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Study Objective: Interpretation of gastric ultrasound relies on the use of a clinical algorithm that combines qualitative analysis of the gastric antrum contents with the calculation of the volume of fluid contents. This reference method may be difficult to apply in the parturient. We therefore aimed to assess the diagnostic accuracy of a simple qualitative assessment in the supine position for the diagnosis of high-risk gastric contents in the parturient. We also assessed the diagnostic accuracy of a composite scale and another clinical algorithm based on a mathematical model different to that used in the reference method., Design: Prospective observational cohort study., Setting: University hospital, Lyon, France., Patients: Adult women admitted to the delivery room., Interventions: Qualitative and quantitative gastric ultrasound examination within the first hour following admission., Measurements: With respect to the reference method, the diagnostic accuracy of a simple qualitative assessment for the diagnosis of high-risk gastric contents was assessed. The diagnostic accuracy of a composite scale and another clinical algorithm, and the agreement between each approach were also assessed., Main Results: A total of 235 parturients were included and analyzed. The simple qualitative assessment led to conclusive ultrasound assessment in 233 (99%) women, while the reference method led to conclusive assessment in 213 (91%) women (P < 0.05). The sensitivity and the specificity of the simple qualitative assessment were 97% (95%CI: 93 to 99%) and 96% (95%CI: 90 to 99%), respectively. These were not significantly different from those of the composite scale and the clinical algorithm. The four approaches showed almost perfect agreement with each other., Conclusions: These results suggest that simple qualitative assessment may be useful in clinical practice to help the anesthesiologist in the assessment of gastric contents status and risk of aspiration., Competing Interests: Declaration of competing interest Lionel Bouvet and Laurent Zieleskiewicz received lecture expenses from GE Healthcare. Other authors declare that they have no conflict of interest. This study was solely supported by institutional funding. No grants were received from any funding agencies in the public, commercial, or non-profit sectors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This multicentre prospective observational study sought to determine the prevalence and the factors associated with high-risk gastric contents in women admitted to the maternity unit for childbirth, and to identify the clinical situations in which ultrasound assessment of gastric contents would be most helpful (i.e. when the prevalence of high-risk gastric contents is close to 50%)., Methods: Ultrasound assessments of gastric contents were performed within the first hour after admission to the maternity unit. The prevalence of high-risk gastric contents was calculated and variables associated with high-risk gastric contents were identified using logistic regression analyses., Results: A total of 1003 parturients were analysed. The prevalence of high-risk gastric contents was 70% (379/544; 95% confidence interval: 66-74%) in women admitted in spontaneous labour and 65% (646/1003; 95% confidence interval: 61-67%) in the whole cohort. Lower gestational age, increased fasting duration for solids, and elective Caesarean delivery were independently associated with reduced likelihood of high-risk gastric contents. In women admitted in spontaneous labour and in the whole cohort, the prevalence of high-risk gastric contents ranged from 85% to 86% for fasting duration for solids <6 h, 63%-68% for fasting 6-8 h, 54%-55% for fasting 8-12 h, and 47%-51% for fasting ≥12 h., Conclusions: Around two-thirds of parturients had high-risk gastric contents within the first hour after admission to the maternity unit. Our results suggest that gastric emptying for solids continues in labouring women, and that gastric ultrasound would be most helpful when fasting duration is ≥8 h., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: It has been reported that qualitative ultrasound assessment performed in the semi-upright position had high sensitivity to detect gastric fluid volume >1.5 mL.kg -1 . Nevertheless, the diagnostic accuracy of qualitative assessment for the diagnosis of empty stomach (fluid volume <0.8 mL.kg -1 ) has not been assessed. We aimed to assess the diagnostic accuracy of simple qualitative ultrasound assessment with and without head-of-bed elevation to 45° for the diagnosis of an empty stomach. We also aimed to determine the diagnostic accuracy of a composite ultrasound scale and clinical algorithm., Methods: We performed a supplementary analysis of a prospective observer-blind randomized crossover trial in which adult fasting volunteers attended two distinct sessions, with the head-of-bed angled either at 0° or 45°, in a randomized order. Three tests were performed within each session, each corresponding to a different (either 0, 50, 100, 150 or 200 mL) and randomized volume of water; the same volumes were ingested in both sessions, in a randomized order. Ultrasounds were performed 3 min after water ingestion, blindly to the volume ingested., Results: We included 20 volunteers in whom 120 measurements were analyzed. The sensitivity and specificity of the qualitative assessment in the semirecumbent position were 93% (95% CI: 68-100) and 89% (95% CI: 76-96), respectively. The composite scale and clinical algorithm did not have better diagnostic accuracy than the qualitative assessment performed with head-of-bed elevation. Without head-of-bed elevation, the clinical algorithm had significantly higher specificity (98% [95% CI: 88-100]) than qualitative assessment (67% [95% CI: 51-80]; p < 0.05)., Conclusion: These results suggest that qualitative assessment in the semirecumbent position had high diagnostic accuracy for the diagnosis of fluid volume <0.8 mL.kg -1 ; this method can be used in clinical practice for reliable diagnosis of empty stomach., (© 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: To date, the use of the plethysmographic variability index (PVI) has not been recommended to guide fluid management in the paediatric surgical population. This systematic review and meta-analysis aimed to summarise available evidence about the diagnostic accuracy of digital PVI to predict fluid responsiveness in mechanically ventilated children., Methods: We searched the Pubmed, Embase and Web of Science databases, from inception to January 2022, to identify all relevant studies that investigated the ability of the PVI recorded at the finger to predict fluid responsiveness in mechanically ventilated children. Using a random-effects model, we calculated pooled values of diagnostic odds ratio, sensitivity, and specificity of PVI to predict the response to fluid challenge., Results: Eight studies met the inclusion criteria with a total of 283 patients and 360 fluid challenges. All the studies were carried out in a surgical setting. The area under the summary receiver operating characteristic curve of PVI to predict fluid responsiveness was 0.82. The pooled sensitivity, specificity, and diagnostic odds ratio of PVI for the overall population were 72.4% [95% CI: 65.3-78.7], 65.9% [58.5-72.8], and 9.26 [5.31-16.16], respectively., Conclusion: Our results suggest that digital PVI is a reliable predictor for fluid responsiveness in mechanically ventilated children in the perioperative setting. The diagnostic performance of digital PVI reported in our work for discrimination between responders and non-responders to the fluid challenge was however not as high as previously reported in the adult population., (Copyright © 2023 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Study Objective: This study aimed to assess whether elevating the head of the bed to 45° was associated with sensitivity >90% of the qualitative ultrasound assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg -1 . We also assessed the performance of qualitative assessment, composite ultrasound scale, and clinical algorithm, for the diagnosis of fluid volume > 1.5 ml.kg -1 according to whether the head of the bed was elevated to 45° or not., Design: Prospective randomized observer-blind crossover trial., Setting: Hospices Civils de Lyon, France., Patient: Healthy adult volunteers., Interventions: Two separate study sessions in fasting volunteers: with and without head-of-bed elevation to 45°, in a randomized order. Each session consisted of three tests, each corresponding to a randomized and different volume of water (either 0, 50, 100, 150 or 200 ml); the same volumes were used in both sessions and in a randomized order. Gastric ultrasounds were performed three minutes after the ingestion of water by an investigator blinded to the volume ingested., Measurements: Diagnostic performance of each approach for the diagnosis of gastric fluid volume > 1.5 ml.kg -1 ., Main Results: Twenty volunteers were included, and 120 measurements were analyzed. The sensitivity of the qualitative assessment for the diagnosis of gastric fluid volume > 1.5 ml.kg -1 with and without head-of-bed elevation was 91% (95%CI: 75-98) and 75% (95%CI: 57-89), respectively. The clinical algorithm with head-of-bed elevation had significantly better sensitivity than the qualitative assessment with no head-of-bed elevation; there was no significant difference for other comparisons., Conclusions: The results suggest that qualitative examination of gastric antrum in the supine position with head-of-bed elevation to 45° can discriminate between low and high gastric fluid volume with high sensitivity, while neither the composite ultrasound scale nor the clinical algorithm improved the diagnostic performance of gastric ultrasound for the diagnosis of gastric fluid volume > 1.5 ml.kg -1 ., (Copyright © 2022 Elsevier Inc. All rights reserved.)

