronium and inhalation of 60% nitrous oxide in oxygen. At the fifth minute, clamping increased mean arterial pressure (Pa) by 11%, systemic vascular resistance (Rsa) by 26% and decreased cardiac output (CO) by 20%. Nifedipine was administered intranasally at this time. Heart rate remained unchanged; mean pulmonary arterial and mean pulmonary wedge pressures were slightly decreased. Pa and Rsa fell to significantly lower levels between the fifth and fifteenth minutes (24 and 43% respectively). Although CO increased by 28%, this was not significant. The administration of intranasal nifedipine during anaesthesia was well tolerated. This study demonstrated that intranasal nifedipine prevented adverse haemodynamic effects of cross-clamping of the aorta below the renal arteries.

The authors report a case of a life-threatening form of juvenile polyposis coli in a 7-year-old girl. The cure of this affection required a total coloproctectomy with ileoanal anastomosis.

The diagnosis of adrenal haemorrhage complicating heparin therapy is often delayed, despite computed tomography (CT). Moreover, its pathogenesis is not clear. Adrenal haemorrhages are often seen in cases where there is no unduly excessive anticoagulation, and can be accompanied by a paradoxical thrombosis of the central adrenal vein. Symptoms usually occur within the first 8 to 12 days after starting heparin. The difficulty in establishing the diagnosis stems from the fact that symptoms are rather nonspecific: abdominal pain and backache, nausea, vomiting, lethargy, weakness, hypotension, hyperpyrexia. To confirm the diagnosis, both hormonal proof of adrenal failure and anatomic evidence of haemorrhage must be found. Early CT scans may show the haemorrhage. Several possible causes have been put forward to account for these adrenal haemorrhages. The degree of anticoagulation did not seem to be a prerequisite, 30 to 50% of patients showing no evidence of other bleeding or coagulation tests outside the therapeutic range. Capillary fragility of old age might be a factor. Stress would seem to be an important factor predisposing to adrenal haemorrhage. Many authors consider the paradoxical central vein thrombosis as a result of the haemorrhage rather than its cause, whereas other conclude the opposite. Unfortunately, to date coagulation studies are often incomplete; platelet counts were missing in most reports published before 1985. Since that date, a heparin induced thrombosis-thrombocytopaenia syndrome (HITTS), in which thrombosis may occur in any vascular bed, has been recognized with increasing frequency. Nine cases of adrenal haemorrhage associated with HITTS have been reported. It seems highly likely that a proportion of cases of heparin-related adrenal destruction are due to HITTS.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty patients undergoing cystoscopy (group A) and forty patients undergoing transurethral resection (group B), aged more than 65 years, were anaesthetized. Duration of anaesthesia was less than 15 min for cystoscopy, and more than 30 min for transurethral resection. No premedication was given. The patients were ASA I or ASA II. Group A patients were allocated randomly to receive either 1.5 mg . kg-1 propofol (n = 10) or 2 mg . kg-1 methohexitone (n = 10) for induction of anaesthesia. Anaesthesia was maintained using incremental doses of propofol or methohexitone and 60% N2O with a face-mask. Forty group B patients undergoing transurethral resection were randomly assigned to four equal groups (PB: propofol 1.5 mg . kg-1; MB: methohexitone 2 mg . kg-1; PF: propofol and 1.5 micrograms . kg-1 fentanyl; PFV: propofol, 2 micrograms . kg-1 fentanyl and 0.1 mg . kg-1 vecuronium). Suxamethonium (1 mg . kg-1; groups PB, MB and PF) and vecuronium (0.1 mg . kg-1; group PFV) were given to facilitate endotracheal intubation. Anaesthesia was maintained by infusion of propofol or methohexitone, using a calibrated pump started immediately after intubation. Ventilation was controlled only in group PFV. Induction with 1.5 mg . kg-1 propofol resulted in stopping counting after 62 s and loss of the eye-lash reflex after 84 s versus 47 and 67 s respectively with methohexitone. The anaesthesist's assessment was favourable for cystoscopy with propofol and methohexitone; recovery times were similar for the two drugs in cystoscopy lasting less than 30 min.(ABSTRACT TRUNCATED AT 250 WORDS)