There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg -1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration., (© 2022 Association of Anaesthetists.)

Study Objective: Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound., Design: Prospective observational cohort study., Setting: Specialist pediatric center over a 30-month period., Patients: Children undergoing surgery within 24 h of an acute extremity fracture., Interventions: None., Measurements: According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg -1 , thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis., Main Results: Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred., Conclusions: At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The lack of reliable data on gastric emptying of solid food during labor has led to some discrepancies between current guidelines regarding fasting for solid food in the parturient. This prospective comparative study aimed to test the hypothesis that the gastric emptying fraction of a light meal would be reduced in parturients receiving epidural analgesia and with no labor analgesia compared with nonpregnant and pregnant women., Methods: Ten subjects were enrolled and tested in each group: nonpregnant women, term pregnant women, parturients with no labor analgesia, and parturients with epidural labor analgesia. After a first ultrasound examination was performed to ensure an empty stomach, each subject ingested a light meal (125 g yogurt; 120 kcal) within 5 min. Then ultrasound measurements of the antral area were performed at 15, 60, 90, and 120 min. The fraction of gastric emptying at 90 min was calculated as [(antral area90 min / antral area15 min) - 1] × 100, and half-time to gastric emptying was also determined. For the Parturient-Epidural group, the test meal was ingested within the first hour after the induction of epidural analgesia., Results: The median (interquartile range) fraction of gastric emptying at 90 min was 52% (46 to 61), 45% (31 to 56), 7% (5 to 10), and 31% (17 to 39) for nonpregnant women, pregnant women, parturients without labor analgesia, and parturients with labor epidural analgesia, respectively (P < 0.0001). The fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-Epidural group than in the Nonpregnant and Pregnant Control groups. In addition, the fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient-No-Epidural group than in the Parturient-Epidural group., Conclusions: Gastric emptying in parturients after a light meal was delayed, and labor epidural analgesia seems not to worsen but facilitates gastric emptying. This should be taken into consideration when allowing women in labor to consume a light meal., (Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved.)

Background: There is ongoing debate regarding the optimal general anaesthetic technique for manual removal of the placenta after vaginal delivery. Using ultrasound examination of the gastric antrum, this study aimed to assess the change in gastric contents during vaginal delivery and to determine the prevalence of stomach at risk for pulmonary aspiration in the immediate postpartum period before placental delivery., Methods: In this prospective multicentre cohort study, antral ultrasonography was performed at full cervical dilatation within the thirty minutes preceding the beginning of expulsive efforts and after vaginal birth, before placental delivery. High-risk gastric content was defined as the visualisation of any solid content in the antrum or antral cross-sectional area in the semi-recumbent position (SR-CSA) > 608 mm²., Results: Twenty-six women were included and analysed. There was a significant decrease in both the proportion of patients with solid gastric content and the SR-CSA between the two-ultrasound examinations. Twenty-one patients (80.8%) exhibited a decrease in the SR-CSA during vaginal delivery. The prevalence of stomach at risk for pulmonary aspiration was significantly lower after vaginal delivery than before vaginal delivery (23.1% vs. 57.7%, P = 0.0004)., Conclusion: Our results suggest that gastric emptying is at least partially preserved during vaginal birth. Nevertheless, almost a quarter of women did have high-risk gastric content in the immediate postpartum period. Point-of-care antral ultrasonography may be of interest for the fast assessment of the gastric content status when a general anaesthesia is required for manual removal of retained placenta., (Copyright © 2021 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: Maternal satisfaction and comfort may in part depend on fasting instruction given during labor. This study aimed to assess the satisfaction and the wishes of parturients with regards to fasting during labor., Study Design: This prospective cohort study was conducted among parturients assessing the fasting instructions they were given. We assessed whether women did have any oral intake during labor and focused on women's view of fasting during labor. Maternal discomfort related to thirst and hunger was assessed using 0-10 scales., Results: A total of 193 women were included, among whom 71 (37 %) received spontaneously given instructions and 60 (31 %) received instruction upon request. One hundred sixteen (60 %) women were allowed to drink clear fluids, in a limited way for 106 women (91 % of those concerned); 119 women did drink clear fluids during labor. One hundred thirty-two (68 %) women had a thirst-related discomfort score ≥ 4 without any statistical difference whether they had or had not drunk clear fluids. Colder water, unrestricted volume of water and sweet drink were desired by 74 (64 %), 38 (33 %) and 28 (24 %) women who had been allowed to drink, respectively., Conclusion: These results emphasize that thirst contributes to maternal discomfort during labor. Permitting limited intake of water does not ensure high maternal satisfaction. Fresh clear fluids, unrestricted amounts of fluids and sweet fluids could contribute to improve maternal comfort., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Pulse pressure variation (PPV) and plethysmographic variability index (PVI), dynamic indicators of preload dependence based on heart-lung interactions, are used to predict fluid responsiveness in mechanically ventilated patients in the supine position. The sitting position for neurosurgery, by changing intrathoracic blood volume, could affect the capacity of PPV and PVI to predict fluid responsiveness. The aim of the study was to assess the ability of PPV and PVI to predict fluid responsiveness during general anesthesia in the sitting position., Methods: In total, 31 patients were included after settling in the sitting position but before surgery began. PPV, PVI with a finger sensor (PVI finger), and PVI with an ear sensor (PVI ear) were recorded before and after a fluid challenge of hydroxylethylstarch 250 mL over 10 minute. Esophageal Doppler was used to record stroke volume. Patients were defined as fluid responders if stroke volume increased by more than 10% after the fluid challenge., Results: In total, 13 (42%) patients were fluid responders. PPV and PVI ear were higher in responders than in nonresponders before the fluid challenge (12±5 vs. 7±3; P=0.0005 and 14±5 vs. 8±3; P=0.001, respectively). Areas under the receiver-operating curves to predict fluid responsiveness were 0.87 for PPV (P<0.0001), 0.87 for PVI ear (P<0.0001), and 0.64 for PVI finger (P=0.17). PPV ≥8% or PVI ear ≥11% predicted fluid responsiveness with sensitivities of 83% for both, and specificities of 83% and 91%, respectively. However PVI ear data were not available in 26% of patients., Conclusions: PPV can be used to predict fluid responsiveness in the sitting position for neurosurgery.

Background: Assessment of the effectiveness of obstetric epidural analgesia may be difficult and techniques for objective assessment of epidural spread of local anesthetic would be useful. In this prospective cohort study we assessed whether obstetric epidural analgesia from a low concentration of ropivacaine led to significant change in cutaneous temperature, related to sympathetic block detected by infrared thermography, at dermatomes C4, T4, T10, L2 and L5., Methods: Women in spontaneous labor who requested epidural analgesia were consecutively recruited. Epidural analgesia was induced with a bolus of 10-15 mL of ropivacaine 1 mg/mL and sufentanil 0.5 µg/mL, followed by continuous epidural infusion. Skin temperature was measured using thermography before and 20 min after the epidural bolus. The verbal pain score using a numeric rating scale was recorded before and 60 min after the epidural bolus. The upper sensory block to cold sensation was tested 30 and 60 min after the bolus by a physician blinded to the skin temperature. Failed epidural analgesia was defined as verbal pain score >3 at 60 min., Results: Fifty-three parturients were included and analyzed. We found a significant increase in skin temperatures measured at T4, T10, L2 and L5 dermatomes, but not at C4, and a significant difference in the change in skin temperature at T10 between failed (n=3) and successful (n=50) epidural analgesia., Conclusions: These results suggest that infrared thermography might be useful for the early diagnosis of successful obstetric epidural analgesia., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Very little evidence for predictive markers of fluid responsiveness has been reported in children as compared to adults. The impact of hypovolemia or hypervolemia on morbidity has driven interest in the fluid challenge titration strategy., Aim: The objective of this study was to explore the ability of a 3 mL kg -1 mini-fluid challenge over 2 minutes to predict fluid responsiveness in children under controlled ventilation., Methods: Children scheduled for surgery under general anesthesia were included and received a fluid challenge of 15 mL kg -1 of crystalloid prior to incision administered over 10 minutes in two steps: 3 mL kg -1 over 2 minutes then 12 mL kg -1 over 8 minutes. Fluid responsiveness was defined as a change of ≥10% in cardiac output estimated by left ventricular outflow tract velocity time integral (VTI) as measured by transthoracic ultrasound before and after the fluid challenge of 15 mL kg -1 ., Results: Of the 55 patients included in the analysis, 43 were fluid responders. The increase in the VTI after the mini-fluid challenge (ΔVTI miniFC ) predicted fluid responsiveness with an area under the receiver operating characteristic curve of 0.77; 95% CI (0.63-0.87), P = .004. Considering the least significant change which was 7.9%; 95% CI (6-10), the threshold was 8% with a sensitivity of 53%; 95% CI (38-68); and a specificity of 77%; 95% CI (54-100)., Conclusion: ΔVTI miniFC weakly predicted the effects of a fluid challenge of 15 mL kg -1 of crystalloid in anesthetized children under controlled mechanical ventilation., (© 2019 John Wiley & Sons Ltd.)

Background: Non-elective caesarean sections may be classified using a three-colour coding system, from code-green caesarean section corresponding to non-urgent delivery (no maternal of foetal compromise) to code-red caesarean section corresponding to emergency caesarean section due to immediate life-threatening maternal or foetal situations. Decision-to-delivery interval≤15min has been advocated in France for code-red caesarean section. This retrospective cohort study aimed to assess the decision-to-delivery interval and the neonatal outcomes according to the anaesthetic technique performed for code red caesarean section in a French tertiary care obstetric unit., Methods: All women undergoing code-red caesarean section between January 2013 and December 2015 were included. Demographic characteristics and anaesthetic, obstetrical and neonatal outcomes were collected from the patient's electronic medical records., Results: Among 194 code-red caesarean sections analysed, 127 (65%) were performed under epidural anaesthesia and 67 (35%) under primary general anaesthesia. The median decision-to-delivery interval was 10 [8-12.5] min, and the interval was≤15min in 174 (90%) women. Effective epidural top-up and epidural top-up requiring supplemental sedation were associated with the shortest decision-to-delivery interval. Primary general anaesthesia was independently associated with depressed 5minutes Apgar score., Conclusion: The decision-to-delivery interval was≤15min in most women, suggesting that optimised organisation ensures short decision-to-delivery interval independently of the anaesthetic technique performed. As general anaesthesia was associated with worse neonatal outcomes, our results support the early insertion of an epidural catheter whenever there is any potential concern that an emergency caesarean section may be required., (Copyright © 2019 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

We assessed the impact of raising the upper section of the bed, and patient positioning, on ultrasound assessment of gastric fluid contents. We performed ultrasound examinations in 25 subjects lying on their back, left and right sides at bed angles of 0°, 30°, 45° and 90°; this was carried out while the subjects were fasted, and repeated 10 min after drinking ≥ 50 ml water. After drinking, gastric contents were detected more frequently in the 45° semirecumbent position compared with the supine and 30° positions. The diagnostic performance of the Perlas qualitative grading scale to detect gastric fluid volume > 1.5 ml.kg -1 was improved at 45°, compared with 0° and 30° angles. The use of a composite ultrasound grading scale at a 45° angle was associated with the best performance, with a sensitivity and specificity of 82%. Antral cross-sectional area was significantly increased when measured in the right lateral position, but there was no effect of raising the bed. In conclusion, raising the upper section of the bed significantly affected qualitative assessment of gastric fluid contents. Further studies are required to determine the most appropriate composite ultrasound grading scale and bed angle for fast and reliable qualitative ultrasound detection of fluid volumes > 1.5 ml.kg -1 ., (© 2019 Association of Anaesthetists.)

Background: Emergent obstetrical procedures may require general anaesthesia in parturients at full cervical dilatation or immediately after vaginal birth. This study aimed to determine the prevalence and the predictive factors of higher estimated gastric content in parturients at full cervical dilatation with epidural analgesia and allowed to drink during the labour, and to assess the ability of the antral area measured in the semirecumbent position (SR-CSA) to identify higher estimated gastric content in this setting., Methods: This prospective observational study was conducted between December 2016 and July 2017. Ultrasonographic examination of the antrum was performed at full cervical dilatation, within the hour preceding the beginning of expulsive efforts. Higher estimated gastric content was defined when solid content was observed and/or if the calculated gastric fluid volume was >1.5 mL/kg., Results: Seventeen of 62 parturients (27%) presented higher estimated gastric content. Maximal pain intensity during the last hour of labour and time interval between the insertion of the epidural catheter and ultrasonographic examination were significantly increased in parturients with higher estimated gastric content. The threshold value of the SR-CSA to identify a higher estimated gastric content was 393 mm 2 , with sensitivity = 88% and specificity = 87%., Conclusion: Around a quarter of parturients with epidural analgesia and free access to clear fluids during labour presented higher estimated gastric content at full cervical dilatation. The SR-CSA may be of interest for the fast ultrasound assessment of the gastric content status in case of emergent obstetrical procedures at full cervical dilatation., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: The relationship between gastric fluid volume, volume of fluid regurgitated, and aspirated fluid volume remains unclear. Using a life-like manikin suitable for a pulmonary aspiration model, we aimed to assess the relationship between regurgitated and aspirated clear fluid volumes, and to determine the minimal value of the volume of liquid regurgitated that may lead to pulmonary aspiration of fluid volume ≥ 0.8 mL kg-1 (around 60 mL) that is likely to cause lung injury., Methods: Several volumes of water ranging from 30 to 150 mL were injected in a randomized order, at a flow rate of 20 mL per second, into the esophagus of a manikin lying in the supine position on a non-tilted table, with the manikin head in the extension or in the sniffing position. Aspirated volumes were measured in the manikin bronchi, by an investigator blinded to the volume injected. Aspiration was defined as positive when the volume of collected water was ≥ 60 mL for at least one of the five injections of each volume of water., Results: The minimal volume of water injected into the esophagus for an aspirated volume ≥ 0.8 mL kg-1 was 85 mL in the sniffing position, and was 150 mL in the extension position., Conclusions: These results suggest that the critical cut-off value of gastric fluid volume to be considered for the risk of significant pulmonary aspiration would be ≥ 85 mL (≥ 1 mL kg-1), in the sniffing position. These results should however be confirmed in further studies using other models.

Background: Though pulmonary aspiration of gastric contents occurs mainly in the setting of emergency surgery, it may also occur in children scheduled for elective surgery without any obvious clinical risk factor. Increased gastric content volume is one the predisposing factors for pulmonary aspiration that could affect such children and may be identified using ultrasound examination of the gastric antrum., Aims: We aimed to assess the prevalence of "at-risk stomach" defined by ultrasound visualization of any solid content in the antrum and/or by calculated gastric fluid volume > 1.25 mL/kg, in children scheduled for elective surgery., Methods: Children scheduled for elective surgery were consecutively included into this prospective cohort study. Preoperative ultrasound examination of the antrum was performed in both the supine and the right lateral decubitus positions. Gastric fluid content was assessed using a 0-2 qualitative grading scale. The antral cross-sectional area was also measured in both the supine and the right lateral decubitus positions, allowing the calculation of the gastric fluid volume according to a formula previously described., Results: We analyzed 200 elective children. Median duration of fasting was 4 hours for liquids and >13 hours for solids. None of the children included in this study had evidence of solid content. Six (3%) children had a Grade 2 antrum (fluid content seen in both the supine and the right lateral decubitus positions). Two children had a gastric fluid volume >1.25 mL/kg. The prevalence of "at-risk stomach" was 1% (95% confidence interval: 0.2%-3.9%)., Conclusion: According to our results, only 1% of elective children had potentially increased risk for pulmonary aspiration. Further studies should be performed in order to define the target population of elective children for which ultrasound assessment of gastric content should be performed prior to general anesthesia., (© 2018 John Wiley & Sons Ltd.)

Objective: Epidural blood patch is the procedure of choice to relieve postdural puncture headache. Hydroxyethyl-starch (HES) has been proposed as a patch in some circumstances such as in the case of hematological disease due to the theoretical risk of neoplastic seeding to the central nervous system. Acute neurological HES toxicity has been excluded by a previous animal study, but the long-term neurological toxicity has not been evaluated., Methods: Rats were randomly assigned to one of three groups: no intrathecal injection, 20 μL of intrathecal saline, or a 20-μL intrathecal HES (6% hydroxyethyl starch 130/0.4) administered via a cervical puncture. Clinical daily rat activity was measured before and after dural puncture by actinometry. The rats were killed at day 28, and the spinal cord was surgically removed and stained with hematoxylin-phloxine-saffron for gross and microscopic examination., Results: Eleven rats underwent dural puncture without injection, 11 were injected with normal saline, and 12 received intrathecal HES. No clinical or actimetric changes (total distance traveled, number of direction changes, and number of rearings) were observed up to one month after injection. Nonspecific histopathological changes were equally observed in all groups., Conclusions: The results of the current study indicate that intrathecal injection of HES in rats does not induce any clinical or histopathological evidence of long-term neuronal toxicity. Further safety studies in animals are warranted before HES might be considered a safe alternative to the classic epidural blood patch.

Introduction: The balance between the sympathetic and parasympathetic systems could be used to predict the onset of hypotension following spinal anaesthesia. The autonomic innervation of the pupil may reflect this balance. The aim of this study was to evaluate the ability of pupillometry to predict the risk of hypotension after spinal anaesthesia for caesarean section., Methods: Two hundred patients receiving spinal anaesthesia for caesarean section were recruited. Changes in pupillary diameter, pupillary reaction latency, pupil constriction velocity and maximum and minimum pupillary diameters were measured with a pupillometer (Neurolight ® , IDMed) prior to induction of spinal anaesthesia with 10mg bupivacaine and fentanyl 30μg. Hypotension was defined as a systolic blood pressure drop of > 20% compared with the baseline value., Results: A total of 141 patients (70%) presented at least one episode of hypotension. Pupillary reaction latency can poorly predict hypotension and severe hypotension after spinal anaesthesia. The areas under the receiver-operating characteristic curves were 0.654 (95% confidence interval: 0.584-0.720, P=0.0001) and 0.633 (95% confidence interval: 0.562-0.700, P=0.004) for optimal threshold values of 223 and 231ms, respectively. In multivariate analysis, a baseline systolic blood pressure > 130mmHg (odds ratio: 1.98, P=0.04) and a PRL > 223ms (odds ratio: 3.42, P=0.0002) were independently associated with the risk of spinal anaesthesia-related hypotension., Conclusion: Following spinal anaesthesia in patients undergoing caesarean section, though the predictive capacity pupillary reaction latency for the onset of hypotension and severe hypotension is poor, it is nevertheless the strongest predictor of hypotension identified in our study., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: Ultrasound examination of the gastric antrum allows reliable pre-operative assessment of gastric contents and volume in adult patients. However, during pregnancy, the change in the anatomical position of the stomach due to the gravid uterus leads to a change in the measured value of the antral area. Therefore, current mathematical models predicting gastric content volume (GCV) in the adult may not apply in term pregnant women., Objective: To propose a mathematical model which is predictive of GCV in pregnant women and to assess the performance of an ultrasound qualitative grading scale (0 to 2) for the diagnosis of clear fluid volumes more than 0.8 and 1.5 ml kg., Design: Prospective cohort study., Setting: Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon and Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Marseille, France., Patients: Pregnant women in the third trimester of pregnancy., Main Outcome Measures: Comparison of the GCV as measured by MRI and the ultrasound measured antral cross-sectional area, and an assessment of gastric contents according to a 0 to 2 qualitative grading scale., Results: Data from 34 women were analysed. A linear model predictive of GCV was constructed with a 95% agreement band of ±95 ml, with a mean polar angle of -8.7°. Performance of the qualitative grading scale to detect fluid volumes >0.8 and >1.5 ml kg was improved when used in a composite scale including a 505 mm antral area cut-off value in the semirecumbent supine position., Conclusion: We report a new mathematical model predictive of GCV in women in the third trimester of pregnancy. Furthermore, the combination of the qualitative and the quantitative ultrasound examination of the gastric antrum might be useful to assess gastric fluid volume in pregnant women., Trial Registration: ANSM Register N°2015-A00800-49.

Background: Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors., Methods: This prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children <18 yr undergoing general anaesthesia were consecutively included. For each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis., Results: Incident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001]., Conclusions: Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies., (Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Ultrasound examination of the gastric antrum is a non-invasive tool that allows reliable estimation of gastric contents. We performed this prospective cohort study in non-elective paediatric surgery to assess whether gastric ultrasound may help to determine the best anaesthetic induction technique, whether rapid sequence or routine. The primary outcome was the reduction of inappropriate induction technique. A pre-operative clinical assessment was performed by the attending anaesthetist who made a provisional plan for induction. Gastric ultrasound was performed in the semirecumbent and right lateral decubitus positions for a qualitative assessment of gastric contents, using a 0-2 grading scale. A final induction plan was made based on this assessment. Immediately after tracheal intubation, gastric contents were suctioned through a multi-orifice nasogastric tube; these were defined as above risk threshold for regurgitation and aspiration if there was clear fluid > 0.8 ml.kg -1 , and/or the presence of thick fluid and/or solid particles. Gastric ultrasound was feasible in 130 out of 143 (90%) of children, and led to a change in the planned induction technique in 67 patients: 30 from routine to rapid sequence, and 37 from rapid sequence to routine. An appropriate induction technique was therefore performed in 85% of children, vs. 49% planned after pre-operative clinical assessment alone (p < 0.00001). Our results suggest that gastric ultrasound is a useful guide to the general anaesthetic induction technique with respect to the risk of pulmonary aspiration, in comparison with pre-operative clinical assessment alone., (© 2017 The Association of Anaesthetists of Great Britain and Ireland.)

Background: Current fasting guidelines allow oral intake of water up to 2 h before induction of anaesthesia. We assessed whether gum chewing affects gastric emptying of 250 ml water and residual gastric fluid volume measured 2 h after ingestion of water., Methods: This prospective randomized observer-blind crossover trial was performed on 20 healthy volunteers who attended two separate study sessions: Control and Chewing gum (chlorophyll flavour, with 2.1 g carbohydrate). Each session started with an ultrasound measurement of the antral area, followed by drinking 250 ml water. Then, volunteers either chewed a sugared gum for 45 min (Chewing gum) or did not (Control). Serial measurements of the antral area were performed during 120 min, and the half-time to gastric emptying (t½), total gastric emptying time, and gastric fluid volume before ingestion of water and 120 min later were calculated., Results: Gastric emptying of water was not different between sessions; the mean (sdsd) t½ was 23 (10) min in the Control session and 21 (7) min in the Chewing gum session (P=0.52). There was no significant difference between sessions in gastric fluid volumes measured before ingestion of water and 120 min later., Conclusions: Chewing gum does not affect gastric emptying of water and does not change gastric fluid volume measured 2 h after ingestion of water., Clinical Trial Registration: NCT02673307., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Ultrasound examination of the gastric antrum allows reliable assessment of gastric contents and volume. Postoperative assessment of gastric contents before recovery from anaesthesia could help the physician to choose the most appropriate extubation technique after surgery in children. In this prospective observational study, we assessed whether significant changes occurred in gastric contents during the intra-operative period in children undergoing elective ear, nose and throat (ENT) surgery. Children aged between six months and 16 years were recruited consecutively. Ultrasound examination of the antrum was performed before induction of anaesthesia and at the end of surgery before tracheal extubation, and included quantitative and qualitative assessment of gastric contents. The mean (SD) gastric volume was 0.28 (0.30) ml.kg -1 before surgery and 0.27 (0.30) ml.kg -1 after surgery, p = 0.82. No solid contents were identified in the antrum, and the gastric volume was < 1.5 ml.kg -1 in all patients during both ultrasound examinations. Our results suggest that, after elective ENT surgery, children are not at risk of a full stomach before tracheal extubation, and that pulmonary aspiration of blood that may occur after elective ENT surgery is probably not related to regurgitation of ingested blood from the stomach., (© 2017 The Association of Anaesthetists of Great Britain and Ireland.)

Purpose: Although perioperative hypothermia may increase maternal morbidity, active warming is infrequently performed to maintain normothermia during Cesarean delivery (CD). The aim of this prospective observational study was to determine the factors associated with maternal hypothermia in this setting., Methods: Women scheduled for elective or emergency CD were consecutively included in this study from November 2014 to October 2015. Maternal temperature was measured using an infrared tympanic thermometer on the patient's arrival in the operating room, at skin incision, and at the end of skin suture. Maternal hypothermia was defined by tympanic temperature < 36°C at the end of skin suture. Univariate analysis was performed, followed by multivariate logistic regression analysis, in order to determine the factors associated with maternal hypothermia at the end of the surgery., Results: Three hundred fifty-nine women were included and analyzed during this study. The incidence of hypothermia was 23% (95% confidence interval, 18 to 27) among the total population included. According to multivariate analysis, obesity, oxytocin augmentation of labour, and use of active forced-air warming were associated with a decreased risk of maternal hypothermia, while maternal temperature < 37.1°C on arrival in the operating room, maternal temperature < 36.6°C at skin incision, and an infused volume of fluids > 650 mL were significantly associated with maternal hypothermia. Both goodness of fit and predictive value of multivariate analysis were high., Conclusion: Several predictive factors for maternal hypothermia during CD were identified. These factors should be taken into account to help prevent maternal hypothermia during CD.

Background: Ultrasound measurement of the antral cross-sectional area of the stomach, performed in the supine position, has been described for preoperative assessment of gastric content in the adult, but, to date, no study has determined the cut-off value of the antral area for the diagnosis of an empty stomach in the parturient. Nevertheless, previous studies in parturients have reported that the use of a simple qualitative grading scale (0 to 2) was reliable for the estimation of the gastric fluid volume. However, this qualitative grading score requires turning the parturient into the right lateral decubitus position for the ultrasound examination, something which may not be easily feasible, particularly in the case of an obstetric emergency., Objective: To calculate the cut-off value of the antral area, measured in the supine position during established labour, for the diagnosis of 'empty' stomach., Design: A prospective cohort study., Setting: Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France., Patients: Seventy-three women in established labour., Interventions: For each parturient, ultrasound assessment of gastric contents was performed in the supine and right lateral decubitus position and scored 0 to 3 on a qualitative grading scale. This assessment was followed by ultrasound measurement of the antral cross-sectional area in both the supine and right lateral positions., Main Outcome Measures: To assess the performance of the antral area measured in the supine position for the diagnosis of an 'empty' stomach (gastric antrum grade 0), a receiver operating characteristic curve was plotted, and the area under the receiver operating characteristic curve was calculated., Results: Data from 73 women were analysed. For the diagnosis of grade 0, the cut-off value for the antral area measured in the supine position was 381 mm (sensitivity, 81%; specificity, 76% and negative predictive value, 80%)., Conclusion: With a parturient lying in the supine position, a single assessment of the antral cross-sectional area may be used for the fast diagnosis of an empty stomach. This tool could be useful in assessing the risk of aspiration for parturients who require emergency anaesthesia during labour.

Background: This prospective observational study sought to assess the rate of full and empty stomach in elective and emergency patients and to determine the factors associated with full stomach., Methods: Non-premedicated patients were consecutively included between May 2014 and October 2014. Ultrasound examination of the gastric antrum was performed by an operator blinded to the history of the patient. It included measurement of the antral cross-sectional area, performed in the supine position with the head of the bed elevated to 45°, and qualitative assessment of the gastric antrum, performed in both semirecumbent and right lateral decubitus positions. Full stomach was defined by the appearance of any gastric content in both positions (Grade 2). Empty stomach was defined either by empty antrum in both positions (Grade 0) or by empty antrum in the semirecumbent position only (Grade 1) with measured antral area <340 mm2. The combination of Grade 1 and antral area >340 mm2 defined intermediate stomach. Logistic regression analyses were performed for the identification of factors associated with full stomach., Results: Four hundred and forty patients were analysed. The prevalence of full stomach was 5% (95% confidence interval: 2–9) in elective patients and 56% (95% confidence interval: 50–62) in emergency patients (P<0.0001). Obesity, diabetes mellitus, emergency surgery, and preoperative consumption of opiates were independent factors predictive of full stomach., Conclusions: The results suggest that preoperative ultrasound assessment of gastric content should be performed in all emergency patients, and in elective patients with identified predictive factors for full stomach., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Ultrasound measurement of the antral cross-sectional area allows a quantitative estimate of gastric contents in non-pregnant adults, but this relationship may be affected by compression of the stomach exerted by the gravid uterus during pregnancy. This study aimed to assess differences in quantitative (Perlas score) and qualitative (antral cross-sectional area) ultrasound assessments of the gastric antrum performed immediately before and after caesarean section. Forty-three women having elective caesarean section performed under spinal anaesthesia were studied in the semirecumbent and semirecumbent-right lateral positions. Thirty-nine women showed no change in stomach contents using the Perlas score between the two measurement periods; four women showed a change, but by one grade only. The median (IQR [range]) antral cross-sectional area was 323 (243-495 [103-908]) mm 2 before, and 237 (165-377 [112-762]) mm 2 after, caesarean section in the semirecumbent position (p = 0.001); the comparable values in the semirecumbent-right lateral position were 418 (310-640 [161-1238]) mm 2 and 362 (280-491 [137-1231]) mm 2 (p = 0.09). The distance between the skin and the antrum, and the aorta and the antrum, decreased significantly in both positions after surgery. We suggest that our results indicate that stomach contents remain largely unchanged in women having elective caesarean section, but antral cross-sectional area decreases, especially in the semirecumbent position, related to a change in the position of the stomach within the abdomen. This implies that the relationship of antral cross-sectional area to volume of stomach contents, which has been determined for non-pregnant subjects, may not apply in term pregnant women., (© 2016 The Association of Anaesthetists of Great Britain and Ireland.)

Background: Evacuation of gastric content through a nasogastric tube, followed by rapid sequence induction, is usually recommended in infants undergoing pyloromyotomy. However, rapid sequence induction may be challenging, and is therefore controversial. Some anaesthetists regularly perform classical non-rapid induction technique, after blind aspiration of the gastric contents, although this aspiration may have been incomplete. This prospective observational study aimed to assess whether the ultrasound monitoring of the aspiration of the stomach contents, may be useful to appropriately guide the choice of the anaesthetic induction technique, in infants undergoing pyloromyotomy., Methods: Infants undergoing pyloromyotomy were consecutively included. Ultrasound assessment of the antrum was performed before and after the aspiration of the gastric contents through a 10 French gastric tube. The stomach was defined as empty when no content was seen in both supine and right lateral positions. The correlation between antral area and the aspirated gastric volume was also tested., Results: We analysed 34 infants. Ultrasound examination of the antrum failed in three infants. The stomach was empty in 30/34 infants (nine before aspiration, 21 after aspiration), allowing to perform a non-rapid induction technique in 88.2% of the infants. There was a significant correlation between antral area measured in right lateral decubitus and the aspirated gastric volume., Conclusions: Our results suggest that the qualitative ultrasound assessment of the antral content may be a simple and useful point-of-care tool, for the choice of the most appropriate anaesthetic technique for pyloromyotomy according to the estimated risk of pulmonary aspiration of gastric contents., (© Crown copyright 2016.)

Objective: To compare management of injured children in an adult trauma center (TC) with competencies in pediatric trauma care (2005-2007) and in a pediatric-only trauma center (2010-2012)., Study Design: A before-after retrospective study., Patients and Methods: Fifty-nine children between 1 and 15 years of age admitted to the adult TC (2005-2007) were compared to 56 children admitted to the pediatric TC (2010-2012). Epidemiological data, severity scores, early outcome, and care duration in trauma resuscitation before whole-body CT were collected and compared between the two periods., Results: This study found no significant differences between the two periods in terms of care duration before the whole-body CT scan (28 min [18-40] vs 26.5 min [21-36], P=0.89) and early mortality (eight children [13.5%] vs ten children [17.8%], P=0.35)., Conclusion: With no differences in early management of injured children demonstrated, this study validates the organization within our pediatric trauma center. The effectiveness of management of children between 1 and 15 years of age with severe trauma seems to be similar in the two contexts., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Several clinical and surgical factors can influence the occurrence of allogeneic blood transfusion (ABT) during oncologic neurosurgery., Objectives: To identify the potential predictive factors of ABT during craniotomy for the removal of brain tumors in children and the potential impact of intraoperative ABT on early postoperative outcome., Methods: A retrospective study was performed in all pediatric patients younger than 18 years who underwent craniotomy for brain tumor removal from December 2009 to December 2012 in our institution. Pre-, intra-, and postoperative data were collected from medical and stored electronic anesthesia records. The predictors of intraoperative ABT were determined using multivariate logistic regression., Results: A total of 110 patients were included. Twenty-seven patients (25%) received intraoperative ABT with a volume of 16 ± 8 ml·kg(-1) . On multivariate analysis, an age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) were independently associated with the need for intraoperative ABT. We did not show any significant difference concerning postoperative early outcome and length of stay between the transfused and non-transfused patients except for the duration of postoperative mechanical ventilation that was significantly higher in the transfused group (P = 0.04)., Conclusion: In children, craniotomy for brain tumor removal is at risk of intraoperative ABT. An age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) are the main factors associated with intraoperative ABT during this surgery., (© 2015 John Wiley & Sons Ltd.)

Background: Dynamic indices of preload have been shown to better predict fluid responsiveness than static variables in mechanically ventilated adults. In children, dynamic predictors of fluid responsiveness have not yet been extensively studied., Aim: To evaluate the diagnostic accuracy of respiratory variation in aortic blood flow peak velocity (ΔVPeak) for the prediction of fluid responsiveness in mechanically ventilated children., Method: PubMed, Embase, and the Cochrane Database of Systematic Reviews were screened for studies relevant to the use of ΔVPeak to predict fluid responsiveness in children receiving mechanical ventilation. Clinical trials published as full-text articles in indexed journals without language restriction were included. We calculated the pooled values of sensitivity, specificity, diagnostic odds ratio (DOR), and positive and negative likelihood ratio using a random-effects model., Results: In total, six studies (163 participants) met the inclusion criteria. Data are reported as point estimate with 95% confidence interval. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and DOR of ΔVPeak to predict fluid responsiveness for the overall population were 92.0% (84.1-96.7), 85.5% (75.6-92.5), 4.89 (2.92-8.18), 0.13 (0.07-0.25), and 50.44 (17.70-143.74), respectively. The area under the summary receiver operating characteristic curve was 0.94. Cutoff values for ΔVPeak to predict fluid responsiveness varied across studies, ranging from 7% to 20%., Conclusion: Our results confirm that the ΔVPeak is an accurate predictor of fluid responsiveness in children under mechanical ventilation. However, the question of the optimal cutoff value of ΔVPeak to predict fluid responsiveness remains uncertain, as there are important variations between original publications, and needs to be resolved in further studies. The potential impact of intraoperative cardiac output optimization using goal-directed fluid therapy based on ΔVPeak on the perioperative outcome in the pediatric population should be subsequently evaluated., (© 2015 John Wiley & Sons Ltd.)

Decompressive craniotomy (DC) in children is a life-saving procedure for the treatment of refractory intracranial hypertension related to traumatic, ischemic and infectious lesions. Different surgical procedures have been proposed including uni or bilateral hemicraniectomy, bi-frontal, bi-temporal, or bi-parietal craniotomies. DC can avoid the cascade of events related to tissue hypoxia, brain perfusion reduction, hypotension and the evolution of brain edema that can be responsible for brain herniation. The monitoring of intracranial pressure (ICP) is very important to take a decision as well as the value of Trans cranial Doppler (TCD). Repeated TCD in the intensive care unit give important information about the decrease of the cerebral perfusion pressure (CPP) and facilitates the decision making. The important question is about how long time we have to wait before to perform the DC. Three conditions can be distinguished: 1) ICP stable and TCD with good parameters: the decision can be postponed; 2) ICP>20 mmHg with good TCD and without clinical signs of deterioration: the decision can be postponed; 3) ICP>20 mmHg with altered CPP and degraded TCD value and clinical signs of brain herniation: the surgical procedure is indicated. The decision of a ventricular drainage can also be discussed but in cases of slit ventricles it is preferable to realize a DC to avoid the problems of multiple taps without finding the ventricular system. In some very specific situations, DC has to be contraindicated. The first one is a prolonged cardiopulmonary arrest with a no-flow longer than 15 minutes and irreversible lesions on the TCD or on the CT-scan. The second most common situation is a patient with GCS of 3 on admission associated with bilaterally fixed dilated pupils. In this case TCD is very useful to document the decrease or the absence of diastolic flux that indicates a very poor cerebral perfusion. In case of severe polytraumatism with multiorgan failure, especially in very severe hemorrhagic shock with incontrollable coagulopathy, the realization of DC is definitely hazardous with y a high risk of cardiac arrest during the surgical procedure. The decision to realize a hemicraniectomy or a bi-frontal craniotomy is related to the presence or not of associated traumatic lesions as hemorrhagic contusions or a sub-dural or extradural hematoma. In cases of diffuse cerebral edema the bi-frontal bone flap is indicated. In all cases a closure of the dura mater with a large dural patch has to be performed avoiding compression of the nervous system. Our results showed a mortality rate of 18%. Eighty percent of the survivors have a good quality of life but only 43% in a scholar age could attend a normal program. Patients treated with DC need a long follow-up and an important rehabilitation program to improve their quality of life. Our report shows that DC in children is effective to control the post-traumatic intracranial hypertension but a long follow-up is recommended to access the sequels and quality of life of these patients.

Epidural blood patch is the gold standard treatment for post-dural puncture headache, although hydroxyethyl starch may be a useful alternative to blood if the latter is contraindicated. The aim of this experimental study was to assess whether hydroxyethyl starch given via an indwelling intrathecal catheter resulted in clinical or histopathological changes suggestive of neurotoxicity. The study was conducted in rats that were randomly allocated to receive three 10-μl injections on consecutive days of either saline or hydroxyethyl starch administered via the intrathecal catheter. Eight rats were given injections of saline 0.9% and 11 were given 6% hydroxyethyl starch 130/0.4 derived from thin boiling waxy corn starch in 0.9% sodium chloride (Voluven). Daily clinical evaluation, activity measured by actimetry and neuropathological analysis of the spinal cord were subsequently performed to assess for signs of neurotoxicity. No clinical or actimetric changes were observed in either group following intrathecal saline or hydroxyethyl starch administration. Histopathological examination showed non-specific changes with no differences between the two groups. This experimental study in the rat suggests that repeated intrathecal injection of hydroxyethyl starch is not associated with neurotoxicity., (© 2015 The Association of Anaesthetists of Great Britain and Ireland.)

Local anesthetic intoxication is an uncommon complication of regional anesthesia. We report the case of a 4-month-old infant who presented with generalized tonic-clonic seizure complicated by cardiac arrest secondary to a severe intoxication to local anesthesia. These complications were observed after a bilateral dorsal penile nerve block with lidocaine for circumcision in a non-hospital setting. This report emphasizes the potential risk of local anesthetic systemic toxicity in such circumstances and describes its treatment., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)